Fortunately, treatment is available and can often result in significant improvements in BDD symptoms.
What is effective?
Studies have shown that treatment with medications and/or cognitive-behavioral therapy can result in significant improvement in symptoms and functioning.
Frequently asked questions about medication treatment for BDD
The following information is provided as a guideline and should not be used in substitution for a consultation with a psychiatrist. People with BDD may have a variety of additional problems and may experience varying responses to treatments, so a comprehensive assessment by a psychiatrist and an individualized treatment plan (ideally in conjunction with a psychotherapist) are highly recommended. Stay tuned for future FAQs about psychotherapy treatment for BDD.
- If I want treatment for BDD, should I consider taking medications or should I do psychotherapy?
Individuals who suffer from moderate to severe BDD generally benefit from combining psychotherapy and medication treatments. Those with mild BDD symptoms may benefit from either medications or psychotherapy alone.
- Shouldn’t I try psychotherapy alone first, and then consider medications if it isn’t helpful?
Psychotherapy alone may be effective for some individuals with BDD, particularly if it is mild. Most individuals with moderate to severe BDD ultimately need both medication and psychotherapy for successful treatment. It is therefore usually a more effective and faster road to recovery to do both in combination. In addition, for many people with BDD it is difficult to engage in therapy because of the degree of depression, anxiety, obsessive thoughts, rigid thinking patterns, and limited insight. These symptoms usually improve with medication treatment, making it easier to engage in therapy.
- What kind of medications should I take if I have BDD?
The category of medications called serotonin reuptake inhibitors, also known as selective serotonin reuptake inhibitors (SRIs or SSRIs), is considered the first-line medication treatment for BDD. These medications are traditionally known as antidepressants, but are also effective for treating BDD, most anxiety disorders including obsessive-compulsive disorder, and other conditions. These medications include fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil). Citalopram (Celexa) is another SRI, but the FDA limits the dose to 40 mg and individuals with BDD usually need higher doses. Another medication similar to these is clomipramine (Anafranil), which is also effective for treating BDD. There are no medications that currently have FDA approval for treating BDD; nevertheless research and clinical experience suggests that these medications are safe and effective.
- What doses are usually effective?
Most people with BDD benefit from relatively high doses of SRIs. Examples are fluoxetine ≥60 mg, escitalopram ≥30 mg, fluvoxamine ≥200 mg, sertraline ≥150 mg, paroxetine ≥50 mg, and clomipramine ≥150 mg.
- What is the evidence that these medications are effective for BDD?
Controlled studies of fluoxetine and clomipramine have demonstrated that these are effective for treating BDD symptoms. In these controlled 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 therefore controls for the “placebo effect.” There have also been “open-label” studies (which did not use sugar pills or comparison medications and everyone knew they were receiving the medication) demonstrating 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 equally effective.
- Can I just take these medications on the days when I feel the worst?
No. SRI medications do have an immediate effect on symptoms. Rather, the beneficial effects appear to develop over the course of many weeks. Therefore, one should take them every day and try not to miss doses. If one misses a day the symptoms are not likely to return immediately, and one can just resume the normal dose the next day.
- How long will it take for my symptoms to improve?
It may take as long as 6-12 weeks for the medications to start working. Because of this, it is important to for individuals and their psychiatrists to give the medication enough time to start working before switching to another one. 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 respond to SRIs spend less time obsessing about their appearance and have better control over their repetitive behaviors. The distress associated with BDD symptoms, as well as anger, suicidality and overall functioning also usually improve significantly. This often makes it easier to engage in and have success with cognitive-behavioral therapy (CBT), which can then further help reduce symptoms.
- Will taking these medications make me perceive that I look more attractive? If not, I’m worried that by taking them I will just end up feeling “OK” about my ugly appearance.
The experiences of people who take these medications, in terms of how they perceive themselves in the mirror, are quite varied. More consistently, most people who take these medications become less preoccupied with appearance, feel less self-conscious in social situations, are less distressed and less depressed about their appearance, and in general are able to function better.
- Will this medication be enough to “fix” my BDD?
