Body Dysmorphic Disorder Medication

Updated: Oct 03, 2019
  • Author: Iqbal Ahmed, MBBS, FRCPsych(UK); Chief Editor: David Bienenfeld, MD  more...
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Medication

Medication Summary

The goals of pharmacotherapy in patients with body dysmorphic disorder (BDD) are to reduce symptoms and morbidity and prevent complications. Selective serotonin reuptake inhibitors (SSRIs) appear to be useful in the treatment of this condition. For the most part, other classes of drugs, including benzodiazepines, neuroleptics, and anticonvulsants, yield minimal or no improvement, though may be helpful in augmentation. In general, medication use is recommended in conjunction with psychosocial interventions.

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Antidepressants, SSRIs

Class Summary

SSRIs are antidepressant agents that are chemically unrelated to TCAs, tetracyclic antidepressants (TeCAs), or other available antidepressants. They inhibit central nervous system (CNS) neuronal uptake of serotonin and may have a weak effect on neuronal reuptake of norepinephrine and dopamine. They have been used to treat patients with BDD, as well as those with anxiety, phobias, or obsessive-compulsive disorder (OCD).

SSRIs are strongly preferred to the other types of antidepressants. Because their adverse effect profile is less prominent, compliance is improved. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered in the treatment of a child or adolescent with a mood disorder. All SSRIs are equally efficacious; the choice depends on adverse effects and drug interactions.

Escitalopram (Lexapro)

Escitalopram is the S-enantiomer of citalopram. It is used for the treatment of depression. The mechanism of action is thought to be potentiation of serotonergic activity in the CNS resulting from inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief is typically after 1-2 weeks, which is sooner than that noted with other antidepressants.

Citalopram (Celexa)

Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane. Although no head-to-head comparisons of SSRIs exist, citalopram is considered the SSRI of choice for patients with head injury.  Caution is advised with using high doses (which may be needed for BDD) due to the QT prolonging effects.

Fluoxetine (Prozac)

Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on reuptake of norepinephrine or dopamine. It is approved by the US Food and Drug Administration (FDA) for OCD and major depressive disorder in children aged 8 years or older. Dosages used to treat OCD are also effective for BDD. A low starting dose and a more gradual increase are advisable in patients sensitive to medications (ie, slow metabolizers).

Fluoxetine is available in 10- and 20-mg capsules and in a 20 mg/5 mL liquid form. Because of its stimulating properties, dosing should be initiated in the morning. If nausea is a problem, it may be helpful to take the medication with food.

Fluvoxamine (Luvox)

Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do. In the treatment of BDD, higher doses than those used for depression generally are needed. Fluvoxamine is FDA-approved for children with OCD.

Sertraline (Zoloft)

Sertraline selectively inhibits presynaptic serotonin reuptake. It is approved for obsessive-compulsive disorder in children aged 6 years or older.

Paroxetine (Paxil, Pexeva)

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. It is approved for obsessive-compulsive disorder.

For maintenance dosing, make dosage adjustments to maintain patient on lowest effective dosage, and reassess patient periodically to determine need for continued treatment.

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Antidepressants, TCAs

Class Summary

TCAs are used when SSRIs are ineffective. They are structurally related to the phenothiazine antipsychotic agents and exhibit 3 major pharmacologic actions in varying degrees: amine pump inhibition, sedation, and anticholinergic action (peripheral and central). They inhibit reuptake of norepinephrine or serotonin at the presynaptic neuron.

Physicians should be cautious when using TCAs because overdose has the potential to be deadly. Patients with BDD may have a higher risk of suicidal behavior; accordingly, the potential harm to the patient in an overdose situation must be taken into account in choosing the type of antidepressant.

Clomipramine (Anafranil)

Clomipramine affects serotonin uptake and affects norepinephrine uptake when converted into the metabolite desmethylclomipramine. Because of its sedative properties, nighttime dosing is recommended. Therapy should be initiated at a low dosage to minimize adverse effects. Clomipramine is available in 25-, 50-, and 75-mg capsules.

Imipramine (Tofranil, Tofranil PM)

Imipramine inhibits the reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at the presynaptic neuron.

Amitriptyline

Amitriptyline increases the synaptic concentration of serotonin or norepinephrine in the central nervous system (CNS) by inhibiting their reuptake by the presynaptic neuronal membrane.

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Neuroleptic Agents

Class Summary

Neuroleptic medications reduce psychotic symptoms (eg, hallucinations and delusions).

Pimozide (Orap)

Pimozide is a centrally acting dopamine-receptor antagonist. In the United States, it is available in 2-mg scored tablets; in Canada, it is available in 2-, 4-, and 10-mg tablets.

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