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Mechanisms of cognitive-behavioral therapy effects on symptoms of body dysmorphic disorder: a network intervention analysis

Published online by Cambridge University Press:  09 November 2021

Emily E. Bernstein Open the ORCID record for Emily E. Bernstein [Opens in a new window] ,
Katharine A. Phillips ,
Jennifer L. Greenberg ,
Joshua Curtiss ,
Susanne S. Hoeppner  and
Sabine Wilhelm
Emily E. Bernstein*
Affiliation:
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
Katharine A. Phillips
Affiliation:
Rhode Island Hospital and Alpert Medical School of Brown University, Providence, RI, USA New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA
Jennifer L. Greenberg
Affiliation:
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
Joshua Curtiss
Affiliation:
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
Susanne S. Hoeppner
Affiliation:
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
Sabine Wilhelm
Affiliation:
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
*
Author for correspondence: Emily E. Bernstein, E-mail: eebernstein@mgh.harvard.edu
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Abstract

Background

Body dysmorphic disorder (BDD) is a severe and undertreated condition. Although cognitive-behavioral therapy (CBT) is the first-line psychosocial treatment for this common disorder, how the intervention works is insufficiently understood. Specific pathways have been hypothesized, but only one small study has examined the precise nature of treatment effects of CBT, and no prior study has examined the effects of supportive psychotherapy (SPT).

Methods

This study re-examined a large trial (n = 120) comparing CBT to SPT for BDD. Network intervention analyses were used to explore symptom-level data across time. We computed mixed graphical models at multiple time points to examine relative differences in direct and indirect effects of the two interventions.

Results

In the resulting networks, CBT and SPT appeared to differentially target certain symptoms. The largest differences included CBT increasing efforts to disengage from and restructure unhelpful thoughts and resist BDD rituals, while SPT was directly related to improvement in BDD-related insight. Additionally, the time course of differences aligned with the intended targets of CBT; cognitive effects emerged first and behavioral effects second, paralleling cognitive restructuring in earlier sessions and the emphasis on exposure and ritual prevention in later sessions. Differences in favor of CBT were most consistent for behavioral targets.

Conclusions

CBT and SPT primarily affected different symptoms. To improve patient care, the field needs a better understanding of how and when BDD treatments and treatment components succeed. Considering patient experiences at the symptom level and over time can aid in refining or reorganizing treatments to better fit patient needs.

Keywords

Body dysmorphic disordercognitive behavioral therapymechanismsnetwork analysissupportive psychotherapy
Type
Original Article
Information
Psychological Medicine , Volume 53 , Issue 6 , April 2023 , pp. 2531 - 2539
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Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press

