There has been very little research on the treatment of BDD. The NICE guidelines on BDD recommend two treatments as helpful: cognitive behaviour therapy (CBT), which is specific for BDD, or serotonergic anti-depressant medication.Cognitive learning theory in nursing education as yet, there have been no controlled trials to compare the two treatments to determine which is the more effective, or if a combination of treatments does better, or which treatment might best suit which type of person.Cognitive learning theory in nursing education we urgently need funding for more research in this area. However, at present the NICE guidelines recommend:

“cognitive” refers to the events that take place in your mind (thoughts, images, memories, or processes like ruminating and worry).Cognitive learning theory in nursing education “behaviour” is what you do (for example escape, avoid, check). CBT starts with building a good understanding of the problem and what is keeping it going in terms of how your mind works.Cognitive learning theory in nursing education very often it turns out that ‘the solution is the problem’. For example, you might examine your appearance in the mirror to try and work out ‘how do I really look?’ but rather than leaving you feeling more certain of how you look, it might leave you feeling less certain and more preoccupied.Cognitive learning theory in nursing education

One way of thinking about BDD is that it is a problem of ‘not being able to see the wood for the trees’ – that you can no longer make an objective assessment of your appearance because you have become so distressed and preoccupied.Cognitive learning theory in nursing education because you are excessively self-focused on your felt impression, you assume that this is how others view you. This often leads to radically different opinions on your appearance between yourself and those who are close to you.Cognitive learning theory in nursing education being self-focused through scrutinising and monitoring your appearance, or the reactions of others, can increase feelings of self-consciousness and make being out in social situations very uncomfortable.Cognitive learning theory in nursing education

During therapy, you are likely to learn to re-focus your attention away from your self and re-engage with activities that will improve your mood and your life.Cognitive learning theory in nursing education many people come to view their negative self-image of their looks as a bad memory from the past, such as bullying or teasing. To help reduce self-consciousness a CBT therapist might recommend specific attention-training exercises.Cognitive learning theory in nursing education to further fight back you will be asked to resist comparing your appearance, to stop ruminating, test out your fears without camouflage and stop rituals such as checking and excessive grooming.Cognitive learning theory in nursing education many people find it helpful to think of CBT for BDD as training in how to stop being bullied by their BDD and to re-direct themselves into all the other aspects of living that are important to them.Cognitive learning theory in nursing education the main side effects of the treatment are the anxiety that occurs in the short term. However, testing one’s fear gets easier and easier and the anxiety gradually subsides.Cognitive learning theory in nursing education the principles of CBT for BDD are described in various books, which are linked on this site. Below is a description of how to get therapy in the UK.Cognitive learning theory in nursing education good CBT for BDD is likely to involve the following:

The second type of treatment recommended for BDD is anti-depressant medication, which is strongly “serotonergic”.Cognitive learning theory in nursing education these are referred to as ssris. The dose may need to be in the high range and taken daily for at least 12 weeks to determine its effectiveness.Cognitive learning theory in nursing education the medication may provide the full range of outcomes – either a cure (rare) or no benefit at all. On average, people with BDD obtain about a 40-50% reduction of symptoms.Cognitive learning theory in nursing education

In general, all ssris are likely to be equally effective for BDD, but individuals respond differently to different drugs. Your doctor will help you choose the most appropriate SSRI for you, given your circumstances and history.Cognitive learning theory in nursing education some ssris, such as paroxetine, may be more difficult to withdraw from and other things being equal are best avoided.

The normal starting dose and suitable target doses of different ssris are listed in the table below.Cognitive learning theory in nursing education sometimes it is helpful to go above these target doses (for example fluoxetine 80 or 100mg but it should be monitored closely). When progress is slow, you may need to increase the dose and you should check this with your doctor.Cognitive learning theory in nursing education if you experience significant side effects, you can always start on a lower dose, after discussion with your doctor. You can then build the dose up slowly.Cognitive learning theory in nursing education

If a SSRI or clomipramine is effective, you need to remain on it for at least a year, often longer, as discontinuing the medication may lead to high rate of relapse.Cognitive learning theory in nursing education it is not known how the medication “works” but it may do so in the absence of depression. Expert opinion is that a SSRI may be used either alone or best in combination with CBT.Cognitive learning theory in nursing education this is an area of research that badly needs to be done.

SSRI medication may have side effects but for most people these are minor irritations that usually decrease after a few weeks.Cognitive learning theory in nursing education alternatively, the dose may be adjusted or a different drug prescribed. The drugs are not addictive but you should stop them only under medical advice.Cognitive learning theory in nursing education medication is especially helpful when you are depressed as it may help improve your motivation to take advantage of CBT. The risk of relapse can probably be minimised by combining the medication with CBT in the long term but we require urgent research in this area.Cognitive learning theory in nursing education

Where the guidance states that, “in some areas an assessment service will help to decide what type of treatment is best. If this is the case, you can choose a provider once the assessment has recommended a type of treatment”, this means that if an assessment on a care pathway recommends out-patient CBT you can choose where to be referred and don’t have to exhaust treatment locally or be taken to a funding panel.Cognitive learning theory in nursing education

