SSRIs May Offer Modest Benefit In Body Dysmorphic Disorder

When people have body dysmorphic disorder, they are obsessed with supposed flaws in their appearance—say, “a crooked lip,” “a bumpy nose,” “tiny breasts,” or “drooping buttocks.” They may spend hours a day brooding about their“ defect” and lead painfully isolated lives. Although the disorder appears to affect about 1 percent of the population, which makes it about as common as bipolar disorder, patients rarely share their obsessions with a doctor and thus go undiagnosed.

Both SSRI antidepressants and cognitive-behavioral therapy can reduce the symptoms of body dysmorphic disorder, growing evidence suggests. But can SSRIs also improve functioning and quality of life for such patients? The answer appears to be “to some degree,” a study conducted by Katharine Phillips, M.D., a professor of psychiatry at Brown University, and Steven Rasmussen, M.D., an associate professor of psychiatry at Brown, has found. Results appeared in the October Psychosomatics.

In this study, 60 subjects with DSM-IV-defined body dysmorphic disorder received either the SSRI fluoxetine or a placebo for a 12-week period. Subjects getting fluoxetine started at 20 mg a day and reached a maximum dose of 80 mg a day if tolerated. The average fluoxetine dose at the end of the study was 77.7 mg a day. Subjects did not receive psychotherapy during the study.

Patients' psychosocial functioning and quality of life were assessed at the start and end of the study with SOFAS, a global clinician-rated measure of functioning; LIFE-RIFT, a reliable and valid semistructured clinician-rated measure of functional impairment; and SF-36, a reliable, valid, and widely used self-report measure of mental and physical health-related quality of life.

Patients' average scores on the SOFAS, LIFE-RIFT, and SF-36 at the start of the study reflected impaired functioning in many domains and a very poor mental health–related quality of life. Their SF-36 scores, in fact, were even poorer than for patients with major depression.

By the end of the study, subjects getting fluoxetine had improved significantly more on the measures of functioning than had subjects getting a placebo. But even though they improved significantly more in function than subjects on placebo did, they were still not functioning at all that high a level and did better in some domains, such as work functioning, than in others, such as relationships with friends. Regarding the quality-of-life measure, subjects on fluoxetine did not score significantly higher than subjects on a placebo. In fact, the post-treatment SF-36 mental health subscale scores of the fluoxetine group were poorer than posttreatment scores on that instrument in other 12-week pharmacotherapy trials, including studies of major depression and posttraumatic stress disorder.

Psychiatric News asked Phillips whether she was disappointed with these results. “Yes and no,” she replied. “Our finding that even after treatment patients are not functioning at a high level and quality of life is still fairly poor underscores the need to develop even more effective treatments for body dysmorphic disorder. [Still,] these patients are often so severely ill, functionally impaired, and suicidal that even partial improvement in functioning and quality of life is a welcome relief and can make a big difference in their lives.”

The take-home message for clinical psychiatrists, she added, is that“ SSRIs can be very helpful in improving not only the core symptoms of body dysmorphic disorder, a serious mental illness, but also daily functioning.”

The study was funded by the National Institute of Mental Health. Study medication and matching placebo were supplied by Eli Lilly and Company.

The study, “Change in Psychosocial Functioning and Quality of Life of Patients With Body Dysmorphic Disorder Treated With Fluoxetine: A Placebo-Controlled Study,” is posted online at<http://psy.psychiatryonline.org/cgi/content/full/45/5/438>.▪