- Treat for 12 to 16 weeks with an SSRI before concluding that the medication is ineffective. The average time to response is between 6 to 9 weeks.12,14,16 Clinical experience suggests that with continued treatment, relapse is rare and many patients further improve.
- Try sequential SSRIs if the first or second one does not work. A substantial percentage of patients who fail an initial SSRI trial will respond to a subsequent SSRI.17
- Continue an effective SSRI for at least 1 year before discontinuing it, as relapse appears likely with discontinuation.17 Severely ill patients may require treatment for life.
- Several SSRI augmentation and combination strategies might be helpful (Figure 1).16,17 If clomipramine is used in combination with an SSRI, the clomipramine level should be monitored.
What is the role of psychotherapy?
Although research on psychotherapy for BDD is limited, findings from clinical series and studies using waiting-list controls indicate that cognitive-behavioral therapy (CBT) is often effective.18-20 In contrast, supportive psychotherapy and insight-oriented and psychodynamic psychotherapy alone appear to be ineffective.9 CBT usually consists of a cognitive element (e.g., changing distorted views of the appearance “flaw”), exposure to feared and avoided situations (often social), and response prevention, avoiding repetitive behaviors such as excessive grooming.
- Consider using CBT as a first-line approach for milder BDD without significant comorbidity requiring pharmacotherapy.
- Use more intensive CBT treatment including frequent sessions and use of homework rather than less intensive treatment, although the optimal number and frequency of sessions is unknown.
- Consider maintenance and booster sessions for patients with more severe BDD following treatment to prevent relapse.
- Consider combining CBT and an SSRI. Although it is not known whether a combination of these treatments is more effective than either one alone, they are compatible and their combination may benefit certain patients. For patients with severe BDD, especially very depressed or suicidal patients, it is probably best to use CBT in combination with medication only, as sicker patients may not be able to tolerate or participate in CBT without first experiencing some improvement with medication.
- Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press, 1996.
- Pope HG, Phillips KA, Olivardia R. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York, NY: The Free Press, 2000.
- Phillips KA, Van Noppen B, Shapiro L. Learning to Live with Body Dysmorphic Disorder. Milford, Conn: Obsessive-Compulsive Foundation, 1997.
- Body Dysmorphic Disorder (BDD)and Body Image Program Homepage at Butler Hospital (Providence, RI). http://www.bodyimageprogram.com
Drug brand names
- Bupropion • Wellbutrin, Zyban
- Buspirone • Buspar
- Citalopram • Celexa
- Clomipramine • Anafranil
- Clonazepam • Ativan, Diastat, Halcion
- Fluoxetine • Prozac, Sarafem
- Fluvoxamine • Luvox
- Mirtazapine • Remeron, Remeron Solitab
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Sertraline • Zoloft
- Venlafaxine • Effexor
Disclosure
The author reports that she receives grant support and occasional speaking honoraria from Eli Lilly and Co.; receives grant support from Forest Pharmaceuticals and Gate Pharmaceuticals; is on the speakers' bureau of Solvay Pharmaceuticals; and serves as a consultant for Wyeth-Ayerst Pharmaceuticals.