Selective Seratonin Reuptake Inhibitor Archives

Serotonin-Reuptake Inhibitors in the Treatment of Body Dysmorphic Disorder (BDD)

August 1, 2013 By Stephen

Most commonly used serotonin-reuptake inhibitors used in the treatment of Body Dysmorphic Disorder (BDD) and the average effective dosages based on clinical studies:

You can read more about augmenting SSRI’s in the treatment of BDD if a single agent is not effective.

Generic Name	Brand Name	Average Dose (milligrams per day)*
Citalopram	Celexa	66
Escitalopram	Lexapro	29
Fluoxetine	Prozac	67
Fluvoxamine	Luvox	308
Paraxetine	Paxil	55
Setraline	Zoloft	202
Clomipramine	Anafranil	203

How to dose an SSRI in BDD

There’s no one-size-fits-all formula; dosing will depend on a number of factors. The most tolerable dosing strategy is to start with a low dose and gradually increase the dose while monitoring for side effects.

So, for example, if you try escitalopram (Lexapro), the usual starting dose is 10 mg a day. After 2 weeks or so, assuming you’re tolerating it well, you could raise it to 20 mg a day. After 2 to 3 weeks on 20 mg a day, you could then raise it to 30 mg a day, unless you’re already starting to improve or are having problematic side effects.

For fluoxetine (Prozac), the usual starting dose is 20 mg per day. After taking this dose for 2 weeks or so you could raise the dose to 40 mg a day. After another 2 to 3 weeks you could raise it to 60 mg/day, and then raise it to 80 mg a day after another 2 to 3 weeks, unless you’re getting better on a lower dose or are having trouble with side effects. But these dosing schedules are only general guidelines.

Generally, I recommend raising the dose more quickly for people who are severely ill and are tolerating the medicine well. Patients who are closely monitored during hospitalization can also have their dose raised more quickly than described above.

Conversely, it makes sense to raise the dose more slowly if you start substantially improving on a lower dose (because you may not need to raise it further) or if you’re having trouble with side effects. Your preference also matters.

A reasonable goal, however, is to reach the maximum dose that the manufacturer recommends (if a lower dose isn’t already working) within 4 to 9 weeks of starting the medicine.

Don’t give up on an SRI until you’ve tried it for at least 12 to 16 weeks, while reaching a high enough dose during that time

To see if a particular SRI will work for you, it’s important to try it for a total of at least 12 to 16 weeks, while reaching a high dose if possible (unless a lower dose works for you) for at least 3 of those weeks. This is called an “adequate” trial. The trial is considered “inadequate” if you don’t reach a high enough dose or if you try the medicine for less than a total of 3 months. An inadequate trial may not be sufficient to successfully treat BDD.

Studies indicate that the vast majority (nearly 90%) of SRI treatments that people with BDD receive aren’t optimal (reaching the highest dose) for this disorder. And two-thirds of SRI treatments that are received aren’t even minimally adequate for BDD.

You need to take the medicine every day as prescribed

It’s very important to take the medication every day, exactly as prescribed, even if it doesn’t seem to be helping. If you take less than prescribed, or you take it sporadically, it may not work as well or at all. If you have trouble remembering to take it every day, try using a pill box (which you can buy at a pharmacy), setting an alarm, or finding another way to remember. If you don’t want to take the medicine as prescribed because of side effects or because you have concerns about it, it’s better to discuss your concerns with your doctor, rather than stopping the medicine or not taking it as prescribed.

Try to be patient; SRIs usually begin to work gradually

Occasionally, the medication begins to work suddenly. Some people can pinpoint the day, or even the hour, that it starts working. But typically, it starts working gradually. People say things like “I felt a little better three days ago and today, but not for very long, so I don’t know if it’s really working.” Don’t get discouraged if the medicine takes a while to work and you get off to a slow start. With more time on the medicine, these brief intermittent spurts of improvement gradually develop into more sustained periods of well-being. Good hours gradually turn into entire good days. Good days then become good weeks, months, and years.

If you improve with an SRI, you’re likely to continue to feel well for as long as you take it

In my clinical experience, the vast majority of people who improve with an SRI continue to feel well over months and even years while taking the medication. Some patients I’ve treated have done well on the medication for more than a decade. In fact, many people say that the longer they take the SRI, the better they feel. I’ve found that about 40% of people who improve with an SRI in the first 3 months of treatment continue to improve even more over the next 6 months. I’ve also found that fewer than 10% of people who respond to an SRI experience a full return of their BDD symptoms while continuing to take the SRI.

