Approach

​The main goal of treatment is to reduce the severity of BDD symptoms, psychiatric comorbid conditions (e.g., major depressive disorder, social anxiety disorder, obsessive-compulsive disorder), and suicidality if present, ideally achieving full remission.

There are no up-to-date major practice guidelines available to guide management of body dysmorphic disorder and current practice is based on the best available evidence and clinical experience (where evidence is lacking).

General approach

Pharmacotherapy and cognitive behavioral therapy (CBT) are the main treatment options.[33][34]

  • For mild BDD (Yale-Brown Obsessive-Compulsive Scale Modified for BDD [BDD-YBOCS] score of 20-24) use CBT or pharmacotherapy

  • For moderate BDD (BDD-YBOCS score of 25-30) use CBT and/or pharmacotherapy

  • For severe or extremely severe BDD (BDD-YBOCS score 31 or above) use both CBT and pharmacotherapy. Consider more intensive CBT.

The above are general recommendations; treatment must be tailored to the individual patient.

When choosing between pharmacotherapy and CBT, consider factors such as patient preference, presence of a comorbidity that is likely to improve with pharmacotherapy, availability of CBT, and the patient’s treatment history. Pharmacotherapy takes several weeks, or even several months, before it might start to work.[69]​ For CBT, 6 months of weekly hour-long sessions are often needed.[33]

It can be difficult to engage and retain patients in psychiatric treatment because poor or absent insight is a standard feature in patients with BDD. Most patients seek cosmetic treatment for BDD symptoms.[64]​ This treatment is rarely effective for BDD and should be avoided. Some general recommendations for supporting patients throughout their treatment are:[33] International OCD Foundation: What is BDD? Opens in new window

  • Be nonjudgmental and express empathy for the patient’s suffering

  • Provide psychoeducation about BDD

  • Do not try to talk patients out of their appearance concerns, especially those with delusional beliefs (it is not effective)

  • Explain that cosmetic treatment is not recommended for BDD because the patient is likely to be dissatisfied with the outcome, and BDD symptoms can worsen

  • Convey that psychiatric treatment is likely to be helpful, and encourage the patient to try it

  • If the patient resists psychiatric treatment, focus on their suffering, poor functioning, and the likelihood that recommended treatments will alleviate their suffering

  • Involve supportive family members in treatment if clinically appropriate.

​Patients require ongoing monitoring of BDD symptom severity and for suicidal ideation and behavior during treatment. See Monitoring.

Pharmacotherapy

Selective serotonin-reuptake inhibitors (SSRIs) and the tricyclic antidepressant clomipramine are the first-line medications for BDD.[53][64]​​​[69] ​Note, however, that no medications are approved for BDD in the US because pharmaceutical companies have not sought licensing for this indication. Prescription of the medications discussed below for BDD is therefore considered off-label.

SSRIs (e.g., fluoxetine, sertraline, escitalopram) are usually tried before clomipramine because they are usually better tolerated.[70]​​ High doses of SSRIs or clomipramine are usually needed, typically in the range used for obsessive-compulsive disorder and higher than those often used for other disorders (e.g., depression).[33]

  • ECG monitoring may be required with SSRIs as they can cause QT prolongation. Escitalopram has the disadvantage of requiring ECG monitoring at doses that are relatively low compared with fluoxetine and sertraline (although escitalopram has fewer drug-drug interactions than some of the other SSRIs).[64]​ There is also some evidence to not use escitalopram, or use it with caution, in patients over 65 years.[71]​ ECG monitoring is recommended with clomipramine, see Continuing treatment below.[33][64]

  • Do not give citalopram for patients with BDD because the maximum dose is often too low to effectively treat BDD.[72][73]

  • Clomipramine blood levels are recommended to guide dosing, where available (follow your local protocols).[64] In the author’s opinion, clomipramine blood levels must always be carried out.

Lower than standard starting doses are usually used for younger patients (ages under 18 years), elderly patients, and those with panic disorder or a history of sensitivity to medication adverse effects. Based on the author’s experience, gradually increase the SSRI dose over 5-10 weeks to reach the maximum approved dose, unless a lower dose starts to improve the symptoms, in which case the lower dose can be continued for a longer time to see if it is sufficiently helpful.

An adequate trial of a medication should be at least 12-16 weeks, with at least 4 of these weeks on the maximum approved dose (if a lower dose is not effective).[33] If it takes longer than 5-10 weeks to reach the maximum approved dose, the trial will need to be longer before deciding whether the medication is effective.

No randomized clinical trials have examined the next best step if a first-line SSRI does not adequately improve BDD. The options are to:

  • Further raise the dose of the SSRI to the maximum daily dose

  • Augment the SSRI with another medication (e.g., buspirone, an atypical antipsychotic)

  • Switch to a different SSRI or to clomipramine

    • Clomipramine can be tried if several SSRI trials are not effective. The dose of clomipramine is determined by blood levels. Clomipramine is a tricyclic antidepressant and thus has a low therapeutic index.

In the author’s opinion, the best choice, if tolerated, is to gradually further raise the SSRI dose (e.g., fluoxetine, sertraline, escitalopram - but not citalopram, which is not recommended for BDD) to the maximum dose recommended in the American Psychiatric Association practice guideline for obsessive-compulsive disorder (OCD).[70][64]​ Consider ECG monitoring for patients on high doses of SSRIs - see below. Clinical experience suggests that this approach is often the simplest and best tolerated, and it is often effective.

