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Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance, or excessive concern over a slight physical anomaly. It is characterised by time-consuming behaviours such as mirror gazing, comparing one’s appearance with others, excessive camouflaging to hide the defect, skin picking and seeking reassurance.[1] Symptoms often begin in adolescence.[2] One study suggested that patients with BDD pay more attention to facial appearance in others, compared to controls.[3] Another found that BDD sufferers have a tendency to misinterpret the neutral facial expressions of others in a negative way.[4]

Epidemiology

Population studies suggest a point prevalence rate of 0.72-2.4%.[5] International studies suggest that 6-15% of patients attending cosmetic surgery and dermatology clinics are estimated to have body dysmorphic disorder (BDD).[2] Data concerning sex predominance are sparse. One study of medical students found a higher preponderance in males[6]

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Differences between body dysmorphic disorder and obsessive-compulsive disorder[2][7]

Although there are many similarities between the two conditions – which often co-exist – some differences have been identified. Patients with body dysmorphic disorder (BDD) have significantly poorer insight than those with obsessive-compulsive disorder (OCD) and are more likely to be delusional. They are also significantly more likely to have lifetime suicidal ideation, as well as lifetime major depressive disorder and a lifetime substance use disorder. See also separate Obsessive-compulsive Disorder article.

The General Practitioner’s role[8]

The National Institute for Health and Clinical Excellence (NICE) recommends referral to a specialist multidisciplinary team offering age-appropriate care. This is unlikely to be available in many areas, due to lack of resources but it is worth getting in touch with local mental health trusts to see what is currently available. The GP’s role depends on expertise but it should be remembered that drug management should be part of a package which includes psychological care.

In all patients, however, the GP will need to:
•Identify cases.
•For patients at risk of body dysmorphic disorder (BDD) (depression, social phobia, substance misuse, obsessive-compulsive disorder (OCD),[9] eating disorder, mild disfigurement or blemish seeking dermatology or cosmetic surgery referral), ask the following questions: •Do you worry a lot about the way you look and wish you could think about it less?
•What specific concerns do you have about your appearance?
•On a typical day, how many hours a day is your appearance on your mind? (More than one hour a day is considered excessive).
•What effect does it have on your life?
•Does it make it hard to do your work or be with friends?

•Assess severity – ie how much it is affecting the patient’s ability to function in everyday life.
•Assess risk of self-harm or suicide and presence of comorbidity such as depression.
•Arrange referral to appropriate secondary care provision.
•Ensure continuity of care to avoid multiple assessments, gaps in service and a smooth transition from child to adult services (many patients have lifelong symptoms).
•Promote understanding – make patients/families aware of the involuntary nature of symptoms. Consider patient information leaflets, contact numbers of self-help groups, etc.
•Consider the bigger picture – cultural, social, emotional and mental health needs.
•If the patient is a parent, consider child protection issues.

Management in adults[8]

Patients with mild functional impairment can be managed with low-intensity psychological treatment. This may involve:
•Individual cognitive behavioural therapy (CBT) plus ‘exposure and response prevention’ (ERP)*.
•Individual CBT and ERP by telephone.
•Group CBT.

*ERP is a technique in which patients are repeatedly exposed to the situation causing them anxiety (eg exposure to dirt) and are prevented from performing repetitive actions which lessens that anxiety (eg washing their hands). This method is only used after extensive counselling and discussion with the patient, who knows fully what to expect. After an initial increase in anxiety, the level gradually decreases. This is extremely therapeutic, as the patient feels that they have confronted their worst fears without anything terrible happening.
•Adults with mild symptoms should be offered a selective serotonin reuptake inhibitor (SSRI) if they cannot engage in low-intensity psychological treatment, if such treatment has failed, or if they opt not to have more intensive psychological treatment.
•Adults with moderate symptoms or where low-intensity psychological treatment has failed should be offered high-intensity CBT and ERP (more than 10 hours per patient) or an SSRI.
•Adults with severe symptoms – offer high-intensity psychological therapy plus an SSRI.

