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Internet-based, therapist-guided, cognitive–behavioural therapy for body dysmorphic disorder with global eligibility for inclusion: an uncontrolled pilot study
  1. Andrew J Gentile1,2,
  2. Christopher La Lima1,2,
  3. Oskar Flygare1,2,
  4. Jesper Enander1,2,
  5. Sabine Wilhelm3,
  6. David Mataix-Cols1,2,
  7. Christian Rück1,2
  1. 1Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
  2. 2Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
  3. 3Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Christian Rück; christian.ruck{at}


Objectives Cognitive–behavioural therapy (CBT) has been shown to be an effective treatment for body dysmorphic disorder (BDD), but access to treatment around the world is limited. One way to increase access is to administer CBT remotely via the internet. This study represents the first effort to remotely deliver a therapist-supported, internet-based CBT treatment with no restrictions on enrolment based on geographical location, and it aims to assess whether this treatment can be delivered safely across international borders, with outcomes comparable to previous BDD-NET trials.

Design Uncontrolled clinical trial.

Participants Patients (n=32) in nine different countries were recruited primarily through internet advertisements.

Intervention BDD-NET is a 12-week treatment, consisting of eight treatment modules previously shown to be effective in a Swedish version.

Setting Therapists based at a single, secondary care centre in Sweden provided active guidance and feedback throughout the treatment via asynchronous electronic messages.

Main outcome measure The clinician-administered Yale-Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS). Symptom severity was assessed pretreatment, mid-treatment (6 weeks), post-treatment and at the 3-month follow-up.

Results There were significant improvements on BDD-YBOCS scores (F(3, 71.63)=31.79, p<0.001), that were maintained at 3-month follow-up. Mean differences from baseline in BDD-YBOCS scores were −8.12 (week 6), –12.63 (post-treatment) and −11.71 (3-month follow-up). 47% and 50% of participants were considered treatment responders at post-treatment and 3-month follow-up, respectively. Additionally, remission rates were 28% at post-treatment and 44% at 3-month follow-up. The treatment was also deemed acceptable by patients.

Conclusions The results suggest that BDD-NET can be safely and effectively delivered across international borders to a culturally diverse sample. Larger scale randomised controlled trials with more participants from non-Western cultures are warranted to further validate the cross-cultural generalisability of this treatment.

Trial registration number NCT03517384.

  • adult psychiatry
  • anxiety disorders
  • clinical trials
  • information technology
  • telemedicine
  • world wide web technology

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  • Contributors Author contributions: CR was the primary investigator for the study and drafted the design of the study with CL, JE and DM-C. AJG and CL both independently served as project manager during different periods of time. The treatment manual was written by JE with notable influence from work by SW, and was translated to English by CL. CL also developed the study website, protocol, drafted the ethics submissions and international regulations pertaining to treatment. AJG was in charge of the recruitment, assessment and treatment of participants, with significant contributions by CL and additional work by OF. Data analysis was primarily conducted by OF and AJG. CR, AJG, CL and OF had full access to data and are guarantors for the accuracy of raw data and statistical analyses. The manuscript was primarily written by AJG, with significant contributions by OF, CR, JE, SW, DM-C and CL.

  • Funding This study was funded through the regional agreement on medical training and clinical research (ALF) between the Stockholm County Council and Karolinska Institutet. CR was supported by the Swedish Research Council (grant No: K2013-61X-22168-01-3).

  • Disclaimer The funders had no role in study design; collection, management, analysis and interpretation of data; writing of the report and the decision to submit the report for publication.

  • Competing interests None declared.

  • Ethics approval The central ethical review board in Sweden approved the protocol (CEPN Ö 7–2016), as well as institutional review boards (IRB) at Massachusetts General Hospital (approved 23/112015) and Hofstra University (14/1/2016).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

  • Patient consent for publication Not required.

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