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Delusional versus nondelusional body dysmorphic disorder: recommendations for DSM-5

Published online by Cambridge University Press:  10 May 2013

Katharine A. Phillips ,
Ashley S. Hart ,
Helen Blair Simpson  and
Dan J. Stein
Katharine A. Phillips*
Affiliation:
Body Dysmorphic Disorder Program, Rhode Island Hospital, Providence, Rhode Island, USA Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
Ashley S. Hart
Affiliation:
Body Dysmorphic Disorder Program, Rhode Island Hospital, Providence, Rhode Island, USA Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
Helen Blair Simpson
Affiliation:
Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York, USA Anxiety Disorders Clinic and the Center for OCD and Related Disorders, New York State Psychiatric Institute, New York, New York, USA
Dan J. Stein
Affiliation:
Department of Psychiatry, University of Cape Town, Cape Town, South Africa
*
*Address for correspondence: Katharine A. Phillips, MD, Rhode Island Hospital, Coro Center West, Suite 2.030, 1 Hoppin Street, Providence, RI 02903, USA. (Email Katharine_Phillips@brown.edu)
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Abstract

The core feature of body dysmorphic disorder (BDD) is distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. BDD beliefs are characterized by varying degrees of insight, ranging from good (ie, recognition that one's BDD beliefs are not true) through “absent insight/delusional” beliefs (ie, complete conviction that one's BDD beliefs are true). The Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R) and The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) classified BDD's nondelusional form in the somatoform section of the manual and its delusional form in the psychosis section, as a type of delusional disorder, somatic type (although DSM-IV allowed double-coding of delusional BDD as both a psychotic disorder and BDD). However, little or no evidence on this issue was available when these editions were published. In this article, we review the classification of BDD's delusional and nondelusional variants in earlier editions of DSM and the limitations of their approaches. We then review empirical evidence on this topic, which has become available since DSM-IV was developed. Available evidence indicates that across a range of validators, BDD's delusional and nondelusional variants have many more similarities than differences, including response to pharmacotherapy. Based on these data, we propose that BDD's delusional and nondelusional forms be classified as the same disorder and that BDD's diagnostic criteria include an insight specifier that spans a range of insight, including absent insight/delusional BDD beliefs. We hope that this recommendation will improve care for patients with this common and often-severe disorder. This increased understanding of BDD may also have implications for other disorders that have an “absent insight/delusional” form.

Keywords

Body dysmorphic disorderclassificationdelusional disorderdelusionsDSMDSM-5eating disordersinsightobsessive-compulsive disordertreatment
Type
Review Articles
Information
CNS Spectrums , Volume 19 , Issue 1 , February 2014 , pp. 10 - 20
Copyright
Copyright © Cambridge University Press 2013 

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Footnotes

Drs. Phillips, Stein, and Simpson were members of the DSM-5 Workgroup on Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders, which was responsible for body dysmorphic disorder during the DSM-5 development process. This paper is consistent with the workgroup's deliberations on and recommendations for DSM-5.

This work was supported by the National Institute of Mental Health (K.A.P., grant number K24MH063975).