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Management in children[8]
•Mild dysfunction – offer guided self help. As for moderate-to-severe if this fails.
•Moderate-to-severe – offer cognitive behavioural therapy and exposure and response prevention (CBT ERP) as for adults but involve family/carers: individual or group depending on the preference of the patient.
•If psychological treatment fails, factors which might require other interventions may be involved, eg co-existence of comorbid conditions, learning disorders, persisting psychosocial risk factors such as family discord, presence of parental mental health problems. In children over the age of 8, adding an SSRI might be appropriate, following multidisciplinary review (but see below concerning safety issues).

Using SSRIs[8][10]

See separate article Selective Serotonin Reuptake Inhibitors and below:
•SSRIs in adults – evidence for use of SSRIs in obsessive-compulsive disorder (OCD) is stronger than for body dysmorphic disorder (BDD). Caution is advised in view of increased risk of suicidal thoughts and self harm in people with depression. It is unclear whether this applies to people with OCD or BDD in absences of other comorbidity; further guidance is awaited.

When prescribing, discuss the following and provide written supporting material: •Craving and tolerance do not occur.
•There is a risk of discontinuation/withdrawal symptoms on stopping the drug, missing doses, or reducing the dose.
•There is a range of potential side-effects, (see individual drugs) including worsening anxiety, suicidal thoughts and self harm, which need to be carefully monitored, especially in the first few weeks of treatment.
•There is commonly a delay in onset of up to 12 weeks, although depressive symptoms improve more quickly.
•In high-risk patients, prescribe limited quantities, keep in contact, especially during first few weeks, and actively monitor for akathisia (restlessness and the urge to move), suicidal ideation, increased anxiety, agitation.
•Monitor all patients around the time of dosage changes.
•NICE recommends fluoxetine as there is more supporting evidence than for other SSRIs.
•If there is no response to a standard dose, check compliance, check interaction with drugs and alcohol, then consider titrating to maximum dose according to the Product Characteristics.
•Continue for at least twelve months; withdraw gradually.

•SSRIs in children and young people (8-18 years) •Caution is advised as there is a risk of self harm or suicide in patients with depression. They are only prescribed by specialists, in conjunction with psychological therapy following assessment by a child and adolescent psychiatrist who should also be involved in dosage changes and discontinuation.
•Fluoxetine is the first-line SSRI for BDD. In the presence of depression, follow NICE guidance for treatment of childhood depression.
•Discuss adverse effects, dosage, monitoring. etc. with the patient/family/carers as per adults (see above).

Treatment failures (applicable to adults, children and young people)[2][8]

The following in conjunction with specialist assessment and multidisciplinary review:
•Try another SSRI.
•Change to clomipramine – but this has greater tendency to produce adverse effects. Do baseline ECG and check blood pressure; start with a small dose, titrate according to response, and monitor regularly.
•Antipsychotics – sometimes used to augment the effect of an SSRI.
•Inpatient treatment – for ‘last resort’ treatment failures.
•Residential/supportive care – for patients with chronic severe dysfunction.
•Patients with BDD do not usually benefit from surgical treatment.[11]

Cognitive and behavioural therapies are both forms of psychotherapy (a psychological approach to treatment) and are based on scientific principles that help people change the way they think, feel and behave. They are problem-focused and practical. (Please also refer to the separate article Psychotherapy and its Uses.)

In 2005 the Government made a commitment to improve the availability of psychological therapies, the preferred method being cognitive behavioural therapy (CBT) for patients, especially in depressive and anxiety disorders. This led to the launch of the Improving Access to Psychological Therapies (IAPT) programme in 2007.[1]

Definitions

Behavioural therapy

This is a treatment approach based on clinically applying theories of behaviour that have been extensively researched over many years. It is thought that certain behaviours are a learned response to particular circumstances and these responses can be modified. Behavioural therapy aims to change harmful and unhelpful behaviours that an individual may have.

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Cognitive therapy

This was developed later and focuses on clinically applying research into the role of cognitions in the development of emotional disorders. It looks at how people think about, and create meaning about, situations, symptoms and events in their lives and develop beliefs about themselves, others and the world.[2] These ways of thinking (harmful, unhelpful or ‘false’ ideas and thoughts) are seen as triggers for mental and physical health problems. By challenging ways of thinking, cognitive therapy can help to produce more helpful and realistic thought patterns.

