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Delusional versus nondelusional body dysmorphic disorder
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Comprehensive Psychiatry 51 (2010) 177 – 182 www.elsevier.com/locate/comppsych
Delusional versus nondelusional body dysmorphic disorder Serafino G. Mancusoa,b , Natalie P. Knoesena , David J. Castlea,c,⁎ b
a St Vincent's Mental Health, Melbourne, Australia Swin-PsyCHE Research Unit, Swinburne University of Technology, Melbourne, Australia c Department of Psychiatry, St Vincent's Hospital, Melbourne, Australia
Abstract This study assessed demographic and clinical features in 65 subjects with body dysmorphic disorder (BDD) and compared the 39 (60%) with the delusional form (receiving an additional diagnosis of delusional disorder, somatic type) with those who did not meet delusionality criteria. Delusional and nondelusional patients did not statistically differ on most demographic and clinical variables. Delusional patients, however, had significantly more severe BDD symptoms at both baseline and follow-up assessments than those of nondelusional patients. Furthermore, poorer insight was significantly associated with more severe BDD symptoms at both baseline and follow-up. Overall improvement in BDD symptom severity was similar for the 2 groups. Our results support other studies in the view that BDD and its delusional variant have more similarities than differences and that the delusional variant may be simply a more severe form of BDD. Implications for the diagnostic classification of BDD and future research directions are discussed. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved.
1. Introduction Individuals with body dysmorphic disorder (BDD) are preoccupied with a perceived or minor defect in 1 or more aspects of their appearance [1]. The most common preoccupations concern the hair, nose, and skin, but any body part can be the focus of concern [2,3]. The preoccupations are typically difficult to resist or control and, on average, consume 3 to 8 hours daily [2]. Although not a diagnostic criterion, almost all people with BDD perform compulsive behaviors to examine, improve, or hide their perceived defect [2,3]. Insight into the appearance preoccupations is often impaired such that BDD patients hold their beliefs about the perceived defects with strong conviction [2,4]. Case reports suggest that patients fluctuate between obsessional thoughts, overvalued ideation, and delusionality [5]. Those patients who maintain their beliefs with delusional intensity qualify for an additional diagnosis of delusional disorder, somatic type [1]. Body dysmorphic disorder tends to begin in late adolescence, with the mean age of onset between 16 and 18 years [3]. There are similar prevalence rates for males and ⁎ Corresponding author. St. Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria 3065, Australia. E-mail address: [email protected] (D.J. Castle).
females in adult clinical samples [6]. Studies within the general population have reported prevalence rates ranging from 0.7% [7] to 1.7% [8]. Higher rates have been reported in clinical samples, ranging from 3.2% [9] to 16% [10] in psychiatric settings, 11.9% in dermatologic settings [11], and 7% [12] to 17% [13] in cosmetic surgery settings. Individuals with moderate to severe symptoms tend to follow a deteriorating course and experience BDD for an average of 15 to 16 years [6]. Almost all BDD patients experience impairment in social, occupational, and/or academic functioning because of their appearance concerns [14]. Major depressive disorder, social anxiety disorder, and obsessive-compulsive disorder are often comorbid with BDD [15,16]. Patients with BDD are also often diagnosed with comorbid personality disorders, the most common of which are avoidant, paranoid, and obsessive-compulsive personality disorders [16,17]. Psychological and pharmacological treatments for BDD have received increased attention. Psychological treatment studies have focused on cognitive-behavioral therapy (CBT), whereas pharmacological treatment studies have concentrated on selective serotonin reuptake inhibitors (SSRIs). Cognitive-behavioral therapy approaches comprise cognitive restructuring for maladaptive beliefs about appearance and exposure and response prevention for appearancerelated behaviors [18]. Cognitive interventions incorporating
0010-440X/$ – see front matter. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2009.05.001
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exposure and response prevention seem efficacious in reducing symptom severity and overvalued ideation [19]. Pharmacotherapy trials consistently indicate that SSRIs, including fluoxetine [20], fluvoxamine [21], clomipramine [22], citalopram [23], and escitalopram [24], are often efficacious in treating both delusional and nondelusional variants of BDD. 1.1. Classification According to Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R), BDD is classified as a somatoform disorder and its delusional variant as a psychotic disorder [1]. However, Phillips and McElroy [5] have contended that both delusional and nondelusional variants of BDD may reflect 1 single disorder, with the degree of insight varying along a continuum, ranging from good through poor to absent. Unpublished data [25] using the Brown Assessment of Beliefs Scale [26] in 129 BDD patients highlights this varying degree of insight, with only 0.78% having excellent insight, 3.1% good insight, 12.4% fair insight, 31% poor insight, and 52.7% absent insight (ie, delusional). Phillips et al [4] also compared 52 delusional to 48 nondelusional patients and found that the 2 groups did not differ in relation to demographics, phenomenology, course, comorbidity, and treatment response. Delusional patients, however, had more severe BDD symptoms and greater impairment in occupational or academic functioning than those of nondelusional patients. Comparable results were reported by Phillips et al [27], who found that delusional (n = 68) and nondelusional (n = 123) BDD patients were similar in terms of demographics, clinical characteristics, course of illness, and probability of remitting from BDD. Although delusional patients were found to have more severe symptoms, greater functional impairment, poorer quality of life, higher suicidality, and greater substance abuse than those of nondelusional patients, these differences were accounted for by their more severe BDD symptoms. These data taken together suggest that although insight in BDD is often impaired, BDD and its delusional variant have many more similarities than differences. However, there remains debate about the delusional and nondelusional classification of BDD. We present here a naturalistic study of an Australian sample of BDD patients and compare demographics, clinical features, and treatment response between patients classified as delusional and nondelusional. We hypothesized that delusional patients would differ from nondelusional ones in terms of symptom severity but that, overall, there would be more similarities than differences between the groups.
