Body dysmorphic disorder (BDD) is characterized by excessive preoccupation with an imagined or greatly exaggerated defect in appearance, and often by related rituals or pursuit of medical or surgical treatments. The frequent comorbidity of BDD with obsessive-compulsive disorder (OCD) and the phenomenological similarities between these two disorders suggest that they may be related. BDD reportedly responds to oral clomipramine (CMI).

We present here two case studies of patients meeting DSM-IV criteria for BDD with comorbid delusional disorder, somatic type, to whom we administered pulse-loaded intravenous (IV) CMI (150 mg on day 1, 200 mg on day 2). After a 4.5-day drug holiday, both patients continued on oral CMI. As reflected in modified Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores, both patients' BDD improved by about one third within 4.5 days of the second IV dose. Improvement continued over 2 months on oral CMI, and comorbid major depression present in one patient remitted. By the end of 8 weeks of oral CMI, the patients' modified Y-BOCS scores had decreased about 55%, and their social functioning had markedly improved.

As in OCD, pulse-loaded, IV CMI may produce a much faster response than oral CMI or selective serotonin reuptake treatment and can be well tolerated. This treatment approach to BDD deserves further study in a prospective, randomized controlled trial.

The World Health Organization has determined that obsessive-compulsive disorder (OCD) is the 10th leading medical cause of disability across the globe. Unfortunately, a substantial proportion of patients with OCD fail to respond to medication trials. In the pivotal double-blind, placebo-controlled trials that established the efficacy of clomipramine and the selective serotonin reuptake inhibitors (SSRIs), 40% to 60% of patients were nonresponders to a given drug. Moreover, patients who do not respond to their first medication trial may be less likely than treatment-naive patients to respond to subsequent trials. For example, only 33% of patients participating in double-blind trials who had failed trials of one or more serotonin reuptake inhibitors (SRIs) benefited from a subsequent trial of sertra-line, compared with 53% of those who were treatment naive (Rasmussen, Baer, Eisen, and Shera, unpublished data, 15th Annual Meeting, American Psychiatric Association, May 17-22, 1997).

At the Fourth International Obsessive-Compulsive Disorder Conference, held in February 2000 in St. Thomas, US Virgin Islands, an afternoon panel was devoted to considering issues and strategies related to treatment-refractory OCD. The panel presentations were divided into three groups: time to response and outcome after long-term followup; pharmacologic strategies for nonresponders; and new data concerning nonpharmacologic interventions.

The construct of quality of life (QOL), which has both subjective and objective components, has gained increasing importance in psychiatric research for several important reasons, not the least being the current importance of pharmacoeconomic issues. Obsessive-compulsive disorder (OCD) has been suggested to be the worlds 10th most disabling disorder, and pharmacoeconomic studies have indicated that its cost to the world economy runs into the billions of dollars. The use of QOL scales derived from general medicine and other areas of psychiatry has demonstrated the enormous negative impact of OCD on several domains, including occupational function, social function, and family function. Further work to ascertain the extent of changes in QOL during treatment of OCD is necessary.

Objective: To determine the adequacy of pharmacotherapy received by patients with newly-diagnosed obsessive-compulsive disorder (OCD), based on current practice guidelines.

Methods: A 9 year (1997–2006) retrospective claims analysis of adults enrolled in Florida Medicaid for at least 3 continuous years was conducted to determine the percentage who received both a minimally effective duration (≥ 8 continuous weeks) and dose of first-line OCD pharmacotherapy during the year following their first (“index”) OCD diagnosis.

Results: Among 2,960,421 adult (≥ 18 years of age) enrollees, 2,921 (0.1%) were diagnosed with OCD. Among the 2,825 OCD patients without comorbid Asperger syndrome or autism, 843 had newly-diagnosed OCD and at least 12 months of follow-up data after their index diagnosis. Among these 843 patients, 588 (69.7%) received first-line OCD pharmacotherapy but only 323 (38.3%) received a minimally effective pharmacotherapy trial in the year following their index diagnosis.

Conclusions: Among clinically-diagnosed persons with OCD (<10% of those with the disorder), a minority of newly-diagnosed patients receive a minimally effective pharmacotherapy trial consistent with current standards of care. Reasons such as limited patient adherence and/or physician awareness of guidelines must be identified and redressed to ameliorate the patient, healthcare system, and economic burdens associated with OCD.