Body dysmorphic disorder (BDD) is a psychiatric disorder consisting of distressing or disabling preoccupations related to nonexistent or slight defects in appearance, combined with repetitive behaviors performed in response to these concerns about one’s appearance — for example, checking the mirror repeatedly or excessive grooming. BDD is often associated with significant functional impairment and poor quality of life, as well as increased risk of attempted and completed suicide.
Multiple studies support the use of cognitive behavioral therapy (CBT) for the treatment of BDD. A previous study from Hilary Weingarden, PhD and her colleagues from the Center for OCD and Related Disorders (CORD) demonstrated that 52% of patients receiving 24 weeks of therapist-delivered CBT experienced a sustained remission of their symptoms at six months after treatment completion, as compared to 27% in participants receiving supportive psychotherapy.
While CBT is an effective treatment for BDD, many individuals are unable to find treaters with expertise in this area or cannot afford treatment. Given the scarcity of trained mental health providers, there has been considerable interest in the use of app-based treatments. In a recent publication, Sabine Wilhelm, PhD and colleagues report on data from a pilot study of a coach-supported app-based cognitive behavioral therapy (CBT) for BDD.
Perspectives App for BDD
Previous research has demonstrated that computer-based therapist-guided CBT for BDD (BDD-NET) is a safe and efficacious option for the treatment of BDD. The Perspectives app builds upon this foundation, modifying treatment components for delivery via smartphone in order to increase flexibility and facilitate engagement.
The Perspectives app was developed in a collaborative user-centered design process including engineering and design experts, clinician-researchers with expertise in CBT for BDD, and BDD patient consultants.
The Perspectives app covers each of the core components of CBT for BDD: psychoeducation, cognitive restructuring, exposure with response prevention, mindfulness, attention retraining, and relapse prevention. Each treatment module includes brief psychoeducation followed by short interactive exercises designed to engage the user and teach the specific CBT skill(s) from that module. Exercises were designed to be completed relatively quickly and can be repeated as often as desired.
Waitlist-Controlled Trial of the Perspectives App
In a randomized controlled trial, 80 adults (N = 80) with BDD were assigned to either 12 weeks of the Perspectives digital intervention or waitlist. To promote engagement and to answer questions, bachelor’s-level coaches were available through in-app messaging and phone calls.
BDD severity was measured at baseline, mid-treatment, and at the end of treatment by blinded independent evaluators using the Yale-Brown Obsessive Compulsive Scale Modified for BDD; (BDD-YBOCS). In addition, standardized questionnaires were used to assess BDD-related insight, depressive symptoms, quality of life, and overall functioning.
Overall, uptake and satisfaction with the app were high. Participants in the Perspectives app-based CBT group expressed significantly lower BDD-YBOCS severity at the end of treatment (mean [SD]: 16.8 [7.5]) compared to those in the waitlist group (26.7 [6.2]; p < 0.001). Two-thirds (68%) of individuals using the Perspectives app were responders and over half experienced symptom remission. App-based CBT was also associated with greater improvements in BDD-related insight, depressive symptoms, quality of life, and overall functioning.
Coaches spent a mean of 26.9 min (SD 10.9) speaking on the phone per participant across 2.1 phone calls, and 1.5 min (SD 1.3) per participant per week via chat. Participants self-reported using the app or practicing skills on average 60 minutes per week (range: 2–420).
A Scalable, Efficacious Treatment Option
The current randomized waitlist-controlled trial demonstrates that the Perspectives app, supported by a bachelor’s-level coach, is an efficacious, scalable treatment for adults with BDD. In this trial, 68% of the adults using the Perspectives app were responders, exceeding the response rates observed in 12-week face-to-face CBT trials, which range from 40% to 54%.
At the present time, the demand for psychotherapy far exceeds the availability of clinicians. Perspectives offers a scalable, accessible solution. Implementing app-based treatment – even with coach support – would reduce clinician time required from an estimated minimum 600 minutes per patient to under 60 minutes. In addition, digital treatments are expected to reduce disparities across healthcare by mitigating practical and attitudinal barriers that disproportionately impact racial and ethnic minority patients. Apps can be used regardless of location, scheduling constraints, or comfort with face-to-face interventions.
Read More
Wilhelm S, Weingarden H, Greenberg JL, Hoeppner SS, Snorrason I, Bernstein EE, McCoy TH, Harrison OT. Efficacy of App-Based Cognitive Behavioral Therapy for Body Dysmorphic Disorder with Coach Support: Initial Randomized Controlled Clinical Trial. Psychother Psychosom. 2022; 91(4):277-285.
Wilhelm S, Weingarden H, Greenberg JL, McCoy TH, Ladis I, Summers BJ, et al. Development and pilot testing of a cognitive-behavioral therapy digital service for body dysmorphic disorder. Behav Ther. 2020 Jan; 51(1):15–26.
