نتایج طولانی مدت از رفتار درمانی شناختی برای اختلال بدریخت انگاری: مجموعه موارد طبیعی از 1 تا 4 سال پس از یک مطالعه کنترل شده

: There is some evidence for the efficacy of cognitive behavior therapy (CBT) for body dysmorphic disorder (BDD) after 1-6 months but none in the long-term. Aims: The aim of this study was to follow-up the participants in a randomized controlled trial of CBT versus anxiety management to determine whether or not the treatment gains were maintained over time. Method: Thirty of the original 39 participants who had CBT were followed up over 1-4 years and assessed using a number of clinician and self-report measures, which included the primary outcome measure of the Yale-Brown Obsessive Compulsive Scale modified for BDD. Results: Outcome scores generally maintained over time from end of treatment to long-term follow-up. There was a slight deterioration from n= 20 (51.3%) to n= 18 (46.2%) who met improvement criteria at long-term follow-up. Eleven (28.2%) were in full remission and 22 (56.4%) were in partial remission. Conclusions: The gains made were generally maintained at long-term follow-up. However, there were a significant number of participants who maintained chronic symptoms after treatment and may need a longer-term or more complex intervention and active medication management.

Body dysmorphic disorder (BDD) consists of a preoccupation with a perceived defect or ugliness, most commonly around the face. The ‘flaw(s)’ is not noticeable to others, or appears only slight, yet causes enormous shame, depression, and a poor quality of life (Phillips, 2000). BDD is reported as a chronic and unremitting condition (Phillips, Pagano, Menard, & Stout, 2006) with sufferers experiencing high rates of being housebound, hospitalization, suicide attempts and completed suicide (Phillips, Coles, et al., 2005; Phillips & Diaz, 1997; Phillips, Menard, & Fay, 2006; Veale, Boocock, et al., 1996). It is therefore particularly important to develop and evaluate interventions for such a disabling condition. The UK National Institute of Health and Clinical Excellence (NICE) guidelines on OCD and BDD recommended the use of Cognitive Behavior Therapy (CBT) that is specific for BDD, and Selective Serotonin Reuptake Inhibitors (National Collaborating Centre for Mental Health, 2006). However, the evidence base for this recommendation is relatively poor and little is known about long-term outcomes of treatment. To date, there are 4 RCTs that have evaluated CBT for BDD against a wait list. These are all small studies that have demonstrated greater efficacy of CBT compared to a wait-list over 12-22 sessions (Rabiei, Mulkens, Kalantari, Molavi, & Bahrami, 2012; Rosen, Reiter, & Orosan, 1995; Veale, Gournay, et al., 1996; Wilhelm et al., 2014). These studies reported follow-up outcomes between 1 to 6 months where participants have generally maintained their gains. McKay (1999) reported on a 2 year follow-up of 10 participants after they received behavior therapy for 6 weeks and were randomly assigned to either a maintenance program or a control group for 6 months. The author found that a maintenance program was superior to no maintenance at 2-year follow-up. No RCTs have examined whether a selective serotonin reuptake inhibitor (SSRI) can enhance outcome of CBT for BDD either in the short or long-term. There are 4 long-term naturalistic outcome studies of people with BDD with 12-month outcomes (Fontenelle et al., 2006; Phillips, Grant, Siniscalchi, Stout, & Price, 2005; Phillips, Pagano, et al., 2006). In these studies, full remission was defined as minimal or no BDD symptoms, and partial remission as meeting less than full DSM-IV criteria for at least 8 consecutive weeks. Phillips, Grant, et al. (2005) retrospectively assessed that at 1 year follow- up, 24.7% of 95 participants had achieved full remission, while another 33.1% had experienced partial remission at the 6-month and/or 12-month follow-up. After 4 years, 58.2% of subjects had reached full remission, and another 25.6% had experienced partial remission. Of those subjects who attained partial or full remission, 28.6% subsequently relapsed. Although all patients had received SSRI medication, only 21.7% had received CBT. Phillips, Pagano, et al. (2006) conducted a prospective follow-up of 183 participants in which 9% achieved a full remission and 21% partial remission at 1-year follow-up. There was an overall average probability of relapse of .15 in the study. Although most patients had received psychotropic