Cognitive therapy was developed in the 1960s by Aaron Beck, an American psychiatrist. He felt that his patients were not improving enough through simple analysis and believed that it was their negative thoughts that were holding them back. At around the same time, another therapist, Albert Ellis, was also realising that people’s negative thoughts and irrational thinking could be underpinning mental health problems. He developed a form of cognitive therapy that has come to be known as rational emotive behavioural therapy (REBT).

Subtypes of cognitive therapy
•Rational emotive behavioural therapy (REBT): this is based on the belief that we all have sets of very rigid, and perhaps illogical, beliefs that can make us mentally unhealthy. It teaches the patient to recognise and spot the beliefs that could be causing them harm and to replace them with more logical and flexible ones.
•Cognitive analytic therapy (CAT): this is another form of cognitive therapy that combines some of the ideas of cognitive therapy with the more analytical approach of psychodynamic psychotherapy. The client and the therapist work together to look at what has hindered changes in the past, in order to understand better how to move forward in the present.[3] It was founded by Dr Anthony Ryle in the 1970s. The therapy sessions explore the patient’s past and childhood and determine why any problems have happened. They will then look at the effectiveness of any current coping mechanisms that the patient may have and will help the patient find ways to improve these. The work is very active. Diagrams and written outlines may be created to help recognise and challenge old patterns and coping mechanisms that do not work well, and provide revised mechanisms.[3] There is a professional organisation known as the Association for Cognitive Analytic Therapy (ACAT) with a wealth of explanation about the therapy on the website (see link in Internet and further reading section below).

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CBT

The term ‘cognitive behavioural therapy’ (CBT) has come to be used to refer to behavioural therapy, cognitive therapy and therapy that combines both of these approaches. The emphasis on the type of therapy used by a therapist can vary depending on the problem being treated. For example, behavioural therapy may be the main emphasis in phobia treatment or obsessive compulsive disorder (OCD) because avoidance behaviour or compulsive actions are the main problems. In depression, the emphasis may be on cognitive therapy.

The rest of this article focuses on CBT.

Conditions that can be treated by cognitive behavioural therapy

There is a strong evidence base for the effectiveness of CBT. It can be used in a wide number of mental health and physical conditions. The National Institute for Health and Clinical Excellence (NICE) has recommended its use as a treatment option for a number of diagnoses.

Examples of conditions that can be treated by CBT include:
•Depression[4] – low-intensity CBT (eg 6-8 sessions over 10-12 weeks) is recommended for mild- and moderate-severity depression. Computerised CBT (cCBT) is also recommended for both these severities. Severe depression will need high-intensity CBT, ie 16-20 sessions over 6-9 months, in combination with antidepressants. A cCBT package called ‘Beating the Blues®’ is one option recommended by NICE to deliver CBT in mild and moderate depression.
•Generalised anxiety disorder (GAD) and panic disorder – high-intensity CBT is recommended for GAD and low-intensity for panic disorder. There are cCBT packages available for panic disorder.
•Obsessive compulsive disorder (OCD)[5] – mild OCD should be treated with low-intensity CBT, with which accompanying exposure and relapse prevention (ERP) is recommended. CBT can take the form of brief, individual CBT, using self-help materials, or by the telephone or, alternatively, by group CBT, which may help. If this fails, or OCD leading to moderate functional impairment is present, then high-intensity CBT (including ERP) with medications is advised by NICE.
•Body dysmorphic disorder (BDD)[5] – mild functional impairment caused by this disorder should be treated with CBT (including ERP). Moderate functional impairment will require more intensive CBT or medical therapy, and severe functional impairment will usually require a combination of these.
•Post-traumatic stress disorder (PSTD)[6] – all sufferers should be offered trauma-focused CBT on a regular and continuous basis (usually 8-12 sessions).
•Other conditions where CBT maybe useful, but NICE guidance is lacking include: •Bulimia
•Chronic fatigue syndrome
•Drug and alcohol addiction
•Chronic pain
•Schizophrenia
•Bipolar disorder
•Learning disability
•Sexual and relationship problems
•Habits
•Anger problems
•Sleep disturbance problems

