The Perspectives App: CBT-Based Treatment of Body Dysmorphic Disorder

March 24, 2023

Ruta Nonacs, MD PhD

As the demand for psychotherapy far exceeds the availability of clinicians, the Perspectives smartphone app offers a scalable, accessible solution for the treatment of body dysmorphic disorder.

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. While CBT is an effective treatment for BDD, many individuals are unable to find providers with expertise in this modality of treatment or cannot afford treatment. Given the scarcity of trained mental health providers, there has been considerable interest in the use of app-based treatments.

Perspectives App for the Treatment of BDD

Perspectives is a new therapy app for individuals with BDD that was developed by Sabine Wilhelm, PhD, Hilary Weingarden, PhD, and Jennifer Greenberg, PsyD from the Center for OCD and Related Disorders (CORD) in collaboration with Koa Health. Last week, the British National Institute for Health and Care Excellence (NICE) announced that it had identified the Perspectives app as a promising new medical technology and conditionally recommended this app for rapid deployment into the National Health Service (NHS).

Perspectives is a coach-supported app providing CBT for BDD. The app covers each of the core components of CBT for BDD, including 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.

In addition, app-based treatment is supported by a bachelor’s-level coach, with the goal of promoting engagement via in-app messaging and brief phone calls.

In a randomized waitlist-controlled trial including 80 adults with BDD, Wilhelm and colleagues demonstrated that the coach-supported Perspectives app is an efficacious, scalable treatment for adults with BDD. In this trial, 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. Furthermore, the Perspective app exceeded the responded rates observed in 12-week face-to-face CBT trials for BDD, which range from 40% to 54%.

Using Technology-Based Interventions to Address Increasing Mental Health Needs

There has been increasing interest in the use of digital interventions and apps to provide mental health support to patients. Long before the COVID-19 pandemic, there has been a shortage of mental health providers and significant barriers to accessing care. With the pandemic, the crisis has worsened, with a steadily increasing number of individuals experiencing depression, anxiety, stress and trauma. At the same time, we face limited availability of in-person therapeutic services.

Mental health apps have the potential to increase access to care in a cost-effective and scalable way; however, despite the enthusiasm for and proliferation of mental health apps, a recent systematic review and meta-analysis (Weisel et al, 2021) concluded that while some trials have demonstrated the effectiveness of some apps to target mental health symptoms, many digital health interventions have not received adequate scrutiny.

While mental health apps can be a useful tool, not everyone will benefit from an app. More research is needed to understand what treatments work for whom and when.