Advancing Psychosocial Treatment for Body Dysmorphic Disorder (BDD): A state-of-the-science review

Introduction

Body dysmorphic disorder (BDD) is an underrecognized psychiatric illness characterized by a preoccupation with perceived defects in one’s appearance and ritualistic behaviors or mental acts in response to these concerns, often leading to significant distress or impairment in functioning (American Psychiatric Association & Association, 2013). BDD preoccupations are commonly centered around the face, skin, hair, or nose, and the related repetitive behaviors involve excessive grooming, camouflage of perceived flaws, skin picking, or cosmetic surgery (Phillips, Didie, et al., 2006; Samad et al., 2021).

The estimated prevalence of BDD in the general population is 1.7–2.9% (Koran et al., 2008; Rief et al., 2006; Schieber et al., 2015), with women comprising a slightly higher proportion of those affected (Veale et al., 2016; Zimmerman & Mattia, 1998). BDD typically develops gradually, with adolescence being the most common age for its onset (Bjornsson et al., 2013; Malcolm et al., 2021). BDD is distinguished from eating disorders in that eating behavior and weight are in the normal range among these individuals. However, the illness may occur alongside an eating disorder or other mental health problems such as major depressive, substance use, social anxiety, and obsessive-compulsive disorder(s) (Phillips & Kelly, 2020). In addition to these comorbidities, across the lifetime, 78-81% of individuals with BDD experience suicidal ideation, and 24-28% attempt suicide (Phillips, 2007).

BDD is underdiagnosed, and most affected individuals do not receive appropriate treatment (Marques et al., 2011; Schulte et al., 2020). This is partly because many mental health professionals lack training in and knowledge of BDD(Veale et al., 2016). It is also because roughly one-third of individuals with BDD lack insight into their difficulties or experience delusional beliefs, which they attribute to objective physical flaws rather than being psychological in origin (Phillips & Kelly, 2020; Phillips et al., 2005). Accordingly, up to 76% of people with BDD initially seek non-psychiatric treatments for their appearance-related concerns (Crerand et al., 2010), with evidence suggesting that the prevalence of BDD in general cosmetic surgery is approximately 13.2% and 20% in rhinoplasty surgery (Veale et al., 2016). Individuals with BDD are rarely satisfied with cosmetic surgery results and can develop increased distress over the modified body part or preoccupations with different aspects of their appearance (Crerand et al., 2010; Tignol et al., 2007). Additional barriers to treatment include shame, stigma, and skepticism of psychological therapies (Schulte et al., 2020). Left untreated, BDD-related avoidance and compulsions can disrupt social, occupational, or role functioning, leading to poor quality of life and social isolation (Kelly et al., 2017; Phillips, Pagano, et al., 2006).

Evidence-based psychological or pharmacological intervention is needed to prevent or reduce such outcomes. The recommended first-line psychological treatment for BDD is cognitive behavioral therapy (CBT) (Castle et al., 2021). CBT for BDD is tailored to address the complex symptoms of this disorder, offering structured sessions to challenge dysfunctional beliefs about appearance while integrating exposure and response prevention techniques (Veale & Neziroglu, 2010; Wilhelm et al., 2010; Wilhelm et al., 2012). In comparison to CBT for other disorders like social anxiety disorder or OCD BDD (Berman et al., 2016; Heimberg, 2002), CBT for BDD focusses on appearance-related beliefs (which are often delusional) using cognitive restructuring and motivational strategies, and addresses behaviors specific to BDD such as mirror checking (Veale & Neziroglu, 2010; Wilhelm et al., 2011; Wilhelm et al., 2012). Pharmacologically the primary form of treatment is serotonin reuptake inhibitors (SSRIs) (Castle et al., 2021). Together psychological and pharmacological interventions represent a comprehensive, integrated approach that may be necessary for individuals affected by this challenging illness.

The primary objective of this State of Science review (see Comer, this issue) review is to provide an overview of the present knowledge about psychosocial treatments for BDD (Comer, this issue). We describe CBT’s theoretical and conceptual underpinnings for BDD and then discuss the available treatments, areas of innovation such as technology-based interventions, as well as potential mechanisms of change, and predictors of treatment response. Particular attention is devoted to treatment disparities in traditionally underserved populations and considerations for cultural adaptation of available interventions. Finally, based on the existing gaps in treatment, we offer suggestions for future research to encourage treatment development, dissemination, and implementation.

Conceptual and Theoretical Underpinnings of Treatment for BDD

Multiple cognitive-behavioral theories have been proposed to explain the development and maintenance of BDD symptoms (Fang & Wilhelm, 2015; Veale, 2010; Wilhelm et al., 2010). These theories emphasize that individuals with BDD exhibit a distinctive reaction to their perceived appearance flaws – characterized by selective attention to the body part(s) of concern and appearance-related assumptions and biases that prompt intense negative emotions such as shame, self-loathing, humiliation, and disgust. To manage the challenging emotions, individuals with BDD engage in maladaptive coping strategies, including avoidance (e.g., social withdrawal), ritualistic (e.g., mirror-checking), and safety (e.g., camouflaging body part of concern) behaviors (Fang & Wilhelm, 2015; Summers & Cougle, 2018). These strategies may temporarily reduce distress, but long-term they can exacerbate symptoms because they prevent individuals from recognizing that abstaining from these rituals or confronting avoided situations does not result in feared consequences (Wilhelm et al., 2012). The CBT for BDD model draws upon research highlighting attention and interpretive biases and impaired visual processing as factors contributing to BDD maintenance. The following sections discuss recent advancements in these areas and their implications for treatment strategies.

Selective attention and aberrant visual scanning

Individuals with BDD demonstrate an attentional bias towards their perceived flaws. Specifically, they tend to focus intensely on distinct features such as the eyes, nose, or mouth (local processing – focusing on specific, small-scale details rather than overall picture) at the expense of considering their facial features or body as a whole (global or holistic processing – attending to overall features and broad organizational aspects of a complex figure) (Beilharz et al., 2017; J. Feusner, H. Moller, et al., 2010; Johnson et al., 2018; Kerwin et al., 2014). This tendency for local processing leads to self-focused attention, characterized by individuals’ examination of perceived flaws in the mirror or another reflective surface (Greenberg et al., 2014; Grocholewski et al., 2012; Windheim et al., 2011), but also reflects underlying neural dynamics. Individuals with BDD exhibit impairments in brain connectivity related to visual processing, particularly in balancing global versus detailed information (Li et al., 2015; Wong et al., 2022; Wong et al., 2021). This neural predisposition towards focusing on specific details, at the expense of the overall image, is at the core of the distorted self-perceptions observed in BDD (Feusner et al., 2011; J. D. Feusner et al., 2010). This tendency extends beyond mere perception, influencing cognitive processes as well. Cognitive models of BDD, supported by research evidence, indicate that faced with ambiguous or neutral situations requiring interpretation – such as observing someone glancing at them – individuals with BDD are prone to negative, appearance-related interpretations, which in turn escalate their distress (Buhlmann et al., 2002; Fang & Wilhelm, 2015). Such findings suggest the need for interventions targeting these atypical visual patterns through strategies designed to enhance holistic perception and reduce flaw and detail-focused rumination.

Early eye movement tracking studies demonstrated that BDD individuals selectively attended to disliked aspects of their own faces and the corresponding regions in other people’s faces, emphasizing disruptions in holistic processing (Greenberg et al., 2014; Grocholewski et al., 2012). More recent studies have suggested that when looking at others’ faces, individuals with BDD showed less interest in the details of the face, particularly the eyes, nose, and mouth (Toh et al., 2015) and focused on others’ self-rated attractive features while neglecting their own self-rated attractive features (Kollei et al., 2017). This finding suggests encouraging patients to refrain from visual social comparisons may be a useful treatment strategy. Additionally, when looking at their own photograph, some fixated excessively on their perceived problem areas, while others adopted avoidance scanning behaviors, suggesting a range of processing differences within BDD clinical samples (Toh et al., 2017). Interestingly, participants with BDD focused longer on others' faces than their own, suggesting limited abilities in scanning their own faces. Recognizing BDD individuals' visual hyperfixation or avoidance can be valuable in treatment, especially when perceptual retraining exercises are incorporated.

Facial expression studies have revealed that individuals with BDD tend to interpret negative emotions in ways that distort reality, further entrenching their beliefs over appearance-related flaws and fears of social rejection (Buhlmann et al., 2006; Buhlmann et al., 2004; J. Feusner, A. Bystritsky, et al., 2010). Complementing these findings, recent eye-tracking studies indicate that those with BDD demonstrate reduced accuracy and speed when identifying emotions such as anger, neutrality, or sadness, although these difficulties were not directly correlated with the severity of their symptoms (Grace et al., 2019). Relatedly, studies in female, non-clinical samples suggest that prolonged gazing – episodes lasting 5 minutes or more – can lead to greater dissociation and lower attractiveness ratings of the observed face (Möllmann et al., 2019; Möllmann et al., 2020). Increased gazing-induced dissociation is presumed to interfere with accurate processing and perception of stimuli, indicating that prolonged gazing during mirror checking or related rituals may negatively influence how individuals with BDD perceive their own attractiveness. Some early evidence suggests altering eye-gaze behaviors may influence the balance between global and local processing – offering the potential for translational research in perceptual retraining (Wong et al., 2022).

Interpretive biases

According to the CBT model, selective attention biases, aberrant visual processing, and deficits in emotion recognition contribute to negative interpretive biases (Dietel et al., 2018; Fang & Wilhelm, 2015; Summers et al., 2021). Negative self-evaluations of physical appearance are a core feature of BDD that can contribute to low self-esteem. Low self-esteem among individuals with BDD is correlated with symptom severity and a common treatment target in BDD treatment (Kuck et al., 2021; Wilhelm et al., 2012). It is hypothesized that biased information processing intensifies negative appearance-related thoughts.

