Psilocybin Promising for Body Dysmorphic Disorder

WASHINGTON — Psilocybin is safe and effective in patients with body dysmorphic disorder (BDD), preliminary findings of a small pilot study show.

Dr Franklin Schneier

“The results suggest that psilocybin appears to be relatively safe and potentially helpful for people with BDD, and that it has a broader scope than just depression,” study investigator Franklin Schneier, MD, co-director of the Anxiety Disorders Clinic, NY State Psychiatric Institute, and special lecturer in psychiatry at Columbia University Medical Center in New York City, told Medscape Medical News.

So far, psilocybin has mostly been examined in clinical trials among patients with major depression. Schneier said is aware of only a single case in the literature of its use in BDD: a patient who self-treated with psilocybin and reported symptom improvement.

The current study was presented at the Anxiety and Depression Association of America (ADAA) meeting.

Few Treatment Options

Patients with BDD are preoccupied with a body part they perceive as ugly or defective, “and not just mildly so,” said Schneier. “It bothers them to the extreme such that they may obsess about it on and off all day long.”

Such patients may engage in compulsive behaviors like constantly checking themselves in the mirror, and going to great lengths to conceal the body part they feel is defective. “They often seek out cosmetic procedures that objectively aren’t warranted,” said Schneier.

BDD patients often have co-morbid depression and many attempt suicide. As with other anxiety and depressive disorders, BDD is twice as prevalent in women vs men, said Schneier.

Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) are the only approved therapies for BDD.

The investigators thought there may be a good chance BDD patients could benefit from psilocybin. Psilocybin alters bodily self-awareness, which “might shake up people’s beliefs about their abnormal body perceptions,” said Schneier.

There’s also some suggestion that psilocybin relaxes inflexible thinking, he added. “People with BDD have very rigid beliefs about their body distortions that aren’t easily swayed by logic.”

The study included 12 adults (8 women, 4 men) with a mean age 34 years and moderate-to-severe BDD who failed at least one course of SSRI and had had BDD for an average of 21 years.

Participants had preliminary sessions with a therapist familiar with psilocybin who prepared them psychologically and discussed what to expect from the experience. On the day of the intervention, subjects took a single 25 mg oral dose of synthetic psilocybin in a comfortable setting.

Therapists were present for the next 8 hours to answer questions and support subjects through the experience.

High Response Rate

The primary efficacy outcome was change in the BDD Yale-Brown Obsessive Compulsive Disorder Scale Modified (BDD-YBOCS) total score.

The mean baseline BDD-YBOCS score was 29.17. Researchers regularly assessed this score in the following weeks.

At 12 weeks, BDD-YBOCS scores decreased significantly from baseline (P < .001) with a large effect size (partial eta squared = .54).

However, said Schneier, what really stood out was the proportion of responders. At week 12, seven (58%) of the 12 participants were responders, as defined by a 30% or greater decrease in the BDD-YBOCS score. Of these, 3 were “almost symptom-free,” he added.

A number of secondary outcomes, including conviction of belief, disability, and negative affect, also significantly improved.

It’s too early to determine if additional treatment is required. The investigators plan to follow up with the cohort at 1 year.

Although exciting, these early results warrant caution, said Schneier. “On the one hand, this is a sample of people who have struggled for a long time and have failed previous therapies, so that’s good. But on the other hand, it’s an open trial with no placebo group, and everyone has high expectations, so we don’t know how much of a placebo effect there was.”

Most adverse events, including headaches and fatigue, were mild and resolved within the first week after dosing, and there were no serious adverse events.

Based on these findings, Schneier said controlled trials of psilocybin in BDD are warranted.

Need for Scientific Rigor

Commenting on the research for Medscape Medical News, Charles B. Nemeroff, MD, PhD, professor and chair, Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, said while promising, psilocybin is “not for everyone” and patients need to be closely screened.

“We want to know their medical history and if they have a family history of schizophrenia or bipolar disorder. We don’t know whether these [psychedelic] medicines might trigger an episode.”

Nemeroff also noted there’s a risk of “troubling” side effects from the drug.

“My view is psilocybin clearly has therapeutic effects and we need to apply scientific rigor as we would any medicine in order to determine the risk/benefit ratio,” said Nemeroff, who was not associated with this psilocybin trial.

In addition, BDD and major depression, psilocybin is being tested in other conditions including anorexia nervosa, postpartum depression, and alcohol use disorder, he added.

The study received funding from COMPASS Pathways PLC.

Nemeroff reports he has received research support from the NIH and Stanley Medical Research Institute; served as a consultant for Bracket (Clintara), Fortress Biotech, Intra-Cellular Therapies, Janssen Research and Development, Magstim, Navitor Pharmaceuticals, Sunovion Pharmaceuticals, Taisho Pharmaceuticals, Takeda, TC MSO, and Xhale; served on scientific advisory boards for the American Foundation for Suicide Prevention, the Anxiety and Depression Association of America, Bracket (Clintara), Brain and Behavior Research Foundation, Laureate Institute for Brain Research, Skyland Trail, and Xhale; is a stockholder in AbbVie, Antares, BI Gen Holdings, Celgene, OPKO Health, Seattle Genetics, and Xhale; serves on the board of directors for the American Foundation for Suicide Prevention, Anxiety and Depression Association of America, and Gratitude America; has received income or equity of $10,000 or more from American Psychiatric Publishing, Bracket (Clintara), Magstim, CME Outfitters, and Intra-Cellular Therapies; and holds patents on a method and devices for transdermal delivery of lithium and a method of assessing antidepressant drug therapy via transport inhibition of monoamine neurotransmitters by ex vivo assay.

Anxiety and Depression Association of America (ADAA) Conference 2023: Abstract 131. Presented April 14, 2023.

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