Continue an effective SRI for a year or two, or even longer

Clinical guidelines recommend staying on an effective SRI for at least a year or two, even if you’re feeling better. You may want to stay on it longer than that, especially if you’ve tried stopping an SRI in the past and your symptoms returned, or if your BDD has been severe. A year or more of decreased symptoms can allow you to get back to work or do your job more effectively, socialize more, and start enjoying your life.

If you decide to stop an effective SRI, plan this carefully with your doctor

There’s no way to predict whether your symptoms will return if you stop an SRI. Some people assume that if they’ve had CBT while taking an SRI that they can safely stop the SRI, but this shouldn’t be assumed to be true; this, too, can’t be predicted, and your symptoms could return.

What to do about side effects, if they occur

Like all medications, the SRIs have the potential to cause side effects. In general, however, the SRIs are well tolerated. If side effects occur, they’re often quite minimal, and they may improve or disappear on their own with the passage of time. Most people have no side effects or fairly minimal and tolerable ones. Side effects are most likely to occur early in treatment (for example, within the first few weeks). This can be frustrating, because often the medicine hasn’t had a chance to work yet. It helps to be patient! But with more time, they may disappear. Side effects are also more likely to occur when the dose is raised.

Nonetheless, side effects can occur. Some of the more common ones are nausea, insomnia, feeling jittery, fatigue, sweating, decreased appetite, and decreased sex drive and sexual functioning (although sometimes sex drive and functioning improve with an SRI because people are no longer as depressed or self-conscious about their body). Clomipramine (Anafranil) can cause dry mouth and constipation. These side effects are tolerable for many people, and they go away after stopping the medication. None of the SRIs have life-threatening side effects. People with BDD who experience side effects are often willing to tolerate them because they so appreciate the symptom relief they obtain.

When side effects do occur, they can often be reduced. Here are a few possible approaches that you and your doctor can consider:

Keep taking the medicine and wait: Often, side effects diminish or disappear simply with the passage of time, as your body adjusts to the medicine.
Change the time the medicine is taken: Certain side effects may improve by doing this. For example, if an SRI makes you tired (which is pretty uncommon), this side effect may go away—and possibly improve your sleep—if you take it at bedtime instead of in the morning.
Slow down the rate at which the dose is being raised: If your doctor is in the process of trying to raise your dose to get it high enough to work, one alternative is to slow down the rate at which the dose is being increased. This will give your body more time to adjust to the medicine. If and when the side effects become more tolerable, you can try raising the dose again.
Lower the dose: If side effects are more problematic and not tolerable on the current dose, your doctor can slowly decrease the dose (while watching carefully for worsening of BDD or depressive symptoms) to see if side effects disappear. If they do, an attempt can then be made to increase the dose again if BDD symptoms are still present.
Add other medications to try to counteract side effects: There are many potentially helpful options, depending on the side effect you’re experiencing.
Try other options: Depending on the side effect, there are other options that may help. For example, if the medicine makes you feel jittery, lowering caffeine intake may help. Of if it causes some nausea, it may help to take the medicine with some food. Often, such strategies are helpful. If they aren’t, you and your doctor can consider trying another SRI. You may tolerate one better than another.

An important reminder:

Be sure your doctor knows you have BDD. Don’t just tell him or her that you have just depression or anxiety. A common clinical error is to focus treatment on depression rather than BDD. This often leads to use of an antidepressant other than an SRI, too brief an SRI trial, or an SRI dose that’s too low for BDD. In such cases, BDD (and the depression) may not improve. An effective medication regimen for depression won’t necessarily effectively treat BDD. However, an effective medication regimen for BDD will often effectively treat depression, whether or not the depression is due to BDD.

Post based on text by: Phillips, Katharine A. (2009-01-12). Understanding Body Dysmorphic Disorder Oxford University Press.

Augmenting a Serotonin Reuptake Inhibitor for the Treatment of BDD

November 2, 2012 By Stephen

Follow this link for a list of Selective Serotonin Reuptake Inhibitors used for the treatment of Body Dysmorphic Disorder.

