Journal of Affective Disorders 352 (2024) 237–249

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Is cognitive behavioral therapy an efficacious treatment for psychological

interventions in body dysmorphic disorders? A meta-analysis based on
current evidence from randomized controlled trials
Fei Zhao a, Zhong Guo a, Yan Bo a, LiJuan Feng b, *, Jin Zhao a, *
a
Key Laboratory of Environmental Ecology and Population Health in Northwest Minority Areas, Medical College of Northwest Minzu University, Lanzhou, China
b
Students’ Counseling and Psychological Education Center, Northwest Minzu University, Lanzhou, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Clinical guidelines and some studies recommend cognitive-behavioral therapy (CBT) as the most
Cognitive behavior therapy effective treatment for body dysmorphic disorder (BDD). However, owing to the lack of randomized controlled
Body dysmorphic disorder trials (RCTs), the research evidence is insufficient. This study aimed to explore the effectiveness of CBT in the
Obsessive-compulsive behavior
treatment of BDD using RCTs. This meta-analysis was registered in PROSPERO (CRD42023410577).
Depression
Anxiety
Methods: After a literature search and screening, 11 RCTs with 667 patients were included. The ROB 2.0 tool,
Meta-analysis funnel plots, sensitivity analysis, and meta-regression analysis were used to assess the quality, publication bias,
and sources of heterogeneity.
Results: After CBT intervention, the severity of BDD (SMD = − 1.73, 95 % CI (confidence interval) = [− 2.90;
− 0.57]), depression symptoms (SMD = − 1.72, 95 % CI = [− 3.16; − 0.28]), and anxiety levels were all reduced in
the patients of the experimental group; the remission of BDD (OR = 7.37, 95 % CI = [2.17; 24.98]) and the
response of BDD (OR = 8.86, 95 % CI = [4.85; 16.18]) were all increased; incorrect beliefs such as disability and
BABS were also reduced; the quality of life was improved. The difference between the groups was statistically
significant (p < 0.01). Meta-regression analysis showed that age and sample size were the predictive factors of
the effectiveness of CBT.
Limitations: The heterogeneity of most meta-analyses was high (I2 > 75 %).
Conclusions: Although CBT is effective in treating BDD, there is insufficient evidence to suggest that it is the best
psychological intervention for BDD. More high-quality evidence is still needed in the future.

1. Introduction forms of treatment are considered clinically effective for BDD: serotonin
reuptake inhibitor (SRI) medication and cognitive behavioral therapy
Body dysmorphic disorder (BDD) is a chronic, disabling mental dis­ (CBT). CBT is a non-drug intervention method developed based on
order in which patients experience mental distress or injury due to cognitive therapy and behavioral theory, which can change patients
nonexistent or minor physical defects (American Psychological Associ­ with BDD through mechanisms such as cognitive restructuring and
ation, 2013; Phillips et al., 2013). It has a point prevalence of 1.7–2.9 % reducing safety behaviors (Fang et al., 2020; Wilhelm et al., 2020a).
and is characterized by time-consuming compulsive behaviors, signifi­ As early as 2005, the Guidelines International Network (GIN) and the
cant distress, and impairment (Hartmann and Buhlmann, 2017). BDD is National Institute for Health and Clinical Excellence (NICE) published
associated with significantly higher levels of suicidality than other guidelines recommending the use of CBT for patients with BDD. Then,
psychiatric disorders, with a high risk of suicidal thoughts and acts the International OCD Foundation released treatment manuals for BDD
(Snorrason et al., 2019; Angelakis et al., 2016). Without intervention, in 2010 and 2013, both of which recommended CBT treatment (Body
BDD is unlikely to resolve and can have serious consequences (Phillips Dysmorphic Disorder: A Treatment Manual, by David Veale and Fugen
et al., 2013). Treatment of BDD often involves a combination of psy­ Neziroglu. West Sussex: Wiley Blackwell, 2010; Cognitive-Behavioral
chological and pharmacological interventions. Currently, two main Therapy for Body Dysmorphic Disorder: A Treatment Manual, by

* Corresponding authors at: Medical of Northwest Minzu University, No. 1 Northwest XinCun, ChengGuan District, Lanzhou, Gansu, China.
E-mail addresses: f_ljflying@163.com (L. Feng), gz6768@163.com (J. Zhao).

https://doi.org/10.1016/j.jad.2024.02.004
Received 23 May 2023; Received in revised form 27 January 2024; Accepted 6 February 2024
Available online 16 February 2024
0165-0327/© 2024 Published by Elsevier B.V.
F. Zhao et al. Journal of Affective Disorders 352 (2024) 237–249

