There has been very little research on the treatment of BDD. The NICE guidelines on BDD http://www.nice.org.uk/cg031 recommend two treatments as helpful: cognitive behaviour therapy (CBT), which is specific for BDD, or serotonergic anti-depressant medication. As yet, there have been no controlled trials to compare the two treatments to determine which is the more effective, or if a combination of treatments does better, or which treatment might best suit which type of person. We urgently need funding for more research in this area. However, at present the NICE guidelines recommend:
- CBT, which is specific for BDD, when the problem causes mild functional impairment.
- A choice of either CBT or a SSRI medication when the problem causes moderate impairment.
- A combination of CBT and SSRI medication when the problem causes severe impairment.
Cognitive Behaviour TherapyCognitive Behaviour Therapy (CBT) is based on a structured programme of self-help so that a person can learn to change the way they think and act. “Cognitive” refers to the events that take place in your mind (thoughts, images, memories, or processes like ruminating and worry). “Behaviour” is what you do (for example escape, avoid, check). CBT starts with building a good understanding of the problem and what is keeping it going in terms of how your mind works. Very often it turns out that ‘the solution is the problem’. For example, you might examine your appearance in the mirror to try and work out ‘how do I really look?’ but rather than leaving you feeling more certain of how you look, it might leave you feeling less certain and more preoccupied. One way of thinking about BDD is that it is a problem of ‘not being able to see the wood for the trees’ – that you can no longer make an objective assessment of your appearance because you have become so distressed and preoccupied. Because you are excessively self-focused on your felt impression, you assume that this is how others view you. This often leads to radically different opinions on your appearance between yourself and those who are close to you. Being self-focused through scrutinising and monitoring your appearance, or the reactions of others, can increase feelings of self-consciousness and make being out in social situations very uncomfortable. During therapy, you are likely to learn to re-focus your attention away from your self and re-engage with activities that will improve your mood and your life. Many people come to view their negative self-image of their looks as a bad memory from the past, such as bullying or teasing. To help reduce self-consciousness a CBT therapist might recommend specific attention-training exercises. To further fight back you will be asked to resist comparing your appearance, to stop ruminating, test out your fears without, camouflage and stop rituals such as checking and excessive grooming. Many people find it helpful to think of CBT for BDD as training in how to stop being bullied by their BDD and to re-direct themselves into all the other aspects of living that are important to them. The main side effects of the treatment are the anxiety that occurs in the short term. However, testing one’s fear gets easier and easier and the anxiety gradually subsides. The principles of CBT for BDD are described in various books, which are linked on this site. Below is a description of how to get therapy in the UK.
Good CBT for BDD is likely to involve the following:
- A shared understanding of your main problems and goals
- A ‘formulation’ – a diagram or verbal explanation of how your BDD developed and how it is being maintained that will be tested out in therapy
- Sessions focused largely upon your BDD
- Tasks within the session for example testing some of your fears
- Agreed ‘homework’ tasks to be completed outside the sessions, and reviewed at the next session
- The understanding of your CBT therapist and genuine care that you improve
- A strong focus upon you re-claiming your life, facing feared/avoided situations, and reducing the repetitive behaviours (e.g. comparing, checking, reassurance seeking, camouflaging and concealing)
- A clear focus upon reducing your preoccupation and distress, and improving function. Body image in BDD usually only returns to normal once the person’s preoccupation and distress have reduced and functioning has improved.
Good CBT would generally NOT include:
- Reassuring you about your appearance or entering into extensive debates about how you look or whether appearance is important
- Teaching you phrases about your appearance to tell yourself
- Long discussions about childhood, unless they relate to experiences clearly connected to the development of your BDD and lead to exercises that help to update the ghosts from the past so they are not relevant for your life now
- Homework tasks that are not explained and negotiated or that do not seem linked to your BDD.
Questions to ask a therapist
- Have you been to specific workshops or had training on treating BDD?
- Do you follow a recognized protocol on treating BDD?
- Do you keep up to date and attend conferences?
