By Katharine Phillips, MD
Perhaps the most important thing to keep in mind is that many patients with BDD do not spontaneously reveal their BDD symptoms to their clinician because they are too embarrassed and ashamed, fear being negatively judged (e.g., considered vain), feel the clinician will not understand their appearance concerns, or do not know that body image concerns are treatable. Yet, research has shown that patients want their clinician to ask them about BDD symptoms. It is especially important to inquire about BDD symptoms in mental health settings, substance abuse settings, and settings where cosmetic treatment is provided (e.g., surgical, dermatologic, dental).
To diagnose BDD, the DSM-5  criteria should be followed. DSM-5 classifies BDD in the chapter of “Obsessive-Compulsive and Related Disorders.” The DSM-5 diagnostic criteria for BDD require the following:
- Appearance preoccupations: The individual must be preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance. “Preoccupation” is usually operationalized as thinking about the perceived defects for at least an hour a day. Note that distressing or impairing preoccupation with obvious appearance flaws (for example, those that are easily noticeable/clearly visible at conversational distance) is not diagnosed as BDD; rather, such preoccupation is diagnosed as “Other Specified Obsessive-Compulsive and Related Disorder”).
- Repetitive behaviors: At some point, the individual must perform repetitive, compulsive behaviors in response to the appearance concerns. These compulsions can be behavioral and thus observed by others – for example, mirror checking, excessive grooming, skin picking, reassurance seeking, or clothes changing. Other BDD compulsions are mental acts – such as comparing one’s appearance with that of other people. Note that individuals who meet all diagnostic criteria for BDD except for this one are not diagnosed with BDD; rather, they are diagnosed with “Other Specified Obsessive-Compulsive and Related Disorder.”
- Clinical significance: The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This criterion helps to differentiate the disorder BDD, which requires treatment, from more normal appearance concerns that typically do not need to be treated with medication or therapy.
- Differentiation from an eating disorder: If the appearance preoccupations focus on being too fat or weighing too much, the clinician must determine that these concerns are not better explained by an eating disorder. If the patient’s only appearance concern focuses on excessive fat or weight, and the patient’s symptoms meet diagnostic criteria for an eating disorder, then he or she should be diagnosed with an eating disorder, not BDD. However, if criteria for an eating disorder are not met, then BDD can be diagnosed, as concerns with fat or weight in a person of normal weight can be a symptom of BDD. It is not uncommon for patients to have both an eating disorder and BDD (the latter focusing on concerns other than weight or body fat).
- Specifiers: Once BDD is diagnosed, clinicians should assess the two BDD specifiers to identify meaningful subgroups of individuals with BDD:
- Muscle dysmorphia: The muscle dysmorphia form of BDD is diagnosed if the individual is preoccupied with concerns that that his or her body build is too small or insufficiently muscular. Many individuals with BDD are additionally preoccupied with other body areas; the muscle dysmorphia specifier should still be used in such cases. Individuals with the muscle dysmorphia form of BDD have been shown to have even higher rates of suicidality and substance use disorders, as well as poorer quality of life, than individuals with other forms of BDD. In addition, the treatment approach may require some modification.
- Insight specifier: This specifier indicates degree of insight regarding BDD beliefs (for example, “I look ugly” or “I look deformed”) – that is, how convinced the individual is that his/her belief about the appearance of the disliked body parts is true. Levels of insight are “with good or fair insight,” “with poor insight,” and “with absent insight/delusional beliefs.” Note that absent insight/delusional beliefs are diagnosed as BDD, not as a psychotic disorder.
BDD is often misdiagnosed as another disorder. It is important that BDD not be misdiagnosed as one of the following disorders. If it is misdiagnosed, patients may not receive appropriate care or improve with treatment that is provided.
- Obsessive Compulsive Disorder: If preoccupations and repetitive behaviors focus on appearance (including symmetry concerns), BDD should be diagnosed rather than OCD.