Sabine Wilhelm, Katharine A. Phillips, and Gail Steketee. New York, NY: cognitive behavior therapy OR cognitive behavior therapies OR cogni­
Guilford Press, 2013). Current studies have reported that CBT has a tion therapy OR cognition therapies) [Title/Abstract] OR “cognitive
significant effect in treating BDD, with some studies proposing that CBT behavioral therapy”[Mesh]; (3) random*. The final search strategy was
is the gold standard for BDD treatment (Wilhelm et al., 2019; Wilhelm selected as “(1) AND (2) AND (3)”. In addition, a reference track,
et al., 2022). However, the evidence base supporting CBT, upon which ClinicalTrials.gov (https://www.clinicaltrials.gov/, accessed January
these international guidelines rely, has so far been relatively weak. An 2023) and Google Scholar (https://www.scholar.google.com) were used
authentic evaluation of the effectiveness of CBT in treating BDD needs a as supplementary searches.
more comprehensive examination through high-quality, large-sample
RCTs for further exploration. This also led to the development of follow- 2.2. Selection criteria
up RCTs. As of 2015, only a small number of RCTs have examined the
efficacy of different therapeutic interventions for BDD. Particularly, few The PICOS principle in the PRISMA guidelines was the basis for
RCTs have examined the effectiveness of CBT in treating BDD. In the setting the inclusion/exclusion criteria. The inclusion criteria were as
latest meta-analysis published in 2016, only 299 patients were included follows: (1) Patients/P: patients diagnosed with BDD, not limited to the
in the 7 included RCTs (Harrison et al., 2016). Although the results of patient’s age and specific diagnostic criteria, such as the diagnostic and
this study confirmed that CBT is effective in treating BDD, it is difficult statistical manual of mental disorders (DSM)-IV/V or International
to present direct evidence owing to the small sample size and low quality Classification of Diseases (ICD)-10/11; (2) Intervention/I: patients in
of the included studies. the experimental group were treated with CBT-based therapy alone; (3)
The paucity of published RCTs that have used CBT for BDD may be Comparison/C: did not receive CBT-based intervention; (4) Outcome/
related to the failure of most patients to undergo CBT. Reasons may O: outcomes associated with severity of BDD, degree of insight impair­
include, but are not limited to: (1) therapists familiar with BDD and ment, mental state (such as depression and anxiety), quality of life of
trained to deliver CBT are limited (Marques et al., 2011); (2) wait times patients, and no restrictions on the scales used to assess the outcomes;
are often long and treatment is inaccessible (Schulte et al., 2020); (3) (5) Study design/S: clinical RCTs.
access is further limited by barriers such as costs, scheduling constraints, The exclusion criteria were as follows: (1) patients with other dis­
and shame (Weingarden et al., 2016). The digital therapeutics that have eases; (2) without limiting the time, frequency, and specific form of CBT;
emerged in recent years can close the gap in access to care among pa­ (3) no limit to the specific intervention methods in the control group; (4)
tients because they are scalable and address the aforementioned barriers no control group or the intervention in the experimental group was not
(Wilhelm et al., 2020a, b). Currently, Internet-based digital technology- just CBT; (5) case reports, conference papers, in vivo/in vitro experi­
based psychotherapy is used to treat a variety of psychiatric disorders. ments, review articles, and letters; and (6) unreliable or incomplete
The development of a therapist-led computer-based CBT application for data.
BDD (BDD-NET) has shown that internet-CBT (iCBT) can be safe and
effective for BDD (Enander et al., 2016; Gentile et al., 2019; Enander 2.3. Data extraction
et al., 2014). Since then, the implementation of CBT has increased, along
with the corresponding RCT research evidence. The detailed information of the included studies was collected
The purpose of this study was to systematically evaluate the efficacy independently by two authors (FZ and ZG) and included: (1) author
of CBT intervention on physical impairment cognition, insight belief name and year of publication; (2) study design, nation, clinical trial
assessment, and psychological states, such as depression and anxiety, as registration number; (3) patient baseline characteristics (age, sample
well as the quality of life in patients with BDD across all age groups, size, female rate); (4) information on treatment/control group,
based on existing RCT research evidence. Simultaneously, the meta- including the specific forms and details of CBT intervention, follow-up
regression method was used to explore the impact of various factors time, etc.; (5) primary outcome indicators (the remission and response
such as patient characteristics, intervention strategies, and control rate of BDD, the scores of BDD-YBOCS: Yale-Brown Obsessive Compul­
methods on the treatment effect and to examine predictors of CBT out­ sive Scale Modified for BDD/BDDE: Body Dysmorphic Disorder Exam/
comes. Finally, we provided a theoretical basis for the clinical treatment BABS: Brown Assessment of Beliefs Scale/SDS: Sheehan Disability
practice by accurately evaluating the therapeutic utility of CBT for BDD. Scale); (6) secondary outcome indicators (mental health status, such as
anxiety, depression, quality of life).
2. Methods Dichotomous variables are represented by the number of occur­
rences, and continuous variables are expressed in the form of mean ±
This meta-analysis was conducted in accordance with the Preferred standard deviation (SD). Multiple sets of data that met the criteria in the
Reporting Items for Systematic Reviews and Meta-Analyses guidelines same study were extracted and labelled according to the different data.
(PRISMA) (Moher et al., 2009) and the recommendations of the The evaluation results of the scale were compared with the changes in
Cochrane Collaboration (Higgins et al., 2011). The study was registered the values of the data before and after the intervention. The data con­
in PROSPERO under registration number CRD42023410577. version formula was as follows: change value(c) = post-intervention
evaluation value(a) - baseline (before intervention) evaluation value(b).
2.1. Search strategies A negative change indicated that the post-intervention assessment value
was lower than the pre-intervention value; otherwise, a positive result
The following databases were searched: PubMed/MEDLINE, indicated an increase after the intervention. The calculation formulas
EMBASE, Web of Science, Cochrane Library, and APA PsycInfo. The are as follow: Xc = Xa − Xb (mean value change); Sc =
retrieval time for all databases was from the start of the database to 31 √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
January 2023 and the search was conducted without language re­ S2a + S2b − 2 × corr × Sa × Sb ， (corr = 0.5, SD value change) (Cump­
strictions. The keywords used included the following terms: (1) (Body ston et al., 2019; Higgins et al., 2022).
Dysmorphic Disorder* OR Body Image Disfunction* OR Body Image
Disorder* OR dysmorphophobia* OR dysmorphia* OR Body image 2.4. Quality evaluation and statistical analysis
disturbance* OR imagined ugliness)[Title/Abstract] OR “Body Dys­
morphic Disorders”[Mesh]; (2) (cognitive behavioral therapy OR Two authors (FZ and BY) independently assessed and crosschecked
cognitive behavioral therapies OR cognitive behavior therapy OR the risk of bias in the included studies. All included studies were RCTs
cognitive behavior therapies OR cognitive therapy OR cognitive thera­ and were assessed for quality using the revised Cochrane Collaboration
pies OR cognitive psychotherapy OR cognitive psychotherapies OR Risk of Bias tool (ROB 2.0) (Cumpston et al., 2019). This tool analyzes