- How often do you treat BDD? How many people with BDD have you treated?
- Do you have supervision, and how?
- Are you accredited in CBT (in the UK by BABCP) – this is not crucial but is common in the private sector to demonstrate a minimum standard of training, supervision and continuing professional development.
Other things to consider
- Do you feel the therapist is someone you can trust, who respects you?
- Do you think your therapist can support you – like a good teacher or coach?
- Do you feel well understood by the therapist? You should feel your views are sought and you are involved in the process.
- Do you find the therapist encouraging and positive about your ability to make improvements (especially in the moment), seeing problems as a way of learning better ways of dealing with the BDD? The therapist should be challenging and have high expectations about your ability to change.
- Ask how other people referred to the service for their BDD have got on.
- A good therapist keeps a record of outcome session by session, for example by using a questionnaire or rating scale that is specific for BDD to monitor progress (see examples on this website)
- Your sessions should focus on BDD most of the time unless there are more pressing problems interfering with your progress.
MedicationThe second type of treatment recommended for BDD is anti-depressant medication, which is strongly “serotonergic”. These are referred to as SSRIs. The dose may need to be in the high range and taken daily for at least 12 weeks to determine its effectiveness. The medication may provide the full range of outcomes – either a cure (rare) or no benefit at all. On average, people with BDD obtain about a 40-50% reduction of symptoms. A SSRI may therefore reduce your preoccupation and distress with your feature. SSRIs enhance normal activity in the brain and improve its ability to dampen anxiety and reduce preoccupation. In general, all SSRIs are likely to be equally effective for BDD, but individuals respond differently to different drugs. Your doctor will help you choose the most appropriate SSRI for you, given your circumstances and history. Some SSRIs, such as paroxetine, may be more difficult to withdraw from and other things being equal are best avoided. The normal starting dose and suitable target doses of different SSRIs are listed in the table below. Sometimes it is helpful to go above these target doses (for example fluoxetine 80 or 100mg but it should be monitored closely). When progress is slow, you may need to increase the dose and you should check this with your doctor. If you experience significant side effects, you can always start on a lower dose, after discussion with your doctor. You can then build the dose up slowly.
|Chemical name||Common trade names||Usual starting dose||Target dose||Liquid preparation|
|Citalopram||Cipramil, Celexa||20mg||40mg||Yes (20mg = 5ml)|
|Escitalopram||Cipralex, Lexapro||10mg||20mg||Yes (5mg = 5ml)|
|Fluoxetine||Prozac||20mg||60mg||Yes (20mg = 5ml)|
|Paroxetine||Seroxat, Paxil||20mg||60mg||Yes (10mg = 5ml)|
|Sertraline||Lustral, Zoloft||50mg||200mg||Yes (100mg = 5ml)|
Getting help on the NHS in the UKIn England, the NHS uses a stepped care approach to treating BDD. First visit your GP and talk about your symptoms. It can be daunting but consider taking along a friend or relative. Work out what you want to say beforehand. Your can download an information sheet and a copy of the NICE Guidelines for your GP that you take with you. The first treatment of choice is cognitive behaviour therapy (CBT). In England you may be referred by your GP – or you maybe able to self-refer – for CBT at an Improving Access to Psychological Therapies (IAPT) service. The website will allow you to find your local service. Individual CBT is usually offered for 12-15 sessions. However, recent research suggests it may need to be longer (for example 20 or more sessions) especially when there are additional problems. There are two levels of therapy at an IAPT service – a higher step that consists of individual therapy (recommended) and a “lower intensity” support, delivered by “Psychological Well-Being Practitioners” (PWPs) usually over the telephone. We do not think it is appropriate to be offered treatment for BDD by weekly support from a PWP, as there is no evidence of benefit in BDD. Equally it is not helpful to be offered just group CBT as there is no evidence of benefit as a stand-alone intervention in BDD. Please let us know if you are offered low intensity CBT with a PWP or group therapy within IAPT. Some people may want to register with a GP that is linked to an IAPT service that has a service for BDD. The NHS Constitution says “You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons.” You can choose which GP surgery you’d like to register with. That GP surgery must accept you unless there are good reasons for not doing so, for example, you live outside the boundaries”. However some GPs are more flexible and the NHS is piloting more choice in some cities. For adolescents, there is now an IAPT service that is being developed. If you are an adult, in Scotland and Wales, your GP may refer you to an equivalent service to IAPT. We recommend you monitor your progress using a standardised scale on this site as this may be helpful if you need your care to be stepped up. Secondary Care – In complex cases or when initial treatment is not successful, you or your GP can ask for your care to be stepped up to a community mental health team (CMHT) (“secondary care”). If necessary, ask for a second opinion for care to be stepped up. In England, your GP can now refer you to a Consultant team of your choice (see below for specialist services). The questions to be answered are
- Has the therapy failed or was it not delivered well enough?