Support for this hypothesis comes from findings that individuals with BDD are more prone to interpreting appearance-related situations negatively, exhibiting a significant bias towards negative appearance-related interpretations when compared to social and generalized anxiety disorders (Dietel et al., 2021). Further studies reveal that individuals with BDD exhibit strong automatic associations linking "attractive" with "competent" and "self" with "bad" on the Implicit Association Test (Buhlmann et al., 2009; Windheim et al., 2011). These associations reflect maladaptive core beliefs, predicting symptom severity and distress during mirror-checking rituals (Buhlmann et al., 2009; Windheim et al., 2011). Interpretation biases and related maladaptive coping mechanisms such as mirror-checking and avoidance have been shown to, in turn, further increase sadness, anger, and negative body-related cognitions (Kollei & Martin, 2014), as well as self-focused attention (Windheim et al., 2011). As such, these interpretation biases are important targets for intervention that can be addressed through cognitive restructuring and exposure exercises that aim to confront and gradually reduce these biases.

CBT for BDD Treatment Components

Based on the aforementioned research, the core treatment components of CBT for BDD includes psychoeducation, cognitive restructuring, exposure and ritual prevention (ERP), mindfulness and perceptual retraining, and relapse prevention (Wilhelm et al., 2011). Psychoeducation and case formulation involve developing a CBT model tailored to the individual's specific BDD symptoms and exploring potential factors that maintain one’s symptoms. Cognitive restructuring is designed to help individuals work on deeper level core beliefs that may contribute to low self-esteem and shame as well as step back from their thoughts and consider another perspective by identifying and challenging these beliefs and interpretation biases. ERP, designed to address ritualistic, safety, and avoidance behaviors, involves setting specific behavioral goals and entering anxiety-provoking or feared situations while abstaining from appearance-related safety behaviors and rituals. Mindfulness and perceptual training aim to counter global processing deficits and selective attention to perceived flaws. Within this regard, mirror retraining, designed to address individuals' conflicted relationship with mirrors and reflective surfaces, involves instructing individuals, during self-observation in front of a mirror, to nonjudgmentally and holistically (e.g., viewing the body as a whole) describe their body beyond the perceived flaws. Retraining also entails encouraging individuals to shift their attention during social interactions so that they learn to pay attention to other aspects of appearance, nonappearance characteristics, and their environmental surroundings. All CBT for BDD participants develop a relapse prevention plan, which may include identifying triggers or listing treatment strategies to facilitate the maintenance of treatment gains (Wilhelm et al., 2011). Additional therapeutic techniques include motivational interviewing and flexible modules such as habit reversal training (e.g., identifying triggers and implementing alternative responses to replace problematic behaviors) (Greenberg, Blashill, et al., 2016), which are designed to address common co-occurring concerns in BDD (e.g., skin picking/hair plucking, depression, surgery-seeking).

Research and Supporting Evidence

This section describes findings and recent advancements in BDD treatment. First, we review studies examining the effectiveness of CBT for adults and children/adolescents; then, we review evidence on Internet and smartphone-based interventions, as well as emerging approaches (Table 1). Finally, we discuss mechanisms of change and predictors of treatment response in BDD patients.

Table 1.

