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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).

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