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Section 16
The Delusionality Controversy in Body Dysmorphic Disorder

Question 16 | Test | Table of Contents

Another controversial unanswered question is whether BDD and its delusional variant are the same or different disorders. BDD is classified in DSM-IV as a somatoform disorder (in which insight is present), whereas its delusional variant is classified as a psychotic disorder (delusional disorder, somatic type). Although classified separately, clinical observations (Phillips &; McElroy, 1993) and available data (Phillips et al., 1994) suggest they are the same disorder, with the delusional variant a more severe form. Indeed, in DSM-IV, delusional and nondelusional BDD may be double coded, so delusional patients receive both diagnoses, reflecting the likelihood that they are the same disorder. This approach views delusionality as a dimensional construct, with insight occurring on a continuum and sometimes changing.  In a study that examined similarities and differences between delusional and nondelusional patients, there were more similarities than differences (Phillips et al., 1994). The two groups were similar in terms of demographics, phenomenology, retrospectively assessed course, associated features, and comorbidity. However, delusional patients appear to have a more severe form of the illness. Delusional patients had higher BDD severity scores, and were more impaired in work/academic functioning (Phillips et al., 1994). Delusional patients are also more likely to avoid occupational/academic and social activities, be housebound, have suicidal ideation, attempt suicide, and be hospitalized due to BDD (Phillips, unpublished data). Consistent with these findings, delusional subjects have higher levels of perceived stress (DeMarco et al., 1998) and poorer quality of life (Phillips, 1999).  

BDD in children and adolescents
Appearance concerns are very common during adolescence, raising the question of whether BDD can be diagnosed in this age group. The diagnosis can be made in this age group, and, in fact, BDD usually begins during adolescence and can begin during childhood. In a series of 188 subjects (Phillips & Diaz, 1997), mean age of BDD onset was 16.0 +/-7.2 years, with a range of 4-43 years and a mode of 13. BDD began before age 18 in 70% of cases.

Reported cases in children and adolescents suggest that the disorder's clinical features in this age group are generally similar to those in adults (Hay, 1970; Phillips, Atala, & Albertini, 1995; Sondheimer, 1988). In the largest series in children and adolescents (N = 33; Albertini 8c Phillips, 1999), bodily preoccupations most often focused on the skin (61%) and hair (55%). All subjects had associated compulsive behaviors, most often camouflaging (e.g., with clothing) in 94%, comparing with others (87%), and mirror checking (85%). All subjects reported significant distress over their perceived defect, with 25% reporting moderate distress, 61% severe distress, and 11% extreme and disabling distress. As several subjects stated, "I'm tormented by my looks" and "My life is like hell on earth." Most subjects (68%) spent more than 3 hours a day thinking about their defect, and some said it was virtually all they thought about.

Ninety-four percent of the children and adolescents in this series reported impairment in social functioning, and 85% reported impairments in academic or job functioning due to BDD. Eighteen percent had dropped out of elementary school or high school because of BDD symptoms. Thirty-nine percent had been psychiatrically hospitalized, and 21% had attempted suicide. These findings indicate that BDD can cause considerable morbidity in children and adolescents and does not simply consist of normal appearance concerns. As in adults, to diagnose BDD in children and adolescents, it is often necessary to specifically inquire about BDD symptoms (asking, for example, "Is there some aspect/part of your appearance that you're really unhappy about?"), because symptoms typically are not divulged due to embarrassment and shame. If it is unclear whether appearance concerns qualify for BDD in an adolescent, it may be helpful to emphasize the impairment criterion: If the appearance concerns interfere with normal functioning, the concerns are abnormal and would point toward the diagnosis of BDD.

Cognitive-behavioral therapy
Preliminary data suggest that CBT may be effective for BDD. Cognitive restructuring, exposure (e.g., to social situations), and response prevention (avoiding compulsive behaviors, such as mirror checking) appear effective for a majority of patients (Marks & Mishan, 1988; Rosen, Reiter, &; Orosan, 1995; Veale, Gournay, et al., 1996; Wilhelm, Otto, Lohr, &; Deckersback, 1999). Of interest are recent data suggesting that exposure and response prevention alone may not be effective for BDD (Campisi, personal communication, 1995), perhaps due to the poor insight and depression characteristic of this disorder--characteristics that also predict poor response to CBT in OCD (Foa, 1979). Another study, however, found that exposure and response prevention alone was effective (McKay et al., 1997). Whether cognitive restructuring is a necessary component of treatment remains unclear.

