What medications are used to treat Body Dysmorphic Disorder (BDD)?

Medications for Body Dysmorphic Disorder (BDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for Body Dysmorphic Disorder, with higher doses typically required compared to those used for anxiety or depression. 1, 2

First-Line Treatment: SSRIs

• SSRIs are considered the medication of choice for BDD due to their established efficacy, tolerability, safety profile, and absence of abuse potential 2
• Higher doses of SSRIs are typically needed for BDD compared to those used for anxiety disorders or major depression 1
• Treatment should be continued for a minimum of 12-24 months after achieving remission to prevent relapse 1
• Initial significant improvement in symptoms may be observed within the first 2-4 weeks of treatment, with the greatest incremental gains occurring early in treatment 1

Medication Selection Considerations

• When choosing between different SSRIs, consider:
  • Past treatment response
  • Potential adverse effects (particularly gastrointestinal symptoms and sexual dysfunction)
  • Potential drug interactions
  • Presence of comorbid medical conditions
  • Cost and medication availability 1
• Careful assessment of SSRI adverse effects is crucial when establishing the optimal dose for each patient 1

Alternative Medication Options

• Clomipramine, a non-selective serotonin reuptake inhibitor, was the first agent to show efficacy in BDD 1, 2
• While some meta-analyses have suggested clomipramine may be more efficacious than SSRIs, head-to-head trials indicate equivalent efficacy 1
• SSRIs have a higher safety and tolerability profile compared to clomipramine, supporting their use as first-line agents 1

Treatment Duration and Dosing

• NICE guidelines recommend that SSRIs should be used as a second-line treatment for young people aged 12-18 years with moderate to severe BDD-related functional impairment who have not responded adequately to CBT 1
• The optimal duration of an initial SSRI trial to determine efficacy is 8-12 weeks 1
• Maintenance treatment should continue for at least 12-24 months after achieving remission 1
• Longer treatment may be necessary for many patients due to the risk of relapse after discontinuing medication 1, 3

Augmentation Strategies for Treatment-Resistant BDD

• For patients with inadequate response to SSRIs, various adjunctive medications can be considered:
  • Atypical antipsychotics
  • Anxiolytics
  • Anticonvulsants such as levetiracetam 2
• However, large-scale randomized controlled trials for augmentation strategies are lacking, and BDD is not an approved indication for these medications 2
• One placebo-controlled study of pimozide augmentation of fluoxetine found it was not more effective than placebo, even in more delusional patients 4

Important Clinical Considerations

• BDD is associated with high morbidity and mortality, including significant suicide risk, making appropriate pharmacotherapy essential, particularly for severely ill and suicidal patients 5, 1
• Approximately half of young people with BDD report self-harm, and the disorder is considered a particularly high-risk psychiatric condition 1
• Treatment should include psychoeducation, particularly addressing the dangers associated with cosmetic procedures 2
• Many patients experience substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, and suicidality when treated with appropriate pharmacotherapy 5
• Medication treatment is often combined with cognitive behavioral therapy (CBT) for optimal outcomes 2, 6

Treatment Algorithm

1. First-line: SSRIs at higher doses than typically used for depression or anxiety
2. If inadequate response after 8-12 weeks: Consider increasing SSRI dose
3. If still inadequate response: Consider switching to a different SSRI or to clomipramine
4. For partial response: Consider augmentation strategies (though evidence is limited)
5. Maintain treatment for at least 12-24 months after achieving remission 1, 2, 3