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.

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Resources:

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