Available Psychosocial Treatments for BDD

Study	Sample size (n)	Trial design	Treatment Length	Follow Up Period	Primary Outcome Measure	Main Findings*	Statistical Test	Effect Size*	P Value
Cognitive Behavioral Therapy (CBT) for Adults
Rosen et al. (1995)	54	RCT: Group CBT for BDD w/ ERP vs. WLC	8-12 weekly sessions	4.5 months	BDDE	Reductions in BDDE scores were significantly greater in the CBT group (m=41.1, SD = 16.9) at posttreatment than control (m=83.2, SD=19.7) 100% of participants (n=54) attended all 8 sessions; on average participants completed 86% of homework assignments 81.5% (n=22/26) of CBT participants were considered clinically improved at posttreatment and 76.9% (n=20/26) at follow-up	ANCOVA	NR	0.000
Veale et al. (1996)	19	RCT: Individual CBT vs. WLC	12 weekly sessions	No follow-up	BDDE	Average BDDE was 72.90 (SD=17.04) at baseline and 42.37 (SD=25.20) at endpoint for CBT group, compared to 91.36 (SD=29.75) at baseline and 95.50 (SD=11.41) at endpoint for WLCs 7 out of 9 CBT participants had absent or subclinical BDD at the end of the trial, compared to 0 of the WLC participants	Wilcoxin	NR	< 0.02
Rabiei et al. (2012)	20	RCT: MCT vs. WLC	8 weekly sessions	6 months	BDD-YBOCS	MCT participants improved on BDD-YBOCS pre- to posttreatment to follow-up while control participants did not No participants dropped out of the study; the mean # of sessions attended was 6 (2 participants missed 2 sessions) 70% of participants in MCT had BDD-YBOCS <= 20 at posttreatment compared to 0% in WLC; at follow-up, these rates were 60% and 0%, respectively	ANOVA	d=0.33	< 0.005
Wilhelm et al. (2014)	36	RCT: Individual CBT vs. WLC	22 sessions over 24 weeks (or 12-week waitlist)	3-, 6-months	BDD-YBOCS	BDD-YBOCS scores decreased from baseline to posttreatment (week 24) By posttreatment, 81% (n=26/32) in the intention-to-treat sample were treatment responders, 83% of treatment completers (and 81% of ITT sample) were responders at posttreatment CBT participants maintained gains throughout the 6-month follow-up period	T-test, pooled variance	d=2.1	<0.0001
Veale et al. (2014)	46	RCT: Individual CBT vs. Anxiety Management (AM)	12 weekly sessions + 4 additional weekly sessions	1 month	BDD-YBOCS	CBT participants showed greater reductions in BDD-YBOCS scores over time compared to AM participants 48% (n=10/21) of CBT participants were responders at posttreatment (12 sessions) compared to 12% (3/25) of AM participants; at follow-up, 100% of responders in both groups had maintained gains 52% of CBT participants were responders after 16 sessions	LMM	d=0.99	<0.01
Veale et al. (2015)	30	Longitudinal follow-up/naturalistic case series of Veale et al. (2014)	16 weekly sessions	1-4 years	BDD-YBOCS	Baseline to long-term follow-up (1-4 years after CBT completion) BDD-YBOCS reduction was significant, and week 16 (posttreatment) to follow-up BDD-YBOCS reduction was not significant (p = .964), showing maintenance of treatment gains At long-term follow-up, a slight decrease in the # of participants meeting the improvement criteria (30% decrease in BDD-YBOCS scores) was observed, from 51.3% (n=20) at week 16 to 46.2% (n=18).	Wilcoxin	d=2.52	<0.001
Wilhelm et al. (2019)	120	RCT: Individual CBT vs. SPT	24 weekly sessions, treatment responders received 2 booster sessions 1-/3-months after treatment	3-, 6-months	BBD-YBOCS	Across two different sites, there was a significant group x time interaction at only one of two sites, such that CBT participants showed greater reductions in BDD-YBOCS scores than SPT participants (Site 1: estimated mean (SE) slopes −18.6 (2.2) vs. −7.6 (2.0), p <.001 vs. Site 2: (−18.6 (1.9) vs. −16.7 (1.9), p = .48) Completers (n=48/59) attended an average of 21.1 (SD=2.0) CBT-BDD sessions and 20.5 (SD=2.2) SPT sessions 85% of CBT group responded at posttreatment compared to 69% of SPT group at one site; at the other site, 83% of CBT group responded at posttreatment compared to 45% of SPT group Secondary analysis of 6-month follow-up reported in Weingarden et al., (2021): Posttreatment remission: CBT 68%, SPT 42%, delayed 6-month remission: CBT 10%, SPT 14% Sustained 6-month remission from initial treatment: CBT 52%, SPT 27%, 6-month recurrence: CBT 20%, SPT 14% No remission achieved: CBT 18%, SPT 45%	Linear latent growth curve modelling	d=−6.46	.002
Cognitive Behavioral Therapy (CBT) for Adolescents
Mataix-Cols et al. (2015)	30	RCT: CBT with family involvement vs. Psychoeducation control	14 sessions over 4 months	2-months	BDD-YBOCS-A	CBT participants showed greater BDD-YBOCS-A reductions compared to control at posttreatment and follow-up (d = −9.62, p = .002) 8 of 15 participants required more time to complete treatment (mean and median = 18 weeks, range 13-28 weeks) 40% (n =6) of CBT participants were responders compared to 7% of control group participants at posttreatment and follow-up	ITT-MERA	d=−11.26	0.000
Greenberg et al. (2016)	13	Open trial of individual CBT	12-22 weekly sessions	3-, 6-months	BDD-YBOCS-A	BDD-YBOCS-A scores significantly decreased from severe to subclinical range at posttreatment for ITT and completer samples (p <.001, d = 8) Of the 62% (n = 8/13) who completed treatment the average number of sessions ranged from 15 to 22 (M = 20.31, SD = 2.23) Mean percentage decrease in BDD-YBOCS-A for ITT was 49.5% (SD = 29.0) and 68.2% (SD= 18.77) for completers 75% of completers (n = 6) were responders at 3- and 6-month follow-up	Paired t-test	d=5.09	<0.001
Krebs et al. (2017)	26	Naturalistic follow-up of Mataix-Cols et al. (2015) –RCT finished after 2-month follow up – all patients were offered CBT after this time point	14 sessions over 4 months, and 1 booster session was provided at 2-, 6- and 12-months	2-, 6-, 12-months	BDD-YBOCS-A	Reductions in BDD-YBOCS-A were observed at all follow-up timepoints: 2-month, 6-month (d= −12.82, p < 0.001), 12-month (d= −14.72, p <0.001) 34.6% (n = 9) were responders at posttreatment (session 14), 38.5% (n = 10) at 2- and 6-month follow-up and 50% (n=13) at 12-month follow-up 19.2% (n=5) were remitters at posttreatment and 2-month follow up, 23.1% (n=6) at 6- and 12-month follow-up 96.2% (n=25) completed administered treatment (14 sessions)	MERA	d=−11.50	<0.001
Rautio et al. (2022)	140	Individual CBT for BDD; no control	20 sessions	3-, 6-, 12-months	BDD-YBOCS-A	Significant BDD-YBOCS-A reduction from baseline to posttreatment and to 12-month follow up (d=−2.38, p <0.001) Only 15.6% (n=15) completed all planned sessions, median number of sessions was 15 (m = 17.2, SD = 10.4, range 2-80) 33.7% (n=34) received one or more booster sessions during the 1-year follow-up (mean = 11.3, SD = 9.4, range 1-30). At posttreatment 79.3% of completers (n = 107) were treatment responders, 59.3% (n = 80) as full or partial remitters.	MERA	d=−16.33	< 0.001
Meta-analysis
Harrison et al. (2016)	299	Meta-analysis of RCTs – adults and adolescents	N/A	N/A	BDD-YBOCS	At posttreatment improvement on BDD-YBOCS was higher in patients receiving CBT than in patients on waitlist or control CBT remained superior to waitlist/control treatment 2 to 4 months after treatment (Cohen’s delta = −0.89, p <0.001)	N/A	Delta =−1.22	<0.001
Zhao et al. (2024)	667	Meta-analysis of 11 RCTs – adults and adolescents	8-22 sessions	1-6 months	BDD-YBOCS, BDDE	Compared to control group, BDD severity score (BDD-YBOCS, BDDE) in treatment groups decreased after CBT treatment, difference between groups was significant After 12 weeks of CBT treatment, BDD severity values in treatment group were significantly decreased compared to controls (SMD = −1.51, p = NR), but not significant after 3 months of follow-up (SMD = −2.30, p = NR)	Univariate meta-regression analyses	SMD = −1.73	<0.01
Internet Interventions
Enander et al. (2014)	23	Individual iCBT (BDD-NET) w/ ERP; no control	12 weeks, 8 modules	3-months	BDD-YBOCS	Significant reduction in the BDD-YBOCS was observed, pre- to posttreatment and follow-up (d=2.04, p <0.01 83% (n=19) participants completed the core treatment components (modules 1-4) , 26%(n=6) completed all 8 modules, mean number of completed modules was 5.5(SD=2.35) 82% of participants were treatment responders at posttreatment, average reduction was 51% (mean difference = 15.08, 95% CI = 10.86 to 19.30)	Paired t-test	d=2.01	0.01
Enander et al. (2016)	94	Individual iCBT (BDD-NET) w/ ERP vs. online SPT	12 weeks, 8 modules	3-, 6-months	BDD-YBOCS	BDD-NET superior to control at 3- and 6 months (d=0.87, p <0.001) At 3 months, 54% (n=25/46) of the BDD-NET group vs. 6% (n=3/47) of the control group were responders, at 6 months 56% (n=23/41) of the BDD-NET group vs. 3% (n=6/45) of the control group Remission was observed by 32% at 3-months (15/46) in the BDD-NET group and 2% (n=1/47) of the control group, at 6-months remission was observed in 39% (n=16/41) vs. 9% of control (n=4/45)	LMM	d=0.95	<0.001
Enander et al. (2019)	88	Naturalistic: long-term follow-up of Enander et al. (2016)	12 weeks	3-, 12-, 24-months	BDD-YBOCS	Significant reduction in BDD-YBOCS were observed from baseline to posttreatment and for 3- (d=1.45, p<0.001), 12- (d=1.72, p<0.001) and 24-months (d=1.79, p<0.001) Mean reduction in BDD-YBOCS over 24-month follow-up was −13.42 points (95% CI −15.57 to −11.27, p <0.001) At 24-month follow-up, 69% (95% CI = 57 to 80) were responders and 56% (95% CI = 43 to 69) were in remission. Follow-up data should be observed with caution as between posttreatment and 24-month follow-up 71 participants received additional care such as pharmacotherapy, additional face-to-face therapy or cosmetic surgery.	LMM	d=1.25	<0.001
Gentile et al. (2019)	32	Individual iCBT (BDD-NET), therapist-guided; no control	12 weeks, 8 modules	3-months	BDD-YBOCS	From baseline to posttreatment significant improvements on BDD-YBOCS scores were observed, these improvements were maintained at follow-up (d=2.39, p<0.001) 56% (n=18/32) of participants completed the core treatment content (modules 1-5) and 25% (n=8/32) completed all eight modules, the mean number of modules completed was 5.1 (SD=2.47) 47% (n=15/32) were treatment responders at posttreatment, with 50% (n=16/32) responders at 3-month follow-up, 28% (n=9/32) no longer met criteria for BDD at posttreatment and 44% (n=14/32) were in remission at the 3-month follow up	LMM	d=2.57	<0.001
Lundstrom et al. (2023)	163	Individual iCBT for OCD and BDD; no control	12 weeks, 8 modules	No follow-up	BDD-YBOCS	Significant pre to posttreatment reduction in BDD-YBOCS, mean reduction was −11.37 (95% CI = −12.9 to −9.87) BDD-NET participants completed on average 6.5 (SD=2.23) modules and 61% (n=100) of sample completed all 8 modules 69% were treatment responders (95 % CI = 58 to 79), the full or partial remission rate was 48 % (95 % CI = 38 to 58)	LMM	d=2.07	<0.001
Smartphone-Based Interventions
Wilhelm et al. (2020)	10	Open pilot trial: therapist-guided, smartphone-based, CBT for BDD	12 weeks, 8 modules	3-months	BDD-YBOCS	BDD-YBOCS scores decreased from baseline to posttreatment (m=45.27%, SD=14.66%) Smartphone-app-based CBT for BDD demonstrated feasibility and acceptability to patients 90% (n=9/10) of patients were treatment responders at posttreatment and 90% (n=9/10) at 3-month follow-up	Paired t-test	d=2.60	<0.001
Wilhelm et al. (2022)	80	RCT: coach -guided, smartphone-based, CBT for BDD vs. WLC	12 weeks, 8 modules	N/A	BDD-YBOCS	Intent-to-treat group showed greater reductions in BDD-YBOCS scores over time compared to control 68% (n=21/31) of treatment-completing participants were responders at posttreatment compared to 14% in control (n=5/37) 52% (n=16/31) of completers were in remission at posttreatment compared to 8% (3/37) in control	GLMM	d=1.44	<0.001
Acceptance and Commitment Therapy (ACT)
Linde et al. (2015)	21	Pilot study: Group ACT w/ ERP for BDD; no control	12 weekly group & individual sessions	6-months	BDD-YBOCS	Reduction in BDD-YBOCS symptoms at posttreatment: d = 1.93, 95% CI = 0.82 to 3.04 90.5% (n=19) individuals completed treatment, mean number of completed sessions was 10.2 out of 12, and 6.4 out of the 8 individual sessions were completed 79% (n=15/19) of participants were treatment responders at posttreatment, at 6-month follow-up 69% (n=11/16) met criteria for clinically significant improvement	Paired t-test	d=1.93	NR
Dehbaneh (2019)	6	Case series: ACT	8 weekly sessions	3-months	IIP-32, Penn State Worry Questionnaire, WHOQOL-BREF	Interpersonal problems, worry and quality of life scores (physical, psychological, social, and environment) all showed downward trends in scores, though these were all descriptive statistics and have not been tested for significance.	Descriptive statistics	NR	NR
Linde et al. (2023)	5	Randomized, nonconcurrent, multiple baseline across participants design	12 weekly sessions	6-month	Daily self-monitoring of BDD-related behaviors	Daily ratings showed significant decreases in BDD-related behaviors and self-criticism post-treatment for four out of the five participants Three participants demonstrated reductions in body shame compared to baseline Follow-up assessments indicated that improvements in general shame, overall BDD symptoms, depressive symptoms, and quality of life were maintained six months after the treatment for four out of the five participants	N/A	N/A	N/A
Interpretation and Bias Modification (IBM)
Premo et al. (2016)	86	Positive training vs. comparison training	2 sessions	N/A	BDD-IQ: BDD Threat, Social Threat, General Threat	Positive CBM-I training participants demonstrated significant decreases in BDD-relevant interpretations (p = .002) and in socially-relevant interpretations (p < .001) but no significant decrease in general threat interpretations (p = .85) Comparison training participants also demonstrated a significant decrease in socially-relevant interpretations following training (p < .001) but not in BDD-relevant (p = .72) or general threat interpretations (p = 0.12)	N/A	NR	N/A
Summers & Cougle (2016)	40	RCT: IBM vs. PC	4 sessions over 2 weeks	1-month	BDD-YBOCS-SR	Analyses revealed an interaction between pretreatment severity and condition such that the effect of the treatment condition at posttreatment depended on level of symptom severity before treatment Among individuals with high levels of pretreatment symptoms, IBM led to greater reductions in posttreatment symptom severity, relative to the PC group. Individuals with low pretreatment symptoms saw had no significant difference between the IBM and PC conditions in terms of their effect on posttreatment symptoms	MLR	ß=0.63	0.003
Wilver & Cougle (2019)	50	RCT: Individual IBM vs. PMR	2 sessions per week/4 weeks	3 months	BDD-YBOCS	Significant reduction in BDD-YBOCS scores pre to posttreatment and pre to follow-up (d=1.58, p <0.05) but there was no significant difference in reduction between treatment conditions at posttreatment (p = 0.767) or follow-up (p = 0.863) At follow-up 64% (n=16) for IBM and 52% (n=13) for progressive muscle relaxation were considered treatment responders	ANOVA	d=1.65	<0.05
Dietel et al. (2020)	318	RCT: CBM-I vs. active control treatment vs. WLC	Up to 8 sessions over 2 weeks	1-week, 1 month	SWAP, MBSRQ-AO, MBSRQ-AE, FKS	CBM-I led to significant increase in adaptive interpretation patterns, particularly for appearance-related and social situations Both IMP and ICC groups experienced significant reductions in appearance orientation (IMP, b = −0.12; ICC, b = −0.13), this changed was not observed for WLC IMP group showed an increase in positive body evaluation (b=0.14) suggesting improved satisfaction with body image posttreatment, improvement was not significant in the ICC (b=0.01) or WLC IMP (b=−2.77) and ICC (b=0.01) showed significant reductions in BDD symptom severity, no reduction observed in WLC Mean completed sessions in the IMP group was 4.57 (SD=2.72) and 4.28 in the ICC group (SD=2.55)	ITT-MERA	d=0.65 to 1.18	NR
Emerging Approaches
Beilharz (2019)	6	Visual Training Program; no control	10 weeks	N/A	BDD-YBOCS	The visual training program was successful in terms of recruitment rates (57.89%) and acceptability, with some difficulties noted regarding retention rates (54.55%). A 17.23% change in BDD-YBOCS scores from pre- to post-assessment, but this change did not reach standardized reduction levels((>30%), there were overall trends towards lower BDD symptoms	Descriptive statistics	d=0.92	NR
Mohajerin et al. (2019)	124	RCT: Individual UP vs. WLC/TAU	14 sessions over 5 months	3 months	BDD-YBOCS,	Significant improvement of BDD symptoms in UP group between pre- and posttreatment and from pretreatment to follow up (d=8.5, p = 0.00) UP group showed 61.95% reduction on BDD-YBOCS vs. minimal change in the WL/TAU group	ANOVA	d=7.77	0.000
Wong et al. (2021)	67	Controlled experimental design – BDD individuals vs. HC	1 session, 4 different photo-viewing durations, 125, 250, 500 and 3000 ms	N/A	Changes in DEC within DVS and VVS, Fixation Duration	A significant three-way interaction between group (BDD vs. HC), duration, and connectivity category (DVSHigher, DVS Lower, VVSHigher, VVSLower) was found (p = 0.014) BDD individuals exhibited weaker DEC than HCs in DVSHigher during all stimuli presentation durations (for 125 ms p = 0.085, 250 ms p = 0.004, for 50ms, p =0.003, 3000 ms p = 0.064) Within-group, HCs exhibited weaker DEC for VVSLower during short duration compared to long duration (125 ms < 3000 ms, p = 0.018; 500 ms < 3000 ms, p = 0.007 ) HCs showed weaker DEC for DVSHigher during 125 ms duration to during 250 ms duration (125 ms < 250 ms, p = 0.018)	N/A	N/A	N/A
Wong et al. (2022)	67	Controlled experimental design – BDD vs. HCs for two different viewing orders	1 session	N/A	DEC, Fixation Duration	Increased fixation duration during modulated viewing (ModV) compared to natural viewing (NatV) (p=0.023) Enhanced DVS connectivity and suppressed VVS connectivity during ModV compared to NatV (p<0.05) Individuals with more severe BDD symptoms tend to have weaker dorsal visual stream connectivity when viewing their faces naturally (r=−0.434, p = 0.007) Individuals with better or less negative body image had stronger dynamic effective connectivity (r=0.509, p=0.001)	N/A	N/A	N/A
Gu & Zhu (2023)	58	RCT: MBCT vs. TAU	8 weekly sessions	3-month	BDD-YBOCS BABS	MBCT group showed greater reductions in BDD-YBOCS and BABS scores over time compared to TAU (p= 0.13, d=1.03) MBCT group completed 86.2% of sessions average of 7.4 (SD = 0.47) out of 8 sessions 44.8 (n=26) of MBCT participants were responders at posttreatment compared to 12.1% (n=7) in TAU; at follow-up, these rates were 51.7%(n=30) and 15.5% (n=9) 27.5% (n=16/58) of MBCT participants were in remission at posttreatment compared to 1.7% (n=1/58) in TAU; at follow-up, these rates were 31% (n=18/58) and 5% (n=3/58)	GLM	η2 = 0.100	.056
Ritter et al. (2023)	40	Individual Cognitive Training for BDD vs. WLC	20 sessions over approximately 10.5 months	3-, 6-months	BDD-YBOCS, BABS	Significant reductions in BDD-YBOCS were observed between baseline and posttreatment, these positive effects remained stable from posttreatment to 3- and 6-month follow up Mean duration of treatment was 45.6 weeks (SD=20.54), 75% (n=30) completed all treatment sessions 68% (n=27/40) participants were responders after treatment, at 3 months response rate further improved, 83% were classified as treatment responders (n=33/40), at 6-month follow-up 85% were responders (n=34/40) In combined CT-BDD sample – including waitlist, 58% (n=23/40) showed full or partial remission, at 3-month follow-up 60% (n=33/40) showed remission, and 58% (n=23/40) showed full or partial remission	ANOVA	d=1.32	<0.001
Wang et al. (2023)	19	BDD individuals vs. HC	6 training sessions over 6 days	N/A	Performance improvement in detecting LSF, activation changes in FFA, functional connectivity between left/right FFA	BDD individuals (p = 0.005, d = 1.29) and HCs (p = 0.02, d = 0.91) showed significant improvement in detecting LSF faces through training, no significant difference in magnitude of improvement (p = 0.085) Significant difference in activation changes in the FFA between pretest and posttest, with BDD patients showing increased activation for LSF faces relative to HSF (p = 0.017, d = 1.003), while this activation decreased in HCs (tp=0.028, d = 0.827) Functional connectivity between left and right FFA differed significantly between groups from pre- to posttest with BDD patients showing significant decrease in connectivity (p = 0.003, d = 1.407) , where HCs had significant increase (p = 0.025, d = 0.853)	N/A	N/A	N/A