evaluation and treatment of people with BDD. Treatment is free and comprises a standardized pharmacological approach (see Section 2.3), standardized psychoeducation (which includes written information about the nature of BDD and the fundamentals of CBT for BDD), and on-referral to a clinical psychologist for more intensive CBT when required. 2.1. Participants Of the 72 eligible BDD patients, 7 refused to participate or did not attend follow-up appointments; thus, we here report on 65 patients. Referral sources comprised selfreferrals, general practitioners, psychiatrists, psychologists, cosmetic surgeons, and various medical specialists. Participants provided written informed consent to participate in a phenomenological study, which was later amended to include treatment data. The phenomenological study was approved by the University of Melbourne Human Research Ethics Committee (Project 040629X) as was the amendment to obtain treatment data (Project 040629X.2). 2.2. Measures 2.2.1. Body Dysmorphic Disorder Questionnaire The Body Dysmorphic Disorder Questionnaire [28] is a 10-item self-report measure that screens for BDD. For BDD diagnosis, the Body Dysmorphic Disorder Questionnaire has been shown to have a sensitivity of 100% and a specificity of 89% in an outpatient psychiatric setting [29] and a sensitivity of 100% and a specificity of 93% in a dermatologic setting [30]. Items 7, 8, and 9 were used to assess social impairment, occupational impairment, and avoidance, respectively. 2.2.2. Dysmorphic Concern Questionnaire The Dysmorphic Concern Questionnaire (DCQ) [31] is a 7-item self-report measure that assesses cognitive and behavioral symptoms of overconcern with an imagined or slight physical defect. The score for each item ranges from 0 (not at all) to 3 (much more than most people). The DCQ is scored by summing all items, with a score of 11 and above indicative of probable BDD. A cutoff score of 11 has been shown to have a sensitivity of 100% and a specificity of 79% in a dermatologic outpatient setting [32]. In the present study, the reliability coefficient (Cronbach α) was .73. 2.2.3. Self-rating Depression Scale The Self-rating Depression Scale (SDS) [33] is a 20-item self-report measure that assesses cognitive, behavioral, affective, and somatic symptoms of depression on a 4-point scale, from 1 (a little of the time) to 4 (most of the time). The SDS is scored by summing all the items, with total raw scores ranging from 20 to 80. In the present study, the reliability coefficient was .78.
2. Method Potential participants were all consecutive BDD patients seen at the St Vincent's Health Body Image Disorder Service, a statewide outpatient service specializing in the
2.2.4. Social Interaction Anxiety Scale The Social Interaction Anxiety Scale (SIAS) [34] is a 20-item self-report scale that measures cognitive, behavioral, and affective aspects of social anxiety as experienced in
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social interactions in dyads or groups. Items are rated on a 5-point scale, from 0 (not at all characteristic or true of me) to 4 (extremely characteristic or true of me). The SIAS is scored by summing the ratings and total scores ranging from 0 to 80. Higher scores represent higher levels of social interactional anxiety. The SIAS discriminates between clinical and nonclinical samples and between patients with social anxiety and those with other anxiety disorders [35]. In the present study, the reliability coefficient was .92. 2.2.5. Diagnostic interview A diagnostic interview using the Structured Clinical Interview for DSM-IV Axis I Disorders [36] was administered at intake by D.J.C., an experienced psychiatrist with extensive expertise in the area of BDD. All patients fulfilled the DSM-IV diagnostic criteria for BDD or its delusional variant. Level of insight was evaluated according to the score on item 11 of the Yale-Brown Obsessive-Compulsive Scale (YBOCS) modified for BDD [37] (see Section 2.2.6). Participants were considered delusional if they were completely convinced that their perception of their supposed defects was reasonable and unresponsive to contrary evidence (ie, score of 4). Participants who retained some degree of insight were considered nondelusional (ie, score of 3 or less). 2.2.6. BDD Yale-Brown Obsessive-Compulsive Scale The BDD-YBOCS) [37] was used to assess BDD symptom severity. The BDD-YBOCS is a 12-item semistructured clinician-administered instrument designed to assess severity of BDD symptoms during the past week. Ten items assess time occupied by, interference and distress due to, resistance against, and control over both ideational and behavioral BDD symptoms. The score for each item ranges from 0 (no symptoms) to 4 (extreme symptoms). The total score is the sum of items 1 to 10 (range, 0-40), with higher scores indicating more severe BDD. Item 11 was used to assess level of insight, with scores ranging from 0 (excellent insight) to 4 (lacks insight, delusional). In the present study, the reliability coefficient was .93 for the 10-item version. 2.2.7. Clinical Global Impressions Rating Scale The Clinical Global Impressions (CGI) Rating Scale [38] is a 2-item rating scale completed by the treating clinician to indicate global symptom severity (CGI-Severity) and change (CGI-Change). The CGI-Severity rating ranges from 1 (normal) to 7 (extremely ill), whereas the CGI-Change rating ranges from 1 (very much improved) to 9 (very much worse). A score of 1 (very much improved) or 2 (much improved) on the CGI-Change scale indicated response to treatment, whereas a score of less than 4 indicated improvement in BDD symptoms. 2.3. Procedure Patients were treated according to a standardized protocol. The SSRI citalopram was the first-line choice in the