References

1. Keller, J, Schatzberg, AF, Maj, M. Current issues in the classification of psychotic major depression. Schizophr Bull. 2007; 33: 877–885.Google Scholar
2. Phillips, KA, Wilhelm, S, Koran, LM, etal. Body dysmorphic disorder: some key issues for DSM-V. Depress Anxiety. 2010; 27(6): 573–591.Google Scholar
3. Leckman, JF, Denys, D, Simpson, HB, etal. Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V. Depress Anxiety. 2010; 27(6): 507–527.Google Scholar
4. Mataix-Cols, D, Frost, RO, Pertusa, A, etal. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010; 27(6): 556–572.Google Scholar
5. Konstantakopoulos, G, Tchanturia, K, Surguladze, SA, etal. Insight in eating disorders: clinical and cognitive correlates. Psychol Med. 2011; 41: 1951–1961.Google Scholar
6. Bosson, JV, Reuther, ET, Cohen, AS. The comorbidity of psychotic symptoms and posttraumatic stress disorder: evidence for a specifier in DSM-5. Clin Schizophr Relat Psychoses. 2011; 5(3): 147–154.Google Scholar
7. Phillips, KA, Price, LH, Greenberg, BD, etal. Should DSM's diagnostic groupings be changed? In: Phillips KA, First MB, Pincus H, eds. Advancing DSM: Dilemmas in Psychiatric Diagnosis. Washington, DC: American Psychiatric Association; 2003.Google Scholar
8. Eisen, JL, Phillips, KA, Baer, L, etal. The Brown Assessment of Beliefs Scale: reliability and validity. Am J Psychiatry. 1998; 155(1): 102–108.CrossRefGoogle ScholarPubMed
9. Phillips, KA, Pinto, A, Hart, AS, etal. A comparison of insight in body dysmorphic disorder and obsessive-compulsive disorder. J Psychiatr Res. 2012; 46: 1293–1299.Google Scholar
10. Phillips, KA. Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry. 1991; 148(9): 1138–1149.Google ScholarPubMed
11. Stekel, W. Compulsion and Doubt. Translated by Gutheil EA. New York: Liveright; 1949.Google Scholar
12. Campanella, FN, Zuccoli, E. In tema di dismorfofobia. Neuropsichiatria. 1968; 24: 475–486.Google Scholar
13. Koran, LM, Abujaoude, E, Large, MD, etal. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr. 2008; 13(4): 316–322.Google Scholar
14. Eisen, JL, Phillips, KA, Coles, ME, etal. Insight in obsessive compulsive disorder and body dysmorphic disorder. Compr Psychiatry. 2004; 45: 10–15.Google Scholar
15. Mancuso, S, Knoesen, N, Castle, DJ. Delusional vs nondelusional body dysmorphic disorder. Compr Psychiatry. 2010; 51(2): 177–182.Google Scholar
16. Phillips, KA, McElroy, SL, Keck, PE, etal. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull. 1994; 30(2): 179–186.Google Scholar
17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.Google Scholar
18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 1st ed. Washington, DC: American Psychiatric Association; 1952.Google Scholar
19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, DC: American Psychiatric Association; 1968.Google Scholar
20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association; 1980.Google Scholar
21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, rev. Washington, DC: American Psychiatric Association; 1987.Google Scholar
22. McElroy, SL, Phillips, KA, Keck, PE Jr, etal. Body dysmorphic disorder: does it have a psychotic subtype? J Clin Psychiatry. 1993; 54: 389–395.Google Scholar
23. Phillips, KA, McElroy, SL. Insight, overvalued ideation, and delusional thinking in body dysmorphic disorder: theoretical and treatment implications. J Nerv Ment Dis. 1993; 181: 699–702.Google Scholar
24. American Psychiatric Association. DSM-IV Options Book: Work in Progress. Washington, DC: American Psychiatric Association; 1991.Google Scholar
25. Phillips, KA, Hollander, E. Body dysmorphic disorder. In: Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis WW, eds. DSM-IV Sourcebook. vol. 2. Washington, DC: American Psychiatric Association; 1996.Google Scholar
26. Hollander, E, Allen, A, Kwon, J, etal. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. 1999; 56(11): 1033–1039.Google Scholar
27. Phillips, KA, Albertini, RS, Rasmussen, SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. 2002; 59(4): 381–388.Google Scholar
28. Phillips, KA, McElroy, SL, Dwight, MM, etal. Delusionality and response to open-label fluvoxamine in body dysmorphic disorder. J Clin Psychiatry. 2001; 62(2): 87–91.Google Scholar
29. Phillips, KA, Najar, F. An open-label study of citalopram in body dysmorphic disorder. J Clin Psychiatry. 2003; 64(6): 715–720.Google Scholar