^*Effect sizes are reported as provided by the original studies for posttreatment and/or first timepoint after treatment which may include Cohen's d, η², or other measures as appropriate to the statistical test employed. For follow-up, if available effect sizes are reported in main outcomes column. P-values correspond to the statistical test indicated.

ACT: acceptance and commitment therapy, BABS: Brown Assessment of Beliefs Scale, BDD: body dysmorphic disorder, BDD-YBOCS: Yale-Brown Obsessive Compulsive Scale, BDD-YBOCS-A: Yale-Brown Obsessive Compulsive Scale for adolescents, BDD-YBOCS-SR: Yale-Brown Obsessive Compulsive Scale, Self Report, BDDE: Body Dysmorphic Disorder Examination, BI-AAQ: Body Image Flexibility Questionnaire, BIDQ: Body Image Disturbance Questionnaire, CBM-I: Cognitive Bias Modification for Interpretation, DEC: Dynamic Effective Connectivity, DVS: dorsal visual stream, ERP: Exposure and Response Prevention, FFA: fusiform face area, FKS – Fragebogen Körperdysmorpher Symptome ("Body Dysmorphic Symptoms Inventory"), HC: Healthy controls, HSF: high spatial frequency, IBM: Interpretation Bias Modification, ICC: Interpretation Control Condition, iCBT: internet cognitive behavioral therapy, IIP-32: Inventory of Interpersonal Problems – Short Version, IMP: Interpretation Modification Program, ITT: intent-to-treat, LMM: linear mixed model, LSF: low spatial frequency, MBCT: mindfulness-based cognitive therapy, MBSRQ-AE: Multidimensional Body-Self Relations Questionnaire: Appearance Evaluation, MBSRQ-AO: Multidimensional Body-Self Relations Questionnaire: Appearance Orientation, MCT: Metacognitive Therapy, MERA: mixed effects regression analysis, ModV: Modulated Viewing, NatV: Naturalistic Viewing, PC: placebo control, PMR: progressive muscle relaxation, PSWQ: Penn State Worry Questionnaire, RCT: randomized controlled trial, SMD: standardized mean difference, SPT: supportive therapy, SWAP: Sentence Word Association Paradigm, TAU: treatment as usual, TFI: Thought-Fusion Inventory, UP: Unified Protocol, VVS: Ventral visual stream, WHOQOL-BREF: World Health Organization Quality of Life - BREF, WLC: waitlist control.

CBT for BDD in Adults

Most BDD treatment research has focused on demonstrating the efficacy of face-to-face CBT for adults with BDD. In these trials, outcomes are often described in terms of treatment response, defined as a reduction of ≥ 30% of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS (Phillips et al., 2014)) and partial or full remission, defined as a posttreatment BDD-YBOCS score of ≤ 16 (de la Cruz et al., 2021; Phillips et al., 2014).

Studies examining CBT for BDD for adults in an open trial or compared to waitlist controls have demonstrated efficacy in adults with response rates ranging from 48-82% after 8 to 22 sessions (Rabiei et al., 2012; Rosen & Reiter, 1996; Veale et al., 1996; Wilhelm et al., 2014). Though most studies have examined shorter-term treatment (Table 1), one trial found that after 22 sessions of treatment, 81% of CBT for BDD participants in the intention-to-treat sample demonstrated treatment response, with BDD-YBOCS scores significantly decreasing by an average of 16.5 points (SD = 8.3) over the span of treatment (Wilhelm et al., 2014). Interestingly, at 12 weeks, only 50% of the intent-to-treat patients had responded to treatment (vs. 12% of waitlisted participants), suggesting that many patients might benefit from longer treatment (Wilhelm et al., 2014). Treatment gains were maintained over the 6-month follow-up period, with only a small decrease in BDD-YBOCS total score (Wilhelm et al., 2014).

