Psychedelic Therapy for Body Dysmorphic Disorder

This paper (2022) makes the case for using psychedelic-assisted psychotherapy (PAP) for the treatment of body dysmorphic disorder (BDD). Preliminary evidence suggests the safety, feasibility, and potential efficacy of psychedelic treatments in disorders that share similar psychopathological mechanisms with BDD. A Phase II study is suggested with thoughts on how to proceed with this research.

Abstract

“In this opinion piece, we propose the investigation of psychedelic-assisted psychotherapy for the treatment of body dysmorphic disorder (BDD). BDD is a psychiatric disorder characterised by appearance-based preoccupations and accompanying compulsions. While safe and effective treatments for BDD exist, non-response and relapse rates remain high. Therefore, there is a need to investigate promising new treatment options for this highly debilitating condition. Preliminary evidence suggests safety, feasibility, and potential efficacy of psychedelic treatments in disorders that share similar psychopathological mechanisms with BDD. Drawing on this evidence, as well as on relevant qualitative reports and theoretical proposals, we argue that it would be worthwhile to conduct a phase 2a study aimed at assessing the safety and feasibility of psychedelic-assisted psychotherapy in BDD. We also offer some suggestions for how future research ought to proceed.”

Authors: Shevaugn Johnson & Chris Letheby

Summary

In this opinion piece we propose the investigation of psychedelic-assisted psychotherapy for the treatment of body dysmorphic disorder (BDD). Based on preliminary evidence, we argue that it would be worthwhile to conduct a phase 2a study.

Recently, the prevalence of body image disturbance has increased, as have rates of body dysmorphic disorder in adolescent and young adult populations. Therefore, the exploration of novel evidence-based treatments aimed at targeting this complex and debilitating disorder is warranted.

BDD is an obsessive-compulsive disorder characterised by appearance-based preoccupations and accompanying compulsions. Patients may avoid mirrors and social interactions due to a fear of negative evaluations, and may experience poor outcomes when extended treatments are unavailable.

BDD is a pernicious disorder that may result in severe bodily mutilation. It is one of the most debilitating and high-risk mental health conditions, and the first-line treatment for BDD is a combination of cognitive-behavioural therapy, selective serotonin reuptake inhibitors, and/or tricyclic antidepressants.

CBT-BDD helps patients gain a deeper understanding of their condition and address the cognitive, behavioural, and emotional factors that perpetuate symptoms. However, a significant number of patients are considered treatment non-responders, and targeted neurosurgery has been recommended in some cases.

Pharmacological interventions are standardly used as adjuncts to CBT in the treatment of BDD, but their efficacy is inferior to that of psychological interventions. Furthermore, patients with BDD typically require very high doses of medication, which often exceed recommended limits.

BDD populations have a high risk of relapse, and treatment with antidepressants is limited by side effects, prolonged use, and access barriers. Augmentation of SSRIs with antipsychotics has shown some efficacy in patients with treatment-resistant OCD, but limited research suggests efficacy in BDD populations.

Despite adequate mental health infrastructure and minimal financial barriers, BDD is under-recognised and under-treated. The most effective known treatment, CBT-BDD, has limited utility since patients struggle to complete it.

Psychedelic therapy is a mental health treatment that involves administering one to three doses of a psychedelic substance in conjunction with psychotherapy. The aim is to induce a dramatically altered state of consciousness that is believed to facilitate therapeutic progress.

Psychedelics are naturally occurring substances that have been used in religious and medicinal contexts for centuries. Some studies have suggested that psychedelic experiences might have lasting beneficial psychological effects, both in healthy subjects and in psychiatric patients.

Human psychedelic research was virtually halted in the late 1960s, but has since resumed. Several clinical trials have reported substantial reductions in symptoms of anxiety, depression, and substance use disorders, lasting weeks or months after one to three psychedelic sessions combined with psychotherapy.

This case report suggests that psychedelic use may have therapeutic effects in people with eating disorders. Several studies have documented positive changes in body image and relationships to bodies after psychedelic use.

The authors of this paper propose that psychedelics might facilitate therapeutic benefits by disintegrating mental models, especially models of the self. This idea is supported by preliminary evidence from a double-blind randomised trial of nine individuals with moderate to severe OCD.

Psilocybin might alter the functioning of the CSTC pathway in OCD patients, and it might also enhance motivation towards positive cues while decreasing amygdala activity in response to negative facial expressions. This is noteworthy given that mirror therapy is a common element of CBT-BDD.

Psilocybin, an experimental drug with potential anti-compulsive properties, has been proven safe and well-tolerated in multiple controlled studies in healthy volunteers, and has been granted breakthrough therapy status by the Food and Drug Administration for treatment-resistant depression and major depressive disorder. Most evidence for psychedelic therapy in BDD is indirect, and subject to major limitations. However, we contend that the circumstantial case is sufficiently strong to warrant investigation.

BDD is an understudied psychiatric disorder that has only recently entered widespread public and academic discourse. A phase 2a study of psilocybin-assisted therapy in BDD patients would be a natural first step towards reducing the suffering and disease burden of BDD. Consistent with prior studies of psychedelic therapy, feasibility of psilocybin-assisted therapy in BDD populations could be determined by measuring the occurrence of adverse events, grading the severity of these events, and assessing recruitment and retention rates.

There are ethical considerations involved in the design of a trial of this sort, including the potential for participants to rapidly and durably change their personalities, worldviews, and fundamental beliefs.

Safety and ethical concerns specific to BDD populations might include liaising with prescribing practitioners to help participants taper off antidepressant and/or other psychiatric medications. Psilocybin is the best-studied classic psychedelic in recent research.

If early research finds psilocybin to be safe and tolerable, double-blind, randomised controlled trials should be undertaken to investigate combining psilocybin administration with evidence-based interventions targeted at specific features of BDD, such as CBT-BDD. Perceptual retraining is used in the treatment of BDD to retrain attention away from specific aspects of appearance towards a more global mode of perception. It is plausible that psychedelics might assist this process, given their propensity to induce states of “ego dissolution”.

We have highlighted the limitations of current available first-line treatments for BDD and suggested that a phase 2a study assessing the safety and feasibility of psilocybin-assisted therapy for BDD should be conducted.

The authors would like to thank Dr Stephen Bright, Dr Martin Williams, Professor Peter Hendricks and the Australian Government for their support.