The UK’s National Health Service (NHS) provides a stepped-care model which offers different levels of help according to need. We hope the below information will help you to navigate the system and access the right help for you.

Treatments available

The NICE guidelines on BDD recommend two treatments as helpful: Cognitive Behavioural Therapy (CBT) specific for BDD, or serotonergic anti-depressant medication (SSRI). Specifically:

• If BDD causes mild functional impairment: Cognitive Behavioural Therapy specific for BDD.
• If BDD causes moderate functional impairment: a choice of either CBT or a SSRI medication.
• If BDD causes severe functional impairment: a combination of CBT and SSRI medication.

The first step is a visit to your GP

Some people are very nervous about what to say to a GP about their BDD. Some GP’s will be very well informed about BDD but others may have less experience. We have produced an information card that you can give your GP at your first appointment. The GP card can be downloaded by following the link. It explains the condition in full and describes the usual treatment options:

It can be daunting but consider taking along a friend or relative. Work out what you want to say beforehand.

Accessing Cognitive Behavioural Therapy (CBT)

The first treatment of choice is Cognitive Behavioural Therapy (CBT).

In England you may be referred by your GP – or you maybe able to self-refer – for CBT at an Talking Therapies ( formerly known as 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.

IAPT Services – now known as ‘Talking Therapies’

There are two levels of therapy at a Talking Therapies (IAPT) service:

• a higher step that consists of individual therapy (recommended)
• a “lower intensity” support, delivered by “Psychological Well-Being Practitioners” (PWPs) usually over the telephone.

At the BDD Foundation, 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 Talking Therapies 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 on the NHS

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), this is known as ‘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 on the NHS: Specialist Services for BDD

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 an in-patient at the Anxiety Disorders Residential Unit (ADRU) (no nursing staff at night), or
• as an in-patient at the Springfield Hospital, 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 (CCG) funds the first level
• 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, consultant Prof David Veale), Adolescent out-patients (Dr Bruce Clark), Queen Elizabeth II (out-patients and some in-patients) (Professor Naomi Fineberg) and Springfield Hospital (mainly in-patients) 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.

Advocacy

The BDD Foundation can offer some advice on getting help, but we are (for the moment) a very small charity with limited resources. You can contact our e-helpline.

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.

NHS Patient Choice: Right to Choose Service Provider

The NHS Improvement investigation on Patient Choice was followed by the announcement of this 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 that 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 Professor 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).