CBT is a practical treatment approach that teaches skills and includes cognitive restructuring, behavioral experiments, exposure, and response prevention. It focuses on changing and substituting, both, beliefs and thoughts (cognitive aspect) and behaviors (behavioral aspect) such as skin picking and mirror checking. CBT should be tailored to the individual person and performed by a trained therapist who is familiar in treating BDD. It is typically administered as weekly, hourly sessions. Wilhelm et al. developed a treatment manual for CBT for BDD. The CBT-BDD methods include the following facets as outlined below [17]:

A randomized waitlist-control study evaluated the efficacy of CBT-BDD [18]. Efficacy was evaluated using the body dysmorphic disorder-Yale Brown Obsessive Compulsive Scale (BDD-YBOCS), the most frequently used scale for BDD treatment response. Responders were defined as having greater than 30 % improvement at the end of the treatment period. After 12 weeks of weekly 60-min sessions, 50 % (8 of 16) of participants in the treatment group were BDD-YBOCS responders compared to 12 % (2 of 17) in the waitlist control group (p = 0.026). After 12 weeks, all study participants were crossed over into the treatment group, and by the end of the 22-week study, 81 % (26 of 32) of all participants were responders. Patient satisfaction in this study also was high (client satisfaction inventory with score of 87.3 %), and treatment gains were maintained when evaluated at a 6-month follow-up.

Traditional CBT methods (not according to the BDD-CBT protocol) have also been efficacious in the treatment of BDD in a number of controlled trials and case series. A randomized waitlist-controlled study evaluated the efficacy of 12 weeks of CBT in BDD patients. They found that the treatment group had a mean 50 % reduction in symptoms on the BDD-YBOCS with a significant difference compared to the control group (treatment group 22.00 pre-, 10.75 posttreatment; waitlist group 21.18 pre-, 24.33 posttreatment, p < 0.01) [9]. A higher score corresponds to more severe symptoms on the BDD-YBOCS. Evidence has repeatedly supported the efficacy of individual CBT in the treatment of BDD, and it is considered as the first-line psychotherapeutic technique. In fact, CBT was found to be the best-established treatment for a variety of somatoform disorders, including BDD, in a review of 34 randomized controlled trials involving 3922 patients [19].

Group CBT has also been studied and found to be useful in the treatment of BDD. One randomized waitlist-controlled study (n = 54) demonstrated significantly improved scores on the body dysmorphic disorder examination (BDDE) (treatment group 93.9 pre-, 41.4 posttreatment; waitlist group 89.9 pre-, 83.2 posttreatment, p < 0.001) [10]. A higher score corresponded to more severe symptoms. Not only was the treatment effective, but also the patients reported a positive impression of the therapy. During the weekly 2-h sessions of 8 weeks, attendance was 100 %, and 80 % of the participants said they would recommend the program. Another case series demonstrated the efficacy of group CBT (BDD-YBOCS pretreatment 28.5, posttreatment 21.3); however, this study lacked a control group [20]. The demonstrated efficacy of group CBT may have the added benefits of increased social support and decreased cost. Direct comparisons of efficacy and compliance between individual and group CBT for BDD are needed.

BDD is commonly seen in adolescents, but the treatment in this population has not been well studied. From the limited data available, CBT has been successful in the pediatric population. One case series found that 4 of 6 patients were responders by the BDD-YBOCS, and that all of these patients also experienced a concomitant decrease in depressive symptoms [11]. CBT has been demonstrated to be effective in adults and data suggest this is true in pediatrics as well; however, more studies in this population are warranted. When working with a younger population, it is important to adjust the technique by using appropriate language and interaction approach for the age group. Emphasizing behavioral strategies over cognitive strategies may be beneficial for younger patients as well [11].

Inference-based therapy (IBT) is a technique that was originally developed for patients with OCD with particularly fixed beliefs or obsessions. BDD shares features with OCD including obsessions, fixed ideations, and repetitive behaviors. Many BDD patients have overvalued ideation (OVI), which is a very strong conviction in the objective reality of their belief without the level of certainty to qualify as a delusion. Patients with OVI may be less likely to respond to CBT [21].

In IBT, BDD obsessions are conceptualized as a two-step process where the establishment of a faulty inference is used as the basis for a secondary inference with negative anticipated consequences. For example, the belief that “I am not big enough to get noticed” (faulty inference) may be followed by the inference “if I never get noticed, I will never find a girlfriend” (negative consequence). In this case, the patient was 90 % convinced that if he did not perform his rituals (working out), he would suffer the negative consequence (never getting a girlfriend) [12]. In IBT, the therapist first tries to explore the patient’s fear or believed negative consequence and then works backward to help identify the initially held obsessional belief [12]. These faulty inferences are the primary target for therapeutic intervention with IBT. One case series demonstrated the efficacy of IBT for patients with BDD [12]. IBT may be especially useful in patients with firmly held ideations contributing to their BDD. More studies are needed on the emerging topic of IBT for BDD.

SSRIs are useful for the medical management of many psychiatric conditions including: major depressive disorder, OCD, generalized anxiety disorder, panic disorder, phobias, bulimia, posttraumatic stress disorder, and a number of off-label uses, including BDD. They are generally well tolerated, but common mild–moderate side effects include: gastrointestinal disturbances, agitation, anxiety, insomnia, and sexual dysfunction. SSRI medications currently available include: fluvoxamine (Luvox®) 50–300 mg/day, fluoxetine (Prozac®) 20–80 mg/day, paroxetine (Paxil®) 20–50 mg/day, sertraline (Zoloft®) 50–200 mg/day, citalopram (Celexa®) 20–40 mg/day, and escitalopram (Lexapro®) 10–20 mg/day. Clomipramine (Anafranil®) 150–250 mg/day is a nonselective serotonin reuptake inhibitor (SRI) that has also been used as treatment for BDD. Clomipramine is generally not used first-line as it is more likely to cause side effects and can be toxic at very high doses.

Randomized controlled studies and open-label studies have been conducted on fluoxetine, fluvoxamine, citalopram, and escitalopram, all demonstrating clinically significant improvements in symptoms. In a randomized placebo-controlled trial, fluoxetine was shown to be effective in 53 % of patients compared to 18 % in the placebo group. The mean response time was 7.7 weeks in these patients, and the mean dose was 77.7 mg/day [26]. The relative response to fluoxetine compared to the placebo group was 3.07 [23]. Two open-label studies demonstrated the efficacy of fluvoxamine in the treatment of BDD [27, 28]. In one study, 10 of 12 patients were markedly improved after 10 weeks of fluvoxamine therapy [27]. In the other study, 63.3 % (n = 30) of patients responded to fluvoxamine based on the BDD-YBOCS with a mean response time of 6.1 weeks and a mean dose of 238 mg/day [28]. An open-label study evaluated the efficacy of citalopram for the treatment of BDD and found that 73.3 % (11 of 15 patients) were responders after 12 weeks [29]. The mean endpoint dose for citalopram was 51.3 mg/day and mean time to response was 4.6 weeks. An open-label study of escitalopram demonstrated an efficacy of 73.3 % (11 of 15 patients) with a mean endpoint dose of 28.0 mg/day (starting at 10 mg/day, increasing dose by 10 mg every 2 weeks up to 30 mg/day) and a mean time to response of 4.7 weeks [30]. Although no studies have compared one SSRI to another, one author has noted that escitalopram and citalopram had somewhat higher percentages of patient improvement, had higher percentages of “very much improved” compared to only “much improved,” and lastly, many patients in those studies responded earlier (within 2–6 weeks) [2]. More research is needed; however, it may be that escitalopram and citalopram are most efficacious.