Two methodologically robust RCTs have compared face-to-face CBT for BDD to other forms of psychotherapy, such as anxiety management (AM) and supportive psychotherapy (SPT), across different settings (Veale et al., 2014; Wilhelm et al., 2019). The first trial found that after 12 weeks, CBT for BDD demonstrated a superior treatment response of 48% compared to just 12% of the AM controls; this response improved to 52% by week 16 (Veale et al., 2014). These gains were maintained by all CBT for BDD responders at one-month follow-up (Veale et al., 2014). A subsequent RCT compared CBT for BDD and SPT across two metropolitan sites (Wilhelm et al., 2019). After 24 weeks of treatment, across both sites combined, CBT for BDD was associated with a greater reduction in BDD-YBOCS scores compared to SPT. At the first site, CBT for BDD led to significantly greater reductions in BDD-YBOCS scores compared to SPT, and 83.3% of the individuals receiving CBT-BDD responded to the treatment, compared to only 45.5% of those treated with SPT. At the second site, no significant difference was detected between CBT for BDD and SPT in reducing BDD-YBOCS scores; and the overall response rate was 84.6% for the CBT-BDD group and 69.2% for those receiving SPT (Wilhelm et al., 2019). These findings suggest that there may be factors beyond CBT skills, such as therapeutic alliance, that may contribute to treatment response (Wilhelm et al., 2019).

Furthermore, CBT for BDD showed higher rates of remission posttreatment (68% vs. 42% for SPT) and at the 6-month fllow-up where additional participants maintained remission – 10% from CBT and 14% frm SPT (Weingarden et al., 2021). However, recurrences were also noted (20% CBT, 14% SPT), and there were some individuals who never experienced remission (45% SPT, 14% CBT), emphasizing that psychotherapy may not work for everyone (Weingarden et al., 2021). Concerning time to treatment response, a secondary analysis of the CBT vs. SPT study revealed that the median time to first response was 76 days (10.9 weeks) for CBT, compared to SPT’s 88 days, with only 50% of the combined treatment sample reaching treatment response within 11 weeks, once again suggesting some may benefit from longer-term psychotherapy (Hoeppner et al., 2023). Altogether, this trial’s findings emphasize the importance of understanding patient- and therapist-level predictors and moderators of treatment response, as there may be different mechanisms underlying treatment response for each treatment modality.

Building on the specific findings of individual RCTs, the broader efficacy of CBT for BDD is supported by two meta-analyses (Harrison et al., 2016; Zhao et al., 2024). The first, comprising seven RCTs (six trials with adults and one with adolescents) with a total of 299 participants, reinforced the substantial impact of CBT on improving response and remission rates among individuals with BDD. It also highlighted improvements in posttreatment depression symptoms and insight/delusionality compared to waitlist or placebo conditions, with these gains being sustained 2-4 months after treatment (Harrison et al., 2016). Follow-up periods in the included studies ranged from posttreatment to one-year post-treatment, indicating short-term and longer-term effects of CBT for BDD. A second meta-analysis including 11 RCTs (10 trials with adults, 1 with adolescents) provided an updated synthesis of evidence, focusing on CBT’s impact on BDD, depression, and anxiety symptoms as well as quality of life improvements (Zhao et al., 2024). Similarly, significant reductions were observed in BDD and depressive, in addition to anxiety symptoms among individuals receiving CBT, alongside improvements in functioning and quality of life (Zhao et al., 2024). The analysis also highlights the need for more high-quality RCTs that explore the long-term effects of CBT and its comparison with and without pharmacological treatments.

Current knowledge on the long-term remission rate following CBT for BDD is limited, as only one naturalistic follow-up has examined the durability of CBT for BDD’s effects beyond one year (Veale et al., 2015). This study found only a 5% decrease in the proportion of participants meeting improvement criteria at follow-up between 1 and 4 years after treatment (mean = 20 months). The evidence suggests that individuals who respond to CBT for BDD tend to maintain their treatment gains for 1 to 12 months (Harrison et al., 2016), which is encouraging for the treatment's long-term effectiveness. However, it is worth noting that in many long-term studies, individuals in the treatment group may have started new therapies or sought other treatments, which could also contribute to the lasting effects observed. Caution is needed when comparing CBT for BDD trials in adults due to sample and methodological differences.

CBT for BDD in Children and Adolescents

Despite the known effectiveness of CBT for BDD in adults, only several case reports and a single case series support the efficacy of CBT for BDD among children and adolescents (see reviews (Fang & Wilhelm, 2015; Phillips & Rogers, 2011)). Recent efforts to support its effectiveness among youths include two single-arm trials (Greenberg, Mothi, et al., 2016; Rautio et al., 2022) and one RCT (Mataix-Cols et al., 2015) (Table 1). These studies have indicated that CBT for BDD is feasible, acceptable, and satisfactory among young people (Mataix-Cols et al., 2015) and have also demonstrated a 40-79.3% treatment response rate at posttreatment following 14-20 sessions (Greenberg, Mothi, et al., 2016; Mataix-Cols et al., 2015; Rautio et al., 2022). These gains were maintained for at least 2 to 6 months following treatment (Greenberg, Mothi, et al., 2016; Mataix-Cols et al., 2015). Similar to adult CBT for BDD, posttreatment improvements have been demonstrated for secondary outcomes, including BDD-related insight (Greenberg, Mothi, et al., 2016), self-reported BDD symptoms (Mataix-Cols et al., 2015; Rautio et al., 2022), depressive symptoms (Greenberg, Mothi, et al., 2016; Mataix-Cols et al., 2015; Rautio et al., 2022), functional impairment (Rautio et al., 2022) social/academic (Greenberg, Mothi, et al., 2016), and global functioning (Mataix-Cols et al., 2015; Rautio et al., 2022).

The longest follow-up period of CBT for BDD among youth is 12 months (Krebs et al., 2017; Rautio et al., 2022). BDD symptom severity, functional impairment, global functioning, and – in one of the studies – insight (Krebs et al., 2017) continued to improve throughout the follow-up period (at 2, 3, 6, and 12 months (Krebs et al., 2017; Rautio et al., 2022)). In one study, 33.7% received booster sessions (median = 11 sessions), and concurrent intervention was also allowed, with 75% taking medication during treatment or follow-up (Rautio et al., 2022), while 61.5% of participants at one of the study sites missed three or more sessions, making it difficult to ascertain the number of sessions contributing to treatment response and remission (Rautio et al., 2022). In the other study, all participants received three booster sessions over the 12-month follow-up period, and several individuals received further treatment for BDD, like medication (n=6, 23%) (Krebs et al., 2017). Regarding individual outcomes, the number of individuals classified as treatment responders increased from 35% at posttreatment to 50% at the 12-month follow-up (Krebs et al., 2017). The current research on CBT for BDD for youths highlights the need to identify factors that help maintain improvements achieved through treatment such as booster sessions or medication.

Internet Interventions

To increase access to evidence-based treatment for BDD for adults, researchers developed BDD-NET, a structured and interactive therapist-supported internet CBT program based on existing manuals for CBT for BDD (Veale, 2010; Wilhelm et al., 2012). BDD-NET consists of eight interactive modules completed over 12 weeks with therapist support and is feasible, acceptable, and effective, as evidenced by an 82% posttreatment response rate (Enander et al., 2014). The treatment, which utilized therapist support from clinical psychology students, has also demonstrated superiority over digital SPT (Enander et al., 2016) and feasibility for international delivery (Gentile et al., 2019). During the comparison trial, the median weekly therapist time (e.g., which consisted of providing feedback on homework assignments and answering questions from participants) in the BDD-NET group was 13.2 minutes per participant compared to an average of 6.5 minutes reading and answering emails in the SPT group (Enander et al., 2016). In addition to addressing BDD symptoms, BDD-NET also reduced depression scores and improved global functioning and quality of life (Enander et al., 2016). Importantly, the efficacy of BDD-NET was sustained in a naturalistic two-year follow-up (Enander et al., 2019). Two years after treatment, 69% of participants were classified as responders, and 56% no longer met diagnostic criteria for BDD (Enander et al., 2019). Improvements in depressive symptoms and global functioning were also sustained long-term, but advances in health-related quality of life were not (Enander et al., 2019). BDD-NET has further demonstrated efficacy when implemented in a national public health system in Sweden with the largest sample size of a treatment trial to date (n=163), demonstrating a 69% treatment response and improvements in secondary outcomes as well as a 78% completion rate, the highest of any BDD-NET trial thus far (Lundström et al., 2023). Unlike face-to-face treatments for BDD, BDD-NET has not tested the effect of booster sessions on maintenance after termination of CBT, warranting further research on whether internet-based boosters could decrease relapse and improve long-term outcomes.

To date, internet-based treatment for BDD has primarily focused on adults; however, a study protocol for a therapist-guided CBT-based intervention for adolescents suggests there will soon be preliminary evidence on the effectiveness of internet-based treatment in adolescents (Hartmann et al., 2021).

Smartphone-based Interventions

Smartphone-based applications (apps), have also been developed to improve accessibility to CBT for BDD. They also provide novel opportunities for strengthening intervention impact by providing real-time assessments and adaptive feedback, status summaries, and alerts to mental health providers. App-based CBT for BDD, adapted from existing CBT for BDD treatment (Wilhelm et al., 2011), is feasible, acceptable (Wilhelm et al., 2020), and efficacious compared to a waitlist control (Wilhelm et al., 2022). The smartphone app delivers therapy content through a chat feature and is guided by a therapist or coach, who assists individuals with BDD by coaching them through treatment, providing feedback on assignments, and answering questions, replacing the need for face-to-face sessions. In a 12-week RCT, compared to the waitlist, adults using the app-based treatment with light, bachelor-level coach support (consisting of an average of 26.9 minutes speaking on the phone per participant across two phone calls and 1.5 minutes per participant per week via chat) experienced greater improvements in BDD symptom severity, insight, depression, quality of life and functioning (Wilhelm et al., 2022).

