Efficacy and Comparative Evaluation of Psychotherapeutic Interventions for Body Dysmorphic Disorder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Body Dysmorphic Disorder (BDD) is a debilitating psychiatric condition characterized by obsessive concern over perceived physical flaws, which significantly impair daily functioning. While cognitive behavioral therapy (CBT) is considered the standard treatment, the comparative effectiveness of various psychotherapeutic interventions for BDD remains unclear.

Objective: This study aims to systematically review and perform a network meta-analysis (NMA) of different psychotherapies for treating BDD, evaluating their relative efficacy.

Methods: A systematic search was conducted across PubMed, EMBASE, Cochrane Library, and Web of Science to identify randomized controlled trials (RCTs) assessing psychotherapeutic interventions for BDD. The search was updated to October 2024. The main interventions evaluated were CBT, Digital Cognitive Behavioral Therapy (Digital CBT), Cognitive Therapy (CT), Supportive Psychotherapy (SPT), Anxiety Management (AM), Interpretation Bias Modification (IBM), and Progressive Muscle Relaxation (PMR). Waiting List Control (WLC) groups were used as comparators. The primary outcome was the reduction in BDD symptom severity, assessed using the Yale-Brown Obsessive-Compulsive Scale modified for BDD and the Brown Assessment of Beliefs Scale. Two independent reviewers screened studies, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias tool. A Bayesian NMA was used to compare the interventions, considering both direct and indirect evidence. Mean differences with 95% credible intervals (CrI) were reported, and Surface Under the Cumulative Ranking (SUCRA) probabilities were used to rank treatment effectiveness. Forest and funnel plots were generated to visualize results and assess publication bias.

Results: The NMA included 16 RCTs with a total of 914 participants, comparing the efficacy of several psychotherapeutic interventions for BDD. Among these, traditional CBT was the most effective, significantly reducing BDD-YBOCS scores by a mean difference of -9.24 (95% CI: -18.07 to -0.40) compared to WLC. Digital CBT also demonstrated notable efficacy, with a mean difference of -5.89 (95% CI: -20.38 to 8.60) compared to WLC, making it a promising alternative, though slightly less potent than traditional CBT. AM ranked second overall, with a mean difference of -6.52 (95% CI: -27.02 to 13.98) compared to WLC. CT provided moderate benefits, showing a mean difference of -2.29 (95% CI: -15.38 to 10.81) compared to WLC. IBM and PMR showed limited effectiveness, with mean differences of -1.17 (95% CI: -19.66 to 17.32) and -1.00 (95% CI: -27.14 to 25.15) compared to WLC, respectively. SPT led to a moderate reduction in symptoms, with a mean difference of -3.41 (95% CI: -15.86 to 9.05), though it was less effective than CBT-based therapies. SUCRA rankings placed traditional CBT as the most effective treatment (77.9%), followed by AM (59.4%) and Digital CBT (60.2%). Forest plots confirmed CBT's superior efficacy, while funnel plots suggested no publication bias, although some concerns about detection bias and reporting bias were noted in a few studies.

Conclusion: This NMA confirms that traditional CBT is the most effective treatment for reducing symptoms of BDD. Digital CBT and AM offer moderate efficacy and are viable alternatives. CT and SPT show some effectiveness, but to a lesser degree. Future research should focus on optimizing digital therapies and evaluating long-term outcomes.