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References

Abramowitz, J. S. (2006). The psychological treatment of obsessive–compulsive disorder. The Canadian Journal of Psychiatry, 51, 407–416.CrossRefGoogle ScholarPubMed
Bernstein, E. E., Heeren, A., & McNally, R. J. (2019). Reexamining trait rumination as a system of repetitive negative thoughts: A network analysis. Journal of Behavior Therapy and Experimental Psychiatry, 63, 21–27. doi: 10.1016/j.jbtep.2018.12.005CrossRefGoogle ScholarPubMed
Blanken, T. F., Van Der Zweerde, T., Van Straten, A., Van Someren, E. J. W., Borsboom, D., & Lancee, J. (2019). Introducing network intervention analysis to investigate sequential, symptom-specific treatment effects: A demonstration in co-occurring insomnia and depression. Psychotherapy and Psychosomatics, 88, 52–54. doi: 10.1159/000495045CrossRefGoogle ScholarPubMed
Borsboom, D., & Cramer, A. O. J. (2013). Network analysis: An integrative approach to the structure of psychopathology. Annual Review of Clinical Psychology, 9(1), 91–121. doi: 10.1146/annurev-clinpsy-050212-185608CrossRefGoogle Scholar
Boschloo, L., Cuijpers, P., Karyotaki, E., Berger, T., Moritz, S., Meyer, B., & Klein, J. P. (2019). Symptom-specific effectiveness of an internet-based intervention in the treatment of mild to moderate depressive symptomatology: The potential of network estimation techniques. Behaviour Research and Therapy, 122, 103440. doi: 10.1016/j.brat.2019.103440CrossRefGoogle ScholarPubMed
Buhlmann, U., Glaesmer, H., Mewes, R., Fama, J. M., Wilhelm, S., Brähler, E., & Rief, W. (2010). Updates on the prevalence of body dysmorphic disorder: A population-based survey. Psychiatry Research, 178, 171–175. doi: 10.1016/j.psychres.2009.05.002CrossRefGoogle ScholarPubMed
Buhlmann, U., McNally, R. J., Wilhelm, S., & Florin, I. (2002). Selective processing of emotional information in body dysmorphic disorder. Journal of Anxiety Disorders, 16(3), 289–298.CrossRefGoogle ScholarPubMed
Buhlmann, U., Teachman, B. A., Gerbershagen, A., Kikul, J., & Rief, W. (2008). Implicit and explicit self-esteem and attractiveness beliefs among individuals with body dysmorphic disorder. Cognitive Therapy and Research, 32, 213–225.CrossRefGoogle Scholar
Burger, J., Isvoranu, A. M., Lunansky, G., Haslbeck, J., Epskamp, S., Hoekstra, R. H., ... Blanken, T. (2020). Reporting standards for psychological network analyses in cross-sectional data. PsyyArXiv. doi: 10.31234/osf.io/4y9nzGoogle Scholar
Cervin, M., Storch, E. A., Piacentini, J., Birmaher, B., Compton, S. N., Albano, A. M., … Kendall, P. C. (2020). Symptom-specific effects of cognitive-behavioral therapy, sertraline, and their combination in a large randomized controlled trial of pediatric anxiety disorders. Journal of Child Psychology and Psychiatry, 61, 492–502. doi: 10.1111/jcpp.13124CrossRefGoogle Scholar
Curtiss, J. E., Wallace, B., Fisher, L. B., Nyer, M., Jain, F., Cusin, C., & Pedrelli, P. (2021). Change processes in cognitive behavioral therapy and motivational interviewing for depression and heavy alcohol use: A network approach. Journal of Affective Disorders Reports, 3, 100040. doi: 10.1016/j.jadr.2020.100040CrossRefGoogle Scholar
Eisen, J. L., Phillips, K. A., Coles, M. E., & Rasmussen, S. A. (2004). Insight in obsessive–compulsive disorder and body dysmorphic disorder. Comprehensive Psychiatry, 45, 10–15. doi: 10.1016/j.comppsych.2003.09.010CrossRefGoogle ScholarPubMed
Eisen, J. L., Rasmussen, S. A., Phillips, K. A., Price, L. H., Davidson, J., Lydiard, R. B., … Piggott, T. (2001). Insight and treatment outcome in obsessive–compulsive disorder. Comprehensive Psychiatry, 42, 494–497.CrossRefGoogle ScholarPubMed
Enander, J., Andersson, E., Mataix-Cols, D., Lichtenstein, L., Alström, K., Andersson, G., … Rück, C. (2016). Therapist guided internet-based cognitive behavioural therapy for body dysmorphic disorder: Single-blind randomised controlled trial. BMJ, 4, e005923. doi: 10.1136/bmj.i241Google Scholar
Epskamp, S., & Fried, E. I. (2018). A tutorial on regularized partial correlation networks. Psychological Methods, 23(4), 617.CrossRefGoogle ScholarPubMed
Fang, A., Steketee, G., Keshaviah, A., Didie, E., Phillips, K. A., & Wilhelm, S. (2020). Mechanisms of change in cognitive behavioral therapy for body dysmorphic disorder. Cognitive Therapy and Research, 44, 596–610.CrossRefGoogle Scholar
Feusner, J. D., Neziroglu, F., Wilhelm, S., Mancusi, L., & Bohon, C. (2010). What causes BDD: Research findings and a proposed model. Psychiatric Annals, 40(7), 349–355.CrossRefGoogle Scholar