Research suggests that exploring behavioral engagement and treatment expectancy with regard to app-based interventions may be important to consider. For instance, users in app-based CBT for BDD who displayed different patterns of app engagement improved similarly, though users who had longer app use sessions showed marginally significantly greater improvement than users who had short app use sessions (Weingarden et al., 2023). Furthermore, in a comparison between therapist-guided app-based CBT and in-person CBT for BDD, expectancy for improvement was found to be moderately lower for digital CBT than for in-person CBT, higher credibility ratings were also associated with a lower likelihood of dropout from the digital CBT-BDD participants, indicating the need for strategies to enhance optimism about digital treatment outcomes (Bernstein, Weingarden, et al., 2023).

Similar to internet-based treatment for BDD, digital treatments for BDD have primarily focused on adults; however, the development of a prevention and early intervention smartphone app for adolescents and young adults is underway (Kuck et al., 2022).

Acceptance and Commitment Therapy

Several studies have examined the potential for acceptance and commitment therapy (ACT) in reducing BDD symptom severity (Table 1). ACT's core principles, focusing on acceptance, identification of core values, cognitive defusion, self as context, and contact with the present moment, offer some overlap with CBT for BDD. Thus far, a small open trial has demonstrated that ACT may reduce BDD symptom severity with a treatment response rate of 79% after 12 weeks of group treatment (Linde et al., 2015). The study also significantly decreased depressive symptoms and improved disability, quality of life, and psychological flexibility; these gains were maintained at 6-month follow-up (Linde et al., 2015). A recent extension of this study included treatment components designed to target BDD-related shame and self-criticism and increase self-compassion, finding that at posttreatment the majority of participants had significant increases in self-compassion and flexibility, as well as a decrease in self-criticism and shame (Linde et al., 2023). A case study has also found that ACT may improve interpersonal problems, quality of life, and worry (Dehbaneh, 2019). While one study has provided a foundation by incorporating rigorous methodology to explore the efficacy of ACT for BDD (Linde et al., 2015), the empirical basis would be substantially strengthened by additional controlled trials. These trials should involve active comparison groups and utilize standardized and validated measures to test the treatment modalities’ effectiveness.

Interpretation Bias Modification Training

Several trials have evaluated computerized interpretation bias modification (IBM) training to modify problematic interpretation and attention biases observed in BDD (Dietel et al., 2020; Premo et al., 2016; Summers & Cougle, 2016). An initial four-session IBM training program reduced past-week BDD symptoms and BDD-related interpretation bias compared to a placebo-control training condition for BDD patients with high pretreatment BDD symptom severity scores (Summers & Cougle, 2016). A randomized controlled trial extended these findings by testing an eight-session IBM program delivered entirely online, compared to active control (progressive muscle relaxation – PMR). Mirroring previous results, the IBM group exhibited fewer negative/threat interpretation biases and greater positive/benign interpretation biases than the PMR group at posttreatment and 3-month follow-up (Wilver & Cougle, 2019). While there were no differences between treatment conditions on BDD symptoms, depression, or anxiety at posttreatment or follow-up, both conditions exhibited reductions in BDD symptoms between pretreatment and follow-up (IBM – 64%, PMR – 52%). Although IBM and PMR may have contributed to improvements in symptoms, response rates are lower than in CBT trials, suggesting that more involved, higher-dose treatments have stronger impacts on symptom improvement (Wilver & Cougle, 2019). It is also possible that IBM or PMR may represent a helpful adjunctive treatment strategy before, during, or after CBT or medication management.

Emerging Approaches

Several studies have examined the efficacy of other evidence-based approaches that are theoretically grounded in CBT. One such study is an RCT that tested the Unified Protocol (UP), a transdiagnostic, emotion-focused CBT approach, against a waitlist/treatment-as-usual (TAU) group (Mohajerin et al., 2019). The UP demonstrated efficacy in reducing BDD symptoms by 62% after 15 sessions; treatment response was sustained at a 3-month follow-up. Additionally, it improved depression severity, BDD-related anxiety, insight, and overall emotion regulation compared to waitlist/TAU (Mohajerin et al., 2019). However, these preliminary findings call for cautious interpretation and future replication, as standardized measures of treatment response/remission were not reported (de la Cruz et al., 2021; Phillips et al., 2014), nor was there a comparison to an active control.

Cognitive therapy for BDD (CT-BDD) has also been developed to address the feelings of shame and defectiveness that are commonly experienced in BDD (Ritter et al., 2023). CT-BDD targets perceptual, attentional, and imagery-based processes as core mechanisms of change to enhance a holistic image of the self (Ritter et al., 2023). A recent RCT examining the efficacy of CT-BDD found that by 12 weeks, CT-BDD was superior to the waitlist in BDD severity, insight, shame, depression, general symptomatology, and life satisfaction (Ritter et al., 2023). The response rate at 21 weeks was comparable to previous trials of CBT, and remission rates at posttreatment remained stable until follow-up (58%), with further improvements observed at 3-month (83%) and 6-month (85%) follow-ups (Ritter et al., 2023). The increasing response rate over time posttreatment may be due to a focus on adaptive cognitive processing strategies and interpersonal resources (Ritter et al., 2023).

Mindfulness-Based Cognitive Therapy (MBCT), a modified form of cognitive therapy incorporating mindfulness practices, has also garnered interest as an intervention for BDD. While aspects of mindfulness are incorporated into CBT for BDD (Wilhelm et al., 2011; Wilhelm et al., 2019; Wilhelm et al., 2020), MBCT as a standalone emphasizes adopting nonjudgmental attention to one’s experiences through concentration training, present moment awareness, meditation, and breathing exercises. A trial on MBCT demonstrated superiority over TAU for improving BDD symptoms, emotion regulation, and executive function (Gu & Zhu, 2023). However, only 44.8% of MBCT responded to treatment posttreatment, rising only slightly at 3-month follow-up (51.7%) (Gu & Zhu, 2023). Treatment response is attributed to MBCT’s focus on decreasing evaluative self-referential processing and increasing awareness of present-moment experiences.

Finally, several studies have targeted visual processing abnormalities as an area for developing potential BDD treatments. Recent research has shown that non-invasive brain stimulation, such as intermittent theta-burst stimulation (iTBS), can effectively increase brain connectivity in visual processing areas for individuals with BDD, leading to better body image scores, compared to a control group (Wong et al., 2021). This suggests that iTBS could positively affect BDD individuals’ perceptions of visual information and self-image (Wong et al., 2021). In a related study, researchers found that altering visual attention towards less concerning areas of the face led to enhanced communication between brain regions involved in visual processing, suggesting that interventions that help individuals adjust eye-gaze behaviors may influence the balance between global and local visual processing, potentially offering additional therapeutic strategies (Wong et al., 2022). These findings are in line with existing CBT for BDD treatment protocols that incorporate perceptual retraining, promoting sustained changes in visual processing for a more holistic perception of one’s appearance (Wilhelm et al., 2012).

The benefit of such approaches were reflected in a study where both individuals with BDD and healthy controls improved their face recognition skills through visual perceptual learning (Wang et al., 2023). However, the study revealed distinctive patterns of brain activity and connectivity in individuals wit BDD, suggesting they process visual information differently. The research implies that enhancing the ability to perceive larger, more general shapes and forms – lower spatial frequencies or visual elements that capture the broader, more general shapes and forms in an image could enhance holistic visual processing, offering a promising approach for treating BDD (Wang et al., 2023).

Another approach to addressing visual processing deficits involves three phases using a combination of cognitive remediation tasks and perceptual mirror retraining techniques (Beilharz et al., 2018). Over 10 weeks, participants in an open trial exhibited a decrease in BDD symptom severity, although these changes were not clinically significant; there were also downward trends in depression, anxiety, and stress symptoms (Beilharz, 2019). Though the findings from this trial did not demonstrate significant improvements, they illustrate that specific training in emotion recognition can result in reduced hyperscanning (Beilharz, 2019) and could be valuable as an adjunctive treatment to other treatment programs for BDD.

Mechanisms Underlying Treatment Response

These treatment trials highlight that not all patients respond to these treatments. Understanding the mechanisms behind how interventions for BDD operate is a step toward maximizing treatment response and refining therapeutic approaches.

Current treatment models are based on hypothesized pathways for mechanisms of change (Wilhelm et al., 2010; Wilhelm et al., 2011). Specifically, reductions in selective attention to perceived appearance flaws, the importance placed on these flaws, and avoidance and ritualistic behaviors are hypothesized to generate improvement in BDD symptoms. Although these hypotheses are reflected in current treatments, only two studies have directly tested them by examining mediators of treatments for BDD. First, within-subjects mediation analyses pointed to reductions in BDD-related grooming, checking, avoidance behaviors, and cognitions as mechanisms of change throughout CBT (Fang et al., 2020). The study testing CBT for BDD vs. SPT (Wilhelm et al., 2019) indicated that CBT improved efforts to disengage from and restructure maladaptive thoughts and refrain from BDD rituals; SPT improved BDD-related insight earlier during treatment than CBT (Bernstein, Phillips, et al., 2023). In a study of adults undergoing BDD-NET, 75% experienced sudden gains after exposure with response prevention, indicating that this technique may contribute to cognitive changes and symptom reduction (Bjureberg et al., 2020). While these findings are informative, more research is needed to expand the limited evidence on how treatments for BDD impact symptoms.

