There has been very little research on the treatment of BDD. The NICE guidelines on BDD 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.
We outline below the recognised treatments for BDD and how to get help.
Cognitive Behaviour Therapy
Cognitive 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.
So the first step is to ask the therapist what type of therapy they are planning to use. If it is not CBT, beware, as there is little evidence to support other types of psychotherapy for 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.
The 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)|
Clomipramine, an older drug which has a strong serotonergic action, can also be useful in BDD (either alone or in combination with citalopram or escitalopram). At higher doses this does unfortunately tend to have more side effects such as dry mouth, sweating and constipation.
If a SSRI or clomipramine is effective, you need to remain on it for at least a year, often longer, as discontinuing the medication may lead to high rate of relapse. It is not known how the medication “works” but it may do so in the absence of depression. Expert opinion is that a SSRI may be used either alone or best in combination with CBT. This is an area of research that badly needs to be done.
SSRI medication may have side effects but for most people these are minor irritations that usually decrease after a few weeks. Alternatively, the dose may be adjusted or a different drug prescribed. The drugs are not addictive but you should stop them only under medical advice. Medication is especially helpful when you are depressed as it may help improve your motivation to take advantage of CBT. The risk of relapse can probably be minimised by combining the medication with CBT in the long term but we require urgent research in this area.
There is no evidence for the benefit of anti-psychotic drugs in BDD (e.g. risperidone, olanzapine, quetiapine, aripiprazole) and these are not recommended in the NICE guidelines. They are sometimes used to reduce agitation and distress.
Further information on medication for BDD, possible side effects of SSRIs and other medications can be found in the book Overcoming Body Image Problems by David Veale, Rob Willson and Alex Clark, published by Robinson.
NHS Patient Choice: Right to Choose Service Provider
April’s NHS Improvement investigation on patient choice was followed by the announcement earlier this month of the framework/compulsory guidance, “Choice in mental health: how it can work for you”.
It’s hugely significant in giving patients the legal right to a treatment team of their choice.
It means if there any problems following a referral by a GP to a consultant or specialist in mental health, you can immediately go to the commissioner with this document, or go to NHS Improvement directly.
The guidance is relevant for choice of out-patient treatment whether it’s an IAPT provider or a secondary care consultant team. It includes information detailing:
• your right to choose the provider that best meets your individual needs;
• how you can choose any provider of the service you need;
• when your choice isn’t appropriate for your care needs; and
• how your commissioners and healthcare professionals should be proactive in facilitating choice.
Where the guidance states that, “In some areas an assessment service will help to decide what type of treatment is best. If this is the case, you can choose a provider once the assessment has recommended a type of treatment”, this means that if an assessment on a care pathway recommends out-patient CBT you can choose where to be referred and don’t have to exhaust treatment locally or be taken to a Funding panel.
Also, “[Patients] can choose providers known for specialist care or tertiary care if they offer the type of service required.” This is relevant to referring patients to Dr David Veale for the OCD/BDD team at the Centre for Anxiety Disorders and Trauma (CADAT) at the Maudsley Hospital.
There’s also now an out-patient service for compulsive skin-picking/trichotillomania and tics at the Anxiety Disorders Residential Unit at the Bethlem Royal Hospital (as far as The Foundation is aware, the only specialist service for this).
Getting help on the NHS
In 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. You can download an information sheet and a copy of the NICE Guidelines for your GP to 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 Increasing 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.
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 of your choice. 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?
In secondary care, a more experienced psychologist may provide your CBT and your medication can be reviewed by a psychiatrist. Unfortunately many community teams have limited resources and long waiting lists for CBT, and their experience with BDD may be limited. Your CMHT may therefore only provide a very limited service in crisis management and risk assessment. This is where you may need a mental health advocate to get the treatment that you require.
From 1st April 2014, adults and adolescents have the right to be referred by their GP to a consultant team of their choice – anywhere in England. If your local team is not able to provide the care, you need then to consider seeking a referral to a specialist service – see below.
Tertiary care: If treatment is less effective than you hoped for in secondary care, then you can ask for your care to be stepped up to a specialist service – for example as an out-patient at the Centre for Anxiety Disorders and Trauma (CADAT), or as in-patient at the Anxiety Disorders Residential Unit (ADRU) (no nursing staff at night), or as in-patient at the Priory Hospital North London.
Children and Adolescents with BDD can be referred to the OCD Young People’s Service for OCD and BDD.
There are two levels of specialist care funding – your local Clinical Care Commissioning group funds the first level and the NHS England – funds the second level. (This is called the “Highly Specialised Service for severe treatment refractory OCD and BDD”). It consists of a consortium of hospitals including the Maudsley (out-patients), the Bethlem (residential unit) & the Priory North London (in-patients) (Consultant is Dr David Veale), Adolescent out-patients (Dr Bruce Clark), Queen Elizabeth II (out-patients and some in-patients) (Professor Naomi Fineberg) and Springfield Hospitals (mainly in-patients) (Dr Lynne Drummond) who will assess and advise on your particular circumstances.
The level of funding will depend on whether you meet certain criteria (that is, you are in the severe range on the BDD-YBOCS and at least two trials of CBT and 2 trials of SSRI medication at the required dose and duration have failed.)
Both levels of funding will require a referral from your local Community Mental Health Team (CMHT) team, so do ensure that you keep records of all the treatments you have received and maintain a good relationship with your local services
Getting help privately, UK
Finding 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.
The 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 Act
The 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.
Given that a person with BDD is preoccupied with a flaw (or flaws) in their appearance, it is only natural that people seek physical solutions to their appearance concerns. Many people with BDD consider cosmetic or dermatological treatments; sometimes a person with BDD may be satisfied with the results but their symptoms of BDD persist. Some procedures may be safer than others. Cosmetic rhinoplasty (“nose job”) is especially risky procedure in BDD but other procedures such as breast augmentation may be safer, but it depends on the individual and their circumstances.
The majority of people with BDD are not satisfied after the outcome of their chosen procedure. This can lead to a preoccupation with further surgery to try to get a better result, which in some cases will do more harm to a person’s appearance than good. Even when sufferers are happy with the improvement to one area, the focus of their BDD often moves to another area of their appearance.
The key message here of course is that BDD is a psychological or psychiatric problem and thus needs psychological or psychiatric treatment. The best advice is to suspend, at least temporarily, any physical treatments, for say three months, to give yourself an opportunity to tackle your BDD head on with treatments that have been shown to work.