medication, only 16% was considered optimal and only 21.9% had received CBT, in which it was difficult to judge the quality. Phillips, Menard, Quinn, Didie, and Stout (2013) conducted a prospective 4-year follow-up of 166 adults and adolescents with BDD. After 4 years, 20% had achieved full remission from BDD and a further 35% partial remission. Eighty-eight percent of subjects received mental health treatment during the follow-up period although only 10.2% had an optimal length of course of CBT and 34.3% received a SSRI that was considered optimal. Among partially or fully remitted subjects, the cumulative probability was 0.42 for subsequent full relapse and 0.63 for subsequent full or partial relapse. A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake, longer lifetime duration of BDD, and being an adult. Lastly Bjornsson et al. (2013) conducted a naturalistic study in an anxiety disorders clinic. They measured recovery from BDD in 17 participants with current BDD and 22 with a lifetime history of BDD for up to 8 years, and found a recovery probability of 0.76. The probability of recurrence of BDD, once remitted, was low at 0.14. However, it is not known how representative this sample was. The present study is a follow-up report of Veale, Anson, et al. (2014), who conducted a RCT to determine if CBT had greater efficacy than anxiety management (AM) in BDD. Forty-six participants were randomly allocated to either CBT or AM. The participants were fairly typical of outpatients with severe BDD, with a mean BDD-Yale Brown Obsessive Compulsive Score of 35.5 at baseline, and 83% desiring at least one cosmetic or dermatological procedure. These individuals are difficult to engage, and both the expectancy of change and credibility of CBT or AM were rated as very low. Fifty-four percent were classified as having a delusional BDD. Sixty one percent had had a previous trial of a selective serotonin reuptake inhibitor (SSRI) and 45% of participants were stabilized on a SSRI at entry. Thirty seven percent had had previous trial of CBT. The primary end-point was at 12 weeks and the CBT group, unlike the AM group, had 4 further weekly sessions that were analysed for their added value. Both groups then completed measures at their 1-month follow-up. At 12 weeks, CBT was found to be significantly superior to AM on the BDD-YBOCS (β = -7.19, S.E. (β) = 2.61, p < .01, C.I. = -12.31, -2.07, d= 0.99) and on the secondary outcome measures. The conclusion was that CBT was a more effective intervention than AM for individuals with BDD even for those with delusional beliefs or depression at 12 weeks. Participants who were originally randomized to receive AM and still had BDD were then offered up to 16 sessions of CBT. The current study was exploratory and aimed to follow-up all participants who had CBT from the original sample, either as a first or second treatment, to see how their outcomes had changed over time since offered CBT. The difference to previous follow-up studies is that all participants had received CBT and about 45% had received a SSRI. We hypothesized that non-responders in the long term were more likely to have higher levels of depression and delusional beliefs at assessment. Although a previous follow-up study in BDD found only a trend for depression predicting lower remission (Phillips et al., 2013), other follow-up studies in anxiety disorders have found depression to be associated with a worse outcome, for example in CBT for post traumatic stress disorder (Johnson, 1987), obsessive compulsive disorder (Knopp, Knowles, Bee, Lovell, & Bower, 2013), social phobia (Green, 2009) and generalized anxiety disorder (Foa & Goldstein, 1978). We also hypothesized that participants recruited from a secondary care were more likely to be non-responders. This is because individuals in secondary and tertiary care are under the care of psychiatric team and have more complex needs – for example they tend to have greater comorbidity and social problems than those recruited those from primary care and the Improving Access to Psychological Therapies (IAPT) service, and who are not under any psychiatric care (Gyani, Shafran, Layard, & Clark, 2013). This is part of “stepped care” system in which the care of a patient is provided according to their need or they are stepped up to a higher level of care if they fail at a lower level. Method Participants (See Fig. 1.) (See Table 1, Table 2, Table 3, Table 4 and Table 5.) Full-size image (38 K) Fig. 1. Flow diagram of study participants.