Monitoring

Patients require ongoing monitoring of BDD symptom severity during treatment. Three useful monitoring questions to ask the patient are:

  1. How much time do you spend per day preoccupied with negative thoughts about your appearance (add up the cumulative time spent each day)?

  2. How distressing are your BDD symptoms: none, mild, moderate, severe or extreme?

  3. Do your BDD symptoms interfere with your functioning in any way?​

These questions fit with the DSM-5-TR diagnostic criteria for BDD.[1] They are also the first three items of the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS).[57] The complete BDD-YBOCS scale can be used to monitor BDD severity at baseline and as desired during treatment.

It is important to monitor for suicidal ideation and behaviour by asking questions about suicidality and/or using a suicidality measure.[52][59][60][95]​​​​​​​​​ Many BDD patients have suicidal thinking (some are highly suicidal). See Suicide risk mitigation.

Base frequency of monitoring/patient sessions on the severity of BDD, comorbid conditions, suicidality, and other clinical variables. More highly suicidal patients should be seen frequently (for example, weekly), whereas less suicidal patients or patients with no suicidality can be seen less often.

When treating with medication, monitor patients for potential adverse effects. Provide more frequent monitoring when medication causes problematic adverse effects, dose adjustments are needed, or patients are not improving. As patients improve, they can be seen less often. For more highly suicidal patients, consider limiting the amount of medication dispensed, especially clomipramine, which is riskier in overdose than selective serotonin-reuptake inhibitors (SSRIs) because it is a tricyclic antidepressant and has a narrow therapeutic index.

Patients receiving antipsychotic treatment require metabolic monitoring and monitoring for the possible development of abnormal movements (tardive dyskinesia). For those receiving clomipramine, blood levels are recommended, where available, during dose titration to determine when the level is in the therapeutic range (follow your local protocols).[64]​ In the author’s opinion, clomipramine blood levels must always be carried out.

During maintenance treatment, follow-up levels can be obtained (for example, yearly); levels should be obtained when medications are added that could affect clomipramine serum levels.

ECGs are recommended during clomipramine titration and for escitalopram even at relatively low doses, though clinical practice varies (check your local protocols).​[33][64]​​​​ Consider an ECG for patients on a high dose of other SSRIs (especially sertraline and fluoxetine); when SSRIs or clomipramine are combined with atypical antipsychotics; and when patients take other medications that may prolong the QTc interval.​[33][64]​​​ A baseline ECG is recommended for patients with a personal or family history of long QT syndrome, arrhythmia, or other potentially relevant cardiac condition.[64]​ Once maintenance dose is determined, consider obtaining follow-up ECGs (for example, every 6 months or annually).

For patients who obtain CBT for BDD, about 6 months of weekly CBT is typically needed, with symptom monitoring at the beginning of each session.[81]​ More severely ill patients usually need more sessions per week and/or longer sessions per day, and some require more than 6 months of therapy. Once patients have improved, CBT booster sessions (e.g., monthly) may be helpful, and are sometimes needed for a period of time to prevent relapse. Frequency and duration of CBT and CBT booster sessions should be tailored to each patient.

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