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).
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:
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:
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.
Many people have misconceptions about medications, including SRIs, Here are some brief responses to some of the more common misconceptions.
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 (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.
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.
It is recommended (especially when treating more severe BDD) that Cognitive-Behavioral Therapy (CBT) for BDD be delivered by therapists using a CBT treatment manual that has been developed specifically for BDD. Clinical experience suggests that providing CBT without use of a BDD-specific treatment manual may not be effective for BDD. Also, it can be very difficult to treat BDD – especially more severe BDD -- without use of a treatment manual.
It is also important that BDD not be treated as if it were simply OCD, depression, or another disorder. Clinical experience suggests that treating BDD as if it were another disorder is often ineffective for BDD.
There are two treatment manuals that research studies have shown often improve BDD. These treatment manuals provide therapists with a detailed guide to treating BDD with CBT:
If one of these manuals is not adequately helpful for a particular patient, the other manual may be.
We do not recommend that patients create flaws or exaggerate minor flaws (for example, draw red circles on their skin or wear strange hair-dos) and then go out in public. More generally, we believe that patients should not be encouraged to do anything that is purposely humiliating in public as part of their treatment.
Usually about 6 months of weekly manual-guided treatment is needed, with subsequent “booster” sessions provided as needed to help patients maintain their treatment gains. However, the frequency and duration of treatment should be tailored to each patient’s individual needs. More severely ill patients may need more frequent treatment sessions and a longer course of treatment, whereas more mildly ill patients may improve with fewer sessions.
A Few Key Considerations
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.
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.
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.