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  • The Body Dysmorphic Disorder Program at Rhode Island Hospital

  • Treatments for Body Dysmorphic Disorder (BDD)

  • Psychiatric/psychological treatment often improves BDD symptoms and the suffering it causes. The treatments that appear most effective are certain medications (serotonin-reuptake inhibitors) and a type of therapy known as cognitive-behavioral therapy (CBT). For more detailed advice about recommended treatment approaches, please see Katharine A. Phillips, MD's revised and updated book on BDD (Understanding Body Dysmorphic Disorder: An Essential Guide).

    Medications Are Often Helpful for BDD  

    The medications that are currently recommended for BDD are the serotonin-reuptake inhibitors (also known as SRIs or SSRIs). The SRIs are antidepressant medications that also help stop obsessional thinking and excessive compulsive behaviors such as mirror checking. They are often used to treat other disorders, such as depression, social anxiety disorder and obsessive-compulsive disorder. SRIs appear to be effective for a majority of people with BDD. These medications are not addicting and are usually well tolerated.

    The following medications are SRIs:

    • fluvoxamine (brand name Luvox)
    • fluoxetine (brand name Prozac)
    • sertraline (brand name Zoloft)
    • paroxetine (brand name Paxil)
    • citalopram (brand name Celexa)
    • escitalopram (brand name Lexapro)
    • clomipramine (brand name Anafranil)

    A number of research studies done by our group and other researchers have shown that SRIs substantially improve BDD symptoms in a majority of people. These medications can significantly diminish bodily preoccupation, emotional distress, depression and anxiety. They can also significantly increase control over one's thoughts and behaviors. They also often improve daily functioning, for example, making it easier to be around other people or to concentrate at work or school. In some cases (for example, when people are suicidal), they are lifesaving.

    In one of our studies, we found that the SRI fluoxetine (Prozac) was more effective than placebo (a sugar pill) for BDD symptoms and daily functioning. In a study of the SRI clomipramine (Anafranil), done by Eric Hollander, MD, at Mount Sinai Medical Center in New York City, the SRI clomipramine was superior to the non-SRI antidepressant desipramine in improving BDD symptoms and functioning. In other studies, we have found that escitalopram (Lexapro), citalopram (Celexa), and fluvoxamine (Luvox) were effective for most patients. It's important, however, to use a high enough SRI dose for a long enough time to give the medicine a chance to work.

    We need a lot more scientific research to give us more information about effective treatments for BDD. In the meantime, based on the scientific evidence that is available, as well as Phillips's extensive clinical experience treating people with BDD, we generally recommend the following approach:

    • Use an SRI as a first-line medication for BDD, including delusional BDD.
    • You can try any SRI: All of the SRI's appear effective for BDD, so you can use any of them.
    • We suggest that you reach the maximum SRI dose that's recommended by the pharmaceutical company or that you can tolerate, unless a lower dose works for you: It's very important to use a high enough SRI dose. We need more research on this important issue, but it appears that many people with BDD need higher SRI doses than those typically used for depression.
    • Don't give up on an SRI until you've tried it for 12 to 16 weeks, while reaching a high enough dose.
    • If you respond to an SRI, you're likely to continue to feel well for as long as you take it.
    • We suggest you continue an effective SRI for a year or two, or longer.
    • If you decide to stop an effective SRI, plan this carefully with your doctor.
    • An important reminder: Be sure your doctor knows from the beginning that you have BDD. Don't tell him or her that you just have depression or anxiety, because your BDD symptoms may not improve if they aren't targeted directly with treatment

    Other medications appear to sometimes be helpful when used in combination with an SRI. Please see Understanding Body Dysmorphic Disorder: An Essential Guide for details on this topic. The book also covers many other treatment issues, such as what to do if an SRI doesn't work well enough for you.

    Each person with BDD requires individualized assessment of BDD and other symptoms. If other disorders are present along with the BDD, this may influence the medication that's selected. Possible side effects, your response to past treatment, your treatment preference, or a need for immediate symptom relief are some of the factors that my influence treatment decisions. We recommend a comprehensive evaluation by a psychiatrist and development of an individualized treatment plan that includes close monitoring. The above suggestions only general guidelines that must be tailored to you in consultations with your doctor.