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The nature of cognitive behavioural therapy
•Cognitive behavioural therapy (CBT) can be delivered to individuals, couples, families or groups.
•It can be used alone, or in conjunction with medication.
•A therapeutic alliance is formed between the client(s) and the therapist.
•Together, the therapist and client identify the client’s problems in terms of the relationship between thoughts, feelings and behaviour.[2] A shared understanding of the problems is developed.
•Therapy is focused on the present rather than the past; it is orientated towards solving the client’s current problems and initiating behavioural change so that the client can function better in the future.
•Goals, and strategies of how to achieve them, are set and regularly reviewed.
•The therapy is aimed at encouraging empowerment of the client so that they can solve their problems using their own resources.
•The client will learn specific skills that they can use for the rest of their lives. This is the main advantage of CBT over medication.
•’Homework’ is set so that the client can apply what they have learnt in their sessions to real life.
•The number of therapy sessions depends on the client’s problems and need. Typically, sessions usually last about an hour and are once a week. A course of 10-15 sessions is average.
•Follow-up sessions are agreed and planned at the end of therapy to help maintain progress.
•Books and leaflets may give additional help and support.

Different approaches

Cognitive therapy uses a style of questioning called ‘guided discovery’. This helps clients to reflect on their ways of reasoning and thinking and helps them to consider the possibilities of thinking differently and more helpfully.[2] In their ‘homework’, clients can then test out these alternatives and learn to change their perceptions and actions.

Behavioural therapy looks at the way people act and respond when they are distressed or under pressure. It helps to modify unhelpful behaviours such as avoidance, which may exacerbate the problems or the way the client feels. This usually means gradually facing up to feared and avoided situations. As a consequence, anxiety is reduced and new behaviours to deal with problems and situations are learned. This type of therapy is known as exposure therapy.

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Different levels of cognitive behavioural therapy[2]
•Formulation-driven cognitive behavioural therapy (CBT): refers to psychotherapy that involves assessment, formulation and intervention, with a therapeutic alliance between the therapist and the client being paramount.
•CBT approaches: refers to specific CBT interventions for problem areas such as anger, anxiety and pain management groups. It is not psychotherapy as it just involves implementing the intervention. Practitioners delivering the interventions will have had specific training in the CBT intervention and should also receive supervision.
•Assisted self-help CBT: this includes computerised CBT (cCBT) – see below, and self-help material presented to a group/individual by a health worker. No specific formal CBT training is necessary.
•Self-help books/other resources: this is not a form of psychotherapy. No CBT skills or training are needed by the individual using the material.

The therapists
•These are usually psychiatrists, psychologists, mental health nurses, social workers, counsellors, GPs or occupational therapists who have received extra training and undergo supervision in cognitive and/or behavioural therapy.[2]
•Therapy is available on the NHS and privately.
•It is important that cognitive behavioural therapy (CBT) be administered by a trained and qualified professional.
•The Department of Health issued guidelines in 2007 for competences required to deliver effective CBT for people with depression and with anxiety disorders.[7]

Obsessive-compulsive disorder (OCD) may be characterised by the presence of obsessions or compulsions but commonly both.
•Obsessions are unwanted intrusive thoughts, images or urges that repeatedly enter the person’s mind.
•Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. They can be overt (observable by others), eg checking a door is locked; or they can be covert, eg a mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Epidemiology[1]

Studies vary but the figure for prevalence ranges from 1.7-4%.[2] Population surveys produce different results from audits of clinical samples and seem to suggest a predominance of females. Current research in paediatric OCD is investigating a genetic predilection in some families.[3]

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Management of obsessive-compulsive disorder[1][4][5]

The GP’s role

The National Institute for Health and Clinical Excellence (NICE) recommends referral to a specialist multidisciplinary team offering age-appropriate care. This is unlikely to be available in many areas, due to lack of resources; however, it is worth getting in touch with local mental health trusts to see what is currently available. The GP’s role depends on expertise but it should be remembered that drug management should be part of a package which includes psychological care.

In all patients, however, the GP will need to:
•Identify cases – for patients at risk of OCD (depression, anxiety, body dysmorphic disorder (BDD), substance misuse, or eating disorder), ask the following questions: •Do you wash or clean a lot?
•Do you check things a lot?
•Is there any thought that keeps bothering you that you would like to get rid of but cannot?
•Do your daily activities take a long time to finish?
•Are you concerned about putting things in a special order or are you very upset by mess?
•Do these problems trouble you?

