Classification

A clinically important classification controversy is whether delusional and non-delusional BDD are the same or different disorders. Whereas BDD is classified as a somatoform disorder, its delusional variant is classified as a type of delusional disorder (formerly known as monosymptomatic hypochondriacal psychosis). DSM-IV, however, allows delusional patients to be diagnosed with both BDD and delusional disorder. This reflects the available data suggesting that the non-delusional and delusional variants may actually constitute the same disorder, which spans a spectrum of insight. Indeed, there appear to be more similarities than differences between delusional and non-delusional BDD, although the delusional variant appears to be more severe. (U> An important, although preliminary, finding is that delusional as well as non-delusional patients appear to respond to serotonin reuptake inhibitors ( SRIs) but not to antipsychotic drugs alone.

Another interesting and clinically relevant classification controversy is whether BDD is related to, or a form of, another psychiatric disorder. BDD has many similarities to obsessive-compulsive disorder (e.g. prominent obsessions and compulsive behaviours), social phobia (e.g. prominent social anxiety, shame, and rejection sensitivity), major depression (e.g. frequent depressive symptoms), and eating disorders (e.g. disturbed body image). Indeed, BDD appears more similar to these disorders than to some of the somatoform disorders with which it is classified. Few studies, however, have directly compared BDD to another disorder. In a study that compared BDD and obsessive- compulsive disorder/1,6,' there were many similarities (e.g. sex ratio, course of illness) but also some differences (e.g. poorer insight and a higher rate of major depression, social phobia, and suicide attempts in BDD patients). In a comparison study of BDD and eating disorders, (.!7> BDD subjects had more diverse appearance concerns and reported more negative self-evaluation and avoidance due to these concerns, although the two groups had equally severe body-image symptoms overall. Although ICD-10 classifies BDD as a type of hypochondriasis, no studies comparing BDD and hypochondriasis have been performed. In the absence of such data, the relationship between these disorders remains unclear and speculative.

The paucity of comparison studies between BDD and other disorders limits conclusions that can be drawn about their relationship. Also complicating this issue is the likelihood that BDD is a heterogeneous disorder. The most important limitation is the lack of information on BDD's (and other disorders') aetiology and pathophysiology. In the absence of such data we must look to imperfect clues, such as similarities and differences between BDD and other disorders in the domains shown in Table— More definitive conclusions about BDD's relationship to other disorders awaits further (e.g. neurobiological) studies that clarify its causes.

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Table 2 Strength of evidence for the hypothesis that BDD is related to other disordersa

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