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.
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] and [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] and [3].
Insight into the appearance preoccupations is often impaired such that BDD patients hold their beliefs about the perceived defects with strong conviction [2] and [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 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] and [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] and [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 appearance-related behaviors [18]. Cognitive interventions incorporating 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.