    Please also note that no medication has been approved by the FDA for the treatment of BDD. This is because not enough studies that are specifically designbed to obtain such approval have been done. Nonetheless, all of the research that to our knowledge has been done on medications for BDD indicates that the SRIs are effective for BDD symptoms in a majority of people with this disorder.

    Responses to Some Misconceptions About Medication Treatment of BDD  

    Many people have misconceptions about medications, including SRIs, Here are some brief responses to some of the more common misconceptions.

    • Some people worry that SRIs will harm their brain. There is no evidence that this is true. SRI medications appear to correct a “chemical imbalance” in the brain and promote the healthy functioning of serotonin, a natural brain chemical. Antidepressants such as SRIs also appear to prevent brain cells from damage or death and can even stimulate the growth of new brain cells. Research on disorders with similarities to BDD, such as obsessive compulsive disorder, indicate that when patients improve with an SRI, abnormal brain activity (as evidenced by functional neuroimaging, for example) often becomes normalized.
    • Some people worry that SRIs will lead to suicide. However, SRI use has not been shown to increase the risk of actual suicide, and recent studies indicate that antidepressant medications appear associated with a decreased risk of suicidal behavior. While more research is needed, this also appears to be the case for BDD more specifically. However, all people with BDD - whether or not they are taking an SRI -- need to be carefully monitored for suicidal thinking and behavior.
    • Some people worry that taking an SRI will make them behave abnormally or appear “zombie-like.” While occasional people get tired or agitated while taking an SRI, these medications don't make people appear “drugged” or ruin their personality. People who improve while taking an SRI usually say they feel more normal, or more like themselves again.
    • Some people hesitate to take medication because they want to get better on their own. Being motivated to get better is very important, but it isn't realistic to try to recover from BDD, especially more severe BDD, solely on your own. You and the medication work “hand-in-hand” and are on the same team.
    • Side effects with SRIs, if they occur, are generally tolerable and often temporary, and SRIs aren't habit forming or addicting.
    • Some people have found that medication doesn't work for them, and they're reluctant to try it again. But sometimes, this is because the choice of medication or dosing hasn't been optimal for BDD. In these cases, trying medication again, following recommended guidelines, may be helpful.

    More BDD treatment research studies are greatly needed! We need more and better studies of the treatment options discussed above. We also need research to develop new and even more effective treatments for BDD. Find out further information on how our program is dedicated to this cause and the various medication treatment studies we are offering for children, adolescents and adults.

    Cognitive Behavioral Therapy Is Often Helpful for BDD  

    Cognitive-behavioral therapy (CBT) is the best-studied and most promising type of psychotherapy for BDD. When used by trained therapists, CBT is effective for such disorders as depression, phobias, panic disorder, obsessive compulsive disorder and eating disorders. Available research studies indicate that CBT substantially improves BDD symptoms in a majority of people, diminishing obsessional appearance preoccupations and compulsive behaviors, depressive symptoms, and anxiety, and improving body image and self-esteem.

    Still, more research is needed. We and our colleagues at Massachusetts General Hospital/Harvard Medical School in Boston (Sabine Wilhelm, PhD) and Boston University (Gail Steketee, PhD) are currently doing a CBT study, funded by the National Institute of Mental Health. 

    What CBT Consists Of

    CBT is a practical “here and now” treatment that focuses on changing problematic BDD thoughts and behaviors. The purpose of CBT is to learn practical skills that can help a person cope with and overcome BDD—skills that can be used now and in the future to keep BDD under control.

