Treatment of body dysmorphic disorder (BDD) may include cognitive-behavioral therapy (CBT), pharmacologic interventions, and other psychosocial interventions that promote social functioning. The basic goals of treatment are as follows:
To prevent adoption of the sick role
To minimize unnecessary costs and complications by avoiding unwarranted hospitalizations, diagnostic and therapeutic procedures, medications, and, in particular, corrective surgical procedures (BDD patients are rarely satisfied with the results of corrective surgery, and in some cases, they become even more obsessed after such treatment)
To achieve pharmacologic control of comorbid syndromes and BDD
The primary treatment modalities for BDD are selective serotonin reuptake inhibitor (SSRI) therapy and CBT.  Both modalities are supported by level 2 evidence. One study includes a double-blinded randomized controlled trial with placebo or an active comparison condition. 
Pharmacologic agents are employed on an off-label basis; at present, no medications have been specifically approved by the US Food and Drug Administration (FDA) for the treatment of BDD. Drugs with potential for abuse or addiction must be avoided.
The United Kingdom’s National Collaborating Centre for Mental Health published guidelines on core interventions in the treatment of BDD and obsessive-compulsive disorder (OCD), which may be of interest. 
Evidence supports the use of SSRIs such as fluoxetine, fluvoxamine, escitalopram, and citalopram in the treatment of BDD, though caution should be used with citalopram given the FDA dose guidelines regarding QT prolongation, as high dose is frequently needed.  The tricyclic antidepressant (TCA) clomipramine has been widely used as well. [66, 67] Other pharmacologic agents, such as neuroleptics, trazodone, lithium, benzodiazepines, TCAs other than clomipramine, and anticonvulsants have been much less beneficial or ineffective.
Clomipramine has adverse effects similar to those of other TCAs (eg, sedation, anticholinergic effects, orthostatic hypotension, sexual dysfunction, weight gain, cardiac conduction slowing, and a potential for fatal overdose). In a study comparing clomipramine with the selective norepinephrine reuptake inhibitor desipramine in patients with BDD, superior results were noted with clomipramine, including improvements in obsessive characteristics, depression, insight, social performance, and disorder severity. 
The SSRIs fluoxetine and fluvoxamine usually have milder adverse effect profiles than clomipramine does; however, they may be associated with adverse effects such as initial anxiety or agitation, nausea or other gastrointestinal (GI) disturbance, headache, sexual dysfunction (eg, delayed orgasm or loss of libido), and occasional apathy. In addition, they may be associated with various cutaneous reactions, such as the following: 
Cutaneous Reactions Associated with SSRIs (Open Table in a new window)
|Toxic epidermal necrolysis|
Because cross-reactions may occur between SSRIs, even those with different chemical structures, switching to another family of antidepressants may be advisable if an SSRI is linked to a serious skin eruption.
Clomipramine and SSRIs often must be given at high dosages and for lengthy treatment periods (eg, 6–16 weeks for SSRIs  ) before symptoms improve; drug trials should continue for several months after the target dose is reached. Average time to response for fluoxetine and fluvoxamine is generally 6-9 weeks, while the effect from citalopram and escitalopram was slightly faster at 4–5 weeks.  Dosages should be increased gradually to prevent possible adverse effects. Almost 58% of patients with BDD achieve either partial improvement or complete resolution of symptoms with an SRI regimen.
In some situations, patients who show resistance to normal treatment may have positive results when treated with SSRIs in combination with clomipramine. In this case, clomipramine levels should be monitored because SSRIs increase clomipramine concentrations in the blood.
|Medication||Mean Dose||Max Dose|
|Fluoxetine||67 ± 24 mg||120 mg|
|Fluvoxamine||308 ± 49 mg||450 mg|
|Sertraline||202 ± 46 mg||400 mg|
|Paroxetine||55 ± 13 mg||90 mg|
|Citalopram||66 ± 36 mg||40 mg*|
|Escitalopram||29 ± 12 mg||60 mg|
|Clomipramine||203 ± 53 mg||250 mg|
*Reflects FDA dosing limit reduction
Even when the patient’s perceptions are distorted to the point where they are felt to be psychotic, the use of neuroleptics may not ameliorate the delusions. Some patients may still benefit from adjunctive antipsychotics. However, when used at higher dosages similar to those used in the treatment of OCD, SSRIs are frequently effective at ameliorating symptoms. [57, 84] The response to SSRIs is often partial rather than complete, and 40-50% of patients may not respond adequately to medication alone. 
