Body Dysmorphic Disorder (BDD)
Body Dysmorphic Disorder (BDD) is an obsessive-compulsive spectrum disorder (not OCD and not an eating disorder). It is a complex disorder incorporating biological, psychological, and sociocultural factors. BDD is characterized by an intense preoccupation about one or more perceived flaws in a one’s physical appearance. The perceived flaw is either not noticeable to others or if noticeable, it is not as prominent as the sufferer believes.
BDD is common affecting one in every 50 people in the United States. Persons with BDD often feel defined by their perceived flaw which can lead to shame, depression, anxiety and extreme self-consciousness. Sufferers often describe themselves as ugly or hideous, when to others they look normal. Several studies have shown that individuals with BDD have visual processing differences, one of which is selectively attending to details of their appearance instead of seeing themselves holistically.
People with BDD experience severe emotional distress which can be overwhelming and affect their daily functioning. It is common for those with severe BDD to avoid going to work or school, or to see friends. Studies show 60% of people with BDD have comorbid major-depressive disorder. Approximately 80% of those with BDD report they have experienced suicidal thoughts and about one in four or more have attempted suicide. Other common co-occurring disorders with BDD include OCD, eating disorders and social anxiety.
With BDD the preoccupation with the perceived flaw causes sufferers to spend hours a day repeatedly checking the appearance of their “flaw” in mirrors and other reflective surfaces. Other repetitive behaviors or compulsions can include:
- Rumination about the perceived flaw
- Excessive comparison
- Excessive grooming
- Camouflaging the perceived flaw
- Asking for reassurance
- Avoidance of having picture taken
- Avoidance of being in public or social situations
- Frequent consults or procedures with cosmetic surgeons
Treatment of Body Dysmorphic Disorder
Studies have found that Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP) successfully reduces BDD severity and related symptoms such as depression.
Several CBT therapies are effective for treating BDD. Psychoeducation about BDD, the BDD cycle and how it may have developed for the BDD sufferer is discussed. Cognitive Restructuring helps clients identify distorted thoughts about their appearance, broaden their perspective on these thoughts and restructure them to be more rational and reasonable.
Mindfulness training helps clients learn how to allow and tolerate the discomfort of distressing BDD thoughts and feelings without judging them or engaging with them in any way.
Attentional Training helps clients reduce self-focused attention and increase flexibility with switching attention. It is a mental training that, when practiced, can help clients interrupt the cycle of being focused on their perceived flaw. Eventually, they become more aware of their external environment in the present moment which will, in the long term, weaken the cycle and reduce suffering.
Acceptance and Commitment therapy (ACT) reinforces the concept of allowing unhelpful distressing BDD thoughts and feelings to be there while moving towards valued activities that are meaningful to them, rather than letting their unhelpful BDD thoughts and feelings determine their actions.
Once clients learn and practice these tools, they are ready to gradually face their fears using Exposure and Response Prevention (ERP). ERP is a collaborative and compassionate process. The first step of ERP is identifying the mental and physical compulsions clients are currently doing to reduce anxiety from BDD triggers. Together the therapist and client create a hierarchy of the compulsions to eliminate, from easiest to hardest. In treatment clients learn tools to help with this process. They continue to work on gradually facing fears and responding to BDD thoughts, feelings, sensations and urges in a new way that does not feed the BDD cycle. Clients are in charge of the exposures that they choose to do and the pace they do them.
The remainder of therapy is doing ERP, clients applying what they have learned to help them respond skillfully instead of reacting to BDD. Through exposure therapy clients gradually take their lives back, re-engaging with the outside world through work, school and social activities. BDD no longer takes up so much space in their lives. Clients are much more free to pursue those things in life that bring them meaning and joy.
Medications for BDD
Studies have shown that, on average, about two-thirds to three-quarters of people will experience a 30% (or greater) reduction in BDD symptoms from taking a recommended medication for BDD.
By Jamie Feusner, MD and Katharine A. Phillips, MD
Note: the following information is provided as a general guideline and should not be used as a substitute for meeting with a psychiatrist. People with BDD may have a variety of additional problems and may experience different responses to treatments, so a professional assessment by a psychiatrist and an individualized treatment plan are highly recommended.
What kind of medications should I take if I have BDD?
The category of medications called serotonin reuptake inhibitors (SRIs), also known as selective serotonin reuptake inhibitors (SSRIs), is considered the first-line medication treatment for BDD. These medications are antidepressants, but unlike non-SRI antidepressants they also help reduce obsessive thoughts and compulsive behaviors (which are symptoms of BDD). They are effective for treating BDD, major depressive disorder, most anxiety disorders including obsessive compulsive disorder, and other conditions. These medications include fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), and clomipramine (Anafranil). Citalopram (Celexa) is another SRI, but the Federal Drug Administration (FDA) limits the dose to 40 mg a day (20 mg a day for people over age 60), and individuals with BDD usually need higher doses than this. There are no medications that currently have FDA approval for treating BDD; however, research and clinical experience suggests that these medications are safe and effective for a majority of people with BDD.