    • The cognitive aspects of CBT focuses on cognitions-that is, appearance-related thoughts and beliefs. In treatment, you learn about the relationship between thoughts, feelings, and behaviors. The aim of CBT is to identify and evaluate current ways of thinking and to develop more accurate and helpful appearance beliefs.
    • The behavioral aspects of CBT focuses on learning to face and feel more comfortable in situations (such as social situations) that may be avoided or endured with anxiety. The treatment also helps reduce problematic compulsive behaviors, for example, mirror checking and comparing with other people. The aim is to develop healthier, more adaptive coping behaviors.
    • CBT may also include other components, such as increasing involvement in enjoyable activities, improving self-esteem, and developing ways to look at the “big picture” when looking in the mirror, rather than just focusing on certain features.
    • Usually, cognitive and behavioral approaches are combined-hence, the commonly used term “cognitive behavioral therapy.”

    A Few Key Considerations  

    • It's important to determine whether a therapist has been specifically trained in cognitive-behavioral therapy and is familiar with BDD and its treatment
    • CBT requires motivation and a willingness to do the treatment during sessions and to do homework between sessions.
    • For those who have severe BDD or are very depressed or suicidal, it is recommended they consider taking an SRI before or during CBT.
    • CBT and SRIs appear to work well when used together.
    • Other types of therapy (for example, counseling or general psychotherapy) do not appear to be effective when used alone for BDD. However, more research is greatly needed on psychotherapy for BDD - both how to make CBT more effective for BDD and to develop new therapies for BDD.
    • For more information about CBT for BDD, please see Understanding Body Dysmorphic Disorder: An Essential Guide. We also recommend a book by our collaborator, Sabine Wilhelm, PhD, (Feeling Good About the Way You Look), which has very helpful information about CBT for BDD.
    • In collaboration with Sabine Wilhelm, PhD and Gail Steketee, PhD, Katharine Phillips has published a detailed CBT treatment manual for therapists to use when treating patients with BDD, Cognitive Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual.
    • As discussed above, each person with BDD requires an individualized assessment of BDD and other symptoms. If other disorders or problems are present along with the BDD, this may influence the treatment (and the type of therapy) that's recommended. We recommend a comprehensive evaluation by a qualified mental health professional and development of an individualized treatment plan.

    Treatments That Don't Appear to Work for BDD  

    Even though there are effective treatments for BDD (CBT and serotonin-reuptake inhibitor medications), most people with BDD seek and receive treatments that don't seem to work. These ineffective treatments include surgery, dermatologic treatment, and other nonpsychiatric treatment (for example, dental treatment). People with BDD can waste lots of time and money pursuing these treatments, and can end up bitterly disappointed when they don't obtain the relief they're so desperately seeking.

    It makes sense that these treatments almost never improve BDD. BDD isn't a problem with actual appearance; it's a problem with how the person sees themselves - their body image - so changing one's actual appearance through surgery doesn't seem to work. Although more research is needed to confirm that these treatments don't work for BDD, in the meantime, based on current knowledge, we recommend that people with BDD avoid them. They don't seem to help, and they can even make BDD worse. BDD is a serious mental illness that requires psychiatric treatment, which is often very helpful.

    Don't Give Up

    It may take a while to find the exact treatment that works for you. In addition, medication treatment and therapy need to be tailored to each individual. However, most people with BDD do eventually get better with an SRI and/or CBT. Some people respond to the first treatment they try, whereas others need to try more than one. Some people improve quickly, whereas others need more time. But most people who persist in trying recommended treatments do improve. In addition, I and other researchers are continually trying to learn more about what treatments work and to find and develop even more effective treatments for BDD—so new treatment options will hopefully become available in the future.

    What if you’re reluctant to try recommended treatment? Please read Phillips’s thoughts about this in an excerpt from her book Understanding Body Dysmorphic Disorder: An Essential Guide.

    Where Can I Find More Information on Treatments for BDD?  

    Understanding Body Dysmorphic Disorder: An Essential Guide (Published by Oxford University Press in 2009)

    This book, written by Katharine Phillips, MD, is a comprehensive and up-to-date source on BDD and its treatment.

    In addition, as research on what treatments work for BDD is completed in upcoming years, the results will be published in articles in scientific journals. The journals are the most authoritative source about effective treatments. This is a good way to stay abreast of new information about treatment for BDD. Clink the following link for more information on how to access these articles about BDD.