By Katharine A. Phillips, MD
1. Certain medications are recommended for treating BDD, especially moderate to severe BDD. The right medication usually substantially improves BDD symptoms. It can even be lifesaving.
It may be hard to believe that a simple pill can substantially improve BDD symptoms and sometimes even take them all away. After all, if you think you look ugly, abnormal, or unattractive, wouldn’t a cosmetic procedure be the way to go? Unfortunately, cosmetic procedures almost never help BDD concerns and can even make them worse. So they’re not recommended for BDD. In contrast, certain medications can substantially improve BDD symptoms. This is incredibly good news because BDD causes tremendous suffering, usually interferes with day-to-day functioning, and is associated with very high rates of suicidality.
For medication to work you need:
- The right medication
- The right dose
- A long enough try
- Good adherence (not missing any doses)
Medication can be used for milder or more moderate BDD symptoms. It’s always recommended for severe BDD and worrisome levels of suicidality (in addition to therapy).
Even if you think you don’t have BDD, but you’re preoccupied with perceived defects in your physical appearance that cause significant emotional distress or impairment in daily functioning, the right medication can help.
2. Serotonin reuptake inhibitors (SRI’s, SSRI’s) are the first-choice medication for BDD.
SRIs are used to treat many psychiatric and medical conditions, and they’re not addictive or habit forming.
SRIs are often effective for BDD; they substantially improved BDD symptoms in more than 50% to more than 80% of participants in research studies. These numbers are even higher if a full 12 to 14 weeks of treatment is completed. And in clinical practice, we can use higher doses of most SRIs than were used in studies, which can further increase the chance of improving. Furthermore, among people who substantially improve within 12-14 weeks, more than one-third continue to get even better during 6 more months of SRI treatment.
In addition to improving BDD obsessions, repetitive behaviors (i.e., rituals, compulsions), and distress, SRIs also often improve depression, anger/irritability, anxiety, panic attacks, social anxiety and avoidance, insight, functioning, suicidality, and quality of life.
This table lists available SRIs and dosing information for BDD.
|Generic name||Brand names||Average dose (mg/day) for BDD||Maximum dose (mg/day) sometimes used for BDD**||Effective dose range (mg/day) for two-thirds of people with BDD|
|Fluoxetine||Prozac, Sarafem||67 mg||120 mg||43 – 91 mg|
|Escitalopram||Lexapro, Cipralex||29 mg in one sample, 45 mg in another sample||60 mg||17 – 41 mg (first sample), 30 – 60 mg (second sample)|
|Sertraline||Zoloft, Lustral||202 mg||400 mg||156 – 248 mg|
|Fluvoxamine||Luvox, Faverin, Fevarin, Floxyfral, Dumyrox||308 mg||450 mg||259 – 357 mg|
|Clomipramine||Anafranil||203 mg||250 mg||150 – 250 mg|
|Paroxetine||Paxil, Pexeva,Brisdelle, Seroxat||55 mg||100 mg||42 – 68 mg|
|Citalopram (no longer recommended)||Celexa, Cipramil||66 mg (this dose exceeds the revised, fairly firm FDA dosing limit of 40 mg/day and 20 mg/day if over age 60)||40 mg (20 mg/day if over age 60)||30 – 100 mg|
|** Lower maximum doses should be considered for the elderly and younger youth, especially children. It is generally recommended that the FDA maximum dose not be exceeded when treating younger youth.|
All SRIs are probably equally effective for BDD, but I usually prefer fluoxetine, escitalopram, or sertraline. Clomipramine is a good option if several other SRIs haven’t worked. In the United States, citalopram is the least good choice because the FDA’s (Food and Drug Administration’s) revised maximum dose of 40 mg/day seems firmer than for other SRIs (except clomipramine), and it’s often too low to effectively treat BDD.
The FDA hasn’t approved any medication for BDD, but this doesn’t mean that medications don’t work. It simply means that no pharmaceutical company has spent the money and done the research studies necessary to obtain FDA approval.
Currently, genetic testing can’t predict whether an SRI will work for you or whether one SRI will work better than another.
3. It’s essential to take a high enough SRI dose — otherwise, it may not help.
The table shows average SRI doses for BDD, maximum doses sometimes used for BDD, and the dosing range that two-thirds of people need (that is, 1 standard deviation higher and lower than the average dose). No BDD research studies have rigorously compared the effectiveness of different doses, so these doses come from my clinical practice. These maximum doses have been endorsed in a publication on medication for BDD by the International College of Obsessive-Compulsive Spectrum Disorders; they are also the same as those in the American Psychiatric Association’s practice guideline for obsessive compulsive disorder. Lower maximum doses are recommended for children and the elderly. An electrocardiogram (EKG), which is quick and painless, should be obtained when using clomipramine. I also order one when prescribing 40 mg/day (or more) of escitalopram and sometimes when prescribing a high dose of other SSRIs.