Moderators and Predictors of Treatment Response

Another step toward maximizing the number of patients who respond to BDD treatments is understanding which demographic and clinical characteristics moderate or predict treatment response and remission.

Knowledge of treatment moderators can also inform the tailoring of treatments to individuals with BDD. Only one study has investigated moderators of face-to-face CBT versus SPT in treating BDD (Phillips et al., 2021). It found that no demographic, clinical, or treatment-related factors significantly influenced which treatment was more effective (i.e., there were no significant pretreatment moderators on effects of BDD severity) .

A systematic review has explored predictors of treatment outcomes in face-to-face and Internet trials of CBT for BDD (Hogg et al., 2023). Despite conflicting evidence, several significant predictors emerged: In face-to-face trials, lower insight (Greenberg et al., 2019; Neziroglu et al., 2001), BDD and depression severity (Gomez-Perez et al., 1994; Rautio et al., 2022) consistently predicted poorer treatment outcomes. Conversely, motivation/readiness to change (Greenberg et al., 2019), along with higher treatment expectancy/credibility (Greenberg et al., 2019; Phillips et al., 2021) a current obsessive-compulsive personality disorder diagnosis (Phillips et al., 2021) predicted better posttreatment response. Additionally, unemployment was associated with a longer time to treatment response, while higher treatment expectancy was associated with a shorter time to first response (Hoeppner et al., 2023). Importantly, the review on predictors demonstrated that while no variables routinely predicted response, on occasion insight, depression severity, treatment expectancy/credibility, and unemployment were able to predict outcomes (Hogg et al., 2023); thus, replication studies may be warranted. Finally, demographic variables, including age, gender, education level, and relationship status, did not significantly predict face-to-face CBT outcomes (Hogg et al., 2023).

Interestingly, a study examining whether treatment response could predict successful treatment outcomes found that lack of early response did not impact ultimately treatment response (Greenberg et al., 2022). Even among individuals who showed minimal initial improvement at week 4 or 12 of treatment, they still could benefit from the full treatment course (24 weeks) (Greenberg et al., 2022). In other words, these findings suggest that clinicians and providers should not feel pressured to modify the treatment plan due to lack of response and instead should consider completing the full course of CBT, as CBT for BDD may take longer in BDD populations compared to other psychiatric disorders.

Initial BDD symptom severity among youth predicted poorer outcomes posttreatment, although this result did not extend to the 12-month follow-up (Rautio et al., 2022). However, this study failed to replicate other predictors inconsistently reported in the literature, including depressive symptoms, BDD-related insight, BDD duration, and serotonin reuptake inhibitors (SRI) use (Greenberg et al., 2019; Phillips et al., 2021; Phillips et al., 2013).

Furthermore, predictors in digital CBT treatments for BDD have been explored (Flygare et al., 2020; Greenberg et al., 2024). In BDD-NET, negative associations were found between BDD and depression severity and remission posttreatment (Flygare et al., 2020), while treatment credibility and alliance positively correlated with remission at various follow-up intervals (Flygare et al., 2020). Treatment credibility remained a significant predictor at 3, 12, and 24 months. (Flygare et al., 2020). Similarly, smartphone-based CBT for BDD revealed that treatment credibility/expectancy consistently predicted symptom improvement, treatment response, and remission with lower credibility scores associated with non-response and non-remission (Greenberg et al., 2024). Finally, immediate access to smartphone-based CBT led to greater reductions in BDD symptoms compared to delayed treatment (Greenberg et al., 2024).

Further research is needed considering the variations between face-to-face and digital interventions. One study demonstrated that additional predictors may be important to consider with time, such as depressive symptoms and body areas of concern (Flygare et al., 2020). As such, the evaluation of predictors over long-term intervals may also be useful.

Treatment Disparities in Underserved Communities and Culturally Adapted Support

Given that cultural messages about beauty ideals, self-perception, and body image vary greatly across cultures and are central to the presentation of BDD, it is critical to recognize these differences and engage in discussions about how available treatments can be tailored and made accessible to traditionally underserved communities. Our forthcoming discussion will predominantly explore body image issues within marginalized communities. Although these issues are pertinent to BDD, they do not necessarily imply clinical significance in the context of BDD.

Studies from American and Western European perspectives show consistent patterns in BDD prevalence, age of onset, number of body parts of concern, and BDD-related behaviors (Bohne et al., 2002; Cansever et al., 2003). However, gender differences exist concerning features among adults diagnosed with BDD (Phillips, Menard, et al., 2006; Phillips et al., 2005). Women are more likely to be concerned with their legs (calves and/or thighs), while men are more concerned with muscularity or body build (Malcolm et al., 2021). Women also have more severe associated distress and less insight than men (Malcolm et al., 2021). In addition to these differences, there is a lack of studies directly comparing clinical aspects of BDD in cultural contexts.

Evidence among racial and ethnic communities

Studies have shown that African-American adolescents are less dissatisfied with their bodies than those from other ethnic backgrounds (Mayville et al., 1999). Asians are more concerned about hair and skin than Caucasians but less likely to express concerns about specific body areas. BDD-related behaviors showed variations, with Asians engaging in less grooming, touching body parts, and camouflaging compared to Caucasians (Marques et al., 2011).

Despite the expanding body of literature on available BDD treatments, there is a clear lack of representation of individuals from racial and ethnic communities. Only several trials of CBT for BDD reported on or included marginalized racial and ethnic populations (Mataix-Cols et al., 2015; Veale et al., 2014; Wilhelm et al., 2014; Wilhelm et al., 2011; Wilhelm et al., 2019). Two case examples have illustrated modifications within the CBT for BDD framework to enhance effectiveness and retention in ethnic communities, showing promise for face-to-face treatment adaptation (Weingarden et al., 2011). However, they underscore how challenges related to minority status, such as legal system discrimination described in one of the case examples, may impact a sense of self-worth being more than just race and appearance, impacting treatment response (Weingarden et al., 2011).

Technology-based interventions have the potential to address mental health disparities and make treatments accessible to underserved populations. Similar to face-to-face trials, most studies lack demographic information (Enander et al., 2016; Enander et al., 2014; Lundström et al., 2023) or include small sample sizes of traditionally marginalized communities (Wilhelm et al., 2022; Wilhelm et al., 2020). One international trial studied BDD-NET, reaching individuals in nine different countries; however, the participants were mainly from industrialized nations, highly educated, and English-speaking (Gentile et al., 2019).

Evidence among sexual minorities and gender-diverse communities

Psychological research, including BDD treatment literature, often lacks the collection and reporting of sexual orientation and gender diversity treatment studies (Heck et al., 2017). Thus, it is unknown whether general treatments are differentially efficacious across sexual orientations and gender identities or whether adaptations are needed. Sexual minority populations are overrepresented in mental healthcare, seeking treatment at about twice the rate of the general population (Cochran et al., 2017; Lu et al., 2021). These individuals also demonstrate high levels of body image dissatisfaction and clinically relevant BDD symptoms (Frederick & Essayli, 2016). In a non-clinical sexual minority population, clinically relevant BDD symptoms have been associated with factors such as gay-related rejection sensitivity, sexual orientation concealment, internalized homophobia, and heterosexist discrimination (Oshana et al., 2020). These factors may compound the elevated mental health and body image concerns in individuals within the sexual minority community. Recent research has compared clinical characteristics of BDD in sexual minority women compared to heterosexual women and indicated that while most clinical features were similar across groups, SM women were younger, reported better BDD-related insight, and showed a greater number of concerning body parts (Wolfe et al., 2024). The study did not find significant differences in BDD severity or depression levels between the two groups (Wolfe et al., 2024). While these findings potentially bode well for the generalizability of available treatments for BDD, only one treatment study thus far has reported sexual minority status, a secondary data analysis of a smartphone-based treatment for BDD (Greenberg et al., 2024; Wilhelm et al., 2022). This study reported that approximately 41% of the sample identified as a sexual minority (24% bisexual, 3% lesbian or gay, 14% other). Furthermore, sexual minority status was a significant predictor of treatment such that sexual minority individuals were more likely to experience a treatment response by the end of treatment than other participants (Greenberg et al., 2024). These findings suggest that existing treatments may be helpful for these communities while also emphasizing the need to report minority status in future studies so that intervention tailoring can occur if needed.

Recommendations for Cultural Adaptations

Evidence suggests that tailoring evidence-based treatments to the cultural needs of distinct groups leads to more favorable therapy outcomes (Soto et al., 2018). When treatments are tailored to accommodate social-ecological contexts, presenting concerns, and symptom manifestations, they may enhance engagement, retention, satisfaction, and effectiveness of non-adapted versions of these treatments (Barrera et al., 2017; Kalibatseva & Leong, 2014). Nevertheless, more research is needed to determine whether and to what degree existing treatments require adaptations for each minority population or if current therapies are equally effective across all groups.

The theoretical principles of CBT for BDD allow for adjustments to make treatment culturally sensitive. Adaptation frameworks have been developed, but most have not been tested in RCTs. (Chowdhary et al., 2014; Hinton & Patel, 2017; Naeem et al., 2019). To date, most cultural adaptations to existing interventions have been made on-the-fly during implementation rather than being standardized components of the interventions(Chowdhary et al., 2014). We provide several recommendations as potential steps forward within the scope of BDD:

Understand the cultural narrative on body image:

Treatment providers should try to understand the cultural beliefs, values, customs, and practices regarding body image to effectively treat BDD. Body image ideals may differ across cultures, and minority stress can lead to maladaptive behaviors like body surveillance to avoid discrimination or teasing (Oshana et al., 2020). Minority stress may be misinterpreted as or overlap with BDD symptoms (Pachankis et al., 2023). For example, individuals of color living in predominantly White communities may have preoccupations centered around the color of their skin and engage in attempts to lighten their skin; such symptoms may also express the effects of discrimination. While understudied, some cultures practice body modifications such as nose piercing, neck elongation, and henna tattooing; participation or non-engagement with these practices may impact body image ideals. A culturally-informed approach may help clients challenge unrealistic standards with respect to their culture and build healthier self-perception.

