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Therapist guided internet based cognitive behavioural therapy for body dysmorphic disorder: single blind randomised controlled trial

BMJ 2016; 352 doi: (Published 02 February 2016) Cite this as: BMJ 2016;352:i241
  1. Jesper Enander, clinical psychologist1,
  2. Erik Andersson, clinical psychologist1 2,
  3. David Mataix-Cols, professor in child and adolescent psychiatric science and consultant clinical psychologist1 3,
  4. Linn Lichtenstein, assistant psychologist4,
  5. Katarina Alström, assistant psychologist4,
  6. Gerhard Andersson, professor in clinical psychology4,
  7. Brjánn Ljótsson, senior lecturer2,
  8. Christian Rück, senior lecturer and consultant psychiatrist1
  1. 1Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
  2. 2Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
  3. 3Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
  4. 4Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
  1. Correspondence to: J Enander, M46, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden, jesper.enander{at}
  • Accepted 30 December 2015


Objectives To evaluate the efficacy of therapist guided internet based cognitive behavioural therapy (CBT) programme for body dysmorphic disorder (BDD-NET) compared with online supportive therapy.

Design A 12 week single blind parallel group randomised controlled trial.

Setting Academic medical centre.

Participants 94 self referred adult outpatients with a diagnosis of body dysmorphic disorder and a modified Yale-Brown obsessive compulsive scale (BDD-YBOCS) score of ≥20. Concurrent psychotropic drug treatment was permitted if the dose had been stable for at least two months before enrolment and remained unchanged during the trial.

Interventions Participants received either BDD-NET (n=47) or supportive therapy (n=47) delivered via the internet for 12 weeks.

Main outcome measures The primary outcome was the BDD-YBOCS score after treatment and follow-up (three and six months from baseline) as evaluated by a masked assessor. Responder status was defined as a ≥30% reduction in symptoms on the scale. Secondary outcomes were measures of depression (MADRS-S), global functioning (GAF), clinical global improvement (CGI-I), and quality of life (EQ5D). The six month follow-up time and all outcomes other than BDD-YBOCS and MADRS-S at 3 months were not pre-specified in the registration at because of an administrative error but were included in the original trial protocol approved by the regional ethics committee before the start of the trial.

Results BDD-NET was superior to supportive therapy and was associated with significant improvements in severity of symptoms of body dysmorphic disorder (BDD-YBOCS group difference −7.1 points, 95% confidence interval −9.8 to −4.4), depression (MADRS-S group difference −4.5 points, −7.5 to −1.4), and other secondary measures. At follow-up, 56% of those receiving BDD-NET were classed as responders, compared with 13% receiving supportive therapy. The number needed to treat was 2.34 (1.71 to 4.35). Self reported satisfaction was high.

Conclusions CBT can be delivered safely via the internet to patients with body dysmorphic disorder. BDD-NET has the potential to increase access to evidence based psychiatric care for this mental disorder, in line with NICE priority recommendations. It could be particularly useful in a stepped care approach, in which general practitioner or other mental health professionals can offer treatment to people with mild to moderate symptoms at low risk of suicide.

Trial registration ID: NCT02010619.


  • We thank the participants of the BDD-NET trial and Monica Hellberg, Sofia Eriksson, Vania Panes Lundmark, Martin Runeborg, Lina Anderhell Lorena Fernández de la Cruz, and Matteo Bottai for their invaluable help.

  • Contributors: JE and CR had the original idea for the study and, with DM-C and BJ, designed the trial variables and obtained the funding. JE and CR were responsible for study supervision. All authors were responsible for the acquisition of the data. JE, EA, and CR carried out the statistical analysis. JE drafted the manuscript, which was revised by all authors. All researchers were independent of the funders. The funders had no part in the study design, in the collection, analysis, and interpretation of data, in the writing of the report or in the decision to submit the article for publication. JE and CR are guarantors.

  • Funding: This study was funded through the regional agreement on medical training and clinical research (ALF) between the Stockholm County Council and Karolinska Institutet, the Swedish Research Council (grant No: K2013-61X-22168-01-3), and the Swedish Society of Medicine (Söderströmska Königska sjukhemmet, grant No: SLS3B4451).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The regional ethical review board in Stockholm approved the protocol (registration ID: 2013/1773-31/4). All participants gave written informed consent.

  • Transparency: The lead author affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that and discrepancies from the study as planned (and if relevant, registered) have been explained.

  • Data sharing: No additional data available.

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