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initial phases but was supplanted by escitalopram when that compound entered the Australian market. If the patient could not tolerate, or did not respond to, citalopram or escitalopram, other SSRIs or the serotonin-norepinephrine reuptake inhibitor venlafaxine was prescribed. An adjunctive atypical antipsychotic (first-line option was quetiapine) was used if the response to the SSRI was suboptimal or if there were clinically significant generalized anxiety symptoms or insomia. Participants met, on average, with the treating psychiatrist on a monthly basis for medication management. The CGIChange scale [38] was administered during the most recent visit. The time between administration at intake and most recent assessment ranged from 1 to 60 months (M = 17.34, SD = 15.70). 2.4. Statistical analysis Stata 10.1 was used to analyze the data. Associations between categorical variables were assessed using χ2 test, whereas Fisher exact test was used when cell frequencies were small. Differences between continuous variables were measured using t tests, whereas differences between ordinal variables were assessed using the Wilcoxon signed-rank test. Analysis of covariance for continuous variables and logistic regression for categorical variables were used to control for BDD-YBOCS score when further examining significant between-group differences. All missing data were excluded on a pairwise or listwise basis for analyses. A P value of .05 was used to determine statistical significance. 3. Results Of the sample, 60% (n = 39) were classified as currently delusional and 40% (n = 26) as nondelusional. As shown in Table 1, delusional and nondelusional patients did not significantly differ on most demographic characteristics, although delusional patients were less likely to be female or to be employed. Table 2 shows that delusional patients had significantly more severe BDD symptoms on the BDD-YBOCS, CGISeverity, and DCQ scales at baseline than those of nondelusional patients. Delusional patients also had significantly more severe BDD at follow-up on the CGISeverity scale and significantly less improvement on the CGI-Change scale. There were no significant differences between delusional and nondelusional patients in relation to the age of BDD onset and duration. Although delusional patients had more severe social anxiety on the SIAS at baseline, this difference was not statistically significant after controlling for baseline BDD severity (F1,57 = 0.31, P = .72). Delusional patients also had more severe depressive symptoms on the SDS, but this difference was not statistically significant after controlling for baseline BDD severity (F1,45 = 0.01, P = .92). Level of insight, as assessed by item 11 of the BDD-YBOCS, was significantly correlated
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Table 1 Demographic characteristics of delusional versus nondelusional BDD patients Variable
Delusional (n = 39)
Nondelusional (n = 26)
χ2 or t test
P
Effect size
Sex (% female) Age (y) Marital status Married/Partnered Divorced Single Not disclosed Employment status Full-time Part-time Students Unemployed Not disclosed
17 (47.2) 30.87 ± 10.83
19 (52.8) 27.62 ± 7.66
χ2 = 5.50 t = 1.33
.02⁎ .19
V = 0.29 d = 0.35
7 (21.0) 3 (7.7) 27 (69.2) 2 (5.1)
3 (11.34) 2 (7.7) 21 (80.8) 0 (0.0)
χ2 = 0.12 χ2 = 0.23 χ2 = 0.56 –
.37 .69 .45 –
V = 0.09 V = 0.00 V = 0.13 –
15 (38.5) 2 (5.1) 4 (10.3) 16 (41.0) 2 (5.1)
12 (46.2) 2 (7.7) 8 (30.8) 4 (15.4) 0 (0.0)
χ2 = 0.13 χ2 = 0.01 χ2 = 3.1 χ2 = 3.69 –
.72 .83 .04⁎ .03⁎ –
V = 0.13 V = 0.05 V = 0.26 V = 0.27 –
Values are presented as mean ± SD or n (%). df for χ2 tests = 1; df for t test = 63; V, Cramer V. ⁎ P b .05.
with baseline CGI-Severity (r = 0.70, P b .001), BDDYBOCS (r = 0.78, P b .001), and DCQ scores (r = 0.37, P b .01). Level of insight was also correlated with the follow-up CGI-Severity score (r = 0.60, P b .001). Table 3 presents current comorbid psychiatric diagnoses for delusional and nondelusional BDD patients. There were no significant differences in comorbidity between the groups. Five (12.8%) delusional and 4 nondelusional (15.4%) patients refused medication. Selective serotonin reuptake inhibitors alone were received by 20 (39.9%) delusional and 14 (53.8%) nondelusional patients; around 60% received citalopram or escitalopram. Augmentation with atypical
antipsychotics (mostly quetiapine) was received by 8 (20.5%) delusional and 5 (19.2%) nondelusional patients. Treatment response rates (as measured by a score of 1 or 2 on the CGI-Change scale) for delusional patients were 30.0% (n = 6) for SSRIs alone and 37.5% (n = 3) for augmented treatment. Nondelusional patients had treatment response rates of 64.3% (n = 9) for SSRIs alone and 80.0% (n = 4) for augmented treatment. Improvement rates (as measured by a score of less than 4 on the CGI-Change scale) for delusional patients were 70.0% (n = 14) for SSRIs alone and 62.5% (n = 5) for augmented treatment. Nondelusional patients had improvement rates of 78.6% (n = 11) for SSRIs alone and 100.0% (n = 5) for augmented treatment.
Table 2 Clinical characteristics of delusional versus nondelusional BDD patients Variable Clinical features Lifetime body areas of concern Age at BDD onset (y) Duration of BDD (y) Social impairment Occupational/academic impairment Avoidance of activities Baseline measures CGI-Severity BDD-YBOCS DCQa SDSb SIASc Follow-up measures CGI-Severity CGI-Change
Delusional (n = 39)
Nondelusional (n = 26)
χ2, t, or z test
df
2.76 ± 1.77 18.56 ± 9.90 12.31 ± 8.99 33 (84.62) 30 (76.92) 32 (82.05)
2.16 ± 1.25 16.76 ± 7.57 10.85 ± 7.81 26 (100.00) 18 (69.23) 25 (96.15)
t = 1.44 t = 0.78 t = 0.67 – χ2 = 5.80 χ2 = 3.74
63 63 63
3.44 ± 1.27 29.05 ± 2.96 17.01 ± 3.09 49.11 ± 6.00 42.84 ± 12.99
2.84 ± 1.64 22.96 ± 8.83 15.16 ± 3.83 45.70 ± 6.20 34.00 ± 14.55
z = 5.15 t = 7.21 t = 2.11 t = 1.91 t = 2.40
63 63 55 46 54
b.00⁎⁎⁎ b.00⁎⁎⁎ .02⁎⁎ .04⁎ .01⁎⁎
d = 0.41 d = 1.78 d = 0.53 d = 0.56 d = 0.64
4.00 ± 1.19 3.44 ± 1.27
2.76 ± .78 2.85 ± 1.64
z = 4.19 z = 2.25
– –
b.00⁎⁎⁎ .02
d = 1.23 d = 0.40
Values are presented as mean ± SD or n (%). t, t test; z, Wilcoxon rank sum test; d, Cohen d; V, Cramer V. a Delusional: n = 32; nondelusional: n = 25. b Delusional: n = 28; nondelusional: n = 20. c Delusional: n = 31; nondelusional: n = 25. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.
P
Effect size .15 .44 .50
– 1 1
.06 .15
d = 0.39 d = 0.85 d = 0.17 – V = 0.30 V = 0.24
S.G. Mancuso et al. / Comprehensive Psychiatry 51 (2010) 177–182 Table 3 Current comorbid disorders in delusional versus nondelusional BDD patients Variable
Delusional Nondelusional χ2 (n = 39) (n = 26)
Mood disorders Major depressive 21 (53.9) disorder Bipolar disorder 1 (2.6) Anxiety disorders Obsessive-compulsive 6 (15.4) disorder Social 22 (57.9) anxiety disorder Generalized 0 (0.0) anxiety disorder Eating disorders Anorexia nervosa 3 (7.7) Bulimia nervosa 1 (2.6) Impulse control disorders Not otherwise 2 (5.1) specified Trichotillomania 3 (7.7)
P
Effect size
8 (30.8)
3.36 .06 V = 0.23
0 (0.0)
–
4 (16.0)
0.00 .61 V = 0.01
9 (36.0)
2.89 .07 V = 0.21
1 (3.9)
–
3 (11.5) 1 (3.9)
0.01 .46 V = 0.07 0.19 .84 V = 0.04
0 (0.0)
–
–
–
0 (0.0)
–
–
–
–
–
–
–
Values are presented as n (%); df = 1; V, Cramer V.