Research studies on other medications used alone for BDD are very limited. At this time, non-SRI medications are not currently recommended as the only medication treatment for BDD.
What doses are usually effective?
Most people with BDD benefit from relatively high doses of SRIs. Examples are fluoxetine 60 mg a day or more, escitalopram 30 mg a day or more, fluvoxamine 200 mg a day or more, sertraline 150 mg a day or more, paroxetine 50 mg a day or more, and clomipramine 150 mg a day or more. However, many patients need higher doses than these to successfully treat BDD symptoms, and medication doses should be individualized for each person.
What is the evidence that these medications are effective for BDD?
Research on fluoxetine and clomipramine have demonstrated that these medications are effective for treating BDD symptoms. In these studies, half the participants received the medication and half received a sugar pill or a comparison medication, but neither the participants nor the study doctors knew who was receiving which until the end of the study. This method helps distinguish between “true” medication effects and “placebo effects.” There have also been “open-label” studies (which did not use sugar pills or comparison medications, and everyone knew they were receiving the medication), which indicate that fluvoxamine, escitalopram, and citalopram may be effective. Sertraline and paroxetine are very similar to these other SRIs, and clinical experience suggests that they are also effective.
Can I just take these medications on the days when I feel the worst?
No. You need to take the medication every day — not just on the days when you feel the worst. SRI medications do not have an immediate effect on symptoms. Rather, the beneficial effects develop over many weeks. Therefore, you should take them as prescribed every day and try not to miss doses. If you miss a day the symptoms are not likely to return immediately. If you miss a dose, you should just resume the normal dose the next day.
How long will it take for my symptoms to improve?
It can take as little as 2-3 weeks or as long as 14 weeks or so for the medication to start working. Because of this, it is important for individuals and their psychiatrists to give the medication enough time to see the effects begin before switching to another one. To give the medicine a good try, we recommend staying on it for 3-4 months while reaching a high enough dose. However, symptoms of depression and anxiety, which are common in BDD, may start to improve earlier.
How will these medications help with my BDD?
People with BDD who improve with SRIs spend less time obsessing about their appearance and have better control over their compulsive behaviors. The distress that BDD causes, as well as anger, suicidal thinking, and daily functioning, also usually improve significantly. This often makes it easier to engage in and have success with cognitive behavioral therapy (CBT) if it is needed because your symptoms don’t completely resolve with medication.
Will taking these medications make me perceive that I look more attractive? I don’t want to just end up feeling “OK” about my ugly appearance.
The experiences of people who take these medications, in terms of how they see themselves, vary. Some people say that they no longer see the appearance defects that used to upset them so much. Others still see them but don’t find their flaws as upsetting. What is more consistent is the effect the medications have on decreasing obsessional thoughts about appearance, self-conscious in social situations, distress, and depression related to the perceived flaws, and helping people to function better.
Will this medication be enough to “fix” my BDD?
Studies have shown that, on average, about two-thirds to three-quarters of people will experience a 30% (or greater) reduction in BDD symptoms from taking an SRI. This degree of improvement may seem small, but it is usually associated with noticeable improvements in terms of reduced distress and improved day-to-day functioning. Some people’s symptoms go away completely with an SRI. If your medication response doesn’t feel like it is enough, options include increasing the SRI dose, trying another medication, or trying CBT.
Should I just take medications, or should I just do psychotherapy, or both?
In our clinical experience, those with milder or more moderate BDD symptoms may benefit from either medication or psychotherapy alone. Individuals who suffer from severe BDD can potentially improve with either treatment alone, but we often recommend combining psychotherapy and medication, especially if the person is suicidal.
What benefits might I get from both taking medications and doing CBT?
Some people’s ability to use what they are learning in therapy is limited by depression, anxiety, obsessive thoughts, rigid thinking patterns, and poor insight. These symptoms usually improve with medication treatment, making it easier to engage in therapy.
For the majority of people, BDD appears to be a chronic condition, at least if left untreated. So, even after one’s symptoms have improved, having long-term tools for managing symptoms learned through CBT can be helpful. Some individuals with BDD may have other psychological issues (outside of the BDD symptoms themselves) that need to be addressed, and thus they may benefit from psychotherapy to address these.
Will I need to take any other meds in addition to SRIs?
If you don’t improve enough with an SRI, you may potentially benefit from the addition of other medications to the SRI. Based on our clinical experience, such medications include buspirone; other antidepressants such as clomipramine or venlafaxine (Effexor) (although care must be taken when adding these medications to an SRI); a group of medications called “atypical antipsychotics” such as aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdal), quetiapine (Seroquel), or others; or levetiracetam (Keppra). However, research studies are needed to further examine the effectiveness of these treatments for BDD.
If I stop these medications, what can I expect?
