Classification of body dysmorphic disorder — What is the advantage of the new DSM-5 criteria?

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Highlights

  • We report the prevalence rates of BDD (DSM-5) in a large general population sample.

  • The impact of the new BDD criteria was also evaluated.

  • The new criteria do not appear to considerably affect the BDD case identification.

  • The new B-criterion reflects more precisely the clinical symptoms of BDD.

Abstract

Objective

In DSM-5 the diagnosis of body dysmorphic disorder (BDD) has been subjected to two important changes: Firstly, BDD has been assigned to the category of obsessive–compulsive and related disorders. Secondly, a new criterion has been defined requiring the presence of repetitive behaviors or mental acts in response to appearance concerns. The aims of this study were to report the prevalence rates of BDD based on a DSM-5 diagnosis, and to evaluate the impact of the recently introduced DSM-5 criteria for BDD by comparing the prevalence rates (DSM-5 vs. DSM-IV).

Methods

BDD-criteria (DSM-IV/DSM-5), dysmorphic concerns, and depressive symptoms, were assessed in a representative sample of the German general population (N = 2129, aged 18–65 years).

Results

The association between BDD case identification based on DSM-IV and DSM-5 was strong (Phi = .95, p < .001), although point prevalence of BDD according to DSM-5 was slightly lower (2.9%, n = 62 vs. 3.2%, n = 68). Approximately one third of the identified BDD (DSM-5) cases reported time-consuming behavioral acts in response to appearance concerns. In detail, 0.8% of the German general population fulfilled the BDD criteria and reported repetitive acts of at least one hour/day.

Conclusions

The revised criteria of BDD in DSM-5 do not seem to have an impact on prevalence rates. However, the recently added B-criterion reflects more precisely the clinical symptoms of BDD, and may be useful for distinguishing between various severity levels related to repetitive behaviors/mental acts.

Introduction

Body dysmorphic disorder (BDD) is characterized by a severe preoccupation with a defect in physical appearance that is objectively slight or may even be unobservable, resulting in distress and impairment in social and/or occupational functioning [1]. Two epidemiological surveys among the German general population revealed a point prevalence of 1.7–1.8% [2], [3], and a prevalence rate of 2.4% was found among the general population of the United States of America [4].

BDD was first included in DSM-III as an example of an atypical somatoform disorder called “dysmorphophobia” [5]. In the course of subsequent DSM-editions, BDD was classified in the somatoform section as a self-contained disorder. In DSM-IV (and DSM-IV-TR) the BDD diagnosis was based on three criteria [6], [7]: preoccupation with appearance, distress and impairment, and appearance concerns that are not better accounted for by any other mental disorder. The recently published DSM-5 has experienced two important changes concerning the classification of BDD [8]: a relocation of the diagnosis and an extension of the diagnostic criteria. In DSM-5, BDD is now classified under the new category “obsessive–compulsive and related disorders”, along with obsessive–compulsive disorder, trichotillomania, hoarding disorder, and excoriation disorder. In addition, a new criterion has been defined requiring that “at some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking), or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns” (p. 242, DSM-5 [8]). Furthermore, a specifier for muscle dysmorphia was added as well as a specifier that indicates the degree of insight regarding BDD beliefs. Apart from that, some minor revisions have been made such as more precise phrasing and changes in the wording.

The classification of BDD as a somatoform disorder has often been questioned and similarities between BDD and obsessive–compulsive disorder, social phobia, eating disorders, and affective disorders, have been discussed. Most research has focused on the relationship between BDD and obsessive–compulsive disorder, with empirical evidence underpinning the inclusion of BDD among the obsessive–compulsive and related disorders [9], [10], [11], [12], [13]. The high comorbidity between BDD and obsessive–compulsive disorder [10], [14], [15] as well as similar characteristics [16], [17] such as repetitive thoughts and behaviors, an early onset and a chronic course of the disease [18], [19], shared genetic factors [20], and neurobiological features [21], [22], indicate that BDD and obsessive–compulsive disorder are related disorders. Because of these similarities, classification of BDD among the obsessive–compulsive and related disorders has been widely supported [9]. Nonetheless, BDD and obsessive–compulsive disorder represent distinct disorders [23], [24], [25] and therefore merit independent diagnoses.

