There are both therapy- and medication-based treatment options to help those with BDD. The goal of these treatments is to improve quality of life and overall day-to-day functioning of those with BDD, while also decreasing appearance preoccupations, the distress associated with appearance concerns, and compulsive behaviors that are also commonly seen in BDD.
- Cognitive behavioral therapy (CBT) has been shown to improve BDD symptoms in a majority of people, both in individual therapy or group therapy. It is the only type of psychological treatment for BDD that is well supported by research studies. Importantly, CBT must be tailored to BDD’s unique symptoms. CBT treatment manuals are available for therapists to use when treating BDD; they are the only two treatment manuals that have been tested and shown to be effective in published research studies.
- Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual, by Sabine Wilhelm, Katharine A. Phillips, and Gail Steketee. New York, NY: Guilford Press, 2013
- Body Dysmorphic Disorder: A Treatment Manual, by David Veale and Fugen Neziroglu. West Sussex: Wiley Blackwell 2010.
- A type of medication called serotonin reuptake inhibitors (SRIs) A type of medication called serotonin reuptake inhibitors (SRIs) is the first-line medication treatment for BDD. These medications significantly improve BDD in a majority of people. The following medications are SRIs: fluoxetine, sertraline, escitalopram, fluvoxamine, paroxetine, citalopram, and clomipramine. (These are the “generic” names; each medicine also has brand names that may differ in different countries. High doses of these medications are often needed to successfully treat BDD.” High doses of these medications are often needed to successfully treat BDD (like OCD). Adding other medications to the SRI, such as buspirone or aripiprazole, can be helpful.
Note: The following information is provided as a general guideline and should not be used as a substitute for meeting with a mental health professional familiar with treating BDD. People with BDD may have a variety of additional problems and may experience different responses to treatments, so a professional assessment by a mental health professional and an individualized treatment plan are highly recommended.
Cognitive Behavior Therapy for BDD
Dr Jedediah Siev discusses the four components of cognitive behavior therapy to help treat Body Dysmorphic Disorder (BDD)
Why CBT for BDD?
The use of Cognitive behavioral therapy (CBT) for BDD is based on both clinical experience and research findings that show that individuals with BDD over-focus on small details of their appearance instead of seeing the big picture. In addition, individuals with BDD place excessive value on being physically attractive and this focus on appearance strongly affects these individuals sense of self-worth (“If I feel attractive, then I am a good or lovable person. If I don’t think I’m attractive, I am a loser and no one will ever want to be around me or even see me”).
CBT has been shown to be helpful in treating BDD symptoms both in individual therapy or group therapy, and is the only type of psychological treatment for BDD that is supported by research. CBT focuses on the thoughts (i.e., cognitions) and repetitive behaviors triggered by BDD, such as the excessive attention BDD patients give to specific, small aspects of their appearance (e.g., perceived flaws).
What Does CBT Look Like?
In CBT, the therapist and individual work as a team to identify and challenge the thought and behavior patterns involved in the patient’s specific BDD symptoms. In particular, the goal of CBT is to help individuals in identifying their unhelpful appearance-related thoughts and developing more flexible beliefs. Individuals are also asked to gradually participate in more and more challenging situations (which will help to decrease anxiety in the long term), working to change how their brain responds to triggers. This process is also called habituation.
Individuals with BDD also learn strategies to help decrease using avoidance behaviors (for example, avoiding eye contact with others) and compulsive behaviors (for example, repeatedly comparing oneself to others in the room). When one uses avoidance and compulsive behaviors to help decrease anxiety or distress, these behaviors actually reinforce the BDD symptoms. Only by finding ways to deal with triggers without relying on these avoidance strategies or compulsions, can someone begin to overcome BDD.
In addition, CBT also teaches individuals how to “see the big picture.” For example, individuals learn to view themselves more holistically and non-judgmentally when in front of the mirror instead of focusing on any perceived flaws.