BDD patients with delusional symptoms may benefit from a therapeutic regimen that includes the antipsychotic agent pimozide in addition to an SSRI. Patient insight may improve with the use of pimozide alone. A pimozide-clomipramine combination may lengthen the QT interval on the electrocardiogram (ECG); therefore, close monitoring of the ECG is required.
Pimozide has the adverse effects common to other typical high-potency antipsychotic medications (ie, extrapyramidal symptoms such as dystonia, parkinsonism, akathisia, neuroleptic malignant syndrome, and tardive dyskinesia). It also can slow cardiac conduction and cause hyperprolactinemia.
For the one third of patients who do not respond to treatment with SSRIs or clomipramine alone, the addition of buspirone may prove helpful.
If all other treatment modalities fail, monoamine oxidase inhibitors (MAOIs) may be given, though their use necessitates the imposition of dietary and other restrictions (eg, avoidance of tyramine-containing foods and certain medications). These drugs probably should be prescribed only by experienced specialists.
An open-label trial of the serotonin-norepinephrine reuptake inhibitor venlafaxine suggested that it may be an effective treatment for BDD. 
There is one double-blind, placebo-controlled trial that supports the effectiveness of escitalopram vs placebo with regards to relapse prevention. Escitalopram delayed time to relapse and fewer escitalopram-treated subjects relapsed than did placebo-treated subjects. In addition, body dysmorphic disorder severity significantly improved during the additional six months of escitalopram treatment following acute response, and more than one-third of escitalopram-treated subjects experienced further improvement. 
Use of SSRIs in pediatric patients
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory stating that most SSRIs are not suitable for use by persons younger than 18 years for treatment of “depressive illness.” After review, this agency decided that the risks SSRI treatment poses to pediatric patients outweigh the benefits, except in the case of fluoxetine, which appears to have a positive risk-benefit ratio for the treatment of depressive illness in patients younger than 18 years.
In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. Accordingly, the FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, rather than rises, with the use of antidepressants. To date, this is the largest study to date to address this issue.
Currently, no evidence associates OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.
Psychiatric and Behavioral Interventions
Psychotherapy (especially CBT) and behavioral modification therapy are highly recommended in addition to treatment with SSRIs. [72, 79, 80, 82, 83] Approaches include systematic desensitization, exposure techniques, self-confrontational techniques, and cognitive imagery.
General strategies include the following:
Consistent treatment, generally by the same physician
Supportive office visits scheduled at regular intervals
Gradual shifting of focus from symptoms to personal and social problems
- Identify and evaluate negative thoughts/beliefs and cognitive errors
Exposure and Response (ritual) Prevention
- Aids in reduction of repetitive compusions, gradually improves avoidance
- Development of a more holistic view of appearance, focus on objectively versus negatively describe body
Relapse Prevention and Daily Homework
- Consolidates skills learned in therapy, prepares for termination
Additional approaches include the following:
Problems with seeking and receiving cosmetic treatments
CBT may be beneficial in situations where patients develop a structured and predictable strategy for identifying cognitive errors and maladaptive thinking. When CBT is efficacious, patients learn to alter cognitive distortions and are able to maintain and generalize more adaptive thought patterns in daily life. Therapy within a group setting and supportive psychotherapy may be adequate for people who are not truly delusional. A few studies have claimed successful results with behavior modification alone.