Augmentation therapy

Strategies for augmenting SSRIs or clomipramine with other medications have not been well studied. However, clinical experience indicates that adding buspirone or an atypical antipsychotic (e.g., aripiprazole) can be effective. Because of the potential adverse effect profile of antipsychotics, the author usually reserves augmentation with an antipsychotic for patients who still have severe BDD, depression, moderate-to-severe comorbid OCD, agitation, or suicidality, after treatment with an SSRI or clomipramine alone. However, for patients with severe depression, severe agitation, or concerning levels of suicidality at the beginning of treatment, an atypical antipsychotic can be added before completing an adequate trial of an SSRI or clomipramine.

Case series data and clinical experience indicate that augmentation of an SSRI or clomipramine with buspirone (a nonbenzodiazepine anxiolytic) meaningfully improves BDD in 33% to 46% of patients.[74]​ This strategy can also improve depression and anxiety. Buspirone is usually well tolerated.​[33][64]

Clomipramine can be added to an SSRI (or vice versa), but SSRIs can dramatically and unpredictably increase blood levels of clomipramine, which has a narrow therapeutic index. Thus, clomipramine should be started at a low dose when added to an SSRI. Monitoring of clomipramine blood levels is essential to ensure that the therapeutic range is not exceeded. Monitoring should be continued until a therapeutic blood level is achieved. ECGs should also be monitored.​[33][64]​​ The concomitant use of an SSRI and a tricyclic antidepressant, such as clomipramine, can increase the risk of QT interval prolongation and serotonin syndrome.

Augmentation agents are added to an SSRI or clomipramine individually, but over time they can be combined if needed.

Continuing treatment

Clinical experience indicates that an effective SSRI or clomipramine should be continued for at least 3-4 years. For patients who have had more severe symptoms, high levels of suicidality, suicide attempts, psychiatric hospitalizations, or relapses after SSRI or clomipramine discontinuation, longer-term and even lifelong treatment should be considered.[69]​ How long to continue an effective atypical antipsychotic for should be tailored to each patient based on prior illness severity, medication tolerability, adverse effect risk, and other patient-specific factors. Potential adverse effects, and any adverse effects experienced by the patient, should be considered and weighed against the benefits that the patient has experienced.

Patients receiving an atypical antipsychotic require metabolic monitoring and monitoring for the possible development of abnormal movements (tardive dyskinesia).

For those receiving clomipramine, blood levels of clomipramine are recommended, where available, during dose titration to determine when the level is in the therapeutic range (follow your local protocols).[64]​ In the author’s opinion, clomipramine blood levels must always be carried out. During maintenance treatment, follow-up levels can be obtained (for example, yearly); levels should be obtained when medications are added that could affect serum clomipramine levels.

ECGs are recommended during clomipramine titration and for escitalopram even at relatively low doses, although clinical practice varies (check your local protocols).​[33]​​​[64]​ Consider an ECG: for patients on a high dose of other SSRIs (especially sertraline and fluoxetine); when SSRIs or clomipramine are combined with atypical antipsychotics; and when patients take other medications that may prolong the QTc interval.[33][64]​​ A baseline ECG is recommended for patients with a personal or family history of long QT syndrome, arrhythmia, or other potentially relevant cardiac condition.[64] See Monitoring.

Suicidal ideation

Effective SSRI treatment decreases and protects against suicidal ideation in adults with BDD.​​[75][76]​ This has not been studied in children and adolescents with BDD; clinical observations indicate that suicidality in children and adolescents usually decreases with effective SSRI treatment.

Manufacturers warn that antidepressants may increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults. Closely monitor all patients started on SSRIs for the emergence or worsening of suicidal thoughts and behaviors, and advise families and caregivers of the need for close observation.

Cognitive behavioral therapy

CBT is the psychotherapy of choice for people with BDD.[33] CBT must be tailored to the specific symptoms of BDD. CBT for BDD consists of psychoeducation, setting valued goals, and building a CBT model of the patient’s BDD. Then cognitive restructuring, ritual prevention (gradually reducing and stopping repetitive behaviors/rituals, such as excessive mirror checking), exposure with behavioral experiments, and mirror retraining are introduced. Mirror retraining is a brief (e.g., 5 minute) daily exercise that helps the patient learn to see themselves more holistically and nonjudgmentally; it does not involve staring at perceived flaws in the mirror. Behavioral activation is added for patients with more severe depressive symptoms or those who are inactive, and habit reversal training addresses skin picking and hair pulling/plucking. Practitioners should follow a CBT approach that has been demonstrated in a controlled treatment study to be efficacious: for example, that of Wilhelm and colleagues or Veale and Neziroglu.[77][78]​​​[79]​​​[80]

For patients who obtain CBT for BDD, 6 months of weekly, hour-long CBT sessions are typically needed, with symptom monitoring at the beginning of each session.[81]​ Patients with milder BDD may need fewer sessions and those with more severe BDD may need a longer duration of treatment, or more days per week, and/or more hours per day of CBT. CBT given by a more experienced practitioner or in an intensive outpatient or residential setting may be needed. The median time to response of BDD to weekly hour-long CBT (showing 30% or greater improvement) is about 11 weeks, but more treatment is usually needed for additional improvement in symptoms.[82]

Once patients have improved CBT booster sessions (e.g., monthly) may be helpful, and are sometimes needed for a period of time to prevent relapse. Frequency and duration of CBT booster sessions should be tailored to each patient.

CBT can be challenging, but this is necessary for improvement to occur. The patient should practise their learned CBT skills between therapist sessions.[78]​​

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