Overall, fewer delusional patients (25.6%) responded to treatment than did nondelusional patients (53.4%), χ2 (1) = 5.33, P ≤ .05, Cramer V = 0.29. This difference remained statistically significant after controlling for both baseline BDD severity and length of follow-up (odds ratio, 0.13; 95% confidence interval, 0.03-0.71; z = 2.36; P b .05). However, there was no significant difference in overall improvement rates between delusional (56.4%) and nondelusional patients (73.1%), χ2 (1) = 1.86, P = .20, Cramer V = 0.17.
4. Discussion The proportion of delusional patients in the present study (60%) is consistent with the rate of 53% reported by Phillips [25] but is higher than the rates of 36% and 38% reported in previous phenomenological research [27,39]. This may represent a sampling bias in that most of the patients in our sample were secondary or tertiary referrals for specialized treatment. The present study also supported previous research [27,39] in finding that delusional BDD patients had more severe BDD symptoms and that poorer insight was associated with more severe BDD symptoms. Similarly, our finding that delusional and nondelusional patients did not differ on most demographics, clinical features, and course of illness is consistent with prior research [27]. Although delusional BDD patients reported significantly higher social interactional anxiety and more severe depressive symptoms at baseline, these differences were no longer significant after controlling for BDD symptom severity. This suggests that the severity of social anxiety and depression of
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delusional patients may be consequent on their BDD symptom severity. In the present study, a similar proportion of delusional and nondelusional patients experienced improvement in their BDD symptom severity, albeit that treatment response was more modest in the delusional group. Our results confirm previous findings that SSRIs can be effective as a solo agent in delusional patients [20,21,24]. The results of the present study must be interpreted within the context of several limitations. Patients were classified as delusional if they were completely convinced that their perception of their supposed defects was reasonable and unresponsive to contrary evidence. In further research, insight of BDD patients could be assessed using a multidimensional measure, such as the Brown Assessment of Beliefs Scale [26] or Overvalued Ideation Scale [40], with empirically derived cut-points to classify patients as delusional. Another limitation is that delusionality was assessed once at the commencement of the present study. Because level of insight can fluctuate during the course of BDD [5] or improve with treatment [23,24], additional research could assess insight in BDD at frequent intervals. Notwithstanding the above limitations, the present findings add further support to the view that the delusional and nondelusional BDD variants constitute the same disorder, characterized by a spectrum of insight, with delusional patients having a more severe form of the disorder [5,25,27]. This has implications for the classification of BDD in future nosologies. Phillips et al [27], in particular, propose a single classification of BDD with a psychotic subtype, rather than delusional BDD patients receiving an additional diagnosis of delusional disorder, somatic type. However, further prospective research is required to elucidate the relationship between delusional and nondelusional BDD with larger samples, more frequent assessment intervals, and dimensional measures of delusionality or overvalued ideation.
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[7] Faravelli C, Salvatori S, Galassi F, Aiazzi L, Drei C, Cabras P. Epidemiology of somatoform disorders: a community survey in Florence. Social Psychiatry and Psychiatric Epidemiology 1997;32 (1):24-9. [8] Rief W, Buhlmann U, Wilhelm S, Borkenhagen ADA, Brähler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychological Medicine 2006;36(06):877-85. [9] Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. Comprehensive Psychiatry 1998;39(5):265-70. [10] Conroy M, Menard W, Fleming-Ives K, Modha P, Cerullo H, Phillips KA. Prevalence and clinical characteristics of body dysmorphic disorder in an adult inpatient setting. General Hospital Psychiatry 2008;30(1):67-72. [11] Phillips KA, Dufresne RG, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. Journal of the American Academy of Dermatology 2000;42(3):436-41. [12] Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plastic and Reconstructive Surgery 1998;101(6):1644-9. [13] Bellino S, Zizza M, Paradiso E, Patria L, Rivarossa A, Fulcheri M, et al. Body dysmorphic disorder and personality disorders: a clinical investigation in patients seeking cosmetic surgery. Italian Journal of Psychopathology 2003;9(2):149-56. [14] Phillips K, Quinn G, Stout R. Functional impairment in body dysmorphic disorder: a prospective, follow-up study. Journal of Psychiatric Research 2008;42(9):701-7. [15] Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry 2003;44(4):270-6. [16] Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder: a survey of fifty cases. British Journal of Psychiatry 1996;169:196-201. [17] Phillips KA, McElroy SL. Personality disorders and traits in patients with body dysmorphic disorder. Comprehensive Psychiatry 2000;41 (4):229-36. [18] Neziroglu F, Khemlani-Patel S. A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums 2002;7 (6):464-71. [19] McKay D, Todaro J, Neziroglu F, Campisi T. Body dysmorphic disorder: a preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy 1997;35:67-70. [20] Phillips KA, Albertini RS, Rasmussen SA. A randomized placebocontrolled trial of fluoxetine in body dysmorphic disorder. Archives of General Psychiatry 2002;59(4):381-8. [21] Phillips KA, Dwight MM, McElroy SL. Efficacy and safety of fluvoxamine in body dysmorphic disorder. The Journal of clinical psychiatry 1998;59(4):165-71. [22] Hollander E, Aronowitz BR. Comorbid social anxiety and body dysmorphic disorder: managing the complicated patient. Journal of Clinical Psychiatry 1999;60(9):27-31. [23] Phillips KA, Najjar F. An open-label study of citalopram in body dysmorphic disorder. Journal of Clinical Psychiatry 2003;64 (6):715-20.