A small study of CBT in 13 adolescents with BDD found symptoms were improved at 3- and 6-month followup. Treatment was delivered in 12–22 weekly individual sessions. 
Two recent randomized control trials support the efficacy of CBT for BDD. The first included a broad range of patients, including those with delusional BDD beliefs and those with suicidal ideation. Over 24 weeks, they were randomized to either 24 weeks of manualized CBT or a12-week wait-list, then 24 weeks of CBT. By week 12, 50% of the CBT group were responders compared to 12% of the wait-list group. Post-treatment analysis demonstrated 81% of the intention-to-treat group and 83% of the immediate CBT group were deemed responders.  The second randomized control trial did not use a wait-list control group (to control for nonspecific treatment factors such as therapist time and attention) where CBT for BDD was compared to behavioral therapy for anxiety management after 12 weeks of treatment. The CBT group was found to have a better treatment response. 
Although nonpharmacologic psychiatric treatment is often effective in the treatment of BDD, patients with this condition are likely to try to avoid psychiatric therapy. An on-site psychiatric liaison may be helpful in bridging the gap between dermatologic and psychological treatments.
Therapy with family members, spouses, or significant others should be strongly considered as a means of helping to improve the patient’s outcome. On one hand, people who have a close relationship with the patient may agree with the patient’s perception of the defect and may reinforce his or her maladaptive beliefs and behaviors. On the other, people with a close relationship to the patient may disagree with what the patient thinks is necessary for treatment and may be able to urge a more effective approach.
Patients with BDD frequently consult cosmetic specialists (eg, dermatologists or plastic surgeons) for treatment of their imagined defect. However, cosmetic surgery frequently fails to improve BDD symptoms. Most people with BDD will be displeased with the results, commonly either becoming increasingly preoccupied with the original perceived defect or finding a new one with which to be concerned (such as a surgical blemish or scar from the cosmetic surgery itself).
Given that more than 90% of BDD patients report symptoms that are unchanged and often exacerbated after surgical procedures, plastic or cosmetic surgery intended to correct the perceived defect in BDD is contraindicated. These patients constitute a disproportionate litigious risk for surgeons. Of even greater concern for surgeons considering providing surgical treatment to BDD patients are reports of individuals who become violent after the operation and cause physical harm to their healthcare providers. 
In all suspected cases of BDD, any proposed surgical treatment must be thoroughly documented and discussed with patients. Preoperatively, if a surgeon suspects that a patient may meet diagnostic criteria for BDD, referral to a psychiatrist for further evaluation is indicated. Surgeons are advised not to perform surgery on patients who have been definitively diagnosed with BDD.
Physicians should refer patients to a psychiatrist for a thorough psychiatric evaluation to confirm a suspected diagnosis of BDD, as well as to assess the patient for possible comorbid psychiatric diagnoses and provide appropriate treatment recommendations. [75, 39] Because many of these patients present to surgeons seeking surgical correction of what they consider a clear physical defect, with little or no awareness of their underlying psychiatric disorder, they may react negatively and angrily to such a referral. [74, 76]
The referring surgeon or other physician is advised to treat the referral to a psychiatrist as they would a referral to any other health professional. Treating the referral as a standard aspect of preoperative care increases the likelihood that the patient follows up with the referral and should mitigate the possibility of patient dissatisfaction with the referring surgeon or physician. 
Over the long term, patients achieve the best results when treated by a consistent medical and mental health team. They may derive the greatest benefit from a combination of SSRIs and therapy sessions.
As a chronic condition, BDD requires maintenance therapy and monitoring of SSRI tolerance. According to the American Psychiatric Association, patients who are taking maintenance medications should be seen at least 3-4 times per year. Approximately 53% of those with BDD experience relapse within 6 months of discontinuance of treatment.
For long-term management of a chronic disorder such as BDD, it is usually considered prudent to prescribe the same dosages of medications for initial treatment and ongoing maintenance. The concept of lower maintenance dosages is not well supported; the majority of studies have reported higher relapse rates at lower maintenance dosages.
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