30. Phillips, KA. An open-label study of escitalopram in body dysmorphic disorder. Int Clin Psychopharmacol. 2006; 21(3): 177–179.Google Scholar
31. Steinglass, JE, Eisen, JL, Attia, E, etal. Is anorexia nervosa a delusional disorder? An assessment of eating beliefs in anorexia nervosa. J Psychiatr Pract. 2007; 13(2): 65–71.CrossRefGoogle ScholarPubMed
32. Phillips, KA, Menard, W, Pagano, ME, etal. Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness. J Psychiatr Res. 2006; 40(2): 95–104.CrossRefGoogle ScholarPubMed
33. Didie, ER, Tortolani, CC, Pope, CG, etal. Childhood abuse and neglect in body dysmorphic disorder. Child Abuse Negl. 2006; 30(10): 1105–1115.Google Scholar
34. Bernstein, DP, Fink, L, Handelsman, L, etal. Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am J Psychiatry. 1994; 151(8): 1132–1136.Google ScholarPubMed
35. Phillips, KA, Hollander, E, Rasmussen, SA, etal. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull. 1997; 33(1): 17–22.Google Scholar
36. Miller, IW, Bishop, S, Norman, WH, etal. The Modified Hamilton Rating Scale for Depression: reliability and validity. Psychiatry Res. 1985; 14: 131–142.Google Scholar
37. Zung, WW. A self-rating depression scale. Arch Gen Psychiatry. 1965; 12: 63–70.Google Scholar
38. Mattick, RP, Clarke, JC. Development and validation of measures of social phobia, scrutiny, fear, and social interaction anxiety. Behav Res Ther. 1998; 36(4): 455–470.Google Scholar
39. Weissman, MM, Prusoff, BA, Thompson, DW, etal. Social adjustment by self-report in a community sample and in psychiatric outpatients. J Nerv Ment Dis. 1978; 166: 317–326.Google Scholar
40. Ware, JE. SF-36 Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center; 1993.Google Scholar
41. Phillips, KA. Quality of life for patients with body dysmorphic disorder. J Nerv Ment Dis. 2000; 188(3): 170–175.CrossRefGoogle ScholarPubMed
42. Didie, ER, Loerke, EH, Howes, SE, etal. Severity of interpersonal problems in individuals with body dysmorphic disorder. J Personal Disord. 2012; 26: 345–356.CrossRefGoogle ScholarPubMed
43. Horowitz, LM, Alden, LE, Wiggins, JS, etal. Inventory of Interpersonal Problems Manual. San Antonio, TX: The Psychological Corporation; 2000.Google Scholar
44. Costa, PT Jr, McCrae, RR. Normal personality assessment in clinical practice: the NEO Personality Inventory. Psychol Assess. 1992; 4: 5–13.Google Scholar
45. Warshaw, MG, Keller, MB, Stout, RL. Reliability and validity of the longitudinal interval follow-up evaluation for assessing outcome of anxiety disorders. J Psychiatr Res. 1994; 28(6): 531–545.CrossRefGoogle ScholarPubMed
46. Phillips, KA, Pagano, ME, Menard, W, etal. A 12-month follow-up study of the course of body dysmorphic disorder. Am J Psychiatry. 2006; 163(5): 907–912.Google Scholar
47. Phillips, KA, Menard, W, Quinn, E, etal. A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychol Med. 2013; 43(5): 1109–1117.Google Scholar
48. Guy, W. Clinical Global Impressions (CGI). ECDEU Assessment Manual for Psychopharmacology. rev ed. Rockville, MD: U.S. Department of Health, Education, and Welfare, NIMH; 1976.Google Scholar
49. Phillips, KA, Grant, JE, Siniscalchi, JM, etal. A retrospective follow-up study of body dysmorphic disorder. Compr Psychiatry. 2005; 46(5): 315–321.CrossRefGoogle ScholarPubMed
50. Phillips, KA. Placebo-controlled study of pimozide augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry. 2005; 162(2): 377–379.CrossRefGoogle ScholarPubMed
51. Phillips, KA, Albertini, RS, Siniscalchi, JM, etal. Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study. J Clin Psychiatry. 2001; 62(9): 721–727.CrossRefGoogle ScholarPubMed
52. Phillips, KA, Menard, W. A prospective pilot study of levetiracetam for body dysmorphic disorder. CNS Spectr. 2009; 14(5): 252–260.Google Scholar
53. Phillips, KA. An open study of buspirone augmentation of serotonin-reuptake inhibitors in body dysmorphic disorder. Psychopharmacol Bull. 1996; 32(1): 175–180.Google ScholarPubMed
54. Saccomani, L, Savoini, M, Cirrincione, M, etal. Long-term outcome of children and adolescents with anorexia nervosa: study of comorbidity. J Psychosom Res. 1998; 44: 565–571.Google Scholar
55. Greenfeld, DG, Anyan, WR, Hobart, M, etal. Insight into illness and outcome in anorexia nervosa. Int J Eat Disord. 1991; 10: 101–109.3.0.CO;2-7>CrossRefGoogle Scholar