|Home | About | Journals | Submit | Contact Us | Français|
Body dysmorphic disorder (BDD) is a relatively common and impairing disorder. Selective serotonin reuptake inhibitors (SRIs) appear selectively efficacious for BDD, but pharmacotherapy research is limited, and escitalopram has not been studied. Fifteen subjects with BDD were treated with escitalopram and assessed with reliable and valid measures. BDD symptoms significantly improved (P < 0.001), and 73.3% (n = 11) of subjects were responders. Of the subjects, 46.7% were very much improved, and 33.3% were much improved. Depressive symptoms, delusionality, functioning and quality of life also significantly improved. Escitalopram was well tolerated. These preliminary data suggest that escitalopram is safe and efficacious for BDD.
Body dysmorphic disorder (BDD), a distressing or impairing preoccupation with an imagined or slight defect in appearance, is a severe and relatively common disorder (Phillips, 2001). Patients with BDD have marked impairment in functioning, notably poor quality of life and high suicidality rates (Phillips, 2001). However, the treatment of BDD treatment has received little investigation.
Only five systematic, prospective pharmacotherapy studies have been carried out in BDD. In a double-blind cross-over trial (n = 29), clomipramine was more efficacious than desipramine (Hollander et al., 1999). In a placebo-controlled study (n = 67), fluoxetine was more efficacious than placebo (Phillips et al., 2002). Three open-label studies [two with fluvoxamine (n = 15 and n = 30) (Perugi et al., 1996; Phillips et al., 1998) and one with citalopram (n = 15) (Phillips and Najjar, 2003)] found that a majority of patients improved. There are no studies of escitalopram for BDD.
Fifteen outpatients participated (46.7% female, n = 7; mean age 37.6 ± 8.8 years). Inclusion/exclusion criteria were standard for pharmacotherapy efficacy studies (Phillips et al., 2002). Subjects were aged 18–65 years, had current DSM-IV BDD, a score of ≥20 on the Yale–Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), and no past escitalopram treatment. They took no other psychotropics, and could not begin psychotherapy during the study or have begun it within the past 3 months; individuals receiving cognitive behavioural therapy were excluded. Eleven of the 15 subjects had received a selective serotonin reuptake inhibitor (SRI) in the past; seven had received an SRI trial considered minimally adequate for BDD (Phillips, 2002). Four of these seven subjects had responded to an SRI. The hospital Institutional Review Board approved the study, and all subjects provided their written informed consent.
Reliable and valid measures were used. The BDD-YBOCS, which assesses current BDD severity, was the primary outcome measure; ≥30% decrease in score (an empirically derived cutpoint) determined treatment response (Phillips et al., 1997). The Brown Assessment of Beliefs Scale assessed delusionality of appearance beliefs and categorized subjects as delusional or nondelusional, using an empirically derived cutpoint (Eisen et al., 1998). Other measures were the Structured Clinical Interview for DSM-IV-TR Patient Edition (First et al., 2002), which diagnosed BDD, Clinical Global Impressions (CGI) scale (National Institute of Mental Health, 1985), Hamilton Rating Scale for Depression (24-item) (Miller et al., 1985), Global Assessment of Functioning (GAF) scale (First et al., 2002), Social and Occupational Functioning Assessment Scale (SOFAS) (American Psychiatric Association, 1994), and LIFE Psychosocial Functioning Scale (Keller et al., 1987). The SF-36 (Ware, 1993) and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) (Endicott et al., 1993) assessed quality of life. Higher scores reflect greater severity on symptom measures. On functioning and quality of life measures, lower scores are poorer, except for the LIFE.
After a medical evaluation, subjects received unblinded escitalopram for 12 weeks: 10 mg/day for 2 weeks, then 20 mg/day for 2 weeks, and then 30 mg/day. The BDD-YBOCS, CGI, BABS and HAM-D were performed at baseline, weekly for 4 weeks, and then every other week. The other measures were completed at baseline and endpoint. Medication compliance was assessed by tablet count. Pulse, blood pressure and side-effects were evaluated at each visit. Reported side-effects are those considered possibly, probably, or almost certainly related to the medication.
Analyses are intent-to-treat with last observation carried forward. Baseline and subsequent scores on continuous study measures were compared with repeated-measures analysis of variance (using the Huynh–Feldt statistic when the assumption of sphericity was not met) or paired t-tests. All tests were two-tailed; the alpha level was P < 0.05.
Fourteen (93.3%) subjects completed the study. BDD-YBOCS scores decreased significantly between baseline and endpoint (Table 1 and Fig. 1); 73.3% (n = 11) of subjects responded. On the BDD-CGI, almost one-half of subjects were very much improved, and one-third were much improved. The delusionality of appearance beliefs (BABS score) significantly decreased, with mean scores in the poor range at baseline and good range at endpoint. Four of four subjects with delusional BDD beliefs at baseline responded to escitalopram, and seven of 11 subjects with nondelusional BDD beliefs at baseline responded. Depressive symptoms, functioning, and quality of life also significantly improved, as did suicidality, as assessed by the HAM-D suicide item (F = 3.6, P = 0.001). The mean endpoint escitalopram dose was 28.0 ± 6.5 mg/ day, and the mean time to BDD response was 4.7 ± 3.7 weeks (range 1–12 weeks). Adverse events occurring in 10% or more of subjects were fatigue (n = 6), insomnia (n = 5), nausea (n = 4), sexual dysfunction (n = 4), dizziness (n = 2), dry mouth (n = 2), jaw ache (n = 2), jitteriness (n = 2) and blurred vision (n = 2). Side-effects were generally mild or moderate and often transient. One subject dropped out of the study because of insomnia. The only serious adverse event was medical hospitalization for complications of liposuction, occurring in one subject.
The present study is the first to investigate the efficacy and tolerability of escitalopram in BDD, and found significant improvement across numerous domains. It is notable that almost one-half (46.7%) of patients were very much improved on the BDD-CGI. Previous BDD studies have reported rates of 15% with fluoxetine, 30% with fluvoxamine, and 40% with citalopram (Phillips et al., 1998, 2002, 2003). BDD responded relatively quickly (4.7 ± 3.7 weeks), which is similar to a study with citalopram (4.6 ± 2.6 weeks) (Phillips and Najjar, 2003). By contrast, the mean time to response in other SRI studies was 6–9 weeks (Phillips, 2002). However, these comparisons should be made with caution because no study has directly compared different SRIs, and such studies are needed to further examine the time to response and the degree of response.
Of note, delusional patients were as likely to improve as nondelusional patients, which is consistent with previous BDD studies (Phillips, 2002). Functioning and quality of life also significantly improved after only 12 weeks of treatment, as in previous studies (Phillips, 2002). SF-36 and Q-LES-Q scores were markedly poor at baseline (mean of 1.8 SD poorer compared to the general population or community norms) (Endicott et al., 1993; Ware, 1993); at study termination, mean scores were only 0.2 SD poorer. It is possible that functioning and quality of life may have further improved with continued treatment.
The study limitations include a small sample size, unblinded assessment of treatment outcome, and the lack of a comparison/control group. Placebo-controlled trials of escitalopram and other medications are greatly needed in BDD because few treatment studies of this severe disorder have been conducted.
This study was supported by an unrestricted educational grant from Forest Laboratories. Dr K.A. Phillips has received funding from the National Institute of Mental Health, UCB Pharma and Forest Pharmaceuticals has supplied medication for a treatment study sponsored by the National Institute of Mental Health.