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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social activities, be housebound, have suicidal ideation, attempt suicide, and be hospitalized due to BDD (Phillips, unpublished data).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
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.
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:
The challenge of getting patients into treatment
Reflection Exercise #2
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