Question. I am working with a 23-year-old who is chronically preoccupied with a bulge on his left orbit and hair falling out. These symptoms have severely limited his ability to leave home or interact with others. He has had two severe suicidal attempts as well as numerous hospitalizations. He has tried Luvox, Anafranil, Prozac, Cogentin, and recently a trial of Clozaril has been initiated. He has also been receiving psychotherapy. None of this seems to be alleviating any of his symptoms and the condition continues to haunt him. What can you suggest?
Answer. Some of what you describe sounds consistent with body dysmorphic disorder (BDD), which has been described in detail by Drs. Katherine Phillips and Eric Hollander (Psychiatric Annals, July 1993). It is not clear to me, however, whether your patient’s preoccupations reach delusional proportions. Interestingly, Phillips has found that both nondelusional and delusional types of body dysmorphic disorder (BDD) may respond to the SSRIs (Prozac, Zoloft, etc.).
In some cases, augmentation with an antipsychotic, such as risperidone or pimozine, may be helpful, though clozapine and risperidone can occasionally worsen obsessive symptoms. Since you did not mention sertraline (Zoloft) or paroxetine (Paxil) trials, I would certainly consider these. Non-response to Prozac and Luvox does not predict response to these other agents. Treatment outcome with psychotherapy has been mixed; some evidence points to the usefulness of cognitive-behavioral approaches.
If significant depression is part of the syndrome, I have seen ECT be effective in refractory case, and given the suicide risk with your patient, I would certainly consider this option.