4. It’s essential to try medication for a long enough time – otherwise, it may not help.
Some people take an SRI for only a few weeks or a month or two and then stop it because it isn’t working. But often, this isn’t long enough to see if it will work. Trying it for at least 12 to 14 weeks is recommended, while reaching the following doses (if needed) for at least the last month or so of the 12-14 weeks: fluoxetine 80 mg/day, escitalopram 30 mg/day, sertraline 200 mg/day, fluvoxamine 300 mg/day, paroxetine 60 mg/day. Some people don’t need to reach these doses because a lower dose is working for them; or occasionally, these medications cause side effects that limit dose increases. Clomipramine dosing is guided by blood levels. If it takes longer than usual to reach these doses, more than 12 to 14 weeks are needed to see if an SRI is effective. To work, the medication has to be taken every day.
5. If an SRI doesn’t work well enough, these steps may help.
1) First, take the medication every day if you’ve been missing doses.
2) I usually recommend to next increase the dose further, gradually moving toward the maximum dose in the table, if you haven’t reached this dose and you’re tolerating the medication well (again, lower maximum doses than these are advisable for children and the elderly).
3) You can add another medication to boost (augment) the SRI’s effects (see below).
4) You can switch to a different SRI (see below).
5) You can try a non-SRI medication that boosts the brain chemical serotonin (such as duloxetine [Cymbalta], venlafaxine [Effexor], or vilazodone [Viibryd]). But I usually recommend trying multiple SRIs before doing this. Psychedelics are not currently recommended and have substantial risks.
6. If a good SRI trial doesn’t help enough, “add on” (augmenting) medications may further improve BDD symptoms.
Research studies of this approach are very limited. However, I sometimes recommend adding an “atypical neuroleptic” (also known as “atypical antipsychotics” or “mental health medications”) to an SRI if needed. I generally prefer aripiprazole (brand name: Abilify), but others may also work. They can be especially helpful for more severe BDD symptoms and/or severe depression, agitation, or worrisome suicidality. Sometimes it’s best to start them before completing a good SRI trial. Buspirone (Buspar), NAC (N-acetylcysteine), and memantine (Namenda) may also be helpful SRI add-ons. Other medications are sometimes added to an SRI. These medications have different pros and cons, and the choice needs to be individualized for you.
7. If a good SRI trial plus adding one or more medications doesn’t help enough, another SRI may work better.
If a good try of one SRI doesn’t work well enough, it’s definitely worth trying others. One may work better than another for you, although the best one can’t be predicted ahead of time.
8. Once you find medication that works, stay on it for a long enough time.
I generally recommend continuing an effective SRI for at least 3-4 years. (Women who wish to become pregnant should consult with a reproductive psychiatrist.) I usually recommend longer treatment – sometimes life-long SRI treatment — for some people (for example, those with very severe BDD, hospitalizations for BDD, suicide attempts, or multiple episodes of symptom worsening with previous SRI discontinuation). SRIs have been prescribed for nearly 40 years, are safe over the longer term, and even appear to have multiple physical health benefits.
But everyone is different, and this decision needs to be individualized to you. If you want to stop an effective SRI, plan this carefully with your doctor, because discontinuing an effective SRI can result in a return of symptoms. It’s better to taper it slowly (for example, over 6 or more months), rather than suddenly stopping it, during a low-stress time of your life.
9. Don’t believe false information about psychiatric medication.
There’s so much misinformation about psychiatric medication! This misinformation causes lots of unnecessary suffering…. These medications are often effective, usually well-tolerated, and can be lifesaving. Don’t let false information prevent you from getting well!
10. If you get side effects, be patient. They often disappear with time; if not, they’re often treatable.
Most people get no side effects or only minimal ones. And it can be hard to figure out if a physical symptom is actually a side effect – maybe it is, and maybe it isn’t…. If side effects occur, they’re often tolerable and often get better with time. If not, certain remedies may help. If you think you’re sensitive to medications, you can start medication at a lower than usual dose and increase it more slowly, which may improve tolerability. Don’t let fear of side effects prevent you from getting well! See what the pros and cons are for you after giving medication an adequate try.
Finally – maintain hope! Medication and/or cognitive-behavioral therapy that’s tailored to BDD help most people with BDD, and for more severe BDD symptoms both treatments in combination are recommended.
*These recommendations are based on published studies (most of which I and my colleagues have conducted) as well as my clinical experience treating people with BDD for more than 30 years. However, treatment needs to be individualized to each person, and these recommendations may need to be modified for some people (for example, due to co-occurring psychiatric or medical conditions). Please don’t treat yourself; a knowledgeable licensed prescriber should guide your medication treatment. Recommendations may change in the future, as knowledge about the treatment of BDD increases.
Katharine A. Phillips, M.D., is Professor of Psychiatry, DeWitt Wallace Senior Scholar, and Residency Research Director in the Department of Psychiatry at Weill Cornell Medical College in New York City. She is also Attending Psychiatrist at New York-Presbyterian/Weill Cornell Medical Center, and she is Adjunct Professor of Psychiatry and Human Behavior at the Alpert Medical School of Brown University.
Dr. Phillips is author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (also the Revised and Expanded Edition), and Understanding Body Dysmorphic Disorder: An Essential Guide. She is the editor of Body Dysmorphic Disorder: Advances in Research and Clinical Practice. She has authored or edited 8 additional books on BDD, body image, OCD, and other topics, and she has published hundreds of articles on BDD in scientific journals and books.