Nonresponse to initial pharmacotherapy for body dysmorphic disorder in adults and young people

Consider modifying treatment for body dysmorphic disorder in adults and young people if symptoms persist despite:

  • using an effective dose of at least 2 selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs) as sequential monotherapy, each for a minimum of 4 weeks (full benefit may take 8 weeks or longer); and
  • discounting alternative reasons for treatment nonresponse.

Options for treatment modification include:

  • combining psychosocial interventions (if not already used) with pharmacotherapy
  • referral to a psychiatrist or an age-appropriate mental health service—psychiatrists may use clomipramine or an augmenting agent (see below).

For treatment considerations for females of childbearing potential, including advice on contraception, preconception planning and psychotropic use, see here.

For considerations in managing anxiety disorders such as body dysmorphic disorder during the perinatal period, see here or for considerations in partners, see here.

Psychiatrists may use clomipramine for body dysmorphic disorder; however, intolerance commonly limits the use of clomipramine and toxicity in overdose must be considered. Lower doses are used in older or frail patients. Clomipramine can cause changes in cardiac conduction—an electrocardiogram (ECG) should be obtained before treatment is started and repeated once the dose is stabilised, usually after 6 weeks. If either ECG shows abnormalities, seek advice from a cardiologist before starting or continuing treatment. If clomipramine is considered appropriate for body dysmorphic disorder, a suitable regimen in adults and young people is:

clomipramine 25 to 75 mg orally, at night, increasing as tolerated by 25 to 50 mg every 2 to 3 days to a target dose of 150 mg. If response is inadequate, further dose increases may be needed, to a maximum of 300 mg at night. If an acceptable response is achieved, continue treatment for 6 to 12 months, then consider deprescribing. body dysmorphic disorder clomipramine clomipramine clomipramine

In treatment-resistant body dysmorphic disorder, psychiatrists may use other antidepressants or a combination of drugs. There have been some positive trials combining serotonergic drugs with other drugs that augment their effect. Aripiprazole and risperidone have the strongest evidence base as augmenting agents; there is some evidence in support of olanzapine, levetiracetam and quetiapine. However, there is limited evidence supporting this practice and the adverse effects of antipsychotics should be considered.