Consider the relationship between culture, religion, and spirituality:

Culture and religious narratives can influence perceptions of physical appearance. For some people, this could involve holding core beliefs that there is a connection between how they look and what they consider spiritually important. Research shows inconsistent findings, with some studies suggesting a positive impact of religion and spirituality on body image, while others show no significant relationship or negative association (Boyatzis & Quinlan, 2008; Exline et al., 2016). Some religions engage in varying degrees of body concealment, with different manifestations and terminology depending on the country or region. When working with clients who observe such practices, it is important not to misinterpret religious practices as BDD symptoms or rituals. Understanding these spiritual beliefs may help develop a more thorough conceptualization of the illness. Finally, individuals with BDD may also use religious coping strategies when dealing with distress, such as seeking help from religious leaders or alternative healers. In this case, culturally-informed BDD treatment might promote self-acceptance, mindfulness, and compassion.

Prepare culturally adapted language:

Body dissatisfaction in non-Western cultures may not be easily understood within a Western therapeutic context. Bilingual therapists have shown more effectiveness in culturally-adapted depression treatments, suggesting that translation may not be enough for cultural sensitivity (Kalibatseva & Leong, 2014). Adaptation should include verbal and visual communication forms, such as cultural idioms or metaphors related to body image or perception concerns, ensuring treatment aligns with the client’s cultural context (Kalibatseva & Leong, 2014). Identifying language and metaphors may enhance communication and make therapy more accessible to clients and their families.

Validate the role of lookism:

Sociology, history, and cultural criticism emphasize the culture’s impact on psychopathology. Among individuals with BDD, beauty standards shaped by racism and heterosexism may contribute to symptoms (Gonzales IV & Blashill, 2021). Recognizing the impact of lookism, a form of discrimination based on the perception of attractiveness (Jones, 2011), and societal privileges linked to physical attractiveness is crucial. In South Korea, lookism has led to increased rates of plastic surgery among women (Lee, 2016). Drawing parallels with cultural shifts in eating disorders (Goodman & Lu, 2021), a similar movement in BDD is needed to address lookism. Treatment providers can validate lookism’s role and advocate for greater media representation of diverse facial and body features.

Future directions and implications for research and practice

Though BDD treatments continue to expand, there is still room for improvement. This next section aims to provide a roadmap for future research.

Enhancing Research Study Methodology and Exploring Adjunctive Approaches

First and foremost, to advance CBT for BDD and other emerging BDD treatments, researchers must utilize validated measures such as those consistent with Diagnostic Statistical Manual-5 (American Psychiatric Association & Association, 2013) so that research samples of individuals with clinically significant BDD are distinguishable from individuals with normative body image concerns or eating disorders. The confusion between these samples can lead to misinterpretation of findings and inappropriate treatment recommendations. The utilization of uniform, validated assessment tools will enhance the validity, generalizability, and ability to compare similarities and differences in research findings.

Researchers must also prioritize the implementation of more robust comparative designs, such as comparing treatments to active controls that extend beyond the current standards. While some trials have begun to conduct this type of work (Wilhelm et al., 2019), future research should focus on conducting thorough comparisons against existing CBT for BDD programs, incorporating active controls or placebos, and exploring moderators/mechanisms. Additionally, most of the digital treatments for BDD have not been compared to active controls and should be explored in future research.

Moreover, the current design of BDD treatment trials evaluates treatment response and remission in short follow-up periods, at best 12 months, but often shorter. Researchers should prioritize longitudinal studies that track treatment outcomes beyond the conventional timeframe while also tracking what/how many additional resources might be needed (e.g., booster sessions, medication) to reinforce and sustain treatment gains.

Some emerging BDD treatments may offer potential opportunities as adjunctive treatments to complement existing CBT for BDD treatment programs. For example, independent evaluations of IBM and PMR had limited effects of improving illness severity when administered alone (Wilver & Cougle, 2019); however, perhaps treatment effects could be extended if these forms of treatment were offered as adjunctive to CBT treatment programs. Some research indicates that visual processing treatments combined with CBT show promise as an effective treatment for BDD (Toh et al., 2015, 2017). Accordingly, future research might identify opportunities to integrate these shorter-term therapies or treatment strategies with CBT for BDD treatment programs.

Digital Treatment Development

While evidence on Internet- and smartphone-based treatments for BDD offer promise to enhance accessibility to available treatments, there are several ways in which these interventions can be further developed.

First, research has emphasized treatment utilization barriers such as stigma, shame, and logistic and financial challenges (Marques et al., 2011). Though digital interventions show promise in addressing these barriers, it will be important for researchers to explore whether these interventions are as effective as, more effective, or superior to face-to-face therapies and if they increase treatment utilization and access compared to traditional treatment modalities.

Second, it is important to recognize that the interventions we reviewed here are not entirely self-guided treatments. There is debate about whether and to what degree digital interventions reduce the burden of the healthcare system, as they may still require some degree of provider involvement. Generally, guided interventions have higher engagement than unguided ones (Borghouts et al., 2021), though unguided interventions may have fewer barriers to entry (e.g., cost and shame). Regardless, unguided digital BDD treatments have yet to be developed and then tested with regard to their efficacy and safety. Given the high rates of suicidality in BDD, it is imperative to carefully evaluate the potential risks associated with the absence of guidance in treating individuals with more severe forms of BDD.

Digital treatments also provide an opportunity to identify and test specific treatment mechanisms. Unlike face-to-face interventions, they provide a granular understanding of the therapeutic techniques individuals are exposed to during treatment, allowing for examination of the relationship between treatment components and their impact. Future digital interventions could analyze user interactions with treatment modules, identify engagement patterns, and discern the “active ingredients” of the treatment. Leveraging these metrics could pave the way for personalized and adaptable treatment approaches, custom-tailored to individual needs based on response to strategies, thereby offering a potential alternative to formulation-based CBT.

Finally, while there has been some testing of Internet-based treatments for children and adolescents, thus far, there has only been development and usability testing of smartphone-based treatments for children and adolescents (Kuck et al., 2022), warranting future research.

Tailoring/Testing in Underserved Populations

The evident gap in our understanding of treatment outcomes across marginalized populations highlights the urgent need for more inclusive and comprehensive research approaches. This inclusivity will enable researchers to assess the efficacy of BDD treatments more accurately across diverse groups, potentially identifying unique response variations that could lead to more personalized care strategies. To address this need, as researchers consider necessary or potential adaptations, it will be crucial to include input of stakeholders, such as treatment providers experienced in BDD and individuals with BDD themselves so that language barriers are addressed and materials, messages and images are culturally appropriate and resonate with the communities they aim to serve. Documenting participants' sociodemographic variables should also become a standard practice in future research, including digital treatment studies. Such detailed data collection is important for evaluating the generalizability of findings and understanding how and to what capacity different populations experience and recover from BDD. Furthermore, integrating measures of cultural competency – particularly on the part of treatment providers – into study designs is crucial. This involves developing and validating interventions sensitive to participants' cultural contexts, thereby enhancing accessibility and treatment effectiveness for underrepresented and marginalized communities. Interdisciplinary collaborations with experts in cultural psychology, sociology, and health disparities research will enrich our understanding of BDD treatment outcomes through a multifaceted lens, incorporating diverse perspectives and expertise. Finally, if research finds that adaptations to currently available treatments are necessary, future research should develop and document detailed protocols describing how and what treatment components were adapted to assess their effectiveness and replicate them in subsequent trials.

Addressing Comorbidities Beyond Depression Severity

Though many comorbid illnesses occur alongside BDD, most treatment studies have not ventured beyond addressing and monitoring changes in psychological functioning beyond BDD symptomatology and depression severity. There is limited research on other comorbidities that can lead to poorer outcomes (Grant et al., 2005), such as substance use and personality disorders.

Comorbidity rates of past or current substance use disorders range from 30 to 50% in individuals with BDD (Grant et al., 2005; Phillips et al., 2005; Zimmerman & Mattia, 1998). In most cases, BDD precedes the onset of substance use disorder, and 70% of these individuals attribute their substance use problem at least in part due to their BDD distress (Grant et al., 2005; Phillips et al., 2005). One study has demonstrated that helping behaviors were predictive of substance use disorder remission but only trend level predictive of BDD remission (Pagano et al., 2007). While these findings begin to suggest potential treatment targets for addressing substance use, there is a need for integrated treatments that simultaneously address substance use and BDD.

Several studies have examined personality variables associated with BDD (Phillips & McElroy, 2000). Research suggests that between 40-72% of individuals with BDD meet the criteria for one or more comorbid personality disorder(s), particularly avoidant and paranoid personality disorders. Considering limited research on personality as a predictor of treatment outcome, further studies are needed to understand treatment implications. It may also warrant evaluation of treatments designed for addressing axis-II disorders, such as dialectical behavior therapy or racially open-dialectical behavior therapy, and their impact on BDD symptom severity and reduction in axis-II symptoms (Lynch, 2018; Rizvi & Linehan, 2001).

Conclusion

Due to the relatively limited research on BDD compared to other psychiatric disorders, there is a need for further research in all facets of treatment development research. The future of BDD treatment lies in the commitment to advancing research methodologies, embracing digital innovation, tailoring interventions for underserved, diverse populations, and comprehensively addressing comorbidities. By developing a treatment for BDD in these areas, researchers and practitioners can contribute to a more comprehensive understanding of BDD and facilitate the advancement of effective, inclusive, and personalized treatment strategies for individuals affected by this illness.