[24] Phillips KA. An open-label study of escitalopram in body dysmorphic disorder. International Clinical Psychopharmacology 2006;21 (3):177-9. [25] Phillips KA. Psychosis in body dysmorphic disorder. Journal of Psychiatric Research 2004;38(1):63-72. [26] Eisen JL, Phillips KA, Baer L, Beer DA, Atala KD, Rasmussen SA. The Brown Assessment of Beliefs Scale: reliability and validity. American Journal of Psychiatry 1998;155(1):102-8. [27] Phillips KA, Menard W, Pagano ME, Fay C, Stout RL. Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness. Journal of Psychiatric Research 2006;40(2): 95-104. [28] Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. revised ed. New York: Oxford University Press; 2005. [29] Phillips KA, Atala KD, Pope HG. Diagnostic instruments for body dysmorphic disorder. New Research Program and Abstracts. American Psychiatric Association 148th Annual Meeting. 1995. [30] Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatologic Surgery 2001;27(5):457-62. [31] Oosthuizen P, Lambert T, Castle DJ. Dysmorphic concern: prevalence and associations with clinical variables. Australian and New Zealand Journal of Psychiatry 1998;32(1):129-32. [32] Stangier U, Janich C, Adam-Schwebe S, Berger P, Wolter M. Screening for body dysmorphic disorder in dermatological outpatients. Dermatology & Psychosomatics 2003;4(2):66-71. [33] Zung WWK. A Self-rating Depression Scale. Archives of General Psychiatry 1965;12:63-70. [34] Mattick RP, Clarke JC. Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy 1998;36(4):455-70. [35] Brown TA, Campbell LA, Lehman CL, Grisham JR, Mancill RB. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology 2001;110(4):585-99. [36] First MB, Spitzer RL, Williams JBW, Gibbon M. Structured clinical interview for DSM-IV. New York: Biometrics Research Department, New York State Psychiatric Institute; 1994. [37] Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR, DeCaria C, Goodman WK. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the YaleBrown Obsessive Compulsive Scale. Psychopharmacology Bulletin 1997;33(1):17-22. [38] Guy W. Clinical Global Impressions (CGI). ECDEU assessment manual for psychopharmacology. revised ed. Rockville, MD: US Department of Health, Education, and Welfare, NIMH; 1976. [39] Eisen JL, Phillips KA, Coles ME, Rasmussen SA. Insight in obsessive compulsive disorder and body dysmorphic disorder. Comprehensive Psychiatry 2004;45(1):10-5. [40] Neziroglu F, McKay D, Yaryura-Tobias JA, Stevens KP, Todaro J. The overvalued ideas scale: development, reliability and validity in obsessive-compulsive disorder. Behaviour Research and Therapy 1999;37(9):881-902.
Comprehensive Psychiatry 51 (2010) 177 – 182 www.elsevier.com/locate/comppsych
Delusional versus nondelusional body dysmorphic disorder Serafino G. Mancusoa,b , Natalie P. Knoesena , David J. Castlea,c,⁎ b
a St Vincent's Mental Health, Melbourne, Australia Swin-PsyCHE Research Unit, Swinburne University of Technology, Melbourne, Australia c Department of Psychiatry, St Vincent's Hospital, Melbourne, Australia
Abstract This study assessed demographic and clinical features in 65 subjects with body dysmorphic disorder (BDD) and compared the 39 (60%) with the delusional form (receiving an additional diagnosis of delusional disorder, somatic type) with those who did not meet delusionality criteria. Delusional and nondelusional patients did not statistically differ on most demographic and clinical variables. Delusional patients, however, had significantly more severe BDD symptoms at both baseline and follow-up assessments than those of nondelusional patients. Furthermore, poorer insight was significantly associated with more severe BDD symptoms at both baseline and follow-up. Overall improvement in BDD symptom severity was similar for the 2 groups. Our results support other studies in the view that BDD and its delusional variant have more similarities than differences and that the delusional variant may be simply a more severe form of BDD. Implications for the diagnostic classification of BDD and future research directions are discussed. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved.
1. Introduction Individuals with body dysmorphic disorder (BDD) are preoccupied with a perceived or minor defect in 1 or more aspects of their appearance [1]. The most common preoccupations concern the hair, nose, and skin, but any body part can be the focus of concern [2,3]. The preoccupations are typically difficult to resist or control and, on average, consume 3 to 8 hours daily [2]. Although not a diagnostic criterion, almost all people with BDD perform compulsive behaviors to examine, improve, or hide their perceived defect [2,3]. Insight into the appearance preoccupations is often impaired such that BDD patients hold their beliefs about the perceived defects with strong conviction [2,4]. Case reports suggest that patients fluctuate between obsessional thoughts, overvalued ideation, and delusionality [5]. Those patients who maintain their beliefs with delusional intensity qualify for an additional diagnosis of delusional disorder, somatic type [1]. Body dysmorphic disorder tends to begin in late adolescence, with the mean age of onset between 16 and 18 years [3]. There are similar prevalence rates for males and ⁎ Corresponding author. St. Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria 3065, Australia. E-mail address: [email protected] (D.J. Castle).
