Body Dysmorphic Disorder Treatment
Body dysmorphic disorder treatment research is still limited, serotonin re uptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT) are currently the treatments of choice. Available data indicate that SRIs, but not other medications or electro convulsive therapy, are often efficacious for BDD, even for delusional patients. Following reports of cases that responded to SRIs, a largely retrospective study of 30 patients found that 58% responded to SRIs compared to only 5% for other medications; an expansion of this study (n=130) yielded similar findings.
Another retrospective study (n=50) similarly found that SRIs were more effective than non-SRI tricyclics. Two prospective open-label studies of the SRI fluvoxamine found that two thirds of patients responded. In a prospective study of the SRI citalopram, 11 of 15 patients responded; functioning and quality of life, as well as BDD symptoms, significantly improved.
Only two controlled pharmacotherapy studies have been done; additional controlled studies are needed. In a double-blind cross-over trial (n=29 randomized patients), the SRI clomipramine was more effective than the non-SRI antidepressant desperation. In the only placebo-controlled study (n=67 randomized patients), the SRI fluoxetine was more effective than placebo. Of note, available data consistently indicate that SRIs are effective even for delusional BDD, whereas delusional BDD does not appear to respond to anti psychotics alone.
Although dose-finding studies are lacking, BDD appears to often require higher doses than typically used for depression. In a chart-review study (n=90), the mean SRI doses were 66.7 ± 23.5 mg/day of fluoxetine, 308.3 ± 49.2 mg/day of fluvoxamine, 55.0 ± 12.9 mg/day of paroxetine, 202.1 ± 45.8 mg/day of sertraline, and 203.3 ± 52.5 mg/day of clomipramine. Some patients respond only to doses higher than the maximum recommended dose (e.g., 80-100 mg/day of citalopram or paroxetine).
In most studies, which used fairly rapid dose titration, the average time required for BDD to respond was 6-9 weeks, with some patients requiring 12 or even 14 weeks. It is therefore recommended that patients receive an SRI for at least 12 weeks before switching to another SRI, and that the highest SRI dose recommended by the manufacturer (if tolerated) be reached if lower doses are ineffective. Long-term treatment appears often necessary.
There are only limited data on SRI augmentation strategies. Adding buspirone (40-90 mg/day) or combining clomipramine with an SSRI may be helpful (although clomipramine levels must be monitored). Adding an anti psychotic to an SRI is worth considering for delusional patients, although this strategy has received limited investigation. Agitated or highly anxious patients often benefit from a benzodiazepine in addition to an SRI. Patients who fail one adequate SRI trial may respond to another SRI or venlafaxine. If none of these strategies is effective, an MAO inhibitor may be worth trying.
Although psychotherapy research is also limited, CBT appears to often be effective. Most studies have combined cognitive components (e.g., cognitive restructuring aimed at challenging faulty appearance-related beliefs) with behavioral components, consisting mainly of exposure and response prevention (ERP) to reduce social avoidance and repetitive behaviors (such as mirror checking and excessive grooming).
Early case reports indicated a successful outcome with exposure therapy and cognitive plus behavioral techniques. In a subsequent series of 17 patients who received 4 weeks of daily individual 90-minute CBT sessions (20 total sessions), BDD symptom severity significantly decreased. In an open series of 13 patients treated with group CBT, BDD significantly improved in twelve 90-minute group sessions. In a study of 10 participants who received thirty 90-minute individual ERP sessions without a cognitive component, plus 6 months of relapse prevention, improvement was maintained at up to 2 years.
Two wait-list controlled studies have been published. In a randomized pilot study of 19 patients, those who received 12 weekly sessions of 60-minute individual CBT improved significantly more than those in a no-treatment wait-list control condition. In another study (n=54), women randomized to cognitive therapy plus ERP (provided in 8 weekly 2-hour group sessions) improved more than those randomized to a no-treatment wait-list control condition. (However, patients appeared to have relatively mild BDD, and most had body weight and shape concerns, making it difficult to determine the applicability of the results to more severely ill patients with more typical BDD symptoms.)
The above findings are very promising, but more rigorously controlled studies are needed. Also requiring investigation are the optimal number, duration, and frequency of sessions as well as the relative efficacy of group versus individual treatment. It is not known whether behavioral treatment (ERP) alone is usually effective or whether cognitive restructuring and behavioral experiments are a necessary treatment component because of the poor insight and depression so often characteristic of BDD. A broadly applicable treatment manual is not available and is needed. It is also not known whether SRIs or CBT is more effective, or whether their combination is more effective than either treatment alone. However, for patients with severe BDD, especially very depressed or suicidal patients, an SRI is recommended, as partial response may make CBT more tolerable and enable patients to participate in CBT treatment.
Before instituting an SRI and/or CBT, it is important to provide psycho education on BDD. Many patients appreciate referrals to books or websites (e.g.,). For patients who are reluctant to accept the diagnosis and treatment (e.g., delusional patients), it can be helpful to emphasize that treatment is likely to decrease their suffering and improve functioning.
Research on insight-oriented and supportive psychotherapy is extremely limited but suggests that BDD symptoms - especially severe symptoms - are unlikely to significantly improve with these treatments alone. However, they can be helpful for other problems the patient may have and may be a useful adjunct to CBT and/or an SRI.
A majority of patients with BDD seek and receive surgery or non psychiatric medical (e.g., dermatologic) treatment. Some, in desperation, even do their own surgery - for example, attempting a face-lift with a staple gun or trying to replace their nose cartilage with chicken cartilage in the desired shape. Although prospective studies are lacking, such treatments appear to usually be ineffective. In the largest study (n=250 adults from a psychiatric setting), only 7% of all non psychiatric treatments led to improvement in both concern with the treated body area and BDD more generally.
Systematic treatment outcome studies of patients who clearly have BDD have not been done in non psychiatric settings, but observations in the dermatology and surgery literature generally indicate that the outcome of such treatments tends to be poor. Occasional dissatisfied patients commit suicide or are violent toward the treating physician.