Augmenting a SSRI for the Treatment of Body Dysmorphic Disorder

The only data on the effectiveness of SRI augmentation in BDD comes from the clinical practice of Katharine A Phillips and her study of augmentation of fluoxetine (Prozac) with pimozide.

So it really isn’t known which augmentation approaches are best. However, a number may be worth trying.

The table below shows the augmenting medications Dr. Phillips most often used for BDD, typical dosing ranges, and average doses.

It is best to augment the SRI only after you have tried it for at least 12 weeks and at a high enough dose. You should do this because the SRI may work well enough by itself. This approach can keep the medication regimen simple.

Sometimes, however, it makes sense to augment the SRI sooner, before the SRI alone has been adequately tried. This may be reasonable, for example, for someone with very severe BDD. Or the augmenting medicine may be more helpful than an SRI alone for certain symptoms (e.g., agitation) or a co-occurring disorder other than BDD.

Table: Augmentation Medications for Body Dysmorphic Disorder (BDD)

Table: Phillips, Katharine A. (2009-01-12). Understanding Body Dysmorphic Disorder (Kindle Locations 4227-4233). Oxford University Press. Kindle Edition.

Buspirone Buspirone (Buspar)

An antianxiety medication with effects on serotonin, is sometimes used as an augmenting agent for depression and OCD. Unlike other antianxiety medications, buspirone is generally not sedating and has no potential for causing physical dependence or addiction. In clinical practice, adding buspirone to an SRI has been effective for about one-third of patients. The amount of improvement is fairly large.

People with delusional BDD appear as likely to improve with buspirone as those with nondelusional BDD. Buspirone augmentation is appealing because this medicine typically has so few side effects. It may also improve coexisting anxiety and possibly depressive symptoms as well. you can also treat with buspirone alone for those who prefer not to take an SRI. In studies patients experienced some improvement in BDD symptoms, although none had the robust response that can occur with an SRI.

Levetiracetam (Kepra)

Levetiracetam (Keppra) is a medication that’s marketed for the treatment of seizures. In a 12-week open-label study of 17 people taking Keppra, 53% substantially improved. Of the five patients who had levetiracetam added to an SRI that they were already taking, two got better. Of the 12 patients who took levetiracetam without an SRI, 7 got better.

While the effectiveness of this medication for BDD needs further research, these preliminary findings are encouraging and suggest that levetiracetam may be worth trying in addition to an SRI (or without an SRI; see further discussion below).

Clomipramine (Anafranil)

It is possible to combine the SRI clomipramine (Anafranil) with one of the selective SRIs (SSRIs: fluvoxamine [Luvox], fluoxetine [Prozac], paroxetine [Paxil], citalopram (Celexa), escitalopram (Lexapro), or sertraline [Zoloft]) if improvement isn’t sufficient with an adequate trial of an SSRI alone.

Some patients do better with an SSRI/clomipramine combination than with either medication alone. However, the dosing must be done very carefully. The SSRIs can greatly increase clomipramine blood levels, which can be highly toxic at very high levels. Therefore, a lower dose of clomipramine should generally be used when it’s combined with an SSRI than when clomipramine is used without an SSRI.

If a patient is already on an SSRI, it is best to begin by adding only 25 mg a day of clomipramine and then gradually raising the dose, depending on the response and clomipramine blood level. Clomipramine levels should always be checked when this medication is combined with an SSRI to ensure that the dose isn’t too high. Also, patients should be monitored for a rare syndrome called serotonin syndrome. Studies have shown that up to 44% of patients substantially improved when clomipramine was added to an SSRI or vice versa.

This response rate was somewhat higher than for other augmentation strategies, although the magnitude of the response wasn’t quite as large as for some other strategies. Nonetheless, because clomipramine is an excellent antidepressant, it may be an appealing augmentation choice for people who are severely depressed. Although it is generally recommended that you try an augmenting agent for 6 to 8 weeks, it is worth it to try clomipramine for 12 weeks before deciding whether it’s working well enough.

It is not a good idea to combine clomipramine with an SSRI without first attempting to optimize a trial with just one of them.