•Assess severity, ie how much it is affecting the patient’s ability to function in everyday life.
•Assess the risk of self harm or suicide and the presence of comorbidity such as depression.
•Arrange referral to appropriate secondary care provision.
•Ensure continuity of care to avoid multiple assessments, gaps in service and a smooth transition from child to adult services (many patients have lifelong symptoms).
•Promote understanding – make patients/families aware of the involuntary nature of symptoms. Consider patient information leaflets, contact numbers of self-help groups, etc.
•Consider the bigger picture – cultural, social, emotional and mental health needs.
•If the patient is a parent, consider child protection issues.

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Management in adults

Patients with mild functional impairment – can be managed with low-intensity psychological treatment. This may involve:
•Individual cognitive behavioural therapy (CBT) plus exposure and response prevention (ERP).
•Individual CBT and ERP by telephone or internet.[6][7]
•Group CBT.
•A couples-based course, which has been developed for patients in long-term relationships.[8]

One randomised comparative trial concluded that group CBT was an effective treatment but did not exclude the possibility that individual therapy was superior.[9]

One study found that two prominent features of OCD – overestimations of danger and inflated beliefs of personal responsibility – benefited equally from CBT.[10]

Inference-based treatment (IBT) is a method of psychological treatment sometimes used as an adjunct to CBT in OCD patients with obsessional doubt.[11]

*ERP is a technique in which patients are repeatedly exposed to the situation causing them anxiety (eg, exposure to dirt) and are prevented from performing repetitive actions, which lessens that anxiety (eg, washing their hands). This method is only used after extensive counselling and discussion with the patient who knows fully what to expect. After an initial increase in anxiety, the level gradually decreases. This is extremely therapeutic, as the patient feels that they have confronted their worst fears without anything terrible happening. One study found that, providing there was adherence to a standardised treatment manual, the experience (or inexperience) of the therapist did not affect the outcome
•Adults with mild symptoms should be offered a selective serotonin reuptake inhibitor (SSRI) if they cannot engage in low-intensity psychological treatment, if such treatment has failed, or if they opt not to have more intensive psychological treatment.
•Adults with moderate symptoms or where low-intensity psychological treatment has failed should be offered high-intensity CBT and ERP (more than 10 hours per patient) or an SSRI.
•Adults with severe symptoms should be offered high-intensity psychological therapy plus an SSRI.

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Management in children[12][13]
•Mild dysfunction – offer guided self-help. If this fails, as for ‘moderate-to-severe’, below.
•Moderate-to-severe – offer CBT/ERP as for adults but involve family/carers: individual or group, depending on the preference of the patient.
•If psychological treatment fails, factors which might require other interventions may be involved – eg, co-existence of comorbid conditions, learning disorders, persisting psychosocial risk factors such as family discord, presence of parental mental health problems. In children over the age of 8, adding an SSRI might be appropriate, following a multidisciplinary review (but see below concerning safety issues).

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Using selective serotonin reuptake inhibitors[1][14]

See separate article Selective Serotonin Reuptake Inhibitors and below:
•SSRIs in adults:
Evidence for use of SSRIs in OCD is stronger than for body dysmoprhic disorder (BDD). Caution is advised in view of increased risk of suicidal thoughts and self harm in people with depression. There is no current evidence linking the use of SSRIs for OCD per se with increased risk of suicide.[2]

When prescribing, discuss the following and provide written supporting material:

•Craving and tolerance do not occur.
•There is a risk of discontinuation/withdrawal symptoms on stopping the drug, missing doses, or reducing the dose.
•There is a range of potential side-effects (see individual drugs), including worsening anxiety, suicidal thoughts and self harm, which need to be carefully monitored, especially in the first few weeks of treatment.
•There is commonly a delay in onset of up to 12 weeks, although depressive symptoms improve more quickly.
•In high-risk patients, prescribe limited quantities, keep in contact especially during the first few weeks and actively monitor for akathisia (restlessness and the urge to move), suicidal ideation, increased anxiety, and agitation.
•Monitor all patients around the time of dosage changes.
•NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram. There are no significant differences in efficacy.
•If there is no response to a standard dose, check compliance, check interaction with drugs and alcohol, then consider titrating to a maximum dose according to the Product Characteristics.
•Continue for at least twelve months, and withdraw gradually.

