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ALTHOUGH SEROTONIN-REUPTAKE INHIBITOR (SRI) augmentation with antipsychotics for the treatment of body dysmorphic disorder (BDD) has recently received attention, the benefits of such augmentation remain unclear. Here, we report a case that exhibited a dramatic improvement in BDD symptoms following the addition of olanzapine to SRI therapy.

The patient was a 26-year-old woman with a 10-year history of BDD. At the age of 16, she became obsessed with the idea that she must always keep her body's skin clean. She became preoccupied with the appearance of her skin and spent many hours a day grooming her body hair. At the age of 20, she experienced a relationship breakup. Thereafter, she became preoccupied with the shape of nose, believing it to be ugly. She frequently checked her nose in the mirror and asked her family for reassurance regarding her nose. Her preoccupation with her appearance resulted in her work being impaired. At the age of 24, she was first admitted to our hospital because of severe weight loss and insomnia because she wasted almost her entire day looking in mirrors and grooming her body hair. Based on the DSM-IV criteria, she was diagnosed as having BDD. In the past, she had been treated with selective serotonin reuptake inhibitors (SSRIs) and an atypical antipsychotic. Neither fluvoxamine (300 mg/day) nor risperidone augmentation of the fluvoxamine treatment diminished her BDD symptoms. Her symptoms also did not improve following the administration of paroxetine (40 mg/day). Her symptoms did not change. Therefore, at the age of 26 years, the paroxetine (40 mg/day) treatment that she was receiving was augmented with 2.5 mg/day of olanzapine. This dose was increased to 5 mg/day after a partial response was observed at 4 weeks. At 6 weeks, her preoccupation with her physical appearance began to subside.

Both the amount of time and the frequency with which she checked mirrors and groomed her body hair and toes improved dramatically. This was the first remission of her symptoms since onset at the age of 20 years. Her Yale Brown Obsessive-Compulsive Scale score decreased from 39 to 20. Although she complained of undesired weight gain, at a 1-year follow-up examination, her symptoms were still in remission.

Studies that previously examined the effect of the augmentation of SRI therapy with antipsychotics in patients with BDD failed to show any improvement in symptoms.1,2 To the best of our knowledge, this is the first BDD case to be successfully treated with olanzapine augmentation of paroxetine therapy. With regard to OCD patients, several studies have reported that olanzapine augmentation of ongoing SRI treatment resulted in an improvement of OCD symptoms.3,4

The present case report may support the speculation that BDD has features in common with OCD disorders. Although the neurochemical mechanism underlying BDD is unclear, the serotonin and dopamine system may interact in the mediation of BDD symptoms. Further larger placebo-controlled, double-blinded studies are required to ascertain the effect of olanzapine augmentation of SRI therapy.

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