You should always consult with your psychiatrist whenever you consider stopping or starting medications for BDD. If you stop an SRI medication abruptly, you might have uncomfortable “discontinuation syndrome” symptoms such as dizziness, nausea, and sometimes agitation. These symptoms typically resolve within a week or so on their own, or within an hour or so if one restarts the medication, and they are not dangerous. In terms of BDD symptoms, it appears that people are likely to experience a return of their symptoms if they stop medication, although this important question has not been well studied, so it isn’t known how likely this is to occur. It is possible that the possibility of relapse may be less if one has done a full course of CBT (although this important question has not been studied).
Will I need to be on meds for the rest of my life?
Not necessarily. Some individuals with BDD are able to successfully reduce then stop taking medications. Some people can do this even if they haven’t had CBT; others can do this after completing a full course of CBT and after their symptoms have been minimal for at least a year or two. It is not unusual for at least mild symptoms to return as the individual reduces the dose of medication. In some cases, when the symptoms return, they are too severe trying to reduce medication, or the person may not want to risk return of their symptoms and may choose to stay on the medication. For people with past suicide attempts, especially multiple suicide attempts or severe attempts, the wisest choice is probably to continue the medication.
In general, we recommend staying on the medication for at least a few years after it starts to work. If you’re thinking of stopping your medication, it’s important to talk with your doctor about this and plan carefully.
Do SRI medications have side effects?
All medications, including SRIs, potentially have side effects. However, these vary considerably from person-to-person. Many of the side effects associated with SRIs resolve after a few days or a week or two of being on the medication, so it is important to not stop or switch the medication too quickly unless the side effects are severe and you feel you are unable to tolerate them.
Will these medications cause me to gain weight?
Many individuals with BDD are concerned about weight gain. SRIs are sometimes associated with weight gain, but the risk is relatively low and the amount of weight gain is usually minimal (and sometimes people gain weight for reasons other than taking medication). For example, one study of individuals who took SRIs for 2.5 years found that only 4.5% of those who took sertraline and 8.7% of those who took fluoxetine gained more than 7% of their body weight. If one gains weight, this can be managed by modest changes in diet and exercise. Most individuals find that the benefits outweigh the side effects of these medications.
Are SRIs addictive? Will I get “high”?
SRI’s are not addictive or habit forming. Some people report temporary symptoms following an abrupt discontinuation of SRI’s, but these symptoms don’t represent an addiction to the medication. Individuals taking SRIs do not report feeling a “high” when taking them.
Is there a connection between SRIs and suicide?
In general, the evidence is mixed with some studies showing an increase in suicidality when taking SRIs and others showing a decrease. However, when studied in BDD in particular, research shows that suicidality typically improves significantly when correctly treated with SRIs. Suicidality is, unfortunately, a common experience for individuals with BDD and whether taking SRIs or not, they should be carefully monitored for suicidal thoughts and impulses.
Are there negative long-term side effects of SRIs?
As far as we know, negative long-term side effects have not been found with SRIs, and they have been available for more than 30 years. On the other hand, there is evidence that untreated depression (often associated with BDD) over the long-term may have a damaging effect on certain brain structures, and even on the brain as a whole.
I am not sure I have BDD. Other people tell me that there is nothing wrong with my appearance, but that is not what I perceive. Why should I spend money on medication treatment when I could spend money on fixing my problem by getting a cosmetic procedure?
It is common for people who are diagnosed with BDD to be doubtful and unsure if they really have a psychiatric problem (BDD) or if the root of their problem is actually in their physical appearance. However, studies have shown that the brains of those with BDD process visual information in a distorted fashion; as a result they perceive themselves quite differently than others do. However, one does not have to be convinced that he or she has BDD in order to benefit from medication. Granted, it may seem like a “leap of faith” to take medication. However, it is important to consider that the illness itself appears to often affect the brain’s ability to recognize that there may be something wrong with the way one is thinking about and/or perceiving themselves. At the very least, most people understand that they may be depressed, excessively anxious in social situations, and not functioning well; thus, even if they aren’t sure that they have BDD, because SRIs are effective for these symptoms they may be able to appreciate the medication’s benefits.
Studies have shown that the vast majority of those with BDD who undergo cosmetic procedures do not experience any improvement in BDD symptoms, and there is a risk that their symptoms may actually worsen.
What is a good source to get more information about medications on the Internet?
It is best to get medication information from your doctor. However, if you do use the internet, make sure you use only trusted peer-reviewed sources. There is a lot of information about medications on the Internet. Some of this information may seem conflicting, making it difficult to wade through, and some of it is inaccurate or biased. Many people who have taken medications write about their personal experiences, but in general people are more motivated to write about negative experiences than positive one. Thus, you can get a skewed perception of the effects of these medications.
For more information about medications for BDD, please see Understanding Body Dysmorphic Disorder, by Katharine Phillips, MD.
Feusner, J., & Phillips, K. A. (2021). Medication treatment for BDD: FAQ. BDD. https://bdd.iocdf.org/expert-opinions/medication-faq/.