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possible sources of bias from the randomization process, deviations from group intervention strategy (psychoeducation, supportive psychother­
intended interventions, missing outcome data, measurement of the apy, waiting list), scales to assess depression or BDD, and assessment
outcome, selection of the reported results, and other biases. For each time points. Each variable was analyzed separately in a meta-regression
group at risk of bias, results were rated as “high risk”, “low risk,” or model; the estimate (SE) represented the regression coefficient of each
“some concerns risk/uncertain risk.” linear regression, representing the slope of each model, and 95 % CI was
R studio software (version R x64 4.3.2, Cochrane Collaboration, the 95 % confidence interval of the beta coefficient values. The p value
Oxford, UK) was used for data analysis. Odds ratios (OR) for dichoto­ <0.05 was considered to be statistically significant, and this variable
mous variables and standardized mean differences (SMD)/mean differ­ was used as a predictor of results.
ences (MD) with 95 % confidence intervals (CI) for continuous variables
were calculated. The heterogeneity was assessed by the I2 and Π2 sta­ 3. Results
tistical tests. I2 > 50 % indicated high heterogeneity in the pooled re­
sults. Statistical heterogeneity was reduced or sources of heterogeneity 3.1. Literature screening
were explored by switching between fixed- and random-effects models,
subgroup analyzes, and sensitivity analyses. p < 0.01/0.05 was A total of 634 potentially relevant studies were identified through a
considered a statistically significant difference between groups. When database search (PubMed/MEDLINE, n = 64; EMBASE, n = 75; Web of
>9 data points were merged, a funnel plot with auxiliary lines was Science, n = 198; Cochrane Library, n = 261; APA, n = 36) and sup­
created using the cut-and-fill method, and Egger’s test was used to plementary searching (n = 0), of which 211 were duplicated. After
explore the risk of selective reporting bias. primary and secondary screening, 412 studies were excluded because
they did not meet the inclusion criteria. Finally, 11 eligible studies (all in
English) including 667 patients were selected (Fig. 1).
2.5. Meta-regression analysis

Univariate meta-regression analyzes were performed for compari­ 3.2. Characteristics of the included studies and interventions
sons containing nine or more independent effect sizes. These variables
examined included patient characteristics (age and female proportion), As shown in Tables 1 and 2, among the 11 included RCT, five were
sample size, specific CBT intervention (i-CBT or traditional CBT), control from the United States, three were from the UK, and the others were

Fig. 1. Literature screening flow chart.

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Table 1
Characteristics of 11 included studies.
Study Country Study Multi- Registered Record Patients Age Female (%) Sample Intervention Intervention (C) Outcome
design center patient time /diagnostic size(n) (T)
criteria
T C T C T C

Wilhelm USA RCT Nationally Yes 07/2019–03/ Adults/ DSM-V 27.8 (9.9) 26.2 (9.5) 92.5 75.0 40 40 App based- Waitlist Remission/Respond of
et al., 2022 2021 % % CBT BBD; BDD-YBOCS;
BABS; Depression;
Quality of Life; SDS
Ritter et al., Germany RCT No Yes 09/ Adults/ DSM- 27.5 (7.8) 28.4 (9.1) 71 % 63 % 21 19 CT-BDD Waitlist BDD-YBOCS; BABS;
2023 2016–92,019 V/ ICD-11 BDI; Depression;
Quality of Life;
Wilhelm USA RCT Yes Yes 10/2011–7/ Adults/ DSM- 32.2 (12.8) 71.8 % 33 32 CBT Supportive BDD-YBOCS; BABS;
et al., 2016 IV Psychotherapy Depression (BDI); SDS
2019M
Wilhelm USA RCT Yes Yes 10/2011–7/ Adults/ DSM- 36.0 (13.1) 83.6 % 28 27 CBT Supportive BDD-YBOCS; BABS;
et al., 2016 IV Psychotherapy Depression (BDI); SDS
2019R
Mohajerina Iran RCT No NR NR Adults/ DSM-V 28.71 (6.82) 27.76 (5.24) 51.6 51.6 64 64 UP (CBT- Waitlist/ BABS; Depression
240

et al., 2019 % % based) treatment as usual (BDI); Anxiety

Enander Sweden RCT No Yes 11/2013–01/ Adults/ DSM-V 34 (14) 31 (11) 83 % 87 % 47 47 CBT-NET Supportive BBD-YBOCS; Respond
et al., 2016 2015 therapy of BBD; BABS;
Depression; Anxiety
Mataix-Cols England RCT No Yes 02/2012–08/ Adolescents 16.1 (1.8) 15.8 (1.5) 73.3 100 15 15 CBT psychoeducation BDD-YBOCS; BABS;
et al., 2015 2014 /DSM-IV % % Depression; Anxiety;
Quality of Life
Wilhelm USA RCT No NR 08/2005–12/ Adults/ DSM- 33.2 (11.4) 36.3 (11.8) 53 % 68 % 17 19 CBT Waitlist BDD-YBOCS; BABS;
et al., 2014 2008 IV Depression (BDI)
Veale et al., UK RCT No Yes 04/2009–03/ Adults/ DSM- 30.0 29.0 57.1 60 % 21 25 CBT anxiety BDD-YBOCS; BABS;
2014 2012 IV (24.5–37.5) (25.5–37.0) % management Anxiety
Rabiei et al., Iran RCT No NR NR Adults/ DSM- 23.7 (6.5) 26.6 (6.6) 90 % 90 % 10 10 CBT Waitlist BDD-YBOCS
2012 IV
Veale et al., UK RCT No NR NR Adults/ DSM- 36.67 34.18 (7.55) 90.9 90 % 9 10 CBT Waitlist BDDE; BDD-YBOCS;
1996 IV (13.65 % Depression; Anxiety

