Medication, psychotherapy, or a combination of both, in treating body dysmorphic disorder

Body dysmorphic disorder (BDD) is a condition characterised by a distressing and disabling preoccupation with an imagined or slight defect in appearance. This causes people with this disorder either significant distress or disrupts their daily functioning (or both). There has been a growing recognition that BDD is common, and is associated with significant illness and disability. There is also some evidence that it may respond to pharmacotherapy and psychotherapy. Our systematic review of randomised controlled trials assesses the effects of drug treatment or psychotherapy when used on their own or in combination. We found five eligible trials, including three of psychotherapy (cognitive behavioural therapy (CBT) and exposure and response prevention (ERP)) and two of medication (the serotonin reuptake inhibitors (SRIs) fluoxetine and clomipramine). In the only placebo-controlled medication trial included in our review, people with BDD treated with fluoxetine were more likely to respond (56%, 19 out of 34) than those allocated placebo (18%, 6 out of 33). Symptoms became less severe after treatment with both medication and psychotherapy. Adverse events were mild to moderate in severity and none of the people in the active treatment groups were reported to have dropped out of the studies because of treatment-emergent adverse events. There is preliminary evidence from one trial of CBT that the effects of CBT may persist once treatment has ended. Treatment response in the medication trials was not effected by the degree to which people had insight into their condition. Although few controlled trials have been done, and those that have been conducted were small, indicating that our findings should be used with caution unless confirmed by larger studies (some of which are ongoing), the results suggest that treatment with both medication or psychotherapy can be effective in treating the symptoms of body dysmorphic disorder.

Authors' conclusions: 

Results from the small number of available RCTs suggest that SRIs and CBT may be useful in treating patients with BDD. The findings of these studies need to be replicated. In addition, future controlled studies in other samples, such as adolescents, and using other selective SRIs, as well as a range of psychological therapy approaches and modalities (alone and in combination), are essential in supplementing the sparse data currently available.

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Background: 

Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slight or imagined defect in appearance. Trials have investigated the use of serotonin reuptake inhibitors (SRIs) and cognitive behaviour therapy (CBT) for BDD.

Objectives: 

To assess the efficacy of pharmacotherapy, psychotherapy or a combination of both treatment modalities for body dysmorphic disorder.

Search strategy: 

We searched the Cochrane Depression, Anxiety and Neurosis Trial Register (December 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2007), MEDLINE (January 1966 to December 2007), and PsycINFO (1967 to December 2007). Ongoing and unpublished trials were located through searching the metaRegister of Controlled Trials, the CRISP and WHO ICTRP search portals (databases searched in December 2007), and through contacting key researchers and pharmaceutical companies. Additional studies were located through study reference lists.

Selection criteria: 

Randomised controlled trials (RCTs) of patients meeting DSM or ICD diagnostic criteria for BDD, in which the trials compare pharmacotherapy, psychotherapy or multi-modal treatment groups with active or non-active control groups. Short or long-term trials were eligible.

Data collection and analysis: 

Two review authors independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary effect sizes for dichotomous and continuous outcomes were calculated using a random effects model and heterogeneity was assessed.

Main results: 

Two pharmacotherapy and three psychotherapy trials were eligible for inclusion in the review, with data from four short-term RCTs (169 participants) available for analysis. Response data from a single placebo-controlled trial of fluoxetine suggested overall superiority of medication relative to placebo (relative risk (RR) 3.07, 95% CI 1.4 to 6.72, n = 67). Symptom severity was also significantly reduced in the RCTs of fluoxetine and clomipramine (relative to desipramine), as well as in the two CBT trials (WMD -44.96, 95% CI -54.43 to -35.49, n = 73). A low relapse rate (4/22) was demonstrated in one trial of CBT.

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