By Katharine A. Phillips, M.D.
Medication often substantially improves BDD symptoms. But before saying more about this, I want to briefly mention what BDD is – and isn’t. These days, BDD is often confused with other body image issues that are not BDD. It’s important to be aware of this because some of the things that BDD is confused with need a different treatment than BDD does – or may not need treatment at all.
BDD is not:
- Normal body image dissatisfaction
- “Body dysmorphia,” zoom dysmorphia,” “snapchat dysmorphia,” and other types of “dysmorphias” (more on this below)
- An eating disorder
Here’s what BDD is:
1) People with BDD are preoccupied with flaws or defects that they perceive in their appearance, which other people can’t see or consider to be only slight (not clearly noticeable). In other words, people with BDD have distorted body image. Even though they think they look ugly, unattractive, or even hideous, they actually look normal or attractive. People with BDD usually obsess about their perceived appearance flaws, in total, for least an hour a day. On average, they obsess for 3 to 8 hours a day.
2) To qualify for a diagnosis of BDD, the appearance preoccupations must also cause significant emotional distress (such as anxiety or depressed mood) or significant impairment in day-to-day functioning (for example, poor concentration, avoidance of social situations, or difficulty with work, school, or other life activities). This is an important way to differentiate the disorder BDD – which needs mental health treatment — from more normal and common dissatisfaction with appearance.
3) In addition, people with BDD repeatedly perform certain behaviors (often called “rituals” or “compulsions”) in response to their appearance concerns. Common behaviors are checking mirrors and other reflecting surfaces, excessive grooming (such as hair styling), asking other people if you look okay, skin picking to try to make your skin look better, touching disliked body parts to check them, and taking excessive selfies to check how you look.
Increasingly, we’re hearing new terms like “body dysmorphia,” “snapchat dysmorphia,” “skin dysmorphia,” “acne dysmorphia,” “tanning dysmorphia,” and “zoom dysmorphia.” These terms are usually not well-defined. This makes it hard to know whether they’re referring to the disorder BDD or, instead, to common, non-problematic body image dissatisfaction.
What I say in this blog applies to the disorder BDD.
What’s the best medication for BDD?
Serotonin-reuptake inhibitors (SRIs, or SSRIs) are the first-choice medication for BDD. They work for most people — if you:
- Take the right dose
- Try them for a long enough time, and
- Don’t miss doses
SRI medications usually decrease — or completely stop — appearance preoccupations and repetitive BDD behaviors (like mirror checking). They often make it easier to leave the house, be around other people, and go to school or work. Depression, anxiety, concentration/focus, anger/hostility, and suicidal thinking usually improve as well. They’re not addicting.
Unfortunately, most people take SRI doses that are too low to effectively treat BDD (more on that below).
In my previous blog on this website, “Top Ten Recommendations for Treating Body Dysmorphic Disorder (BDD) with Medication,” I give more detail about treating BDD with an SRI.
My BDD is really bad. How can just taking a pill help me feel better?
It’s true: a medication really can help you feel better, enjoy life more, function better day to day, and be your best self. This is the same as for many other disorders, such as obsessive-compulsive disorder (OCD), major depressive disorder, and anxiety disorders.
People tell me that I have BDD, and I think I might have it because I obsess about how I look and I check mirrors a lot. But I think I really am ugly. How can a medicine help me?
This is a common situation: a person obsesses about flaws that they perceive in their appearance, and these obsessions cause them significant emotional distress or interfere with daily functioning. Yet, the person doesn’t believe that they have BDD because they think they really do look abnormal or ugly (even though they don’t in the eyes of others). These individuals actually do have BDD.
Keep in mind that people with BDD see themselves differently than other people see them. BDD isn’t a problem with a person’s actual appearance. BDD is a problem with how the person perceives their appearance. In other words, it’s a body image problem. In this way, BDD is like anorexia nervosa, where people believe they’re fat even though they’re actually very thin.
If you think you look abnormal but other people say you don’t, I encourage you to be open-minded and find out if you have BDD. There’s no downside to doing this. If you’re diagnosed with BDD, I encourage you to try treatments that are often effective (medication and/or cognitive-behavioral therapy for BDD). These treatments usually improve BDD symptoms, functioning, quality of life, and well-being.
I’ve taken SRIs before, but I didn’t feel better. What should I do?