Journal of Affective Disorders 352 (2024) 237–249

Rosen et al., USA RCT No NR NR Adults/ DSM- 36.5(9.5) NR 27 27 CBT Waitlist BDDE
1995 IV

RCT: randomized controlled trial; NR: not report; T: treatment group; C: control group; BDD-YBOCS: Yale-Brown Obsessive Compulsive Scale Modified for BDD; BABS: Brown Assessment of Beliefs Scale; SDS: Sheehan
Disability Scale; BDDE: Body Dysmorphic Disorder Exam; BDI: Beck Depression Inventory; DSM: Diagnostic and Statistical Manual of Mental Disorders. UP: The unified protocol for the transdiagnostic treatment of
emotional disorders, which based CBT therapy.
F. Zhao et al. Journal of Affective Disorders 352 (2024) 237–249

Table 2
Characteristics of CBT treatment.
Study Intervention(T) Intervention(C) CBT implementer Intervention Pre-treatment Assessment time Follow-up Dropout rate (%)
specific method duration/ drug point time after (Lost /total (n))
Frequency/Total treatment/ treatment
times or time time

Wilhelm Computer- Waitlist Bachelor’s-level NR/NR/12 Yes/at least 2 Baseline/week 6 / 23 % (9/40) T

et al., 2022 delivered, coaches weeks months (mid-treat­ 8 % (3/40) C
guided app- ment)/week 12
based CBT (after treatment)
Ritter et al., Cognitive Waitlist CBT therapists / 50 or 100 min/ Yes/at least 2 Baseline/ post- 6 months 14 %(3/21)T
2023 Training (face- clinical weekly/ 12 months treatment/after 37 %(7/19)C
to-face) psychologists weeks treatment 3,6
months
Wilhelm Traditional CBT Supportive Doctoral− / 60 min/ 22 Yes/at least 3 Baseline/ post- 6 months Site A: Site B:
et al., 2019 (face to face Psychotherapy masters-level sessions/ 24 months treatment/after 18 % 36 %
sessions) therapists weeks treatment 3,6 (6/33) (10/
months T 19 % 28)T
(6/32) 19 %
C (5/27)
C
Mohajerina UP therapy Supportive Doctoral student 60 min/ 14 Yes/at least 2 Baseline/ post- 3 months 0%
et al., 2019 based on Psychotherapy of clinical sessions/ 5 months treatment/after
traditional CBT psychology months treatment 3
(face to face months
sessions)
Enander A tailored online Waitlist/ treatment Clinical NR/ interactive Yes/12 weeks Baseline/ post- 3 months 2 % (1/47) T
et al., 2016 platform (BDD- as usual psychology modules/ 12 treatment/after 4 %(2/47) C
NET) students weeks treatment 3
months
Mataix-Cols Traditional CBT psychoeducation Clinical 60–90 min/ 14 Yes/ 1 month Baseline/ post- 2 months 0 % (0/15) T
et al., 2015 (individual face +telephone psychologists Sessions/ 4 treatment/after 6 %(1/15) C
to face) monitoring months treatment 2
months
Wilhelm Traditional CBT Supportive therapy Post-doctoral-level 60 min/ weekly/ Yes/ 1 month Baseline/ post- 3 months 18 %(3/17) T
et al., 2014 (individual face psychologists 12 weeks treatment 21 %(4/19) C
to face)
Veale et al., Traditional CBT anxiety Therapists in 1 h/ weekly/ 16 Yes/ at least Baseline/ post- 1 month 10 % (2/21)T
2014 (individual face management clinical weeks (4 extra 12 weeks treatment/after 20 %(5/25)C
to face) psychology or treatments) treatment 1
accreditation month
Rabiei et al., Traditional CBT Supportive therapy Master’s degree 45–60 min/ Yes/ NR Baseline/ post- 4 months 0%
2012 (individual face clinical weekly/ 8 weeks treatment/after
to face) psychologist treatment 4
months
Veale et al., Traditional CBT Waitlist Cognitive NR/ 12 sessions/ NR Baseline/ post- NR NR
1996 (individual face behavior 12 weeks treatment
to face) therapists
Rosen et al., Group CBT (4–5 Waitlist Clinical 2 h/ weekly/ 10- NR Baseline/ post- NR 0%
1995 patients and one psychologist/ 12 weeks treatment
therapist) post-masters-level
graduate students