It is not realistic to expect medications to eliminate all BDD symptoms. Studies have shown that on average about two-thirds of people will experience at least a 25-30% reduction in symptoms from taking an SRI. This degree of improvement may seem small, but is usually associated with noticeable improvements in terms of reduced distress and improved functionality. However, to achieve a greater degree of improvement and move towards the BDD not interfering with one’s life, additional treatment with psychotherapy such as CBT is almost always necessary.
For the majority of people, BDD appears to be a chronic condition, at least if left untreated. Thus, even after one’s symptoms have improved with medications and CBT, having long-term tools for symptom management learned through psychotherapy is important. Individuals with BDD often have other psychological issues (outside of the BDD symptoms themselves) that need to be addressed, and thus they may benefit from continuing psychotherapy to address these.
- Will I need to take any other meds in addition to SRIs?
When individuals do not respond to SRIs and CBT sufficiently, they may benefit from the addition of other medications to the SRI. Examples are buspirone; other antidepressants such as clomipramine or venlafaxine (Effexor); an atypical antipsychotic such as aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdal), quetiapine (Seroquel), or others; or levetiracetam (Keppra).
- If I stop these medications, what can I expect?
One should always consult with one’s psychiatrist whenever considering stopping or starting medications for BDD. If one stops SRI medications abruptly, one may have uncomfortable “discontinuation syndrome” symptoms such as dizziness, nausea, and sometimes agitation. These typically resolve within a week or so on their own, or within an hour or so if one restarts the medication. In terms of BDD symptoms, one is very likely to have a relapse (usually over the course of several weeks) after stopping medications. It is possible that the likelihood of this occurring may be lessened if one has done a full course of CBT and, under the guidance of one’s psychiatrist and psychotherapist, then gradually tapers off the meds after the symptoms have been minimal for at least a year or two.
- Will I need to be on meds for the rest of my life?
Not necessarily. Some individuals with BDD are able to successfully taper off medications 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 tapers down the medication. In these cases, “booster” sessions of CBT can be helpful to address these reemerging symptoms. In some cases the reemerging symptoms are too severe when attempting to taper the medication, or the individual does not want the risk of this happing or having relapses in the future, and may elect to stay on medications.
- Do SRI medications have side effects?
All medications, including SRIs, potentially have side effects. However, these vary considerably person-to-person. Most 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 be patient and not stop or switch the medication prematurely unless they are intolerable.
- 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. 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 likely be overcome by modest changes in diet and exercise. Most individuals find that the benefits outweigh the side effects of these medications.
- 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. On the contrary, there is evidence that untreated depression (often associated with BDD) in the long-term may itself have a damaging effect on certain brain structures, and perhaps 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 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 abnormally; thus they may 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 medications. Granted, it may seem like a “leap of faith” for people in this situation to agree to take medications. However, it is important to consider that the illness itself may be affecting the brain’s ability to recognize that there may be something wrong with the way one is thinking about and perceiving themselves. At the very least, most people understand that they may be depressed, excessively anxious in social situations, and not functioning well, even if although they are not sure that they have BDD. Because SRIs are effective at treating these symptoms as well, many will agree to take them.
In terms of cosmetic procedures, studies have shown that the vast majority of those with BDD who undergo cosmetic procedures do not experience any improvement in symptoms, and there is a risk that their symptoms may actually worsen subsequent to them.
- What is a good source to get more information about medications on the Internet?
It is best to get information from trusted sources that are peer-reviewed (checked for accuracy by doctors and pharmacists), such as www.drugs.com .
As with other topics in general, there is a lot of information about medications on the Internet. Some of this information may seem conflicting, making it difficult to wade through. Many individuals who have taken medications will write about their personal experiences, but people seem to be more motivated to write about negative experiences than positive one. Thus one may get a skewed perception of the effects of these medications.
- What if I don’t have insurance and I cannot afford the medications?
Most drug companies have programs that help patients receive medications free or at a reduced cost. For more information, visit Partnership for Prescription Assistance at www.pparx.org  or call 1-888-477-2669.
Where can I get an evaluation and treatment?
Please call 310 206-4951. We will assist you in finding a treatment provider for evaluation and treatment. You may also inquire about participating in a research study if you are interested in which you can obtain a free psychiatric evaluation at UCLA.