females in adult clinical samples [6]. Studies within the general population have reported prevalence rates ranging from 0.7% [7] to 1.7% [8]. Higher rates have been reported in clinical samples, ranging from 3.2% [9] to 16% [10] in psychiatric settings, 11.9% in dermatologic settings [11], and 7% [12] to 17% [13] in cosmetic surgery settings. Individuals with moderate to severe symptoms tend to follow a deteriorating course and experience BDD for an average of 15 to 16 years [6]. Almost all BDD patients experience impairment in social, occupational, and/or academic functioning because of their appearance concerns [14]. Major depressive disorder, social anxiety disorder, and obsessive-compulsive disorder are often comorbid with BDD [15,16]. Patients with BDD are also often diagnosed with comorbid personality disorders, the most common of which are avoidant, paranoid, and obsessive-compulsive personality disorders [16,17]. Psychological and pharmacological treatments for BDD have received increased attention. Psychological treatment studies have focused on cognitive-behavioral therapy (CBT), whereas pharmacological treatment studies have concentrated on selective serotonin reuptake inhibitors (SSRIs). Cognitive-behavioral therapy approaches comprise cognitive restructuring for maladaptive beliefs about appearance and exposure and response prevention for appearancerelated behaviors [18]. Cognitive interventions incorporating
0010-440X/$ – see front matter. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2009.05.001
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exposure and response prevention seem efficacious in reducing symptom severity and overvalued ideation [19]. Pharmacotherapy trials consistently indicate that SSRIs, including fluoxetine [20], fluvoxamine [21], clomipramine [22], citalopram [23], and escitalopram [24], are often efficacious in treating both delusional and nondelusional variants of BDD. 1.1. Classification According to Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R), BDD is classified as a somatoform disorder and its delusional variant as a psychotic disorder [1]. However, Phillips and McElroy [5] have contended that both delusional and nondelusional variants of BDD may reflect 1 single disorder, with the degree of insight varying along a continuum, ranging from good through poor to absent. Unpublished data [25] using the Brown Assessment of Beliefs Scale [26] in 129 BDD patients highlights this varying degree of insight, with only 0.78% having excellent insight, 3.1% good insight, 12.4% fair insight, 31% poor insight, and 52.7% absent insight (ie, delusional). Phillips et al [4] also compared 52 delusional to 48 nondelusional patients and found that the 2 groups did not differ in relation to demographics, phenomenology, course, comorbidity, and treatment response. Delusional patients, however, had more severe BDD symptoms and greater impairment in occupational or academic functioning than those of nondelusional patients. Comparable results were reported by Phillips et al [27], who found that delusional (n = 68) and nondelusional (n = 123) BDD patients were similar in terms of demographics, clinical characteristics, course of illness, and probability of remitting from BDD. Although delusional patients were found to have more severe symptoms, greater functional impairment, poorer quality of life, higher suicidality, and greater substance abuse than those of nondelusional patients, these differences were accounted for by their more severe BDD symptoms. These data taken together suggest that although insight in BDD is often impaired, BDD and its delusional variant have many more similarities than differences. However, there remains debate about the delusional and nondelusional classification of BDD. We present here a naturalistic study of an Australian sample of BDD patients and compare demographics, clinical features, and treatment response between patients classified as delusional and nondelusional. We hypothesized that delusional patients would differ from nondelusional ones in terms of symptom severity but that, overall, there would be more similarities than differences between the groups.
evaluation and treatment of people with BDD. Treatment is free and comprises a standardized pharmacological approach (see Section 2.3), standardized psychoeducation (which includes written information about the nature of BDD and the fundamentals of CBT for BDD), and on-referral to a clinical psychologist for more intensive CBT when required. 2.1. Participants Of the 72 eligible BDD patients, 7 refused to participate or did not attend follow-up appointments; thus, we here report on 65 patients. Referral sources comprised selfreferrals, general practitioners, psychiatrists, psychologists, cosmetic surgeons, and various medical specialists. Participants provided written informed consent to participate in a phenomenological study, which was later amended to include treatment data. The phenomenological study was approved by the University of Melbourne Human Research Ethics Committee (Project 040629X) as was the amendment to obtain treatment data (Project 040629X.2). 2.2. Measures 2.2.1. Body Dysmorphic Disorder Questionnaire The Body Dysmorphic Disorder Questionnaire [28] is a 10-item self-report measure that screens for BDD. For BDD diagnosis, the Body Dysmorphic Disorder Questionnaire has been shown to have a sensitivity of 100% and a specificity of 89% in an outpatient psychiatric setting [29] and a sensitivity of 100% and a specificity of 93% in a dermatologic setting [30]. Items 7, 8, and 9 were used to assess social impairment, occupational impairment, and avoidance, respectively. 2.2.2. Dysmorphic Concern Questionnaire The Dysmorphic Concern Questionnaire (DCQ) [31] is a 7-item self-report measure that assesses cognitive and behavioral symptoms of overconcern with an imagined or slight physical defect. The score for each item ranges from 0 (not at all) to 3 (much more than most people). The DCQ is scored by summing all items, with a score of 11 and above indicative of probable BDD. A cutoff score of 11 has been shown to have a sensitivity of 100% and a specificity of 79% in a dermatologic outpatient setting [32]. In the present study, the reliability coefficient (Cronbach α) was .73. 2.2.3. Self-rating Depression Scale The Self-rating Depression Scale (SDS) [33] is a 20-item self-report measure that assesses cognitive, behavioral, affective, and somatic symptoms of depression on a 4-point scale, from 1 (a little of the time) to 4 (most of the time). The SDS is scored by summing all the items, with total raw scores ranging from 20 to 80. In the present study, the reliability coefficient was .78.
2. Method Potential participants were all consecutive BDD patients seen at the St Vincent's Health Body Image Disorder Service, a statewide outpatient service specializing in the
2.2.4. Social Interaction Anxiety Scale The Social Interaction Anxiety Scale (SIAS) [34] is a 20-item self-report scale that measures cognitive, behavioral, and affective aspects of social anxiety as experienced in
