23 - Drug treatment in body dysmorphic disorder (B

Drug treatment in body dysmorphic disorder (BDD)

Prescribing in children and adolescents CHAPTER 5 Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) in children and adolescents The treatment of OCD and BDD in children and young people largely follows the same principles as those for adults.1 BDD is recognised by both DSM-­5 and ICD-­11 as one of the obsessive compulsive disorders. Cognitive behavioural therapy is effective for both conditions in this age group and is recommended in the UK by NICE as the first-­choice treatment, although it may be combined with medication for optimal effect.2 While CBT is the mainstay of treatment for OCD and BDD, medication alone may be the only viable therapeutic option in some cases. Some children are reluctant to engage with CBT, some may find it difficult to access or they may have very poor insight. This last situation may arise in the autism spectrum disorder alongside comorbid OCD or BDD. Insight in BDD is characteristically poorer than in OCD, with up to 50% of cases having beliefs about their appearance which are of delusional intensity. This too can affect motivation to engage with psychological therapy. Where medication is being used as the only evidence-­based treatment, it is essential that this remains under review so that motivation and ability to engage with CBT are regularly revisited. Drug treatment in obsessive compulsive disorder (OCD) Sertraline (from age 6 years) and fluvoxamine (from age 8 years) are the SSRIs licensed in the UK for the treatment of OCD in young people. Studies have established the efficacy of SSRIs in the child and adolescent population in several placebo-­controlled trials.­3–­5 SSRIs have a medium to large effect size in the treatment of OCD in children and young people.6 A meta-­analysis of 12 RCTs of pharmacotherapy in young people under 19 years of age showed that medication is consistently more effective than placebo. Fluoxetine is the most efficacious SSRI for treatment of depression.7 Many young people presenting with OCD have a diagnosis of comorbid depression, so fluoxetine could be considered as an alternative SSRI to sertraline or fluvoxamine in these cases. Paroxetine is not recommended for use in children and young people. Clomipramine remains a useful drug for some individuals and is debatably more efficacious than the SSRIs in treating OCD in children and young people.8 However, clomipramine’s side effect profile (sedation, dry mouth, potential for cardiac side effects) tends to limit its use in this age group and, as a consequence, SSRIs remain the first-­line choice in OCD. SNRIs are not recommended for treatment of OCD in children and young people, with no clear evidence of efficacy and poorer tolerability than SSRIs. Drug treatment in body dysmorphic disorder (BDD) No treatment is licensed in the UK for either adults or children with BDD. However, evidence shows significant improvements with SSRIs, both in terms of BDD symptoms, suicidality and often comorbid depressive symptoms (­80–­90% of people with BDD also have a comorbid diagnosis of depression9). In the UK, NICE recommends fluoxetine as the SSRI of choice for treating BDD in children. Although BDD cases have delusional intensity beliefs about their appearance, antipsychotics are not effective and are