from Germany, Sweden, and Iran. Three studies were multicenter Compulsive Scale Modified for BDD (BDD-YBOCS) and Body Dysmor­
studies and seven studies (63.6 %) were registered. The baseline con­ phic Disorder Exam (BDDE) are the most commonly used indices for
ditions of patients in both the experimental and control groups were assessing BDD severity. All included studies assessed these measures.
generally similar, including factors such as sample size and age. How­ Seven studies used the BABS, and five studies used the Sheehan
ever, as BDD is more prevalent among women, most of the patients Disability Scale (SDS) to assess patients’ insights and beliefs. Mental
across all included studies were women, with female patients exceeding status was primarily assessed based on depression (10 studies) and
50 %. Most CBT treatments in the experimental group involved tradi­ anxiety (five studies). Five studies reported on patients’ quality of life,
tional individual face-to-face sessions, and one study used group ther­ including the Global Severity Index, Defectiveness/Shame, Difficulties
apy. Only two studies applied CBT using digital technology, such as an in Emotion Regulation Scale, Social Phobia Score, and Appearance
app or online application. Patients in the control groups were treated Evaluation Scale. Eight studies reported loss to follow-up, ranging from
using a waiting list (five studies), supportive psychotherapy (four 2 % to 37 %, and only three studies reported no loss to follow-up at the
studies), psychoeducation, or anxiety management. Most of the imple­ end of the intervention.
menters of CBT were clinical psychologists, but there were also psy­
chology students (four studies). The frequency of the CBT intervention
was mostly weekly, the intervention time was mostly 12 weeks, and the 3.3. Quality evaluation
follow-up time was 1–6 months. It is worth noting that nine studies
(81.8 %) reported that patients had a stable mental state or took Fig. 2 shows the quality assessment of the included studies using the
medication for at least 1–3 months before receiving CBT intervention, Cochrane RoB 2.0. Among the 11 included RCTs, only three (27.3 %)
suggesting that psychotherapy is more effective when emotional sta­ studies mentioned “random,” but did not describe the random method in
bility and cognitive function are intact. The Yale-Brown Obsessive detail, and were judged as “uncertain risks” in random sequence gen­
eration. Other studies used methods such as computers for

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Fig. 2. Risk of bias of the included studies by Cochrane RoB2.0 tool. A. risk of bias graph; B. risk of bias summary.

randomization and were assessed as low-risk; only two studies (18.2 %) interventions received by the participants. This suggests that, owing to
reported allocation concealment; baseline information was consistent the particularity of clinical trial implementation, it is difficult to blind
across most studies (90.9 %); however, in all studies, the patients knew participants or intervention implementers. Eight studies reported loss to
or probably knew the experimental grouping, and in one study, the follow-up and incomplete data, and the loss-to-follow-up rate of one
experimental participants did not know the grouping situation. Nine study was >15 %. However, all 11 RCTs assessed the risk of bias as low.
studies reported that outcome assessors were unaware of the Two studies were assessed as high risk in “Deviations from intended

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interventions” and “Measurement of the outcome,” respectively, both of compulsive behavior was alleviated. In addition, the results of the sub­
which were published before 2014. In the assessment of selective group analysis by time point showed that after 12 weeks of CBT treat­
reporting bias, three studies were categorized as low risk, and the others ment, the BDD severity values in the experimental group were
as uncertain risk. In terms of overall risk, three studies were categorized significantly decreased, and the difference between the groups was
as high risk, and the others as some concerns regarding risk/uncertain statistically significant (SMD = − 1.51, 95 % CI = [− 2.81; − 0.21]).
risk. However, the effect was not significant after three months of follow-up
(SMD = − 2.30, 95 % CI = [− 4.98, 0.37]).
3.4. Response and remission of BDD Seven studies all used the BABS to assess patients’ delusional
severity. This semi-structured, clinician-administered interview assesses
Compulsive behaviors, such as repeatedly looking at the mirror and delusional thinking related to appearance concerns. It contains seven
trying on clothes, are symptoms most often experienced by people with items, and the first six items are summed to generate a total score (range:
BDD. The Yale Brown Obsessive-Compulsive Scale modified for BDD 0–24). Higher scores indicate greater delusionality. The meta-analysis
(BDD-YBOCS) is a validated, 12-item, semi-structured interview widely results showed that after CBT treatment, the delusional level of pa­
administered to measure BDD symptom severity. The scores range from tients in the experimental group statistically reduced (MD = − 5.17, 95
0 to 48, with higher scores indicating greater severity (Phillips et al., % CI = [− 8.23; − 2.10], p < 0.01; heterogeneity I2 = 98 %). The results
1997). In the DSM-V, a BDD-YBOCS score of >20 can be used to assess of the subgroup analysis showed that the degree of BABS reduction after
the severity of BDD. Response to BDD means that the score of BDD- 12 weeks of CBT was better than that after three months of follow-up
YBOCS scale at the end of treatment is reduced by >30 % of the base­ (Fig. 4B).
line evaluation value before treatment, and remission of BDD means that
the score of BDD-YBOCS scale at the end of treatment is ≤16. Four 3.6. Depression and anxiety
studies with five sets of data, and three studies reported BDD responses
and remissions. The results of the meta-analysis showed that after CBT Fig. 5 shows the results of meta-analysis of the mental states of pa­
intervention, the remission of BDD (OR = 7.37, 95 % CI = [2.17; 24.98], tients with BDD. Fifteen sets of data from 11 studies reported the degree
p < 0.01; heterogeneity I2 = 59.3 %) and response to BDD (OR = 8.86, of depression in patients at two time points. However, the scales used to
95 % CI = [4.85; 16.18], p < 0.01; heterogeneity I2 = 5 %) in the assess depression in these studies were different, and SMD values were
experimental group were higher than those in the control group, and the used to combine the effect sizes. The results showed that after CBT
differences between the groups were statistically significant (Fig. 3). treatment, the degree of depression in the experimental group was
NR: not report; T: treatment group; C: control group; UP: The unified alleviated, and the difference between the groups was statistically sig­
protocol based on CBT therapy. nificant (SMD = − 1.72, 95 % CI = [− 3.16; − 0.28], p < 0.01; hetero­
geneity I2 = 97 %). Subgroup analysis suggested that the greatest
3.5. BDD-YBOCS/BDDE and BABS change value reduction in depression occurred after 12 weeks of CBT treatment. In
addition, five groups of data from four studies reported anxiety. Sub­
The BDD-YBOCS scale had satisfactory psychometric properties, and group analysis based on different assessment scales showed that after
the internal consistency in the current study was high, with a Cronbach’s CBT treatment, the anxiety level of BDD patients in the experimental
alpha of 0.85 (Rabiei et al., 2009). Therefore, the severity of BDD could group decreased, but the difference between groups was not statistically
be effectively assessed. Thirteen groups of data from 11 RCTs included significant (SMD = − 3.11, 95 % CI = [− 6.49; 0.28], p > 0.05; hetero­
reported BDD-YBOCS or BDDE scores. Further analysis of changes in geneity I2 = 98 %).
BDD severity before and after treatment can indicate the degree of relief
from obsessive-compulsive behavior in patients. As shown in Fig. 4A, the 3.7. Disability (SDS) and quality of life
meta-analysis results indicated that, compared with the control group,
the BDD severity score of the experimental group decreased after CBT There were five studies (including six sets of data), and six studies
treatment, and the difference between the groups was statistically sig­ (including seven sets of data) reported on patients’ disabled cognition
nificant (SMD = − 1.73, 95 % CI = [− 2.90; − 0.57], p < 0.01; hetero­ and quality of life (QoL). The Sheehan Disability Scale (SDS) is a self-
geneity I2 = 96.3 %). This indicates that the patients’ obsessive- rated, 3-item questionnaire that uses a Likert scale from 0 (not at all)