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social interactions in dyads or groups. Items are rated on a 5-point scale, from 0 (not at all characteristic or true of me) to 4 (extremely characteristic or true of me). The SIAS is scored by summing the ratings and total scores ranging from 0 to 80. Higher scores represent higher levels of social interactional anxiety. The SIAS discriminates between clinical and nonclinical samples and between patients with social anxiety and those with other anxiety disorders [35]. In the present study, the reliability coefficient was .92. 2.2.5. Diagnostic interview A diagnostic interview using the Structured Clinical Interview for DSM-IV Axis I Disorders [36] was administered at intake by D.J.C., an experienced psychiatrist with extensive expertise in the area of BDD. All patients fulfilled the DSM-IV diagnostic criteria for BDD or its delusional variant. Level of insight was evaluated according to the score on item 11 of the Yale-Brown Obsessive-Compulsive Scale (YBOCS) modified for BDD [37] (see Section 2.2.6). Participants were considered delusional if they were completely convinced that their perception of their supposed defects was reasonable and unresponsive to contrary evidence (ie, score of 4). Participants who retained some degree of insight were considered nondelusional (ie, score of 3 or less). 2.2.6. BDD Yale-Brown Obsessive-Compulsive Scale The BDD-YBOCS) [37] was used to assess BDD symptom severity. The BDD-YBOCS is a 12-item semistructured clinician-administered instrument designed to assess severity of BDD symptoms during the past week. Ten items assess time occupied by, interference and distress due to, resistance against, and control over both ideational and behavioral BDD symptoms. The score for each item ranges from 0 (no symptoms) to 4 (extreme symptoms). The total score is the sum of items 1 to 10 (range, 0-40), with higher scores indicating more severe BDD. Item 11 was used to assess level of insight, with scores ranging from 0 (excellent insight) to 4 (lacks insight, delusional). In the present study, the reliability coefficient was .93 for the 10-item version. 2.2.7. Clinical Global Impressions Rating Scale The Clinical Global Impressions (CGI) Rating Scale [38] is a 2-item rating scale completed by the treating clinician to indicate global symptom severity (CGI-Severity) and change (CGI-Change). The CGI-Severity rating ranges from 1 (normal) to 7 (extremely ill), whereas the CGI-Change rating ranges from 1 (very much improved) to 9 (very much worse). A score of 1 (very much improved) or 2 (much improved) on the CGI-Change scale indicated response to treatment, whereas a score of less than 4 indicated improvement in BDD symptoms. 2.3. Procedure Patients were treated according to a standardized protocol. The SSRI citalopram was the first-line choice in the
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initial phases but was supplanted by escitalopram when that compound entered the Australian market. If the patient could not tolerate, or did not respond to, citalopram or escitalopram, other SSRIs or the serotonin-norepinephrine reuptake inhibitor venlafaxine was prescribed. An adjunctive atypical antipsychotic (first-line option was quetiapine) was used if the response to the SSRI was suboptimal or if there were clinically significant generalized anxiety symptoms or insomia. Participants met, on average, with the treating psychiatrist on a monthly basis for medication management. The CGIChange scale [38] was administered during the most recent visit. The time between administration at intake and most recent assessment ranged from 1 to 60 months (M = 17.34, SD = 15.70). 2.4. Statistical analysis Stata 10.1 was used to analyze the data. Associations between categorical variables were assessed using χ2 test, whereas Fisher exact test was used when cell frequencies were small. Differences between continuous variables were measured using t tests, whereas differences between ordinal variables were assessed using the Wilcoxon signed-rank test. Analysis of covariance for continuous variables and logistic regression for categorical variables were used to control for BDD-YBOCS score when further examining significant between-group differences. All missing data were excluded on a pairwise or listwise basis for analyses. A P value of .05 was used to determine statistical significance. 3. Results Of the sample, 60% (n = 39) were classified as currently delusional and 40% (n = 26) as nondelusional. As shown in Table 1, delusional and nondelusional patients did not significantly differ on most demographic characteristics, although delusional patients were less likely to be female or to be employed. Table 2 shows that delusional patients had significantly more severe BDD symptoms on the BDD-YBOCS, CGISeverity, and DCQ scales at baseline than those of nondelusional patients. Delusional patients also had significantly more severe BDD at follow-up on the CGISeverity scale and significantly less improvement on the CGI-Change scale. There were no significant differences between delusional and nondelusional patients in relation to the age of BDD onset and duration. Although delusional patients had more severe social anxiety on the SIAS at baseline, this difference was not statistically significant after controlling for baseline BDD severity (F1,57 = 0.31, P = .72). Delusional patients also had more severe depressive symptoms on the SDS, but this difference was not statistically significant after controlling for baseline BDD severity (F1,45 = 0.01, P = .92). Level of insight, as assessed by item 11 of the BDD-YBOCS, was significantly correlated
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Table 1 Demographic characteristics of delusional versus nondelusional BDD patients Variable
Delusional (n = 39)
Nondelusional (n = 26)
χ2 or t test
P
Effect size
Sex (% female) Age (y) Marital status Married/Partnered Divorced Single Not disclosed Employment status Full-time Part-time Students Unemployed Not disclosed
17 (47.2) 30.87 ± 10.83
19 (52.8) 27.62 ± 7.66
χ2 = 5.50 t = 1.33
.02⁎ .19
V = 0.29 d = 0.35
7 (21.0) 3 (7.7) 27 (69.2) 2 (5.1)
3 (11.34) 2 (7.7) 21 (80.8) 0 (0.0)
χ2 = 0.12 χ2 = 0.23 χ2 = 0.56 –
.37 .69 .45 –
V = 0.09 V = 0.00 V = 0.13 –
15 (38.5) 2 (5.1) 4 (10.3) 16 (41.0) 2 (5.1)
12 (46.2) 2 (7.7) 8 (30.8) 4 (15.4) 0 (0.0)
χ2 = 0.13 χ2 = 0.01 χ2 = 3.1 χ2 = 3.69 –
.72 .83 .04⁎ .03⁎ –
V = 0.13 V = 0.05 V = 0.26 V = 0.27 –
Values are presented as mean ± SD or n (%). df for χ2 tests = 1; df for t test = 63; V, Cramer V. ⁎ P b .05.
with baseline CGI-Severity (r = 0.70, P b .001), BDDYBOCS (r = 0.78, P b .001), and DCQ scores (r = 0.37, P b .01). Level of insight was also correlated with the follow-up CGI-Severity score (r = 0.60, P b .001). Table 3 presents current comorbid psychiatric diagnoses for delusional and nondelusional BDD patients. There were no significant differences in comorbidity between the groups. Five (12.8%) delusional and 4 nondelusional (15.4%) patients refused medication. Selective serotonin reuptake inhibitors alone were received by 20 (39.9%) delusional and 14 (53.8%) nondelusional patients; around 60% received citalopram or escitalopram. Augmentation with atypical
antipsychotics (mostly quetiapine) was received by 8 (20.5%) delusional and 5 (19.2%) nondelusional patients. Treatment response rates (as measured by a score of 1 or 2 on the CGI-Change scale) for delusional patients were 30.0% (n = 6) for SSRIs alone and 37.5% (n = 3) for augmented treatment. Nondelusional patients had treatment response rates of 64.3% (n = 9) for SSRIs alone and 80.0% (n = 4) for augmented treatment. Improvement rates (as measured by a score of less than 4 on the CGI-Change scale) for delusional patients were 70.0% (n = 14) for SSRIs alone and 62.5% (n = 5) for augmented treatment. Nondelusional patients had improvement rates of 78.6% (n = 11) for SSRIs alone and 100.0% (n = 5) for augmented treatment.
