Best Medications for BDD and OCD
For both Body Dysmorphic Disorder (BDD) and Obsessive-Compulsive Disorder (OCD), selective serotonin reuptake inhibitors (SSRIs) at higher doses than those used for depression are the first-line pharmacological treatment due to their established efficacy, tolerability, and safety profile. 1
First-Line Pharmacological Treatment
For BDD:
- SSRIs are recommended as a second-line treatment for young people aged 12-18 years with moderate to severe BDD-related functional impairment who have not adequately responded to CBT 2
- In practice, many patients receive SSRIs as first-line treatment due to limited availability of specialized CBT for BDD 2
- Higher doses of SSRIs are typically required for BDD compared to those used for depression 3
- Treatment should be maintained for at least 8-12 weeks to determine efficacy 1
For OCD:
- SSRIs are the first-line pharmacological treatment for OCD 2, 1
- Clomipramine is also effective for OCD but is generally considered second-line due to more adverse effects 2, 4
- FDA-approved clomipramine has demonstrated efficacy in clinical trials with mean reductions of approximately 35-42% on the Yale-Brown Obsessive Compulsive Scale in adults and 37% in children and adolescents 4
- Higher doses of SSRIs are required for OCD compared to depression or anxiety disorders 1, 5
Dosing and Duration Considerations
- For both conditions, medication trials should last 8-12 weeks to determine efficacy 2, 1
- Significant improvement may be observed within the first 2-4 weeks of treatment 2, 1
- Maintenance treatment should continue for a minimum of 12-24 months after achieving remission due to high risk of relapse after discontinuation 2, 1
- Maximum doses for clomipramine are 250 mg/day for most adults and 3 mg/kg/day (up to 200 mg) for children and adolescents 4
Treatment-Resistant Cases
For BDD:
- Limited evidence suggests that clomipramine may be effective when SSRIs fail 6, 7
- Augmentation strategies may include adding atypical antipsychotics, anxiolytics, or anticonvulsants like levetiracetam, though large-scale RCTs are lacking 7
- Cognitive-behavioral therapy (CBT) should be considered as an augmentation strategy or alternative treatment 8, 7
For OCD:
- Approximately 50% of patients with OCD fail to fully respond to first-line treatments 2, 1
- Options for treatment-resistant OCD include:
- Switching to a different SSRI 2, 1
- Trying higher doses of an SSRI than the maximum recommended dose 2
- Considering a serotonin-norepinephrine reuptake inhibitor (SNRI) like venlafaxine 2, 1
- Augmenting with antipsychotics (particularly risperidone or aripiprazole) 2, 1
- Augmenting with clomipramine (with careful monitoring for adverse effects) 2
- Trying glutamatergic agents such as N-acetylcysteine or memantine 2, 1
Important Considerations and Caveats
- Higher doses of SSRIs are associated with greater efficacy but also higher rates of adverse effects, requiring careful monitoring 1
- Antipsychotic augmentation requires vigilant monitoring of the risk-benefit ratio, particularly for weight gain and metabolic effects 2, 1
- Clomipramine augmentation of SSRIs carries risks of potentially life-threatening events such as seizures, cardiac arrhythmias, and serotonergic syndrome 2, 1
- CBT remains a first-line treatment for both conditions, particularly for BDD in young people, and should be considered alongside pharmacotherapy 2, 5
- For BDD patients, psychoeducation about the dangers of cosmetic procedures is essential as outcomes are typically poor and can worsen symptoms 2, 7