•SSRIs in children and young people (8-18 years): •Caution is advised, as there is a risk of self harm or suicide in patients with depression. Only prescribed by specialists, in conjunction with psychological therapy following assessment by a child and adolescent psychiatrist who should also be involved in dosage changes and discontinuation.
•Sertraline and fluoxetine are the only SSRIs licensed for this use, unless significant co-existing depression is evident, in which case fluoxetine should be used.
•Discuss adverse effects, dosage, monitoring, etc with the patient/family/carers, as per adults (see above).

Treatment failures (applicable to adults, children and young people)[1][15][16]

The following are in conjunction with specialist assessment and multidisciplinary review:
•Try another SSRI.
•One study found that intensive behavioural therapy was effective even in cases resistant to other psychological therapies.[17]
•Change to clonidine; however, there is a greater tendency to produce adverse effects. Do baseline ECG and check BP; start with a small dose, titrate according to response, and monitor regularly.
•Antipsychotics – are sometimes used to augment the effect of an SSRI.
•Inpatient treatment – for ‘last resort’ treatment failures, although one study found that many refractory cases responded to community-based specialist support.[18]
•Residential/supportive care – for patients with chronic severe dysfunction.
•Neurosurgery – this may be considered for severely ill patients who do not respond to CBT and medication. Risks, benefits, long-term postoperative management and patient selection should all be carefully considered before embarking on treatment. Patient selection can be improved by the use of neuroimaging.[19] Steriotactic ablation and deep brain stimulation are currently being explored and have shown promise.[20]

Antipsychotics are medicines that are mainly used to treat schizophrenia or mania caused by bipolar disorder. There are two main types of antipsychotics: atypical antipsychotics and older antipsychotics. Both types are thought to work as well as each other. Side-effects are common with antipsychotics. You will need regular tests to monitor for side-effects while you take theses medicines.

What are antipsychotics?

Antipsychotics are a group of medicines that are mainly used to treat mental health illnesses such as schizophrenia, or mania (where you feel high or elated) caused by bipolar disorder. They can also be used to treat severe depression and severe anxiety. Antipsychotics are sometimes also called major tranquillisers.

There are two main types of antipsychotics:
•Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.
•Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

Antipsychotics are available as tablets, capsules, liquids, and depot injections (long-acting). They come in various different brand names.

Older antipsychotics have been used since the 1950s and are still prescribed today. Newer antipsychotics were developed in the 1970s onwards. It was originally thought that these medicines would have fewer side-effects than the older type of antipsychotics. However, we now know that they can also cause quite a few side-effects.

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How do antipsychotics work?

Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine. These chemicals have the effect of changing your behaviour, mood and emotions. Dopamine is the main chemical that these medicines have an effect on.

By altering the effects of these chemicals in the brain they can suppress or prevent you from experiencing:
•Hallucinations (such as hearing voices).
•Delusions (having ideas not based on reality).
•Thought disorder.
•Extreme mood swings that are associated with bipolar disorder.

When are antipsychotics usually prescribed?

As discussed above, antipsychotics are usually prescribed to help to ease the symptoms of schizophrenia, mania (caused by bipolar disorder), severe depression or severe anxiety. Normally they are started by a specialist in psychiatry, or your GP will ask a specialist for advice on when to start them.

Also, for many years antipsychotics were used to calm elderly people who had dementia, but this use is no longer recommended. This is because these medicines are thought to increase the risk of stroke and early death – by a small amount. Risperidone is the only antipsychotic recommended for use in these people. Even then, it should only be used for short period of time (less than six weeks) and for severe symptoms.

Which antipsychotic is usually prescribed?

The choice of antipsychotic prescribed depends upon what is being treated, how severe your symptoms are, and if you have any other health problems. There are a number of differences between the various antipsychotic medicines. For example, some are more sedating than others. Therefore, one may be better for one individual than for another. A specialist in psychiatry usually advises on which to use in each case. It is difficult to tell which antipsychotic will work well for you. If one does not work so well, a different one is often tried and may work well. Your doctor will advise.

It is thought that the older and newer types of antipsychotics work as well as each other. The exception to this is clozapine – it is the only antipsychotic that is thought to work better than the others. Unfortunately, clozapine has a number of possible serious side-effects, especially on your blood cells. This means that people who take clozapine have to have regular blood tests.