Table 2 Clinical characteristics of delusional versus nondelusional BDD patients Variable Clinical features Lifetime body areas of concern Age at BDD onset (y) Duration of BDD (y) Social impairment Occupational/academic impairment Avoidance of activities Baseline measures CGI-Severity BDD-YBOCS DCQa SDSb SIASc Follow-up measures CGI-Severity CGI-Change
Delusional (n = 39)
Nondelusional (n = 26)
χ2, t, or z test
df
2.76 ± 1.77 18.56 ± 9.90 12.31 ± 8.99 33 (84.62) 30 (76.92) 32 (82.05)
2.16 ± 1.25 16.76 ± 7.57 10.85 ± 7.81 26 (100.00) 18 (69.23) 25 (96.15)
t = 1.44 t = 0.78 t = 0.67 – χ2 = 5.80 χ2 = 3.74
63 63 63
3.44 ± 1.27 29.05 ± 2.96 17.01 ± 3.09 49.11 ± 6.00 42.84 ± 12.99
2.84 ± 1.64 22.96 ± 8.83 15.16 ± 3.83 45.70 ± 6.20 34.00 ± 14.55
z = 5.15 t = 7.21 t = 2.11 t = 1.91 t = 2.40
63 63 55 46 54
b.00⁎⁎⁎ b.00⁎⁎⁎ .02⁎⁎ .04⁎ .01⁎⁎
d = 0.41 d = 1.78 d = 0.53 d = 0.56 d = 0.64
4.00 ± 1.19 3.44 ± 1.27
2.76 ± .78 2.85 ± 1.64
z = 4.19 z = 2.25
– –
b.00⁎⁎⁎ .02
d = 1.23 d = 0.40
Values are presented as mean ± SD or n (%). t, t test; z, Wilcoxon rank sum test; d, Cohen d; V, Cramer V. a Delusional: n = 32; nondelusional: n = 25. b Delusional: n = 28; nondelusional: n = 20. c Delusional: n = 31; nondelusional: n = 25. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.
P
Effect size .15 .44 .50
– 1 1
.06 .15
d = 0.39 d = 0.85 d = 0.17 – V = 0.30 V = 0.24
S.G. Mancuso et al. / Comprehensive Psychiatry 51 (2010) 177–182 Table 3 Current comorbid disorders in delusional versus nondelusional BDD patients Variable
Delusional Nondelusional χ2 (n = 39) (n = 26)
Mood disorders Major depressive 21 (53.9) disorder Bipolar disorder 1 (2.6) Anxiety disorders Obsessive-compulsive 6 (15.4) disorder Social 22 (57.9) anxiety disorder Generalized 0 (0.0) anxiety disorder Eating disorders Anorexia nervosa 3 (7.7) Bulimia nervosa 1 (2.6) Impulse control disorders Not otherwise 2 (5.1) specified Trichotillomania 3 (7.7)
P
Effect size
8 (30.8)
3.36 .06 V = 0.23
0 (0.0)
–
4 (16.0)
0.00 .61 V = 0.01
9 (36.0)
2.89 .07 V = 0.21
1 (3.9)
–
3 (11.5) 1 (3.9)
0.01 .46 V = 0.07 0.19 .84 V = 0.04
0 (0.0)
–
–
–
0 (0.0)
–
–
–
–
–
–
–
Values are presented as n (%); df = 1; V, Cramer V.
Overall, fewer delusional patients (25.6%) responded to treatment than did nondelusional patients (53.4%), χ2 (1) = 5.33, P ≤ .05, Cramer V = 0.29. This difference remained statistically significant after controlling for both baseline BDD severity and length of follow-up (odds ratio, 0.13; 95% confidence interval, 0.03-0.71; z = 2.36; P b .05). However, there was no significant difference in overall improvement rates between delusional (56.4%) and nondelusional patients (73.1%), χ2 (1) = 1.86, P = .20, Cramer V = 0.17.
4. Discussion The proportion of delusional patients in the present study (60%) is consistent with the rate of 53% reported by Phillips [25] but is higher than the rates of 36% and 38% reported in previous phenomenological research [27,39]. This may represent a sampling bias in that most of the patients in our sample were secondary or tertiary referrals for specialized treatment. The present study also supported previous research [27,39] in finding that delusional BDD patients had more severe BDD symptoms and that poorer insight was associated with more severe BDD symptoms. Similarly, our finding that delusional and nondelusional patients did not differ on most demographics, clinical features, and course of illness is consistent with prior research [27]. Although delusional BDD patients reported significantly higher social interactional anxiety and more severe depressive symptoms at baseline, these differences were no longer significant after controlling for BDD symptom severity. This suggests that the severity of social anxiety and depression of
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delusional patients may be consequent on their BDD symptom severity. In the present study, a similar proportion of delusional and nondelusional patients experienced improvement in their BDD symptom severity, albeit that treatment response was more modest in the delusional group. Our results confirm previous findings that SSRIs can be effective as a solo agent in delusional patients [20,21,24]. The results of the present study must be interpreted within the context of several limitations. Patients were classified as delusional if they were completely convinced that their perception of their supposed defects was reasonable and unresponsive to contrary evidence. In further research, insight of BDD patients could be assessed using a multidimensional measure, such as the Brown Assessment of Beliefs Scale [26] or Overvalued Ideation Scale [40], with empirically derived cut-points to classify patients as delusional. Another limitation is that delusionality was assessed once at the commencement of the present study. Because level of insight can fluctuate during the course of BDD [5] or improve with treatment [23,24], additional research could assess insight in BDD at frequent intervals. Notwithstanding the above limitations, the present findings add further support to the view that the delusional and nondelusional BDD variants constitute the same disorder, characterized by a spectrum of insight, with delusional patients having a more severe form of the disorder [5,25,27]. This has implications for the classification of BDD in future nosologies. Phillips et al [27], in particular, propose a single classification of BDD with a psychotic subtype, rather than delusional BDD patients receiving an additional diagnosis of delusional disorder, somatic type. However, further prospective research is required to elucidate the relationship between delusional and nondelusional BDD with larger samples, more frequent assessment intervals, and dimensional measures of delusionality or overvalued ideation.
References [1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: Author; 2000. [2] Phillips KA, McElroy SL, Keck Jr PE, Pope Jr HG, Hudson JI. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993;150(2):302-8. [3] Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics: Journal of Consultation Liaison Psychiatry 2005 07;46(4):317-25. [4] Phillips KA, McElroy SL, Keck PE, Hudson JI, Pope HG. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacology Bulletin 1994;30(2):179-86. [5] Phillips KA, McElroy SL. Insight, overvalued ideation, and delusional thinking in body dysmorphic disorder: theoretical and treatment implications. Journal of Nervous and Mental Disease 1993;181 (11):699-702. [6] Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. Journal of Nervous and Mental Disease 1997;185(9):570-7.
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