I discussed this in my previous blog on this website, but it’s so important that I’ll also say something about it here. For medication to work you need:
- The right medication (an SRI)
- The right dose
- A long enough try
- To take it every day (not miss doses)
If any of these things are missing, medication might not work for you.
Get as much information as you can about your past SRI trials:
- What dose did you reach? Was it high enough?
- How long did you try it for? Did you try it for long enough?
- Did you take it every day?
If you didn’t reach a high enough dose or give the SRI a long enough try (at least 3 to 4 months – or longer, if your dose was increased more slowly than usual), it may be worth trying again. It may also be worth trying it again if you didn’t take it every day.
Or you could try a different SRI. One SRI may work better for you than another one. Unfortunately, there’s no way to predict which one will work best for you.
Many people don’t take a high enough SRI dose, so it doesn’t work. Maximum SRI doses for BDD (and OCD), which some adults need, are:
- Prozac (fluoxetine): up to 120 mg a day
- Zoloft (sertraline): up to 400 mg a day
- Lexapro (escitalopram): up to 60 mg a day (with EKGs)
- Paxil (paroxetine): up to 100 mg a day
- Anafranil (clomipramine): up to 250 mg a day (with EKGs)
- Luvox (fluvoxamine): up to 450 mg a day
It’s wise for younger youth and the elderly to not reach doses quite as high as these.
Not everyone needs doses as high as these, but some people do. If you’re an adult, and a lower dose doesn’t work well enough for you, it’s worth trying a higher dose (if you’re tolerating it well, which most people do).
An EKG (electrocardiogram, a quick and painless procedure that assesses your heart’s electrical rhythm), should be obtained when taking clomipramine or when taking 40 mg a day (or more) of escitalopram. I also often get an EKG when someone is taking a high dose of other SSRIs. Certain medical conditions or symptoms might affect whether you should get an EKG on a lower dose of escitalopram or on one of the other SRIs; you should discuss this with your doctor.
You say that high SRI doses are often needed for BDD. Should I start at a high dose?
No; these medications should be started at a lower dose. The dose is then gradually raised as needed. This reduces the risk of side effects. Also, some people don’t need a high dose to feel better.
Here are some examples of starting doses and how quickly the dose can be increased:
Fluoxetine (Prozac): For adults, the usual starting dose is 20 mg/day for 2 to 3 weeks. The dose can be increased by 20 mg a day every 2 to 3 weeks or so (as tolerated) up to 80 mg a day, unless a lower dose is helping. If a lower dose is helping, that dose can be tried for a longer time to see if symptoms continue to improve. If 80 mg a day is not adequately effective after a total trial duration of 12-16 weeks (with at least 3-4 of these weeks on 80 mg a day), you and your doctor could consider gradually increasing the dose further, up to a maximum of 120 mg a day, if you’re tolerating it well. For younger youth, a suggested starting dose is 10 mg a day, while increasing the dose a little more slowly and reaching a lower maximum dose.
Sertraline (Zoloft): For adults, the usual starting dose is 50 mg a day for 2 to 3 weeks. The dose can then be subsequently increased by 50 mg a day every 2 to 3 weeks or so (if tolerated) up to 200 mg a day, unless a lower dose is helping. If a lower dose is helping, that dose can be tried for a longer time to see if symptoms continue to improve. If 200 mg a day isn’t adequately effective after a total trial duration of 12-16 weeks (with at least 3-4 of these weeks on 200 mg a day), the dose could gradually be raised further, up to a maximum of 400 mg a day. For younger youth, a suggested starting dose is 25 mg/day, while increasing the dose a little more slowly and reaching a lower maximum dose.
If a lower dose seems to be working for you, and you gradually feel better and better while taking that dose, you can slow down the rate at which the medication is increased and give the lower dose more time to work. You might not end up needing to increase the dose further.
My prior blog on this website gives more detail about maximum doses and average doses typically needed for BDD.
How long does it take for an SRI to work?
On average, it takes 4-9 weeks for an SRI to meaningfully improve BDD symptoms. It can take as long as 12 to 14 or even 16 weeks. If you raise the dose more slowly than in the examples above, it can take longer than this. An SRI usually starts working very gradually. It helps to be patient!
If you’ve meaningfully improved with a 12-16 week trial, your BDD and other symptoms (such as depression and anxiety) may continue to further improve with more time on the medication.
I had genetic testing that said an SRI won’t work for me. What should I do?
Currently, genetic testing can’t accurately predict whether you’ll get better with an SRI or any other medication when used for BDD.