In some cases, an injection of a long-acting antipsychotic medicine (depot injection) is used once symptoms have eased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses (recurrences of symptoms). The main advantage of depot injections is that you do not have to remember to take tablets every day.

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6
Schizophrenia
How well do antipsychotics work?

It is thought that for every 10 people who take these medicines, 8 will experience an improvement in their symptoms. Unfortunately, antipsychotics do not always make the symptoms go away completely, or for ever. A lot people need to take them in the long term even if they feel well. This is in order to stop their symptoms from coming back. Even if you take these medicines on a long-term basis and they are helping, sometimes your symptoms can come back.

Symptoms may take 2-4 weeks to ease after starting medication, and it can take several weeks for full improvement. The dose of the medicine is usually built up gradually to help to prevent side-effects (including weight gain).

What is the usual length of treatment?

This depends on various things. Some people may only need to take them for a few weeks, but others may need to take them long-term (for example, for schizophrenia). Even when symptoms ease, antipsychotic medication is normally continued long-term if you have schizophrenia. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms of schizophrenia that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise.

Stopping antipsychotics

If you want to stop taking an antipsychotic you should always talk to your doctor first. This is in order to help you decide if stopping is the best thing for you, and how you should stop taking your medicine. These medicines are usually stopped slowly over a number of weeks. If you stop taking an antipsychotic medicine suddenly, you may become unwell quite quickly. Your doctor will usually advise you to reduce the dose slowly to see what effect the lower dose has on your symptoms.

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What about side-effects from antipsychotics?

Side-effects can sometimes be troublesome. There is often a trade-off between easing symptoms and having to put up with some side-effects from treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.

The following are the main side-effects that sometimes occur. However, you should read the information leaflet that comes in each medicine packet for a full list of possible side-effects.

Common side-effects include:
•Dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
•Drowsiness (sedation), which is also common but may be an indication that the dose is too high. A reduced dose may be an option.
•Weight gain which some people develop. Weight gain may increase the risk of developing diabetes and heart problems in the longer term. This appears to be a particular problem with the atypical antipsychotics – notably, clozapine and olanzapine.
•Movement disorders which develop in some cases. These include: •Parkinsonism – this can cause symptoms similar to those that occur in people with Parkinson’s disease – for example, tremor and muscle stiffness.
•Akathisia – this is like a restlessness of the legs.
•Dystonia – this means abnormal movements of the face and body.
•Tardive dyskinesia (TD) – this is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develops TD.

Atypical antipsychotic medicines are thought to be less likely to cause movement disorder side-effects than typical antipsychotic medicines. This reduced incidence of movement disorder is the main reason why an atypical antipsychotic is often used first-line. Atypicals do, however, have their own risks – in particular, the risk of weight gain. If movement disorder side-effects occur then other medicines may be used to try to counteract them.

Will I need any tests while taking an antipsychotic?

Your doctor will want to monitor you regularly for side-effects if you take an antipsychotic. The tests needed and how often you will need to have them depend on which antipsychotic you are taking.

In general, your doctor will take a sample of blood for certain tests before you start treatment. The tests look at how many blood cells you have, how well your kidneys and liver are working, how much lipid (fat) is in your blood, and if you have diabetes. These tests may be repeated in the first 3 or 4 months of treatment. After this they are normally done every year. However, your doctor may advise you to have these tests more often.

Your weight and blood pressure are usually measured before you start treatment and every few weeks after this for the first few months. After this they are normally measured every year.

The blood level of prolactin (a hormone) may also be measured before starting treatment and six months later. Usually it is then measured every year after this. The prolactin level is measured because sometimes antipsychotics can make you produce too much of this hormone. If you make too much prolactin it can lead to your breasts growing bigger and breast milk being produced.

Note: people taking clozapine need weekly blood tests for the first six months and two-weekly blood tests after that. This is because it can have a serious effect on how many blood cells you make.

Who cannot take antipsychotics?

Antipsychotics are usually not prescribed for people who are comatose (in a coma), have depression of their central nervous system, and who have phaeochromocytoma (tumour on the adrenal gland).

Can I buy antipsychotics?

No – they are only available from your pharmacist, with a doctor’s prescription