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By: Katharine A. Phillips, M.D.

I sometimes hear people say that cognitive-behavioral therapy (CBT) works better than medication for body dysmorphic disorder (BDD) — or that medication works better. But these statements aren’t based on high-quality information. The reality is that both treatments work well for BDD, and no one really knows which one is more effective.

Serotonin reuptake inhibitors (also called SSRIs or SRIs) are the first-choice medications for BDD. These widely used antidepressant medications also improve anxiety and decrease obsessive thoughts and repetitive, compulsive behaviors (rituals), which are core BDD symptoms. Fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro) are examples of SSRIs. Most people have few or no side effects, and they are not addicting. SRIs work as well for people who are completely certain that they look ugly, abnormal, or unattractive (those with “absent insight”) as for people who recognize that their view of their appearance may be distorted. (See my prior blogs on using SSRIs for BDD.)

CBT teaches skills to overcome BDD. CBT must be tailored to BDD’s unique symptoms. Core components of CBT for BDD include: 1) cognitive restructuring (to develop more accurate and helpful thoughts and beliefs about your appearance), 2) gradual exposure to feared and avoided situations (which are usually social situations), 3) ritual prevention (to cut back on and eventually stop toxic repetitive behaviors such as excessive mirror checking and excessive grooming), and 4) perceptual retraining (to learn to see your body with less negative judgment and more holistically, rather than zeroing in on disliked areas).

CBT that is tailored to BDD’s unique symptoms and SRIs/SSRIs are the only treatments that have been shown by good research studies to effectively treat BDD.

We’re very fortunate to have two great treatments for BDD. It’s hard to believe that as recently as just a few decades ago, we didn’t know what treatments work for this common and often-severe disorder that can lead to suicide. Since then, good research studies have been done, so we now know that SRIs and CBT substantially improve BDD symptoms for most people, if they are implemented well.

But we don’t know which treatment is better. The reason is that the kind of research study that’s needed to answer this question hasn’t been done.

The only way to really know which treatment is better is to do what’s called a randomized controlled trial. In this type of research study, participants are randomly assigned (like flipping a coin) to receive one treatment or the other, and the researchers determine which treatment works better. The study needs to be large enough, and the people who assess the effect of each treatment shouldn’t know which treatment the participants received (so their assessments aren’t biased). This kind of study is the gold standard for figuring out whether a treatment works and whether one treatment is more effective than another.

I’m a strong proponent of both CBT and SRIs/SSRIs for BDD. I’ve devoted a lot of my life to doing medication studies to figure out which medications improve BDD. I’ve also spent more than a decade co-developing and testing CBT for BDD. And after treating countless people over many decades with these treatments, it’s clear that they usually improve BDD symptoms, functioning, and quality of life.

I think a better question than which treatment is more effective (since we know that both are very good) is: which treatment is better for whom? Ideally, we’d like to know whether certain characteristics that an individual person has (for example, certain symptoms or biological characteristics known as biomarkers) predict whether they will improve more with one treatment than with another. This would enable us to recommend the treatment that’s most likely to help each person, as a unique individual. But unfortunately, such studies haven’t been done in BDD.  They’re hard to do, and I hope that they’re done in the future.

SRIs/SSRIs and CBT each have some advantages. One advantage of the SRI/SSRI medications is that they usually improve symptoms more quickly than CBT does. And because SRIs/SSRIs are effective for many psychiatric symptoms and disorders (such as depression, anxiety disorders, OCD, and some eating disorders), if you have one or more of these disorders in addition to BDD — which most people do — one medication can effectively treat all of them at the same time. Another advantage is that medication is more widely available than CBT. And many people find medication an easier treatment because they simply need to take a pill every day. This treatment isn’t time consuming, and it doesn’t require much effort.

CBT also has some advantages. It’s terrific to learn strategies that you can implement life-long to overcome and manage your symptoms. CBT for BDD also usually improves co-occurring depression. And there’s a lower risk of adverse effects from CBT. (However, most people tolerate SSRIs well, and very few people need to stop an SSRI because of side effects, if the medication is skillfully prescribed.)

So there are potential pros and cons of both CBT and SRIs – and mostly pros for both! They work well alone and also when they’re received together. And if you’re too depressed to do CBT, medication may improve your symptoms to the point where you can do CBT.

Because we can’t yet predict which treatment is more likely to work for a specific person – for you— my general approach is based primarily on BDD severity:

  • For mild BDD, CBT is a great first step. But medication is a reasonable choice if a knowledgeable CBT therapist isn’t available or if you have co-existing disorders that could also improve with an SRI/SSRI (such as OCD, depression, bulimia nervosa, binge eating disorder, or an anxiety disorder).
  • For moderate BDD, I recommend CBT or an SSRI/SRI or both treatments together. The decision about which option to choose should be based on a number of considerations, such as your specific symptoms and your preference.
  • For severe BDD, I usually recommend getting both medication and CBT at the same time. I also recommend both treatments for people who have more severe suicidal thinking.

So the bottom line is that no one really knows whether SRIs/SSRI medication or CBT is better for BDD. But we do know that both treatments improve symptoms for most people, when they are well implemented. Ideally, we’d like to know which treatment is better for whom. In the meantime, we’re very fortunate to have two excellent treatments for BDD!

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. She is also Attending Psychiatrist at New York-Presbyterian Hospital in New York City. Dr. Phillips is internationally recognized for her clinical and research expertise in body dysmorphic disorder (BDD) and OCD. She has published most of the medication studies of BDD, and she has co-developed and tested CBT for BDD. Her scientific studies on BDD were continuously funded by the National Institute of Mental Health for more than 20 years. Dr. Phillips has published more than 365 articles and chapters in scientific journals and books, and she has authored or edited 11 books, including multiple books on BDD. Her awards for her research studies on BDD include a Special Presidential Commendation from the American Psychiatric Association and the 2023 Outstanding Career Achievement Award from the International OCD Foundation.

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