What is the treatment for Bodily Distress Disorder (BDD)?

Treatment for Bodily Distress Disorder

Cognitive Behavioral Therapy (CBT) is the first-line treatment for Bodily Distress Disorder (BDD), with Selective Serotonin Reuptake Inhibitors (SSRIs) recommended as the primary pharmacological intervention when needed. 1

Psychological Interventions

Cognitive Behavioral Therapy

CBT has demonstrated significant efficacy in treating BDD with robust evidence supporting its use:

• Structure and Format:

  • Typically requires 12-22 weekly sessions 1
  • More severe cases may need extended treatment (up to 80 sessions in some cases) 1
  • Treatment follows three main phases:
    1. Psychoeducation and formulation (sessions 1-3)
    2. Exposure with response prevention/behavioral experiments (from session 4)
    3. Relapse prevention (final sessions) 1

• Key Components:

  • Exposure with Response Prevention (ERP) - core therapeutic technique
  • Behavioral experiments to test negative beliefs
  • Motivational interviewing techniques to enhance engagement
  • Psychoeducation about the nature of bodily distress 1

• Efficacy:

  • Large effect sizes (Cohen's d = 1.13-1.22) in reducing symptoms 1
  • Improvements in secondary outcomes including depression, insight, and quality of life 1
  • Naturalistic studies show 79% response rates and 59% remission rates 1

Pharmacological Interventions

Selective Serotonin Reuptake Inhibitors (SSRIs)

• First-line medication when pharmacotherapy is indicated 2, 3
• Often used in conjunction with CBT (72% of patients in the largest naturalistic study received SSRIs alongside CBT) 1
• Higher doses may be required for optimal response in severe cases 1

Other Medication Options

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) may be considered as alternatives 4
• Tricyclic antidepressants have shown some efficacy (clomipramine specifically) 3
• Benzodiazepines are not recommended for routine use 4

Treatment Algorithm

1. Initial Approach:

   • Begin with CBT as first-line treatment
   • For mild to moderate cases: CBT alone for 12-22 sessions
   • For severe cases: Consider combined CBT and SSRI treatment

2. If Initial Response is Inadequate:

   • Extend CBT course (beyond 22 sessions)
   • Optimize SSRI dosage if already prescribed
   • Add SSRI if patient was on CBT monotherapy
   • Consider home-based CBT sessions for severely impaired patients 1

3. For Treatment-Resistant Cases:

   • Consider alternative medication classes (SNRIs, tricyclic antidepressants)
   • Implement more comprehensive treatment packages 1
   • Address comorbid conditions (particularly anxiety and depression) 5

Special Considerations

Engagement Strategies

• Avoid polarizing physical and psychological explanations
• Focus on reducing distress, improving quality of life, and building self-confidence
• Use motivational interviewing techniques to enhance treatment engagement 1

Family Involvement

• Include family members/carers at least during the psychoeducation phase
• Level of family involvement should be tailored based on:
  • Patient's developmental level
  • Ability to practice techniques independently
  • Extent of family involvement in symptom-reinforcing behaviors 1

Common Pitfalls and Caveats

1. Inadequate Treatment Duration:

   • Short courses of therapy may yield suboptimal results
   • Evidence shows continued improvement beyond 12 sessions 1

2. Poor Engagement:

   • Patients with limited insight may resist psychological interventions
   • Addressing treatment goals in terms of quality of life rather than symptom reduction can improve engagement

3. Overlooking Comorbidities:

   • BDD frequently co-occurs with anxiety and depression 5
   • These conditions should be addressed concurrently for optimal outcomes

4. Premature Medication Discontinuation:

   • After remission, medications should be continued for 6-12 months 4

The evidence strongly supports a structured approach to BDD treatment, with CBT as the cornerstone intervention. While medication can be beneficial, particularly in severe cases, psychological interventions have demonstrated the most robust and enduring treatment effects.