The first treatment of choice is cognitive behaviour therapy (CBT). In england you may be referred by your GP – or you maybe able to self-refer – for CBT at an increasing access to psychological therapies (IAPT) service.Cognitive learning theory in nursing education the website will allow you to find your local service. Individual CBT is usually offered for 12-15 sessions. However, recent research suggests it may need to be longer (for example 20 or more sessions) especially when there are additional problems.Cognitive learning theory in nursing education

There are two levels of therapy at an IAPT service – a higher step that consists of individual therapy (recommended) and a “lower intensity” support, delivered by “psychological well-being practitioners” (pwps) usually over the telephone.Cognitive learning theory in nursing education we do not think it is appropriate to be offered treatment for BDD by weekly support from a PWP, as there is no evidence of benefit in BDD. Equally it is not helpful to be offered just group CBT as there is no evidence of benefit as a stand-alone intervention in BDD.Cognitive learning theory in nursing education

In secondary care, a more experienced psychologist may provide your CBT and your medication can be reviewed by a psychiatrist. Unfortunately many community teams have limited resources and long waiting lists for CBT, and their experience with BDD may be limited.Cognitive learning theory in nursing education your CMHT may therefore only provide a very limited service in crisis management and risk assessment. This is where you may need a mental health advocate to get the treatment that you require.Cognitive learning theory in nursing education

Tertiary care: if treatment is less effective than you hoped for in secondary care, then you can ask for your care to be stepped up to a specialist service – for example as an out-patient at the centre for anxiety disorders and trauma (CADAT), or as in-patient at the anxiety disorders residential unit (ADRU) (no nursing staff at night), or as in-patient at the priory hospital north london.Cognitive learning theory in nursing education

There are two levels of specialist care funding – your local clinical care commissioning group funds the first level and the NHS england – funds the second level. (this is called the “highly specialised service for severe treatment refractory OCD and BDD”).Cognitive learning theory in nursing education it consists of a consortium of hospitals including the maudsley (out-patients), the bethlem (residential unit) & the priory north london (in-patients) (consultant is dr david veale), adolescent out-patients (dr bruce clark), queen elizabeth II (out-patients and some in-patients) (professor naomi fineberg) and springfield hospitals (mainly in-patients) (dr lynne drummond) who will assess and advise on your particular circumstances.Cognitive learning theory in nursing education

A good place to start is a therapist who is accredited with the british association of behavioural and cognitive psychotherapies. Equally, there are clinical psychologists and counsellors who are competent and not accredited by the BABCP.Cognitive learning theory in nursing education A key issue to discuss is their training and experience in treating BDD and which treatment protocol they would follow (see some questions to ask a therapist under a description of CBT).Cognitive learning theory in nursing education

If you need a more intensive programme of CBT or nursing care because of your suicide risk or need for help in self-care or prompting, then you may need to be admitted.Cognitive learning theory in nursing education make sure that this includes individual CBT at least three times a week by a therapist who is experienced in BDD. Nursing staff experienced in BDD and groups run specifically for people with BDD are a bonus.Cognitive learning theory in nursing education

At present, we recommend seeking help from OCD action as BDD is related to OCD. The website has information on obtaining a referral for specialist help; employment rights; housing; and your rights under the mental health act.Cognitive learning theory in nursing education you can also share your concern with others in an online forum on this website under the heading ‘ advocacy’. Sometimes the issues you are seeking help with are common in the BDD community and others may have been in the same position.Cognitive learning theory in nursing education

The vast majority of people receiving treatment in psychiatric wards have agreed to come into hospital. They are called informal or voluntary patients.Cognitive learning theory in nursing education some have been ‘sectioned’ (or ‘detained’) under the mental health act 1983. If you are in hospital as a detained patient you will not be free to leave and will lose some other rights that are available to informal patients.Cognitive learning theory in nursing education further details are available from mind, the mental health charity.

The mental health act is not used lightly and mental health professionals will generally only turn to it as a last resort when they genuinely believe that the mental health of the patient is at significant risk e.G.Cognitive learning theory in nursing education from suicide, self-neglect or violence to others. It may also be used to assess a patient who has, for example, been housebound for many years and refused to seek help.Cognitive learning theory in nursing education

Given that a person with BDD is preoccupied with a flaw (or flaws) in their appearance, it is only natural that people seek physical solutions to their appearance concerns.Cognitive learning theory in nursing education many people with BDD consider cosmetic or dermatological treatments; sometimes a person with BDD may be satisfied with the results but their symptoms of BDD persist.Cognitive learning theory in nursing education some procedures may be safer than others. Cosmetic rhinoplasty (“nose job”) is especially risky procedure in BDD but other procedures such as breast augmentation may be safer, but it depends on the individual and their circumstances.Cognitive learning theory in nursing education

The majority of people with BDD are not satisfied after the outcome of their chosen procedure. This can lead to a preoccupation with further surgery to try to get a better result, which in some cases will do more harm to a person’s appearance than good.Cognitive learning theory in nursing education even when sufferers are happy with the improvement to one area, the focus of their BDD often moves to another area of their appearance.

The key message here of course is that BDD is a psychological or psychiatric problem and thus needs psychological or psychiatric treatment.Cognitive learning theory in nursing education the best advice is to suspend, at least temporarily, any physical treatments, for say three months, to give yourself an opportunity to tackle your BDD head on with treatments that have been shown to work.Cognitive learning theory in nursing education