- Is your view of the problem still fundamentally different from the rest of the world?
- Did the relationship with your therapist break down?
- Were the social circumstances not right?
- Were you ready to change?
- Was another problem such as impulsivity or difficulty in tolerating emotion interfering in therapy and needs to be addressed first?
- Should your medication be reviewed?
Getting help privately, UKFinding a cognitive behaviour therapist A good place to start is a therapist who is accredited with the British Association of Behavioural and Cognitive Psychotherapies. Equally, there are Clinical Psychologists and Counsellors who are competent and not accredited by the BABCP. A key issue to discuss is their training and experience in treating BDD and which treatment protocol they would follow (see some questions to ask a therapist under a description of CBT). Finding a private hospital If you need a more intensive programme of CBT or nursing care because of your suicide risk or need for help in self-care or prompting, then you may need to be admitted. Make sure that this includes individual CBT at least three times a week by a therapist who is experienced in BDD. Nursing staff experienced in BDD and groups run specifically for people with BDD are a bonus.
Advocacy in the UKThe BDD Foundation can offer some advice on getting help, but we are (for the moment) a very small charity with limited resources. At present, we recommend seeking help from OCD Action as BDD is related to OCD. The website has information on obtaining a referral for specialist help; employment rights; housing; and your rights under the Mental Health Act. You can also share your concern with others in an online forum on this website under the heading ‘ Advocacy’. Sometimes the issues you are seeking help with are common in the BDD community and others may have been in the same position.
Use of the Mental Health ActThe vast majority of people receiving treatment in psychiatric wards have agreed to come into hospital. They are called informal or voluntary patients. Some have been ‘sectioned’ (or ‘detained’) under the Mental Health Act 1983. If you are in hospital as a detained patient you will not be free to leave and will lose some other rights that are available to informal patients. Further details are available from Mind, the mental health charity. The Mental Health Act is not used lightly and mental health professionals will generally only turn to it as a last resort when they genuinely believe that the mental health of the patient is at significant risk e.g. from suicide, self-neglect or violence to others. It may also be used to assess a patient who has, for example, been housebound for many years and refused to seek help.
Family & FriendsBDD can be a problem for family, friends and partners. It can be upsetting, confusing or infuriating that the person you care about persists in seeing themselves as ugly no matter what you tell them. You may have spent endless hours trying to reason with and reassure the sufferer, to no lasting effect. At a loss to know what to do or say, some family members end up providing funds for cosmetic procedures in a desperate hope that it will bring relief to their loved-one’s pain. Sometimes people with BDD may be satisfied by a cosmetic procedure but their symptoms of BDD persist.
General guidelines for relatives
- However odd you love one’s behaviors may seem, they are just part of BDD. BDD is not a sign of madness – it’s simply a disorder, of the kind that can affect many people at some stage in their life. Remember BDD is not ‘bad’ behavior done to annoy you.
- If you have a relative or partner with BDD, it’s still important to set consistent boundaries with behaviors that are unrelated to BDD, and to problem-solve BDD behavior where it impinges on your family life (e.g. the length of time the person spends in the bathroom when everyone is getting ready in the morning).
