Nonresponse to initial pharmacotherapy for body dysmorphic disorder in children

Refer to a child psychiatrist or an age-appropriate mental health service for multidisciplinary input if symptoms of body dysmorphic disorder persist despite all of the following:

• using an effective dose of 2 selective serotonin reuptake inhibitors (SSRIs) as sequential monotherapy, each for a minimum of 4 weeks (full benefit may take 8 weeks or longer)
• concurrent use of cognitive behavioural therapy (CBT)
• discounting alternative reasons for treatment nonresponse.

Psychiatrists may consider a trial of clomipramine for body dysmorphic disorder in a child; however, intolerance commonly limits the use of clomipramine and toxicity in overdose must be considered. If there is insufficient response to clomipramine, psychiatrists may augment clomipramine with an atypical antipsychotic; however, there is limited evidence supporting this practice and the adverse effects of antipsychotics should be considered.