CBT strategies are practiced in the therapy sessions and as homework assignments between sessions in order to help individuals learn new skills and to use them in many different types of situations. Family members may also be involved, as it is common for family members or significant others to become involved in a loved one’s compulsive behaviors (for example, repeatedly offering the individual with BDD reassurance about his/her appearance). This happens often and is understandable, as it is difficult to watch a loved one suffer. Therapists can be helpful in providing information about BDD and in working with family members to find more helpful and supportive strategies.
Medication for BDD
The category of medications called serotonin reuptake inhibitors (SRIs), also known as selective serotonin reuptake inhibitors (SSRIs), is considered the first-line medication treatment for BDD. These medications are antidepressants, but unlike non-SRI antidepressants they also help reduce obsessive thoughts and compulsive behaviors (which are symptoms of BDD). They are effective for treating BDD, major depressive disorder, most anxiety disorders including obsessive compulsive disorder, and other conditions.
There are no medications that currently have FDA approval for treating BDD, because no pharmaceutical company has been interested in pursuing this indication; however, research and clinical experience suggests that SRIs are safe and effective for a majority of people with BDD. To learn more about the SRIs used for BDD and typical dosages, read the Medication FAQ here.
Research studies about other medications for BDD are very limited. At this time, non-SRI medications are not currently recommended as the only medication treatment for BDD.
People with BDD who improve with SRIs spend less time obsessing about their appearance and have better control over their compulsive behaviors. The distress that BDD causes, as well as anger, suicidal thinking, and daily functioning, also usually improve significantly. This often makes it easier to engage in and have success with cognitive behavioral therapy (CBT) if it is needed because your symptoms don’t completely resolve with medication.
Individuals with milder or more moderate BDD symptoms may benefit from either medication or therapy alone. Individuals who suffer from severe BDD can potentially improve with either treatment alone, but it is often recommended to combine psychotherapy and medication, especially if the person is suicidal.
Some people’s ability to use what they are learning in therapy is limited by depression, anxiety, obsessive thoughts, rigid thinking patterns, and poor insight. These symptoms usually improve with medication treatment, making it easier to engage in therapy.
Studies have shown that, on average, about two-thirds to three-quarters of people will experience a 30% or more reduction in BDD symptoms from taking an SRI, including noticeable improvements in terms of reduced distress and improved day-to-day functioning. Some people’s symptoms go away completely with an SRI. If your medication response doesn’t feel like it is enough, options include increasing the SRI dose, trying another medication, or trying CBT.
BDD Treatment: What Does Not Work?
Because they see their problems as something physical that needs to be changed, many individuals with BDD (including kids and teens) end up trying many cosmetic treatments to “fix” their perceived flaws. These treatments can vary from cosmetic surgery (such as face lifts) to other procedures (such as skin smoothing treatments) and can cost thousands of dollars, and rarely improve BDD symptoms. More often, individuals actually report an increase in concerns about their appearance (feeling “disfigured”) or develop new areas of concern (changing from a concern with nose size, for example, to hair thickness) following cosmetic treatment. In severe cases, some individuals with BDD consider suicide or become violent toward their physician after a cosmetic treatment. For more information about cosmetic treatments and BDD please visit this page.
Summary
In summary, CBT for adults with BDD is effective in improving BDD symptoms and has also been shown to improve related symptoms, such as depression, insight, body image, self-esteem and social anxiety. SRI medications are also effective for BDD symptoms, and they also improve related symptoms, such as depression, insight, functioning, and quality of life.
While medication and CBT have shown promising results, attention should continue to focus on developing more effective treatment strategies for BDD. In addition, given how severe and chronic BDD can be, early identification and treatment of the disorder are crucial. Appearance concerns associated with BDD are more than a matter of vanity. The serious psychological impact on individuals with BDD and their loved ones calls for increased public and professional awareness of the disorder and the development of more effective interventions.
by Jennifer L. Greenberg, PsyD; Sabine Wilhelm, PhD; Jamie Feusner, MD; Katharine A. Phillips, MD; & Jeff Szymanski, PhD