Fig. 3. Meta-analysis of remission and response in BDD after CBT treatment. A. remission of BDD; B. response in BDD.

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Fig. 4. Meta-analysis of obsessive compulsive scale and insight scale of BDD patients. A. BDD-YBOCS/BDDE; B. Brown Assessment of Beliefs Scale (BABS).

to 10 (extremely) to assess impairment in the occupational, social, and reporting biases of the included studies. This study made funnel plots
family domains. The three items are summed to obtain a total score were created with the labels of each study for the results of the three
(range: 0–30), with higher scores indicating greater functional impair­ meta-analyses to discover the characteristics of each study more intui­
ment. The results of the meta-analysis indicated that after CBT, the pa­ tively (Fig. 7). Combined with the additional contour line funnel dia­
tients in the experimental group had less cognition of their own gram after the cut-and-fill method (Fig. 7A) (Peters et al., 2008), the
disability (SMD = 0.27, 95 % CI = [− 0.33; 0.86]) and improved their funnel plot of the meta-analysis of BDD-YBOCS/BDDE scale was clearly
quality of life (SMD = 1.05, 95 % CI = [− 0.03;3.63]). There were no asymmetrical, and eight missing studies needed to be supplemented (the
significant differences between the groups (p > 0.01) (shown in Fig. 6). studies marked “Filled” in front). However, the two studies (Wilhelm
et al., 2019; Wilhelm et al., 2014) were distributed in a non-statistically
significant area (white area), and the others were distributed in a sta­
3.8. Funnel plot
tistically significant region (green region), indicating that there were no
statistically significant studies that have not been published, suggesting
The funnel plot visually displays the publication and selective

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Fig. 5. Meta-analysis of depression and anxiety of BDD patients after CBT treatment. A. Depression; B. Anxiety.

that there was publication bias in this meta-analysis. which showed that the heterogeneity was mainly due to this study.
The funnel plot of the meta-analysis of the BABS was asymmetrical,
and five missing studies needed to be supplemented. Two studies (Wil­ 3.10. Meta-regression analysis
helm et al., 2019; Wilhelm et al., 2014) were distributed in a non-
statistically significant area, suggesting that there was also publication Univariate meta-regression analyses were conducted for the re­
bias in this meta-analysis. The funnel plot of the meta-analysis of lationships between degree of obsessive-compulsive disorder (BDD
depression was also asymmetrical, and four data (Wilhelm et al., 2019; severity), BDD insight, depression, and various variables. As shown in
Wilhelm et al., 2014; Veale et al., 2014) were distributed in a non- Table 3, the relationship between BDD severity and several independent
statistically significant area, suggesting that these studies had a publi­ variables revealed that the impact of the BDD score was influenced by
cation bias. Simultaneously, the Egger test results suggested that the p- two factors: sample size and age (p all<0.05). Additionally, none of the
values of the BDD-YBOCS, BABS, and depression scales were all <0.05, other regressors investigated were predictive of changes in BDD severity
indicating publication bias. Plots of the Egger test shown in the Sup­ across studies. Similarly, the sample size also influenced response rate to
plementary Figures. self-beliefs and depression. Factors such as female rate, specific CBT
intervention (i-CBT or traditional CBT), control group intervention
3.9. Sensitivity analysis strategy (psychoeducation, supportive psychotherapy, waiting list),
specific assessment scales, and assessment time points did not affect BDD
The heterogeneity in the majority of meta-analysis results was high severity, BDD insight, and depression in patients. We also did not find
(all >50 %) and was not reduced after effect model transformation and evidence that any of the other moderators affected the strength of these
subgroup analysis. This suggests that the observed heterogeneity is not associations. Regression bubble plots of sample size versus BDD severity,
solely attributable to statistical methods. In this study, sensitivity anal­ BDD insight, and depression are shown in Supplementary Fig. 3.
ysis was used to evaluate the stability of the meta-analysis results by
eliminating the included studies individually (Supplementary Fig. 1). In 4. Discussion
the meta-analysis of the BDD-YBOCS, BABS, depression, and anxiety,
heterogeneity did not significantly change after excluding the study, Owing to the high suicide rate associated with BDD and other risks,
which validated the rationality and reliability of our analysis. However, seeking effective treatment methods for BDD has been the focus of
in a meta-analysis of disability and QoL, the heterogeneity decreased research for many years (Phillips et al., 2005). Although some studies
greatly, even to 0 %, after removing the studies (Enander et al., 2016), have reported that CBT is effective in treating BDD because of the