Available data on CBT, while promising, are from clinical series and studies using wait-list controls. Well-controlled studies have not yet been published. Clinically relevant questions that need to be empirically addressed are the following: (1) Is CBT alone effective for severely depressed, suicidal, and delusional patients? (2) Is a cognitive component necessary? (3) For how long are gains maintained? (4) Are booster sessions needed? (5) What is the minimum number of sessions and frequency required? In published studies, the frequency and length of treatment sessions has ranged from 12 weekly 90-minnte sessions (Wilhelm et al., 1999) to 90-minute sessions up to 5 days a week, with up to 48 total sessions (Neziroglu & Yaryura-Tobias, 1993). In clinical settings, however, far fewer sessions may be available to patients because of insurance limitations; is less treatment (e.g., five sessions at monthly intervals) effective?

On the basis of available data and clinical experience, the following approach is recommended:
Consider using CBT as a first-line approach for mild BDD without significant comorbidity requiring pharmacotherapy.

For severe BDD (especially very depressed or suicidal patients), use CBT only in combination with medication, as sicker patients may not be able to tolerate or participate in CBT and occasionally can become more suicidal; partial response to medication can make CBT possible.
Use more intensive treatment (e.g., frequent sessions, homework) rather than less intensive treatment.
Use a cognitive component in addition to exposure and response prevention.
Consider maintenance/booster sessions for patients with more severe BDD following treatment to prevent relapse.

The challenge of getting patients into treatment
Although many patients with BDD welcome psychiatric treatment, some are reluctant. Some patients prefer to receive surgical, dermatological, and other nonpsychiatric treatment (e.g., electrolysis, hair clubs), which is usually ineffective and may even result in increased appearance concerns (Andreasen & Bardach, 1977; Phillips, 1996a). Noncompliance with psychiatric treatment can occur because of patients' poor insight and reluctance to be seen by other people (including their treater), which can lead to missed sessions or dropping out of treatment.
The following suggestions may convince the reluctant patient to accept psychiatric treatment:
Educate the patient about BDD: Explain that he or she has a body image problem (BDD) that often responds to psychiatric treatment. Providing the patient with reading materials for the layperson (Phillips, 1996a; Phillips, Van Noppen, Sc Shapiro, 1997) may be helpful.

Focus on the potential for psychiatric treatment to decrease preoccupation and suffering and to improve functioning; trying to convince delusional patients that their beliefs are irrational or that they look normal is unlikely to persuade them to accept psychiatric treatment.

Involve family members if potentially helpful and clinically appropriate. Families can be an invaluable support and can facilitate treatment; they can be educated, for example, to avoid participating in BDD rituals (such as reassurance seeking or grooming rituals).

With the patient's consent, it can be helpful to interface with dermatologists, plastic surgeons, and other nonpsychiatric clinicians from whom patients have requested or are receiving treatment, informing them about the potential benefits of psychiatric treatment and concerns about the potential outcome of nonpsychiatric treatment.

Some patients (e.g., skin pickers) benefit from a combination of psychiatric treatment (to stop the picking) and dermatological treatment (to repair skin damage due to picking). The treating dermatologist may be helpful in getting patients to accept psychiatric treatment.
- Phillips, Katharine A., Body dysmorphic disorder: Diagnostic controversies and treatment challenges; Bulletin of the Menninger Clinic, 00259284, Winter2000, Vol. 64, Issue 1

Understanding Body Dysmorphic Disorder (BDD)

- Mind for better mental health. (2016). Understanding body dysmorphic disorder (BDD). National Association for Mental Health.

Personal Reflection Exercise #2
The preceding section contained information regarding the delusionality controversy in Body Dysmorphic Disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview—Revised: Development, reliability, and validity. Psychological Assessment, 32(7), 677–689.

Gittus, M., Fuller-Tyszkiewicz, M., Brown, H. E., Richardson, B., Fassnacht, D. B., Lennard, G. R., Holland, E., & Krug, I. (2020). Are Fitbits implicated in body image concerns and disordered eating in women? Health Psychology, 39(10), 900–904.

Hitti, S. A., Avila, M., McDonald, S. E., Romo, S., Benzel, G. K., Hernandez, R. E., Vazquez, G., Sullivan, T. N., & Corona, R. (2020). The relation between body image perceptions, parental messages, and depressive symptoms among Latinx college students. Cultural Diversity and Ethnic Minority Psychology, 26(3), 412–418.

QUESTION 16
According to the DSM, what are the two subtypes of BDD, and how do their classifications lend to controversy over whether both subtypes are in fact the same disorder? To select and enter your answer go to Test.

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