We outline below the recognised treatments for BDD and how to get help.
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.
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.
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.
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.
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.
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.
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”).
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.
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).
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.
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.
Type: User led. The group facilitators have personal experience of both OCD & BDD. This group offers informal meetings in a relaxed atmosphere, where people affected by OCD/BDD can talk to others in a friendly, non-judgmental way. This group does not offer specific therapy or professional guidance but is an opportunity to share ideas and provide mutual support. The group is open to sufferers, carers and friends.
There is no fee to attend this group and there is free parking nearby.
Type: User led. This group is for sufferers, carers, families and friends.
The group provides informal but structured meetings where people affected by OCD and BDD can talk to others in a friendly, non-judgmental way. It does not offer specific therapy or professional guidance, but is an opportunity to share thoughts, ideas and strategies, and to provide mutual support.
Type: This group welcomes people with OCD, BDD and related disorders. The group is professionally led. We are a friendly support group for anyone with BDD, OCD or related disorders. Ten-twelve people attend regularly.
Type: User led. The group facilitators have personal experience of BDD. This group offers informal meetings in a relaxed atmosphere online, where people affected by BDD can talk to others in a friendly, non-judgmental way. This group does not offer specific therapy or professional guidance but is an opportunity to share ideas and provide mutual support. The group is open to sufferers, carers and friends. It is hosted online, so it is open to anyone who is able to use Skype. No video is used, only audio.
OCD Action’s ‘Better Together Project’ is now supporting an independent online support group especially for parents of children (both under 18 and adult children) with BDD. Please note the group only uses audio, not visual (so no webcams are used), and you will be fully supported in setting up the software needed, alternatively you can be added to the session using a landline or mobile number.
The emphasis is on mutual support and an understanding of the issues which are involved with parenting a child with BDD and is facilitated by two parents with children who have BDD.
This group does not offer specific therapy or professional guidance but is an opportunity to share ideas and provide mutual support. It is hosted online, so it is open to anyone who is able to use Skype. No video is used, only audio.