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Fig. 6. Meta-analysis of other outcomes of BDD patients after CBT treatment. A. Disability Scale; B. Quality of Life (QoL).

limited implementation associated with this form of therapy, there are Comparison between the two groups also showed that the experimental
few RCT on the treatment of BDD with CBT, and the relevant research group performed better than the control group. In a naturalistic 4-year
evidence is limited. It is well known that systematic reviews/meta- prospective follow-up study of 166 patients with BDD, the cumulative
analyses based on RCT studies are the highest level of research evi­ probability of full remission was 0.20 (Phillips et al., 2013). This
dence. After searching, we found that three meta-analyses on CBT possibly means that CBT is superior to generic psychological treatment;
treatment for BDD were published in 2009 and 2016, respectively (Ipser however, additional trials are needed to test the specificity of CBT for
et al., 2009; Harrison et al., 2016; Phillipou et al., 2016), including only BDD. These results are superior to those of previous studies, and provide
three, five, and seven RCTs that met the inclusion criteria. However, strong evidence for the effectiveness and superiority of CBT in treating
these studies only evaluated the effects of CBT and/or combination BDD.
therapy. Only one meta-analysis evaluated the effect of CBT alone in the It should be noted that in the study Mohajerin B 2019, the inter­
treatment of BDD, but the included studies have small sample sizes. For vention measures were the “unified standard” for the transdiagnostic
example, in the latest meta-analysis, seven included RCTs included a treatment of emotional disorders (UP), which based on CBT therapy. The
total of 299 patients (Harrison et al., 2016). The meta-analysis results CBT for BDD typically involves a technique known as exposure and
showed that CBT was superior to waitlists or credible psychological response prevention (ERP), which aims to decrease mirror checking,
placebo in reducing BDD (MD = − 1.22, 95 % CI [− 1.66, − 0.79]) and camouflaging, and other compulsive behaviors. ERP often accompanied
depressive symptoms (MD = − 0.49, 95 % CI [− 0.76, − 0.22]. Simulta­ by cognitive restructuring to challenge dysfunctional beliefs, which are
neously, CBT was associated with improvements in insight/delusion­ both common components of traditional CBT. And CBT for emotional
ality (MD = − 0.56, 95 % CI [− 0.93, − 0.19]). However, the meta- disorders typically involves a combination of cognitive therapy and
regression analyses did not reveal any significant predictors of out­ behavioral therapy. Cognitive therapy focuses on identifying and
comes. To date, this is the only secondary evaluation of the use of CBT changing negative thought patterns, while behavioral therapy focuses
alone in the treatment of BDD. on changing negative behaviors and increasing positive behaviors. Thus,
In this meta-analysis, the response and remission of BBD, BDD although the “Unified Protocol” (UP) reduces ERP, other parts of CBT
severity (BDD-YBOCS, BDDE), BDD insight/cognition (BABS, disability), therapy still work. Since BDD is often accompanied by high levels of
depressive symptoms, anxiety levels, and quality of life in patients with depression and other “mood disorder” features, UP therapy would be
BDD were assessed. The results suggested that whether at the end of the more effective. The results of this Meta-analysis indeed proved that as
12-week CBT treatment or after three months of follow-up, the severity long as psychological intervention, which is based on CBT treatment, is
of BDD, depression, and anxiety levels of the patients were all reduced. effective for BDD.
In terms of self-cognition of the patients, incorrect beliefs such as However, in terms of the quality evaluation of the included studies,
disability and BABS were also reduced, and the quality of life was the results of this study differed from those of the previous studies. In
improved. The combined effect values were much statistically higher this study, included earlier studies (earlier than 2014) had a high risk of
than those in a previous study. Moreover, remission and response to BBD bias, especially with respect to blinding of participants, implementers
showed significant differences between the two groups. The BDD and outcome assessors, and “measurement of the outcome.” However, in
response and remission rates in the experimental group were both >50 Harrison et al. (2016), these studies had a low or uncertain risk. In
% (up to 84.8 %), whereas in another study, the response and remission addition, in terms of selective reporting bias, the evaluation results of a
rates in the control group did not exceed 14 %. In Wilhelm et al. (2019), previous study showed that all included studies were at a low risk.
although the response and remission rates of the control group reached However, in this study, most risks were uncertain. The results of the
40 %, they were still lower than those of the experimental group. funnel plot (Fig. 7) also suggested that at least three studies (Wilhelm

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Fig. 7. Funnel plots of the meta-analysis. A. Funnel plots of BDD-YBOCS; B. Funnel plots of BABS; C. Funnel plots of depression.

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Table 3
The results of meta-regression.
BDD severity (BDD-YBOCS/BDDE) BDD insight (BABS) Depression

Patients characteristics Estimate (SE) 95%CI p Estimate (SE) 95%CI p Estimate (SE) 95%CI p

