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

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.

Body Dysmorphic Disorder: Clinical Aspects and Relationship to Obsessive-Compulsive Disorder

“…The new insight specifier conveys several clinically relevant points (10). First, individuals who are completely convinced that their BDD belief is true-that they truly are ugly, deformed, or abnormal looking-should be diagnosed with "BDD with absent insight/delusional beliefs" rather than a psychotic disorder (this point was unclear in prior editions of DSM).…”

Body Dysmorphic Disorder: Common, Severe and in Need of Treatment Research

“…Levels of insight in DSM-5 are ‘with good or fair insight', ‘with poor insight', and ‘with absent insight/delusional beliefs'. This new insight specifier in DSM-5 is important for several reasons [7]: (i) it clarifies that individuals who are completely convinced that their BDD belief is true should be diagnosed with ‘BDD with absent insight/delusional beliefs' rather than a psychotic disorder; (ii) it implies that delusional and nondelusional BDD should be treated similarly - indeed, studies indicate that both delusional and nondelusional BDD respond to serotonin reuptake inhibitor (SRI) monotherapy and to cognitive-behavioral therapy (CBT), and (iii) specifying the level of insight allows the identification of patients with poorer insight, who may be more reluctant to accept the idea that they have a mental disorder (BDD) rather than actual physical deformities. Such patients may need more motivational interviewing and attention to the therapeutic alliance in order to engage and retain them in mental health treatment.…”

Hypochondriasis: considerations for ICD-11

“…Although most of the relevant literature is based on patients with delusional and nondelusional body dysmorphic disorder, hypochondriasis and body dysmorphic disorder are more similar than different in this regard, including in their response to pharmacological treatment. 30 Thus, one might expect the same issues to arise in hypochondriasis.…”