What Can Improve Body Dysmorphic Disorder (BDD) If a Serotonin-Reuptake Inhibitor (SRI, SSRI) Medication Isn’t Effective Enough?

by Katharine A. Phillips, M.D.

In previous blogs I’ve discussed that a class of medications called serotonin-reuptake inhibitors (abbreviated as SRIs or SSRIs) are the first-choice medication treatment for body dysmorphic disorder (BDD). These widely used medications usually significantly improve BDD symptoms and many co-occurring symptoms, such as depression and anxiety.

• Top 10 Recommendations for Treating Body Dysmorphic Disorder (BDD) with Medication
• Frequently Asked Questions about Treatment for Body Dysmorphic Disorder (BDD)

Here I’ll discuss what medication options can be tried if an SRI/SSRI doesn’t work well enough.

Have You Had an Optimal SRI/SSRI Trial?
If an SRI/SSRI doesn’t work well enough, the first important step is to figure out whether you’ve previously had an optimal SRI/SSRI trial by asking these questions:

• Have you tried a high enough dose? If a lower dose doesn’t work well enough, I usually gradually increase the dose up to the maximum SSRI dose that’s commonly recommended for BDD (if this high a dose is needed and well tolerated). I discuss maximum doses here https://bdd.iocdf.org/blog/2022/01/14/top-10-recommendations-for-treating-body-dysmorphic-disorder-bdd-with-medication/. The same maximum SSRI doses are used for OCD. An EKG (electrocardiogram), which is quick and painless, is needed when taking clomipramine (Anafranil), 40 mg/day (or more) of escitalopram (Lexapro), or the maximum BDD dose of other SSRIs. 
• If side effects have prevented the maximum SRI/SSRI dose from being reached (which is unusual but possible), have efforts been made to reduce or eliminate them? This often helps. Or, side effects may improve simply with the passage of time.
• Has the SRI/SSRI been taken for a long enough time (at least 3 to 4 months), while reaching a high enough dose? If the dose is increased slowly, more than 3-4 months may be needed to see how helpful the medication is.
• Have you taken the SRI/SSRI every day (no missed doses)? If medication is missed, even infrequently, it may not work as well. Simply taking the medicine every day (a pill box or app can help with this) may improve BDD, mood, anxiety, and certain other symptoms.

Unfortunately, very few people with BDD get an optimal trial of an SRI/SSRI. Doses are usually too low, the SRI/SSRI may be stopped too soon, or doses are missed. If any of these problems occur, optimizing the SRI/SSRI trial in the ways I just discussed may help, sometimes a lot. An optimal SRI/SSRI trial usually substantially improves BDD symptoms (and co-occurring depression, anxiety, and some other mental health symptoms).

Next Steps
If you’ve had an optimal SRI/SSRI trial, but BDD symptoms haven’t improved enough, here
are options to consider:

1. Another medication can be added to the SRI/SSRI to boost its effectiveness (called “augmentation”).
2. A different SRI/SSRI can be tried.
3. A non-SRI medication that boosts the brain chemical serotonin can be tried.
4. Cognitive-behavioral therapy (CBT) can be added to medication.

Unfortunately, there aren’t many research studies on these strategies, and we don’t know which one works best for BDD. But based on what we do know, all of these strategies may improve BDD. The decision about which approach to use needs to be individualized to each person.

Adding Another Medication to the SRI/SSRI (Augmentation)
If an SRI/SSRI has at least partially improved symptoms, I usually add another medication to the SRI/SSRI rather than switch to different SRI/SSRI. This allows improvement from the SRI/SSRI to be maintained and hopefully boosted. Here are some augmentation strategies:

• Second-generation (atypical) neuroleptics may be helpful when added to an SRI/SSRI. They are often my first choice for SRI/SSRI augmentation for people who are more highly suicidal, more severely depressed, severely anxious or agitated, or at high risk for impulsive or aggressive behavior. For people with symptoms like these, it may be wise to add an atypical neuroleptic at the beginning of SRI/SSRI treatment, rather than waiting for 3 or more months for an optimal SRI/SSRI trial to be done first and then seeing if augmentation is needed. Aripiprazole (Abilify) is often my first choice, but other atypical neuroleptics can also be considered. The best choice may differ for different people.
• Buspirone (Buspar) can be an appealing option because side effects are uncommon. Adding buspirone to an SRI/SSRI can be an especially good choice for people who are anxious but not severely depressed. Effective maximum doses for BDD tend to range from 30 to 60 mg a day and sometimes up to 80 or 90 mg a day.
• N-Acetylcysteine (NAC) or memantine (Namenda): Based on having treated a lot of people, my sense is that these medications probably don’t work as often, or as well, as an atypical neuroleptic or buspirone, but they do help some people when they’re added to an SRI/SSRI. And they only rarely cause side effects. NAC is available as a non-prescription supplement (but be sure that a licensed prescriber oversees use of NAC!). If a lower dose doesn’t help enough, I usually try to gradually raise the NAC dose to as high as 1,800 mg twice a day and memantine to as high as 20 mg twice a day (if needed and well-tolerated).
• Clomipramine (Anafranil) can be added to an SSRI. But SSRIs (selective SRIs) can substantially increase blood levels of clomipramine (which is an SRI). This can be risky. So I recommend 1) getting an EKG before starting clomipramine to be sure that it’s normal, 2) starting clomipramine at a low dose (only 25 mg/day), and 3) getting subsequent clomipramine blood levels and EKGs (to be sure that EKGs remain normal, which they usually do). Blood levels determine the right clomipramine dose for each person.
• Bupropion (Wellbutrin) is sometimes helpful when added to an SRI/SSRI, especially for co-occurring depression that doesn’t fully improve with an SRI/SSRI, or for low sex drive. But it doesn’t seem to usually improve BDD symptoms much, if at all.