- BDD is not something that can be easily stopped. It will take time, commitment, and the right guidance to improve everyone’s quality of life. Each person needs to overcome his or her problems at his or her own pace, even though this may be a lengthy process. As far as possible, stay patient and optimistic about recovery.
Avoid the blame gameNo one should be blamed for BDD – it’s not the fault of the person who has it, and nor is it your fault as a relative. Hence there is no need to feel guilty for ‘causing’ BDD, even if there is a possible genetic link. If you start blaming your genes then you can go all the way back to our reptile ancestors!
Encourage your relative to seek helpEncourage your relative with BDD to seek professional help with therapy or medication if they need it. Support them in either or both routes, and do everything you can to help them change. This means:
- helping them to understand and deﬁne their problems clearly
- if they want you to, being an ally as described above
- encouraging them to persist with their treatment
- and praising improvement, however small.
Don’t participate in BDDFamilies should not try to adapt their ways of doing things to accommodate a relative’s worries. Don’t put family life on hold. Accept that BDD may complicate family life, but get on with it anyway, and encourage your relative to maintain as normal a lifestyle as possible:
- Try not to take on their responsibilities (unless of course you are a parent of a child).
- Don’t make excuses for them (e.g. about their being late for work or for an appointment).
- Don’t collaborate in trying to find ‘magic solutions’, such as getting details about cosmetic surgery out of the paper or offering to pay for surgery or provide a loan.
- If necessary, compromise in the short term in the way we have described, but draw the line when new avoidance behaviors and safety behaviors start.
- Avoid getting drawn into debates about the suffers appearance, or providing reassurance. It is however important to provide emotional support.
- If the person is in therapy, ask your relative if you can see the therapist with him or her and discuss a program of reducing your involvement in your relative’s BDD.
- If the person is not in therapy, try to negotiate a program of gradual withdrawal from the person’s safety and avoidance behavior before you implement it.
- Make sure that you communicate that you are changing your involvement in order to help rather than punish.
- Practise saying ‘No’ or ‘No, thank you’ to requests for reassurance, checking, or debating.
- Help your relative to see the downside of you participating in avoidance and safety behaviors and the effect on your relationship. Highlight how long the effect of the reassurance lasts for and what the effect is on their doubts.
- Individuals with BDD will not come to any harm as a result of anxiety, though they may be distressed in the short term.
- Accommodating rituals and avoidance means that you are helping to fuel BDD in the long term – and you are not taking care of yourself. It may feel as if you’re protecting yourself from stress and helping someone with BDD, but the effect is the opposite.
- What is good for the family is good for the person with BDD, and this can only occur when no one else engages in the BDD. A family that is all pulling together can provide better support for your relative with BDD. Its members can also better support each other and solve problems more efficiently. Working as a team to overcome BDD is tough and usually best done with a therapist guidance.
Be a coach and cheerleaderYou and your relative both need to see BDD, and not the individual experiencing it, as your shared enemy. Approach the problem as a team, working together. As your relative improves, see yourself as a coach shouting encouragement from the sidelines, or cheerleading, as you become less involved. Enthusiasm, empathy, understanding and general support are the best help you can provide.
Looking after yourselfMake sure that you communicate, both with your relative who has BDD and with everyone else in your family.
- Remember that you may need help and support yourself.
- Make sure that you continue to do things you enjoy and have people to talk to about your own feelings and concerns.
- Eventually, you may decide that, for the sake of your own mental health, you can’t carry on caring for your relative with BDD. In that case you’ll need to communicate as a family and get help from the local services.
- Try not to engage in self-pitying thoughts such as ‘Why me?’ or ‘Poor me, I don’t deserve to have BDD in the family.’ These will only make you feel worse and feed another vicious circle.
- Try to detach yourself emotionally from your relative’s BDD and take it less personally.
- If you’re not coping emotionally or it is affecting other areas of your life, seek help. There may be a local caregivers’ group or, even better, a group for caregivers of individuals with BDD. Alternatively, see your family doctor for a referral or go directly to a therapist.