- Social anxiety disorder (social phobia): If social anxiety and social avoidance are due to embarrassment and shame about perceived appearance flaws, and diagnostic criteria for BDD are met, BDD should be diagnosed rather than social anxiety disorder (social phobia).
- Major depressive disorder: Unlike major depressive disorder, BDD is characterized by prominent preoccupation and excessive compulsive repetitive behaviors. BDD should be diagnosed in individuals with depression if diagnostic criteria for BDD are met.
- Trichotillomania (hair-pulling disorder): When hair tweezing, plucking, pulling, or other types of hair removal is intended to improve perceived defects in the appearance of body or facial hair, BDD should be diagnosed rather than trichotillomania (hair-pulling disorder).
- Excoriation (skin-picking) disorder: When skin picking is intended to improve perceived defects in the appearance of one’s skin, BDD should be diagnosed rather than excoriation (skin-picking) disorder.
- Agoraphobia: Avoidance of situations because of fears that others will see a person’s perceived appearance defects should count toward a diagnosis of BDD rather than agoraphobia.
- Generalized anxiety disorder: Unlike generalized anxiety disorder, anxiety and worry in BDD focus on perceived appearance flaws.
- Schizophrenia and schizoaffective disorder: BDD-related psychotic symptoms – i.e., delusional beliefs about appearance defects or BDD-related delusions of reference – reflect the presence of BDD rather than a psychotic disorder.
- Olfactory reference syndrome: Preoccupation with emitting a foul or unpleasant body odor is a symptom of olfactory reference syndrome, not BDD.
- Eating disorder: If a normal-weight person is concerned about being fat or weight, and does not meet diagnostic criteria for an eating disorder, then BDD should be diagnosed.
- Dysmorphic concern: This is not a DSM diagnosis, but it is sometimes confused with BDD. It includes concerns about body odor and somatic concerns, which are not BDD symptoms.
Issues to Consider During a Clinical Assessment
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 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. Appearance flaws 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, or other behaviors described above. 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. 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, 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 social activities, or not dating. Clinicians should also ask about impairment in work 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 performance, or poor concentration.
Preoccupations with fat or weight in a normal-appearing person that meet diagnostic criteria for an eating disorder should not be diagnosed as BDD. However, BDD and eating disorders commonly co-occur, in which case both disorders should be diagnosed, as each needs to be targeted in treatment.
Many individuals with Body Dysmorphic Disorder (BDD) report intense feelings of shame and low self-esteem. A deep sense of self-loathing results in the belief that they are fundamentally unacceptable and therefore unlovable. Individuals with BDD are convinced that others mock them because of their looks. In part, because of this perception, high levels of social isolation and minimal social supports are described by many with BDD. This is a recipe for increased risk for suicide. In fact, approximately 80% of individuals with (BDD) report that they have experienced suicidal thoughts. And, one in four individuals with BDD actually attempt suicide. For the majority of these individuals, BDD symptoms are the reason for their suicidality, and the rates of suicidal thoughts for individuals with BDD is 10 to 25 times higher than that of the general population.
In a small study on muscle dysmorphia in men (i.e., a preoccupation with feeling that they are not muscular enough resulting in excessive weight lifting and steroid use), 50% reported attempting suicide at some point. Another complicating factor is co-existing disorders including Post Traumatic Stress Disorder (PTSD), Substance Use Disorder (SUD) and anxorexia. Those with PTSD and BDD are 6 times more likely to attempt suicide compared to BDD alone. And, individuals with SUD and BDD or anorexia and BDD are 3 times more likely to attempt suicide.
Suicidal thoughts and suicide attempts are common in people with BDD. Suicidality is more common in individuals with BDD than in those with OCD. Factors that are associated with the occurrence of suicidal ideation in BDD are: 1) greater severity of BDD symptoms, and 2) comorbid major depressive disorder. One study showed that 3 out of 4 individuals with BDD who attempt suicide have a very serious intent to die.
