Treatment with risperidone and venlafaxine of a patient with double-coded diagnosis of body dysmorphic disorder and delusional disorder somatic type

Dear Editor,

DSM-IV classifies body dysmorphic disorder (BDD) under the somatoform disorders and its delusional variant as delusional disorder somatic type (DDST)¹. The differential diagnosis is difficult, especially in cases with delusions of dysmorphobia, the subset of DDST which seems nosologically closest to BDD. DSM-IV, recognizing the diagnostic confusion in these definitions, allows these two variants to be double-coded, and delusional patients may be assigned both diagnoses¹. The pharmacotherapy of these disorders has not been extensively studied. Proposals include antidepressants², antipsychotics³ or a combination of both². We present a patient with a double-coded diagnosis, treated with risperidone and venlafaxine.

A 26-year-old male was referred to our consultation-liaison unit by the dermatology department. The last six months he was preoccupied with beliefs that the skin of his arms became ill-structured, as evidenced by the appearance of 'abnormal skin folding'. He had already consulted dermatologists and plastic surgeons and had undergone minor cosmetic laser treatment for deformity correction.

Besides the aforementioned beliefs, he presented low mood. Due to his preoccupation with the perceived defects, he was withdrawn and abandoned his job. No other psychiatric symptoms were present. He had no prior psychiatric or substance abuse history, or family history of mental disorders. Physical examination and laboratory tests including MRI were normal.

A diagnosis of BDD and additionally of DDST was made, since his beliefs were held with delusional intensity. Pimozide, which was initially administered, was switched to risperidone (2mg/day, gradually increased to 4mg/day), due to extrapyramidal side effects. Simultaneously, due to deterioration in his mood, venlafaxine was introduced, 37.5mg/ day, gradually increased to 150mg/day. No side effects developed. Four weeks later the symptoms improved significantly. Six months later he was free of symptoms.

Our patient fulfilled DSM-IV criteria for both BDD and DDST. It was suggested that, rather being distinct, the two disorders may constitute one entity¹. Pimozide, which was suggested as the treatment of choice for DDST³, caused intolerable side effects. Therefore, risperidone was administered, which has been reported as effective in the treatment of this disorder³. Venlafaxine, which was primarily administered for our patient's low mood, was also reported as effective in the treatment of BDD⁴. Additionally, the effectiveness of an antipsychotic-antidepressant combination in the treatment of DDST is established².

This case indicates that combination of risperidone and venlafaxine is effective in the treatment of BDD with somatic delusions. Patients may first seek advice by dermatologists and plastic surgeons, who should be aware of this condition and promptly request psychiatric consultation, for proper treatment and to avoid unnecessary, inefficient or even harmful interventions.