Age 0.25(0.10) 0.05 to 0.46 0.0153* 0.28(0.29) − 0.28 to 0.84 0.3203 0.27(0.14) − 0.01 to 0.55 0.0631
Female rate 4.24(3.43) − 2.47 to 10.96 0.2154 19.45(11.16) − 2.42 to 41.31 0.0814 4.00(5.01) − 5.82 to 13.81 0.4246
Sample size − 0.04(0.01) − 0.07 to − 0.02 0.0018** − 0.12(0.03) − 0.17 to − 0.06 <0.0001*** − 0.06(0.02) − 0.09 to − 0.02 0.0014**
Intervention methods
i-CBT − 2.30(2.95) − 8.08 to 3.48 0.4356 – – – – – –
Traditional-CBT − 3.02(2.65) − 8.20 to 2.17 0.2538 0.38(5.65) − 10.70 to 11.46 0.9466 − 1.36(1.87) − 5.01 to 2.30 0.4663
Control methods
psychoeducation − 4.39(3.54) − 11.33 to 2.55 0.2148 − 1.01(8.66) − 17.99 to 15.97 0.9072 − 4.02(3.63) − 11.15 to 3.10 0.2685
Supportive − 1.45(2.58) − 6.51 to 3.61 0.5747 − 0.95(6.67) − 14.03 to 12.12 0.8862 − 2.06(2.34) − 6.66 to 2.53 0.3788
Psychotherapy
Waitlist 0.23(2.62) − 4.90 to 5.36 0.9312 0.06(7.60) − 14.84 to 14.96 0.9936 − 0.29(2.44) − 5.08 to 4.50 0.9059
Assessment time point
End of treatment 0.78(1.35) − 1.87 to 3.43 0.5635 1.45(3.65) − 5.71 to 8.60 0.6922 0.70(1.71) − 2.66 to 4.06 0.6844
Assessment scales
BDDE 3.11(1.79) − 0.39 to 6.61 0.0817 – – – – – –
BDD-YBOCS 2.57(1.29) − 5.82 to 0.24 0.0623 – – – – – –
BDI-II – – – – – – 1.58(3.29) − 4.87 to 8.03 0.6304
BDI-Y – – – – – – − 1.96(3.34) − 8.51 to 4.60 0.5587
MADRS – – – – – – 1.96(1.92) − 1.81 to 5.73 0.3080
QIDS – – – – – – 1.80(2.46) − 3.03 to 6.62 0.4656

*** p < 0.001 ** p < 0.01 * p < 0.05; SE: Standard Error; i-CBT: internet CBT; BABS: Brown Assessment of Beliefs Scale; BDDE: Body Dysmorphic Disorder Exam; BDD-
YBOCS: Yale-Brown Obsessive Compulsive Scale Modified for BDD; BDI: Beck Depression Inventory; MADRS: Montgomery-Åsberg Depression Rating Scale; QIDS:
Quick Inventory of Depressive Symptomatology; − : not applicable.

et al., 2019; Wilhelm et al., 2014; Veale et al., 2014) had publication 5. Conclusion
bias.
Simultaneously, in the meta-analysis results, the heterogeneities of According to current evidence, CBT is an efficacious treatment for
most outcome measures were relatively high (>75 %) and did not BDD, but there is substantial room for improvement. The specificity and
decrease after using the random effects model and subgroup analysis. long-term effects of CBT on BDD require further evaluation under reli­
However, sensitivity analysis showed that the stability of the meta- able control conditions. Additional trials comparing CBT with pharma­
analysis results did not change significantly. This means that the het­ cological therapies and their combination are warranted. Telecare
erogeneity was derived from clinical heterogeneity, which may be options, such as Internet-based CBT, hold great promise for increasing
related to (1) the different scales used to assess depression, (2) in­ access to evidence-based treatment for the majority of patients who need
consistencies in the specific methods and time of CBT intervention, and it and should be evaluated further.
(3) individual differences among the patients. Supplementary data to this article can be found online at https://doi.
In addition, the results of the meta-regression analysis were mean­ org/10.1016/j.jad.2024.02.004.
ingful. Patient age and sample size were factors in BDD treatment effi­
cacy; however, sex (e.g., female ratio) was not a predictor. Traditional Funding
and Internet-based CBT were equally effective, and the different in­
terventions received by the control group appeared to have no impact on This study was supported by the National Natural Science Founda­
outcome measures. Whether it was a waiting list, supportive psycho­ tion of China (NSFC) (81860716); the Natural Science Foundation of
therapy, or simple psychoeducation had little impact on the therapeutic Gansu Province (22JR11RA237); the Fundamental Research Funds for
effects of CBT. The assessment scale and time point were not predictors the Central Universities of Northwest Minzu University (31920230067).
of BDD treatment efficacy. The regression results also suggest that these
factors were not sources of heterogeneity. CRediT authorship contribution statement
It should be noted that traditional CBT treatment lasts for at least
three months, with face-to-face interviews or conversations once a week, Fei Zhao: Writing – original draft, Software, Methodology, Funding
which greatly limits the intervention venue and personnel arrange­ acquisition, Data curation. Zhong Guo: Formal analysis, Data curation.
ments. The rise of modern emerging technologies, such as Internet Yan Bo: Methodology, Data curation. LiJuan Feng: Writing – review &
networks and mobile phone applications, can help solve the above dif­ editing, Supervision, Methodology. Jin Zhao: Writing – review & edit­
ficulties of CBT implementation (Gentile et al., 2019; Wilhelm et al., ing, Supervision, Conceptualization.
2020a, b). Unfortunately, among the included studies, only two reported
CBT interventions using digital technology (Wilhelm et al., 2022; Declaration of competing interest
Enander et al., 2016), and the effect was similar to that of traditional
CBT treatment. All authors declare no conflict of interest with this work.
Although more RCTs on CBT treatment of BDD have been published
since 2016, and the quality has generally improved (the overall bias was Acknowledgements
uncertain risk), the overall study evidence is still very limited. Currently,
we cannot obtain high-quality study evidence for the analysis. This is a We want to thank all the participants, researchers for their efforts in
limitation of the present study. Similarly, we cannot conclude that CBT this study.
is the most effective psychotherapy for BDD, only that it is effective for
BDD. It is suggested that large-sample, high-quality RCTs of CBT
compared with other therapies are needed to provide more real research
evidence in the future.

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