Foa, E. B., Abramowitz, J. S., Franklin, M. E., & Kozak, M. J. (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive–compulsive disorder. Behavior therapy, 30(4), 717–724.CrossRefGoogle Scholar
Friedman, J., Hastie, T., & Tibshirani, R. (2011). glasso: Graphical lasso-estimation of Gaussian graphical models.Google Scholar
Grace, S. A., Labuschagne, I., Kaplan, R. A., & Rossell, S. L. (2017). The neurobiology of body dysmorphic disorder: A systematic review and theoretical model. Neuroscience & Biobehavioral Reviews, 83, 83–96.CrossRefGoogle ScholarPubMed
Greenberg, J. L., Phillips, K. A., Steketee, G., Hoeppner, S. S., & Wilhelm, S. (2019). Predictors of response to cognitive-behavioral therapy for body dysmorphic disorder. Behavior Therapy, 50, 839–849. doi: 10.1016/j.beth.2018.12.008CrossRefGoogle ScholarPubMed
Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21, 372–378. doi: 10.1037/0735-7028.21.5.372CrossRefGoogle Scholar
Harrison, A., Fernández de la Cruz, L., Enander, J., Radua, J., & Mataix-Cols, D. (2016). Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 48, 43–51. doi: 10.1016/j.cpr.2016.05.007CrossRefGoogle ScholarPubMed
Haslbeck, J. M. B., & Waldorp, L. J. (2020). MGM: Estimating time-varying mixed graphical models in high-dimensional data. Journal of Statistical Software, 93(8), 1–46. doi: 10.18637/jss.v093.i08.CrossRefGoogle Scholar
Hittner, J. B., May, K., & Silver, N. C. (2003). A Monte Carlo evaluation of tests for comparing dependent correlations. Journal of General Psychology, 130(2), 149–168. doi: 10.1080/00221300309601282CrossRefGoogle ScholarPubMed
Jones, P. (2018). Networktools: Tools for Identifying Important Nodes in Networks. R Package Version 1.1.1. https://CRAN.R-project.org/package=networktools.Google Scholar
Krebs, G., de la Cruz, L. F., Monzani, B., Bowyer, L., Anson, M., Cadman, J., … Mataix-Cols, D. (2017). Long-term outcomes of cognitive-behavioral therapy for adolescent body dysmorphic disorder. Behavior Therapy, 48, 462–473. doi: 10.1016/j.beth.2017.01.001CrossRefGoogle ScholarPubMed
Li, W., Lai, T. M., Bohon, C., Loo, S. K., McCurdy, D., Strober, M., … Feusner, J. (2015). Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information. Psychological Medicine, 45(10), 2111.CrossRefGoogle ScholarPubMed
Maltby, N., & Tolin, D. F. (2005). A brief motivational intervention for treatment-refusing OCD patients. Cognitive Behaviour Therapy, 34, 176–184.CrossRefGoogle ScholarPubMed
McNally, R. J. (2016). Can network analysis transform psychopathology? Behaviour Research and Therapy, 86, 95–104. doi: 10.1016/j.brat.2016.06.006CrossRefGoogle ScholarPubMed
Middleton, R. R., & Hezel, D. M. (2019). Utilizing exposure and response prevention to address poor insight in obsessive–compulsive disorder. Journal of Cognitive Psychotherapy, 33(3), 213–227.CrossRefGoogle ScholarPubMed
Mullarkey, M. C., Stein, A. T., Pearson, R., & Beevers, C. G. (2020). Network analyses reveal which symptoms improve (or not) following an Internet intervention (Deprexis) for depression. Depression and Anxiety, 37, 115–124. doi: 10.1002/da.22972Google ScholarPubMed
Phillips, K. A. (2000). Quality of life for patients with body dysmorphic disorder. Journal of Nervous and Mental Disease, 188, 170–175. doi: 10.1097/00005053-200003000-00007CrossRefGoogle ScholarPubMed
Phillips, K. A. (Ed.) (2017). Body dysmorphic disorder: Advances in research and clinical practice. New York, NY: Oxford University PressGoogle Scholar
Phillips, K. A., Coles, M. E., Menard, W., Yen, S., Fay, C., & Weisberg, R. B. (2005). Suicidal ideation and suicide attempts in body dysmorphic disorder. Journal of Clinical Psychiatry, 66, 717–725. doi: 10.4088/JCP.v66n0607CrossRefGoogle ScholarPubMed
Phillips, K. A., Hart, A. S., & Menard, W. (2014). Psychometric evaluation of the Yale-Brown obsessive–compulsive scale modified for body dysmorphic disorder (BDD-YBOCS). Journal of Obsessive–Compulsive and Related Disorders, 3, 205–208. doi: 10.1016/j.jocrd.2014.04.004Google Scholar
Phillips, K. A., Hollander, E., Rasmussen, S. A., Aronowitz, B. R., DeCaria, C., & Goodman, W. K. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the yale-brown obsessive–compulsive scale. Psychopharmacology Bulletin, 33, 17–22.Google ScholarPubMed
Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2005). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics, 46, 317–325. doi: 10.1176/appi.psy.46.4.317CrossRefGoogle ScholarPubMed