The new DSM-5 criterion for a BDD diagnosis, which requires the presence of repetitive behaviors or mental acts (at some point during the course of the disorder), reflects the likely relatedness of BDD to obsessive–compulsive and related disorders [11] and may help to differentiate BDD from other disorders such as major depression or social phobia [11]. Furthermore, repetitive behaviors and thoughts are considered to be key aspects of the clinical picture of BDD. For example, grooming, camouflaging, and mirror checking, are common acts [15] performed by individuals with BDD, with the aim to correct, hide, or distract from perceived defective body parts. Focusing on unattractive body parts, rumination, mental rituals or other mental acts are also often reported by individuals with BDD [15], [26]. They suffer from these symptoms as they are time-consuming and can last several hours or the entire day [27]. However, BDD prevalence has not yet been established using the newly added criterion requiring repetitive behaviors and cognitive processes.

Some diagnostic concepts and assessment procedures [2], [28], [29] suggested the use of a time-criterion to differ between degrees of BDD severity. The Structured Clinical Interview for DSM-IV [29] adds a time-requirement to BDD criterion A and specifies that preoccupation with appearance should last for at least one hour/day. The same procedure was used in a German general population survey [2]. However, the Yale-Brown Obsessive–Compulsive Scale, modified for BDD [28], proposed degrees of severity based on the average time an individual is occupied with thoughts as well as behaviors regarding appearance concerns. A proposal for BDD severity was also made during the DSM-5 development process (www.dsm5.org update nov-8-2010) including the daily amount of time spent on concerns and repetitive behaviors related to physical appearance.

However, the time-specification has not been included in the new DSM-5 classification of BDD. Furthermore, a specific cut-off value for the amount of time that an individual engages in mental acts or behaviors has also not yet been validated, so to our knowledge no evidence-based guideline exists for severity degrees in BDD.

In this study, using a large representative general population sample, we wanted to illustrate any differences that occur as a result of revisions to the criteria of BDD in DSM-5. The aims of this study were therefore, firstly, to report the prevalence rate of BDD based on DSM-5 criteria; secondly, to examine the impact of the recently introduced DSM-5 criteria. To do this we compared prevalence rates based on DSM-5 criteria with prevalence rates based on DSM-IV criteria, in order to assess whether BDD groups identified by DSM-5 and DSM-IV were comparable. We also reported DSM-5 prevalence rates of BDD according to the amount of time spent on repetitive behaviors. Furthermore, we compared individuals diagnosed with BDD according to DSM-5 with individuals without BDD, in terms of socio-demographic and clinical variables.

Section snippets

Design

The design of the study provides a cross-sectional survey of a representative German general population sample. With the assistance of an independent demographic consulting agency (USUMA, Berlin, Germany) a random sample of households was chosen in proportion to the population density of the region. Following this, a target subject of each household was randomly identified with the Kish selection grid. The selected sample was representative of the general German population in relation to age,

Prevalence rates of BDD based on DSM-5 vs. DSM-IV

In the German general population sample, 16% met the first criterion of BDD by reporting to be preoccupied with a flaw in their appearance. All criteria for BDD according to DSM-5 were fulfilled by 2.9% (95% CI = 2.2–3.6; n = 62) of the present sample. Using the DSM-IV criteria for BDD, we found a prevalence rate of 3.2% (95% CI = 2.5–3.9; n = 68). A significant association between the two case definitions (φ = .95; p = .00) was found indicating that the BDD criteria according to DSM-IV, and that of DSM-5,

Discussion

To our knowledge, this is the first study using the DSM-5 criteria to assess the prevalence rate of BDD in a general population sample. All DSM-5 criteria for BDD were fulfilled by 2.9% of the sample. In comparison to previous studies [2], [3], [4], which used the DSM-IV criteria in German and American general population samples (1.7–2.4%), the current prevalence rate is higher. This result raises the question of the impact of the new criteria for BDD. We therefore compared the prevalence rates

Conclusion

The advantage of the new DSM-5 criteria is that repetitive behaviors or mental acts, with respect to appearance concerns, are now considered to be a characteristic of BDD. Thus, the clinical picture of BDD is better defined. However, the new criteria do not appear to considerably affect the BDD case identification. Our findings show that almost the same BDD cases were identified using DSM-IV criteria, as were identified using DSM-5 criteria. Nevertheless, the newly specified criterion B may be

Competing interest statement

The authors (Schieber, Kollei, De Zwaan, Martin) have no competing interests to report.

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    The work was conducted at the Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen and University of Erlangen-Nuernberg, Schwabachanlage 6, 91054 Erlangen, Germany.

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