In body dysmorphic disorder (BDD), the obsessive preoccupation is with perceived defects in physical appearance. Which insight specifier is associated with the poorest prognosis and highest treatment refusal in BDD?

• A Good or fair insight
• B Poor insight
• C Overvalued ideas with partial insight
• D Absent insight/delusional beliefs ✓

Explanation

DSM-5 specifies insight levels in BDD: good/fair, poor, or absent insight/delusional beliefs. Patients with absent insight/delusional beliefs are convinced their appearance concerns are real and accurate, deny any possibility of overestimation, and commonly reject psychiatric treatment. This subgroup has the highest functional impairment, greatest treatment refusal, most frequent cosmetic surgery-seeking (which typically does not help), and highest suicidality. ERP and SSRIs remain the evidence-based treatments even in the delusional subtype — antipsychotics alone are not recommended as monotherapy.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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