Phillips, K. A., Menard, W., Quinn, E., Didie, E. R., & Stout, R. L. (2013). A four-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychological Medicine, 43, 1109–1117. doi: 10.1017/S0033291712001730CrossRefGoogle Scholar
Phillips, K. A., Pagano, M. E., & Menard, W. (2006). Pharmacotherapy for body dysmorphic disorder: Treatment received and illness severity. Annals of Clinical Psychiatry, 18, 251–257. doi: 10.1080/10401230600948464CrossRefGoogle ScholarPubMed
Phillips, K. A., Pinto, A., & Jain, S. (2004). Self-esteem in body dysmorphic disorder. Body Image, 1(4), 385–390.CrossRefGoogle Scholar
Pinsker, H. (1997). A primer of supportive psychotherapy. Hillsdale, N.J: The Analytic Press.Google Scholar
Rasmussen, J., Gomez, A. F., & Wilhelm, S. (2017). Cognitive-behavioral therapy for body dysmorphic disorder. In Phillips, K. A. (Ed.), Body dysmorphic disorder: Research and Clinical Advances (pp. 357–377). New York, NY: Oxford University Press.Google Scholar
Schieber, K., Kollei, I., de Zwaan, M., & Martin, A. (2015). Classification of body dysmorphic disorder - What is the advantage of the new DSM-5 criteria? Journal of Psychosomatic Research, 78, 223–227. doi: 10.1016/j.jpsychores.2015.01.002CrossRefGoogle ScholarPubMed
Schmittmann, V. D., Cramer, A. O., Waldorp, L. J., Epskamp, S., Kievit, R. A., & Borsboom, D. (2013). Deconstructing the construct: A network perspective on psychological phenomena. New Ideas in Psychology, 31(3), 43–53.CrossRefGoogle Scholar
Selles, R. R., Højgaard, D. R., Ivarsson, T., Thomsen, P. H., McBride, N. M., Storch, E. A., ... Stewart, S. E. (2020). Avoidance, insight, impairment recognition concordance, and cognitive-behavioral therapy outcomes in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 59(5), 650–659.CrossRefGoogle ScholarPubMed
Summers, B. J., Aalbers, G., Jones, P. J., McNally, R. J., Phillips, K. A., & Wilhelm, S. (2020). A network perspective on body dysmorphic disorder and major depressive disorder. Journal of Affective Disorders, 262, 165–173. doi: 10.1016/j.jad.2019.11.011CrossRefGoogle ScholarPubMed
Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1(1), 113–125.CrossRefGoogle Scholar
Veale, D., Gledhill, L. J., Christodoulou, P., & Hodsoll, J. (2016). Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image, 18, 168–186. doi: 10.1016/j.bodyim.2016.07.003CrossRefGoogle ScholarPubMed
Veale, D., Miles, S., & Anson, M. (2015). Long-term outcome of cognitive behavior therapy for body dysmorphic disorder: A naturalistic case series of 1 to 4 years after a controlled trial. Behavior Therapy, 46, 775–785. doi: 10.1016/j.beth.2015.06.003CrossRefGoogle ScholarPubMed
Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270–277.CrossRefGoogle ScholarPubMed
Weingarden, H., Hoeppner, S. S., Snorrason, I., Greenberg, J. L., Phillips, K. A., & Wilhelm, S. (2021). Rates of remission, sustained remission, and recurrence in a randomized controlled trial of cognitive-behavioural therapy versus supportive psychotherapy for body dysmorphic disorder. Depression and Anxiety, 38(7), 700–707. doi: 10.1002/da.23148.CrossRefGoogle Scholar
Wilhelm, S., Buhlmann, U., Hayward, L. C., Greenberg, J. L., & Dimaite, R. (2010). A cognitive-behavioral treatment approach for body dysmorphic disorder. Cognitive and Behavioral Practice, 17, 241–247. doi: 10.1016/j.cbpra.2010.02.001CrossRefGoogle Scholar
Wilhelm, S., Phillips, K., & Steketee, G. (2013). A cognitive-behavioral treatment manual for body dysmorphic disorder. New York: Guilford Press.Google ScholarPubMed
Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., … Steketee, G. (2014). Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial. Behavior Therapy, 45, 314–327. doi: 10.1016/j.beth.2013.12.007CrossRefGoogle ScholarPubMed
Wilhelm, S., Phillips, K. A., Fama, J. M., Greenberg, J. L., & Steketee, G. (2011). Modular cognitive-behavioral therapy for body dysmorphic disorder. Behavior Therapy, 42(4), 624–633.CrossRefGoogle ScholarPubMed
Wilhelm, S., Phillips, K. A., Greenberg, J. L., O'Keefe, S. M., Hoeppner, S. S., Keshaviah, A., … Schoenfeld, D. A. (2019). Efficacy and posttreatment effects of therapist-delivered cognitive behavioral therapy vs supportive psychotherapy for adults with body dysmorphic disorder: A randomized clinical trial. JAMA Psychiatry, 76, 363–373. doi: 10.1001/jamapsychiatry.2018.4156CrossRefGoogle ScholarPubMed
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