By Katharine A. Phillips, MD
Issues to Consider During a Clinical Assessment
To diagnoses BDD, clinicians must ascertain that the patient is preoccupied with one or more nonexistent or slight defects in their physical appearance (for example, thinks about the perceived defects for at least an hour a day). To assess this criterion, it is best to ask questions such as whether the patient is worried about their appearance or unhappy with how they look. Asking patients whether they are preoccupied with minimal or nonexistent flaws will usually miss the diagnosis, because patients typically have poor or absent insight, not realizing that the flaws they perceive are actually not visible to others or are quite minimal.
To determine whether a physical flaw is only slight or absent, the clinician can determine whether it is clearly visible and obvious at conversational distance or when first meeting the individual. Preoccupying appearance flaws that cause clinically significant distress or impairment and that are more obvious than “slight” should be diagnosed as “other specified obsessive-compulsive and related disorder” rather than BDD. An exception to this is that BDD-related skin picking can cause obvious skin lesions and scarring; such patients should be diagnosed with BDD.
Clinicians must also ascertain that at some point during the course of the disorder the patient has engaged in one or more repetitive behaviors, such as mirror checking, skin picking, seeking reassurance about perceived appearance flaws, comparing with others, excessive grooming, or other behaviors described in the "Signs and Symptoms" section. Virtually all patients with BDD perform one or more of these behaviors at some point during their illness. Those who do not do so but who meet all other diagnostic criteria for BDD should be diagnosed with “other specified obsessive-compulsive and related disorder” rather than BDD. Because BDD-related repetitive behaviors can potentially be witnessed by other people, they may be a useful clue that a patient who is reluctant to divulge his or her concerns has BDD.
To differentiate BDD from more normal, non-pathological, appearance concerns, the clinician must ascertain that the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-5 uses this diagnostic criterion to differentiate many mental disorders from nonpathological thoughts, emotions, and behaviors. Clinicians can probe for BDD-related distress by asking directly about distress as well as asking about resulting depressed mood or anxious mood, feelings of embarrassment or shame, self-consciousness, anger, irritability, or suicidal ideation. Clinicians should ask about impairment in social situations and relationships that result from the appearance concerns. Examples include problems with emotional or physical intimacy, avoidance of friends or social situations, being late for or canceling social activities, or not dating. Clinicians should also ask about impairment in work, role, or academic functioning that are due to BDD concerns. Examples include quitting jobs or being fired, dropping out of school, being late or missing work or classes, a decline in academic or job performance, being unable to manage a household, or poor concentration.
Preoccupations with fat or weight in a normal-appearing person who has an eating disorder should not be diagnosed as BDD. However, if an eating disorder is not present, weight concerns can "count" toward a diagnosis of BDD; BDD can involve any aspect of appearance, including weight. BDD and eating disorders commonly co-occur, in which case both disorders should be diagnosed, as each needs to be targeted in treatment.
As noted elsewhere, patients who meet all diagnostic criteria for BDD should be evaluated for the muscle dysmorphia specifier, and their level of insight should be determined (see below).
Because individuals with BDD may conceal their appearance concerns and preoccupation, clinicians should be alert to clues to BDD’s presence. Clues include BDD-related repetitive behaviors as well as BDD-related ideas and delusions of reference (thinking that other people take special notice of the person or make fun of them because of how they look), which patients may refer to as "paranoia." Being housebound, having problematic social anxiety and social avoidance, and experiencing depression (especially if treatment-resistant), anxiety, or suicidality are not specific to BDD; however, these symptoms may be a clue to the presence of BDD.
Assessing Insight in BDD
One of the major challenges in working with patients with BDD is that insight is usually absent or poor. That is, patients with BDD are usually mostly convinced or completely convinced that they really do look ugly, abnormal, or deformed, even though they don't. This absent insight (delusional beliefs) or poor insight may make the patient reluctant to accept the diagnosis of BDD, agree to receive recommended medication or cognitive behavioral therapy, or stay in mental health treatment. Instead, many patients pursue and receive cosmetic treatment (which is usually ineffective) because they believe they truly do have obvious physical defects. Poorer BDD-related insight is significantly associated with more severe BDD symptoms.
About one-third of patients with BDD currently have absent insight (delusional BDD beliefs). About three-quarters have absent insight (delusional beliefs) or poor insight. Prior to treatment, fewer than 5% of patients have excellent insight. Differences in level of insight is one of the best-demonstrated differences between BDD and OCD. (An example of insight in OCD is how convinced the patient is that the house will actually burn down if the stove is not checked 30 times.) In contrast to BDD, fewer than 5% of OCD subjects have delusional OCD beliefs, and a majority have excellent or good insight. When assessing insight dimensionally (e.g., with the Brown Assessment of Beliefs Scale), mean level of insight in BDD is typically in the poor range, whereas mean level of insight in OCD is typically in the good to fair range.
It is important to recognize that patients with delusional BDD beliefs should be diagnosed with BDD, not with a psychotic disorder such as delusional disorder, schizophrenia, or “other specified psychotic disorder.” All available evidence indicates that delusional BDD and nondelusional BDD are similar across a large number of validators and are the same disorder. Importantly, delusional BDD responds as well to serotonin-reuptake inhibitor (SRI) monotherapy as nondelusional BDD does, with a majority of patients in both groups experiencing significant improvement with an SRI alone. Thus, it is recommended that patients with delusional BDD be treated with an SRI, not with antipsychotic monotherapy. In addition, most studies have found that level of insight improves with SRI treatment, including in patients with delusional BDD. The efficacy of neuroleptic (antipsychotic) augmentation of an SRI – in particular, for patients with delusional BDD — has not been adequately studied. Clinical experience suggests that certain atypical (second-generation) neuroleptics, such as aripiprazole, can be efficacious as SRI augmenters; studies of this strategy are needed.
Motivational interviewing is often needed when treating individuals with BDD; those who have poor or absent insight may be reluctant to participate in mental health treatment and may benefit from more intensive or frequent motivational enhancement strategies.
Another psychotic symptom that is common in BDD is delusions of reference – i.e., complete conviction that other people are taking special notice of the patient in a negative way because of how they look (for example, staring or laughing at them). Other types of psychotic symptoms are very rarely a symptom of BDD, and thus the presence of such symptoms should prompt the clinician to look for the presence of a comorbid psychotic disorder.
When determining level of insight it is best to elicit a global belief about all of the perceived defect(s) combined (for example, “I look ugly”) rather than a belief about a specific body area (for example, “My hair is really stringy”). The reason is that patients typically have multiple appearance concerns. Even those with only one concern may develop new concerns over time or experience remission of prior concerns, so it is best not to base the assessment on just one body area .
Katharine A. Phillips, MD, is Professor of Psychiatry at Weill Cornell Medical College, Cornell University, and Attending Psychiatrist at New York-Presbyterian Hospital, both in New York City. She is also Adjunct Professor of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University in Providence, RI. She is internationally known for her pioneering research and clinical expertise in body dysmorphic disorder. She is author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder(Revised and Expanded Edition) (2005), Understanding Body Dysmorphic Disorder: An Essential Guide (2009), and Body Dysmorphic Disorder: Advances in Research and Clinical Practice (2017) (all published by Oxford University Press). She is also co-author of Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual, published by Guilford Press in 2013 (with Drs. Sabine Wilhelm and Gail Steketee) and The Adonis Complex: The Secret Crisis of Male Body Obsession, published by The Free Press in 2000 (with Drs. Harrison Pope and Roberto Olivardia).