dmPFC-ACC dTMS for Refractory Body Dysmorphic Disorder: Case Report

Background:

Body dysmorphic disorder (BDD) is a variant of OCD wherethe patient’s preoccupations and/or repetitive behaviors focus on appearance. These patients may benefit from dTMS with a coil (H7) that targets the dorso-medial PFC (dmPFC) and anterior cingulate cortex (ACC), that was shownto be effective and safe in OCD patients.

Objective:

To explore the benefit of dTMS H7 coil over the dmPFC and ACC for BDD.

Methods:

A 25-year-old-woman with lifelong performance anxiety and attention deficit disorder developed significant anxiety after her first job offer. Over five months, she was medicated with antidepressants and antipsychotics without benefit. She exhibited constant preoccupations with minor weight gain, magnified via muscle dysmorphia and poor insight. Her BDD andsuicidal depression resulted in hospitalization. While inpatient, she underwent a course of H1 dTMS coil to the left PFC, which failed to reduce her obsessions or depression, but she was no longer actively suicidal. Because her suicidal ideation stopped with the H1, these treatments continued and the H7 was added. H7 dTMS was administered to the dmPFC-ACC at 100%resting MT of the foot. Immediately before initiating stimulation, the patient’s specific obsessions were provoked. CGI-S, BDI and YBOCS assessed progress.

Results:

After 32 daily treatments of dmPFC-ACC stimulation with the H7, the patient remitted (CGI-S 71, BDI 3911, YBOCS 179) from her BDD and depression. She continued twice-weekly treatments for 12 weeks, when Fluoxetine was added for prophylaxis. She remains gainfully employed in remission for close to two years without further dTMS.

Conclusions:

Patients with BDD who do not respond to pharmacotherapy may benefit from dTMS to the dmPFC-ACC.