More than one of these augmentation treatments can be used at the same time. None of them
(except the SRI clomipramine) are used alone for BDD. They need to be added to an SRI/SSRI.

Switching to A Different SRI/SSRI
If an optimal SRI/SSRI trial doesn’t improve symptoms enough, and if SRI/SSRI augmentation isn’t helpful enough, other SRIs/SSRIs can be tried. Usually, we first treat with an SSRI (a selective SRI). I often try the SSRIs fluoxetine (Prozac) or sertraline (Zoloft) first, but the best SSRI choice must be tailored to each person, considering things like what medications they’ve tried in the past and what effects they had. Then (if needed) we move on to try a second SSRI, and then (if needed) we often try the SRI clomipramine. These sequential steps are similar to how we treat OCD. On average, all SRIs/SSRIs are probably equally effective for BDD, but one may work better than another for a particular person.

Medication Alternatives to an SRI/SSRI
I’m not sure why so many people with BDD (or OCD) who’ve never had a good SRI/SSRI trial are treated with an SNRI (serotonin-norepinephrine reuptake inhibitor). There’s very little scientific evidence regarding their effectiveness for BDD. (And for OCD, there’s much less evidence for their effectiveness than there is for SRIs/SSRIs.) SNRIs include venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq). In my experience, SNRIs sometimes improve BDD and OCD, but they aren’t a first-choice medication for either disorder. However, an SNRI can be considered after trying a number of SRIs/SSRIs.

Other medications that (like SRIs/SSRIs) boost serotonin (vilazodone [Viibryd] and vortioxetine [Trintellix]) can also be tried if multiple SRIs/SSRIs don’t work or aren’t tolerated (which is uncommon). Doses of up to 450 mg/day of venlafaxine, 150 mg/day of duloxetine, and 60 mg/day of vilazodone may be needed.

I’m often asked if psychedelics (such as psilocybin), ketamine, or transcranial magnetic stimulation (TMS) are effective for BDD. No one really knows. Only one small uncontrolled study of a psychedelic has been done, and no scientific studies have examined the effectiveness of ketamine or TMS for BDD. So currently, they aren’t recommended treatments for BDD.

How Do You Know Which Strategy to Try?
There’s no one-size-fits-all approach to choosing the best strategy. The decision must be individualized to each person and is based on multiple considerations, such as:

1. Which medications were tried in the past? To what extent did they improve BDD and co-occurring symptoms? Were there any side effects; if there were, how bothersome were they, and did they improve with the passage of time? Were any strategies used to alleviate them? It can be helpful to get input from family members or friends about what effects they observed.
2. If you’ve tried any of the strategies that I’ve just discussed, how good a try did you give them? For example, what was the maximum SRI/SSRI dose, for how long was it taken, and how often was it missed? Why was it stopped?
3. What co-occurring mental health disorders do you have?
4. What medical problems do you have?
5. Etc.

Don’t Let Genetic Testing Prevent You from Getting Good Treatment
I’ve seen many people with BDD who have needlessly suffered because they thought that they couldn’t or shouldn’t take an SRI/SSRI because of genetic testing results. Currently, genetic testing cannot predict: 1) whether you can take an SRI/SSRI, 2) whether an SRI/SSRI or any of the medications I’ve discussed will improve BDD, or 3) which medication will work best for BDD. So please don’t forgo an SRI/SSRI because of genetic testing results!

Don’t Forget CBT!
CBT (cognitive-behavioral therapy) that’s tailored to BDD’s unique symptoms is the first-choice therapy for BDD. When I say tailored to BDD, I mean that BDD shouldn’t be treated with CBT for OCD, CBT for social anxiety disorder, CBT for depression, or CBT for any other condition, because it probably won’t help much.

Two treatment manuals for therapists to use have been shown in good research studies (randomized controlled trials) to improve BDD. One, authored by Sabine Wilhelm, PhD, myself, and Gail Steketee, PhD, is “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual”. The other, by David Veale, MD, and Fugen Neziroglu, PhD, is “Body Dysmorphic Disorder: A Treatment Manual”.

Concluding Thoughts
Most people with BDD substantially improve with an optimal SRI/SSRI trial. For those who don’t, the options I’ve discussed can help. Deciding which strategy to use is based on multiple considerations and is tailored to each person. Sometimes more than one strategy is needed. Taking the medication every single day can make a big difference. CBT that’s tailored to BDD’s unique symptoms can be added at any time during medication treatment. And medication plus CBT is recommended for more severe BDD. https://bdd.iocdf.org/blog/2024/07/10/which-works-better-for-body-dysmorphic-disorder-bdd-medication-or-cognitive-behavioral-therapy/

Katharine A. Phillips, M.D., is Professor of Psychiatry, DeWitt Wallace Senior Scholar, and Psychiatry 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 380 articles, chapters, and letters 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.