Body dysmorphic disorder

Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5-TR) criteria[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

Clinicians should diagnose BDD based on the American Psychiatric Association’s DSM-5-TR diagnostic criteria. BDD is classified within the chapter "Obsessive-compulsive and related disorders". General guidelines for making the diagnosis are:

• Appearance preoccupations should occur for at least 1 hour a day (adding up the time for negative thoughts about one’s appearance that occur throughout the day)

• Repetitive behaviors in response to the preoccupations must be present currently or in the past

• The appearance preoccupations must cause at least moderate distress or at least moderate impairment in functioning.

International classification of diseases 11th revision (ICD-11) definition[62]​World Health Organization. International classification of diseases, 11th revision. Jan 2023 [internet publication]. https://icd.who.int/en

Published by the World Health Organization, the ICD-11 offers an internationally recognized definition of BDD. It classifies BDD in the “Mental, behavioural or neurodevelopmental disorders” chapter within “Obsessive-compulsive or related disorders”.

Essential diagnostic features (all of which must be present)

• Persistent preoccupation with one or more perceived defects or flaws in appearance, or ugliness in general, that is either unnoticeable or only slightly noticeable to others.

• Excessive self-consciousness about the perceived defect(s) or flaw(s), often including ideas of self-reference (i.e., the conviction that people are taking notice, judging, or talking about the perceived defect[s] or flaw[s]).

• The preoccupation or self-consciousness is accompanied by any of the following:

  • Repetitive and excessive behaviors, such as repeated examination of the appearance or severity of the perceived defect(s) or flaw(s) (e.g., by checking in reflective surfaces) or comparison of the relevant feature with that of others

  • Excessive attempts to camouflage or alter the perceived defect (e.g., specific and elaborate forms of dress, undergoing ill-advised cosmetic surgical procedures)

  • Marked avoidance of social or other situations or stimuli that increase distress about the perceived defect(s) or flaw(s) (e.g., reflective surfaces, changing rooms, swimming pools).

• The symptoms are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects.

• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS)[57]Phillips KA, Hollander E, Rasmussen SA, et al. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull. 1997;33(1):17-22. http://www.ncbi.nlm.nih.gov/pubmed/9133747?tool=bestpractice.com

The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS) is the most widely used measure of BDD severity. This 12-item rater-administered measure is reliable, valid, and sensitive to change. It should be used only with individuals who have already been diagnosed with BDD; it is not a diagnostic measure. In clinical settings, when a quick assessment is needed, the first three items of the BDD-YBOCS (preoccupation, distress, and impairment) can be used to evaluate progress with treatment.

Level of insight[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.[63]Kogan CS, Stein DJ, Rebello TJ, et al. Accuracy of diagnostic judgments using ICD-11 vs. ICD-10 diagnostic guidelines for obsessive-compulsive and related disorders. J Affect Disord. 2020 Aug 1;273:328-40. http://www.ncbi.nlm.nih.gov/pubmed/32560926?tool=bestpractice.com ​​

Level of insight is a specifier for the diagnosis of BDD. Once the diagnosis is made, level of insight should be assessed. First determine a false BDD belief to assess. It is preferable to assess a global belief, such as “I look ugly”, rather than a belief that is relevant to a specific body area, such as “I’m going bald”.

Categories of insight in DSM-5-TR are:[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

• With good or fair insight: the person recognizes that their belief about their appearance is definitely, probably or may not be true

• With poor insight: the person thinks their BDD belief probably is true

• With absent insight/delusional beliefs: the person is convinced that their BDD belief is true. Delusional BDD beliefs should be diagnosed as BDD, not as a psychotic disorder.

ICD-11 has two levels of insight: 1) good to fair, and 2) poor to absent.

Brown Assessment of Beliefs Scale (BABS)[58]Eisen JL, Phillips KA, Baer L, et al. The Brown assessment of beliefs scale: reliability and validity. Am J Psychiatry. 1998 Jan;155(1):102-8. https://ajp.psychiatryonline.org/doi/10.1176/ajp.155.1.102 http://www.ncbi.nlm.nih.gov/pubmed/9433346?tool=bestpractice.com

The BABS is the most widely used measure of insight in BDD (as well as obsessive-compulsive disorder [OCD] and eating disorders). It assesses insight in a range of disorders, such as BDD, OCD, anorexia nervosa, bulimia nervosa, olfactory reference disorder, and hypochondriasis. The BABS provides a dimensional score of current insight/delusionality and also categorizes beliefs according to different levels of insight.