What is the treatment for body dysmorphic disorder (BDD)?

Treatment for Body Dysmorphic Disorder

Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is the first-line treatment for body dysmorphic disorder, typically delivered over 12-22 weekly sessions, with SSRIs added as second-line treatment for moderate-to-severe cases or when CBT alone is insufficient. 1, 2

Primary Treatment: Cognitive-Behavioral Therapy

CBT for BDD should be structured in three distinct phases and represents the most effective intervention for reducing distress, improving quality of life, and decreasing suicidality 1:

Phase 1: Psychoeducation and Formulation (Sessions 1-3)

• Educate patients that body image is subjective perception, not objective reality, using optical illusions (Rubin's vase, Muller-Lyer illusion) to demonstrate how visual perception can be distorted 1
• Explain anxiety habituation: when confronting feared situations, anxiety initially increases but naturally subsides over time, and with repeated practice extinguishes completely 1
• Construct a hierarchy of all BDD-related safety behaviors and avoided situations, rated by anxiety level (0-10 scale) 1
• Develop a CBT formulation showing how early experiences inform appearance beliefs that feed into a maintenance cycle of thoughts, behaviors, and feelings 1
• Set SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) for short-term, medium-term, and long-term outcomes 1

Phase 2: Main Treatment - Exposure and Response Prevention (Session 4 onwards)

ERP is the core therapeutic element where patients confront feared/avoided situations while resisting compulsive safety behaviors 1:

• Start with moderately anxiety-provoking tasks, not necessarily the easiest, prioritizing those most likely to produce functional gains 1
• Complete ERP tasks both in-session with therapist assistance and as homework between sessions 1
• Use behavioral experiments when shame or disgust is the primary emotion (rather than anxiety), explicitly testing negative beliefs like "people will stare and laugh at me" 1
• Evaluate maladaptive thoughts about appearance (e.g., "appearance is all that matters") by examining evidence for and against these beliefs 1

Optional Adjunctive Techniques

• Mirror retraining: Process body image as a whole rather than fixating on specific parts, using non-judgmental language 1
• Attention training: Develop external attentional focus to reduce self-focused attention 1
• Habit reversal therapy: For skin-picking or hair-pulling with habitual quality, using awareness training and competing responses 1

Phase 3: Relapse Prevention (Final 2 Sessions)

• Develop an action plan identifying triggers, warning signs, and sources of support for future symptom re-emergence 1

Treatment Duration and Intensity

A typical course comprises 12-22 weekly sessions, though more severely impaired patients may require extended treatment 1:

• 79% response rate and 59% remission rate achieved in the largest naturalistic study (n=140) with mean 17.2 sessions 1
• Patients with severe functional impairment (e.g., school dropout) may need longer CBT courses, home-based sessions, or medication optimization 1
• Additional improvements occur after session 12 in adult trials, supporting extended treatment for severe cases 1

Pharmacological Treatment: SSRIs

SSRIs are second-line treatment for young people aged 12-18 with moderate-to-severe BDD who have not responded adequately to CBT 2:

SSRI Prescribing Guidelines

• Higher doses are required for BDD compared to anxiety or depression treatment 2
• Initial trial duration: 8-12 weeks to determine efficacy 2
• Maintenance treatment: 12-24 months minimum after achieving remission to prevent relapse 2
• Initial improvement may occur within 2-4 weeks, with greatest gains early in treatment 2

Medication Selection

Choose SSRIs based on: past treatment response, adverse effect profile, drug interactions, comorbid medical conditions, and cost 2

Clomipramine showed initial efficacy but SSRIs have superior safety and tolerability profiles, making them preferred first-line agents 2

Multimodal Treatment Approach

In routine clinical care, 72% of young people receive concurrent CBT and SSRIs, achieving 79% response rates 1:

• CBT alone remains effective: unmedicated patients (n=37) showed similar outcomes to those receiving combined treatment 1
• Consider medication optimization (higher-dose SSRI) for patients not responding to CBT alone 1

Engagement Strategies

Use motivational interviewing techniques throughout therapy, particularly when insight is poor 1:

• Avoid polarizing physical versus psychological explanations 1
• Frame treatment goals as reducing distress, improving quality of life, and building self-confidence rather than challenging appearance beliefs directly 1

Critical Clinical Considerations

BDD carries exceptionally high suicide risk: approximately half of young people with BDD report self-harm, making this a particularly high-risk psychiatric condition 2:

• Appropriate pharmacotherapy is essential for severely ill and suicidal patients 2
• Risk assessment must be conducted at every contact given the high morbidity and mortality 2

Parental Involvement

Include parents/carers in treatment, particularly during psychoeducation phases, to support treatment adherence and home-based ERP practice 1

Access to Treatment

Digital CBT programs with low-intensity therapist support show efficacy comparable to face-to-face treatment and improve accessibility 1, 3:

• Programs using coaches without formal clinical qualifications have demonstrated effectiveness, highlighting scalability 1
• Cost-effectiveness has been formally demonstrated for digital interventions 1