Virtually no research has been done on completed suicide in people with BDD, but available data indicate that those with BDD have a markedly elevated risk of committing suicide. The risk of suicide may be even higher than for individuals with major depressive disorder, anorexia nervosa, and bipolar disorder. Thus, clinicians must assess for suicidal ideation if BDD is suspected.
Finally, patients who meet all diagnostic criteria for BDD should be evaluated for the muscle dysmorphia specifier, and their level of insight should be determined, as discussed previously. Patients who meet DSM-IV diagnostic criteria for BDD should be diagnosed with BDD regardless of their level of insight (i.e., patients with delusional BDD beliefs should receive this diagnosis). When determining level of insight it is best to elicit a global belief about all of the perceived defect(s) combined (for example, “ugly”) rather than to elicit a belief about a specific body area (for example, “stringy hair”). 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.
It is recommended that ICD-10 criteria/guidelines for BDD (dysmorphophobia) not be used. They require that the patient has persistently refused to accept medical advice that there is no adequate physical cause for the perceived abnormality. However, many patients are too embarrassed to reveal their appearance preoccupations to others, including clinicians, and thus they may not have had an opportunity to receive medical advice. In addition, patients may lack health insurance or access to health care for other reasons.
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). 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.
The importance of 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. 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 treatment. Instead, many patients pursue and receive cosmetic treatment (which is usually ineffective) because they believe they truly do have obvious physical defects. Poorer insight is significantly associated with more severe BDD symptoms.
About one-third of patients with BDD currently have absent insight/delusional BDD beliefs, and 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. Importantly, delusional BDD responds as well to 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 antipsychotic augmentation of an SRI – in particular, for patients with delusional BDD — has not been adequately studied, and thus the efficacy of this type of augmentation is unknown.
Another psychotic symptom that is common in BDD is delusions of reference (complete conviction that other people are taking special notice of the patient in a negative way because of how they look). 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.
- Body Dysmorphic Disorder Questionnaire (BDDQ): This brief self-report screening measure mirrors DSM-IV diagnostic criteria. Adult and adolescent versions are available. The BDDQ has had high sensitivity (100%) and specificity (89-93%) for the BDD diagnosis in psychiatric and dermatology samples. The DSM-IV version is expected to perform well with DSM-5 criteria, because the DSM-5 criteria are not expected to change caseness.
- Body Image Disturbance Questionnaire (BIDQ): This brief self-report measure is a slightly modified self-report version of the BDDQ that uses continuous response scaling. It has strong psychometric properties in a non-clinical population, but sensitivity and specificity data are needed.
The following measures have been shown to have adequate reliability.
- Structured Clinical Interview for DSM-IV (SCID): The SCID’s BDD module is a brief semi-structured clinician-administered measure. (The SCID for DSM-5 is not yet available.)
- BDD Diagnostic Module: This brief semi-structured clinician-administered measure is similar to and predated the SCID. A DSM-IV version is available for both adults and youth.
- Body Dysmorphic Disorder Examination (BDDE): This semi-structured interview is fairly lengthy, and it is of limited usefulness for patients with more severe BDD symptoms. A self-report version has been used in some studies, but its psychometric properties have not been established.
- MINI Plus is not recommended for BDD, because it follows the ICD-10 diagnostic criteria for BDD, which are problematic (see above); it likely under-diagnoses BDD.
- BDD-YBOCS: This 12-item semi-structured rater-administered measure is similar to the Y-BOCS for OCD with the exception that it includes two additional items (insight and avoidance). It assesses BDD severity during the past week. Scale scores range from 0-48. The cutpoint for the presence of the BDD diagnosis is 20. It is intended for use only with people who have already been diagnosed with BDD. A self-report version with demonstrated reliability and validity is not available.
- Brown Assessment of Beliefs Scale: This 7-item semi-structured rater-administered measure assesses delusionality in BDD and other disorders that are characterized by false beliefs. It assesses insight/delusionality both dimensionally and categorically.
For more information about diagnosis and assessment please see the book The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, by Katharine A. Phillips (Oxford University Press, 2005).