Genetic testing can give information about how fast you metabolize an SRI, but this doesn’t mean that one won’t work for you.
I remember to take my Prozac most days, and it helps me, but I forget a few times a week. Is this a problem?
It could be. Missing medication, even just once a week or so, could make it not work as well for you. It’s important to take the medicine every day.
If it’s hard for you to remember to take it, brainstorm ways to remember – be creative. Here are a few ideas:
- Keep it with your toothbrush, on top of the coffeemaker (if you drink coffee every day), or on your pillow (if you take it at night).
- Set a daily alarm.
- Try a medication reminder app like Medisafe. This free app is available from both the Apple App Store and Google Play.
- Use a pill box. You can get one online or at your pharmacy.
My BDD, OCD, and depression are all so much better on Zoloft. Can I just stop it now?
No – please don’t stop your medication just because you’re feeling better. Assuming you’re tolerating an SRI well (which most people do), my general recommendation is to take it for at least 3-4 years. This may seem like a long time, but most people find that the time flies by quickly. Many people choose to keep taking an effective SRI for longer than this because they feel so much better.
For people who’ve had very severe BDD, multiple hospitalizations because of BDD, or suicide attempts because of BDD, life-long treatment with an SRI may be best and should be seriously considered.
I’ve already tried some SRIs, but I had side effects. Should I try one again?
Sometimes it can be hard to figure out if a physical symptom is a medication side effect or not. Sometimes it is, and sometimes it isn’t. It depends on the specific symptom, when you had the symptom (for example, is it new or worse since starting the medication?), whether there are other possible explanations for the symptom, etc.
If the symptom was probably a side effect but wasn’t severe you could consider trying the same SRI again (especially if the medication helped you). You might not get the same side effect — but you might. Often, there are things that can improve or minimize side effects (for example, taking the medicine at night if it makes you a little tired). Or you could try a different SRI.
SRI side effects often improve the longer you take the medication, as your body adjusts to it.
I’ve heard that SRIs are the best medication for BDD, but I’m afraid I’ll gain weight.
A few SRIs (Anafranil and Paxil) might cause weight gain (but usually don’t). But it’s uncommon for the ones that I usually prescribe for BDD and OCD (fluoxetine [Prozac], sertraline [Zoloft], and escitalopram [Lexapro]) – especially Prozac. In fact, the official prescribing information for fluoxetine (Prozac) says: “In U.S. placebo-controlled clinical trials for OCD, 17% of patients treated with Prozac and 10% of patients treated with placebo reported anorexia (decreased appetite).” It also mentions the potential for weight loss but not weight gain.
There’s a lot of misinformation about SRI side effects on the internet and social media that can make people fearful. Also keep in mind that you’re different from other people, and it’s hard to predict whether you will get a particular side effect. The best approach is to keep an open mind and give the medication a try. Most people tolerate these medications well. Once you’ve given an SRI an adequate try, you can discuss with your prescriber any pros and cons of the medicine for you.
I have really bad BDD. I can’t leave my house and dropped out of school because I don’t want people to see me. Is an SRI enough treatment for me?
It may be. SRIs work as well for severe BDD as for milder BDD. But for severe symptoms, I sometimes prescribe another medication, such as aripiprazole (Abilify), along with an SRI from the beginning of treatment, especially if the person is also very depressed and more highly suicidal. (For less severe symptoms we usually don’t add another medicine for BDD until we’ve given the SRI a good enough try.)
And for severe BDD, I always recommend cognitive behavioral therapy (CBT) for BDD in addition to an SRI medication. CBT needs to be tailored to BDD’s unique symptoms. CBT can also be used for less severe BDD.
It can be helpful for therapists to use a BDD-specific treatment manual to guide therapy. In well-done, published treatment studies, two treatment manuals have been shown to often improve BDD: Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual by Sabine Wilhelm, myself, and Gail Steketee, and Body Dysmorphic Disorder: A Treatment Manual by David Veale and Fugen Neziroglu. Session frequency varies from an hour a week to multiple days a week for hours a day. The frequency needs to be tailored to each person’s specific needs.
Even though BDD can be very severe and even life-threatening, most people get better with these treatments.
These recommendations are based on published studies (I and my colleagues have conducted most of the published BDD medication studies) 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). A knowledgeable licensed prescriber should guide your medication treatment. Recommendations may change in the future, as knowledge about 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.
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 more than 350 articles (most on BDD) in scientific journals and books.