Dr. Sophie Schneider discusses how Body Dysmorphic Disorder (BDD) can be confused with obsessive compulsive disorder (OCD), social anxiety disorder (SAD), eating disorders, and depression.
By Katharine A. Phillips, MD
To diagnose BDD, the DSM-5  diagnostic criteria should be followed. DSM-5 classifies BDD in the chapter of “Obsessive-Compulsive and Related Disorders,” along with OCD and several other 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 (adding up all the time that is spent throughout the day). Note that distressing or impairing preoccupation with obvious appearance flaws (for example, those that are easily noticeable/clearly visible at conversational distance, such as obesity) is not diagnosed as BDD; rather, such preoccupation is diagnosed as “Other Specified Obsessive-Compulsive and Related Disorder.”
- Repetitive behaviors:To qualify for a diagnosis of BDD, at some point during the course of the disorder, 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 diagnostic 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 DSM-5 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 muscle dysmorphia 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. If it is misdiagnosed, patients may not receive appropriate care or improve with treatment that is provided.
BDD is commonly misdiagnosed as one of the following disorders:
- 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 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 (although these two disorders have many similar characteristics).
- Eating disorder: If a normal-weight person is excessively concerned about being fat or their weight, meets other diagnostic criteria for BDD, 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 focuses on appearance concerns but also includes concerns about body odor and non-appearance related somatic concerns, which are not BDD symptoms.
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 with psychiatric medication and/or therapy. 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).
For more information on the clinical assessment of BDD, click here.
For more information about assessment tools to diagnose BDD and measure/track symptoms, click here.
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).