Other Antidepressants

Antidepressants other than clomipramine can be added to an SSRI. These medications include venlafaxine (Effexor) and bupropion (Wellbutrin). Some patients do well with this approach. Some patients with severe depression who hadn’t responded to lots of medications did particularly well on 400 mg per day of bupropion (Wellbutrin) plus 60 to 100 mg per day of citalopram (Celexa). It’s possible that adding bupropion (Wellbutrin), which doesn’t directly affect serotonin, is more effective for people whose depression doesn’t seem to be largely due to BDD, but this is speculative at this point.

Care should be taken when combining venlafaxine with an SSRI because of the risk of serotonin syndrome (although the risk is low, and I’ve never seen it occur with this combination of medications).

Neuroleptics

The neuroleptics (antipsychotics) are a class of medicines often used to treat psychotic symptoms; they are also effective for a broad range of other symptoms (e.g., agitation and anxiety). (Because some of the newer ones are effective for so many different kinds of symptoms, they are now officially classified “psychotropic agents”—meaning they have effects on psychiatric symptoms). These medications are potentially promising SRI augmenters for BDD.

First, they are effective SRI augmenters in OCD and depression. Second, many people with BDD have prominent delusions of reference and delusional conviction about the perceived appearance defect; neuroleptics are the best treatment for delusional thinking in other disorders. There are two types of neuroleptics: “typical” (or “first generation”) and “atypical” (or “second generation”). Although neither type has been well studied in BDD, the atypicals appear more promising. Some patients have responded well when we added atypical neuroleptics such as ziprasidone (Geodon), olanzapine (Zyprexa), or risperidone (Risperdal) to an SRI. Ziprasidone (Geodon) seems especially promising. These medications can diminish severe distress and agitation resulting from BDD.

For patients with these kinds of severe symptoms I may combine an atypical neuroleptic with an SRI from the beginning of treatment. Using an atypical neuroleptic early in treatment can provide quicker relief than the SRI alone—producing a calming effect (but not usually a sedating effect if the dosing is done correctly). This can help the person function better, and in some cases prevent hospitalization. However, only one study has adequately studied a neuroleptic as an SRI augmenter. This study tested pimozide (Orap), a typical neuroleptic that is effective for Tourette’s disorder (characterized by repetitive, uncontrollable verbal utterances or physical movements known as tics, which are similar to the compulsive behaviors of OCD). Pimozide is an effective SRI augmenter in OCD, and it has long had the reputation (which was based more on word of mouth than scientific studies) of being uniquely effective for delusional BDD and certain other types of delusional disorder.

Methylphenidate

Some patients (10%–20% in my experience) improve significantly when methylphenidate (Ritalin) or another stimulant is added to an SRI. It is best to use this approach when patients are severely depressed and fatigued, because the stimulant can improve depressed mood and energy as well as BDD. One concern, however, is that stimulants are potentially habit forming and are best not used in people at risk for substance abuse or dependence. Because stimulants can potentially worsen tics, there’s a theoretical concern that they might worsen skin picking (which has some features in common with tics), but this is a rare problem.

Lithium

Lithium is a natural substance that’s best known as a treatment for bipolar disorder (manic depressive illness). However, it’s also effective for a broad range of other disorders and symptoms (e.g., mood swings, depression, aggressive behavior, suicidal thinking). About 20% of BDD patients substantially improve when lithium is added to an SRI.

Benzodiazepines

Benzodiazepines (e.g., clonazepam [Klonopin], lorazepam [Ativan]) are used primarily to treat anxiety and insomnia. Strictly speaking, they are not considered augmenting agents, because they can be added to an SRI at any point during treatment—whenever they’re needed.

Benzodiazepines can be very helpful for severe distress, anxiety, or agitation if an SRI doesn’t adequately diminish these symptoms or before an SRI has had a chance to work. Benzodiazepines can also greatly improve poor sleep. They can be used temporarily or over the longer term. Temporary use of benzodiazepines during the first few weeks of treatment (while waiting for an SRI to work) can be especially valuable for people who are severely anxious, agitated, unable to sleep, or suicidal.

Benzodiazepines are potentially habit forming, but in my experience, few people with BDD abuse them.

Cognitive-Behavioral Therapy

If medication doesn’t work well enough, you should strongly consider adding CBT to the medication. Cognitive-behavioral therapy (CBT) can also be used along with medication from the start of treatment. Most of the next chapter is devoted to CBT.

Resources:

Phillips, Katharine A. (2009-01-12). Understanding Body Dysmorphic Disorder Oxford University Press.