If you feel that you are suffering from BDD, or have been diagnosed with BDD, the good news is that treatments are available.
The best evidence so far supports two possible treatment options, which can be delivered independently of each other or can be given together.
One treatment is psychological, Cognitive Behavioural Therapy (CBT), and the other option is medication.
In terms of medication for BDD, anti-depressant medication is recommended, one which is strongly “serotonergic”. These are referred to as SSRIs or Selective Seratonin Reuptake Inhibitors. 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.
How does it work?
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.
Types of SSRI anti-depressants
|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 that 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.
There are some important things to think about when trying medication to help improve BDD worries:
- Medications should be increased slowly and carefully over the course of a few weeks. This allows any possible side effects to be carefully managed or avoided, by allowing your body to get gradually used to the treatment.
- The medications used to help with BDD need to be increased to a high dose. This dose is higher than for other kinds of difficulties such as depression, which is another important reason to increase at a slower pace.
- Medication can take a long time to start working. This means that a trial of medication should be about three months of an adequate dose, so it is important to be patient and not expect instant results. Because of this, the professional prescribing any medication for BDD should take careful note of your symptoms, so that you and they can be clear when things are starting to improve.
- After this period of at least three months, if you and your doctor feel a medication is truly not working after giving it a good try, people often decide to try another SSRI instead.
- Usually, people with BDD are asked to stay on their medication for at least six months after they are feeling better. Stopping too early can often mean the difficulties come back again. Similar to when you start medication, a planned approach is important when you are thinking about stopping it and should be done with support of your prescriber.