Approach
BDD consists of a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.[1] Patients with BDD typically have poor psychosocial functioning and quality of life, and suicidality rates are high.[32][33][34]
It is important to screen for BDD in mental health settings, because patients may not divulge their appearance concerns. BDD usually goes undetected if clinicians do not specifically screen for it or ask patients about it.[7]
It is also important to screen for BDD in cosmetic treatment settings, especially dermatology and cosmetic surgery. BDD is common in these settings, and patients with BDD are usually dissatisfied with the outcome of cosmetic procedures.[5][35] Clinicians who provide cosmetic treatment for people with BDD may be threatened legally or physically by dissatisfied patients.[36]
BDD is diagnosed by asking the patient questions about BDD symptoms and determining whether diagnostic criteria for BDD are met. A diagnostic measure that assesses DSM-5-TR diagnostic criteria can be used.[32][37]
In recent years, a broad range of colloquial terms have been used for constructs with similarities to BDD. These terms include body dysmorphia, skin dysmorphia, acne dysmorphia, and penile dysmorphia. In both the medical literature and the popular press, these terms are often not precisely defined or operationalized, and many scientific studies do not use validated screening or diagnostic measures for BDD. The meaning of these terms and constructs is therefore often unclear. These terms often overlap significantly with BDD and may even be synonymous with the disorder BDD. However, they may instead refer to more normative, nonpathologic, non-BDD body image concerns and dissatisfaction.
History
Use the DSM-5-TR diagnostic criteria for body dysmorphic disorder (or World Health Organization [WHO] International Classification of Diseases 11th revision [ICD-11] criteria) to make a diagnosis of body dysmorphic disorder.
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:[1]
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.
People with BDD often describe themselves as looking "ugly", "abnormal", or "deformed", when in fact they are not. During the course of the disorder, the appearance preoccupations trigger one or more repetitive behaviors (also known as rituals or compulsions), such as comparing one’s own appearance with that of other people, excessive mirror checking, excessive grooming, skin picking, or reassurance seeking.[1][33][34]
Importantly, to meet the DSM-5-TR diagnostic criteria for BDD, the appearance preoccupations must cause clinically significant distress or clinically significant impairment in functioning (social, occupational, academic role, etc.).[1] This criterion is critically important in differentiating the pathologic condition BDD, which warrants mental health treatment, from normative, nonpathologic body image concerns and dissatisfaction, which are common in the general population. For more information on the DSM-5-TR and the ICD-11 diagnostic criteria, see Criteria.
Differentiating BDD from an eating disorder
The final DSM-5-TR criterion is that in order to diagnose BDD, the patient’s preoccupation with their appearance should not be better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.[1]
If an individual is preoccupied with the inaccurate belief that they are "too fat", or that nonfacial parts of their body (such as their thighs or stomach) are "too fat", an eating disorder diagnosis may be more appropriate than a BDD diagnosis. If the patient has an eating disorder, these types of preoccupations are considered a symptom of the eating disorder, rather than BDD. However, if the patient does not have an eating disorder diagnosis, preoccupations with body fat or excessive weight count towards a diagnosis of BDD. In most cases it is easy to differentiate BDD from an eating disorder, as BDD most often involves preoccupations with perceived defects of the face or head.[34] See Bulimia nervosa and Anorexia nervosa.
BDD appearance preoccupations
The appearance preoccupations associated with BDD are sometimes referred to as obsessions. The preoccupations typically consume at least 1 hour or more a day, in total. On average, these thoughts consume 3-8 hours a day.[33][38]
BDD appearance preoccupations are intrusive, unwanted, and distressing.[33] They are usually difficult to resist or control. Telling someone with BDD to simply stop worrying about how they look is not effective. The nature of the preoccupation consists of ruminating, comparing and being self-critical, and perhaps rating their "ugliness".
The appearance preoccupations can focus on any part of the body and may involve one or multiple body areas. On average, over the course of the disorder people with BDD are excessively preoccupied with five to seven different body areas.[33][39] Preoccupation most often focuses on perceived defects of the face or head.[34][40] The skin, usually facial skin, is the most commonly disliked body area. Patients are often obsessed with perceived acne, marks, or scars.[33] Preoccupation with perceived wrinkles, skin color, or other aspects of the skin are also common. Hair preoccupations are the second most common concern: for example, excessive facial or body hair, hair loss, or uneven or insufficient beard growth. The nose is the third most common area of concern, usually nose size or shape.[33] Appearance preoccupations may focus on any other body area: for example, teeth, eyes, mouth, jaw, ears, head size or shape, breasts, thighs, stomach, legs, hands, genitals, or body build.[26] More than 25% of patients have at least one concern involving asymmetry (for example, nostrils or face shape).[41] Asking the patient to draw a self-portrait can be very revealing and highlight the discrepancy between how a person sees themselves in their mind’s eye and how other people see them.
Some people with BDD (usually men and boys) are preoccupied with the belief that their body build is too small or insufficiently muscular. This form of BDD is called muscle dysmorphia.[42]
BDD repetitive behaviors (compulsions, rituals)
Virtually all patients with BDD currently engage in one or more repetitive behaviors. Occasionally, these behaviors occurred in the past but not currently. These behaviors are also referred to as compulsions or rituals, reflecting the fact that patients feel a strong urge to do them and find them difficult to resist or control. Simply telling a patient to stop the behavior is not effective.
The repetitive behaviors are triggered by BDD appearance preoccupations. They aim to check, fix, hide, or obtain reassurance about perceived appearance flaws, but the patient typically feels that they are not successful. On average, people with BDD spend 3-8 hours a day performing these repetitive behaviors.[33]
Common repetitive behaviors include:[33]
Comparing one’s own appearance with that of other people
Excessively checking mirrors or other reflecting surfaces
Excessive grooming
Taking excessive selfies
Seeking reassurance about one’s appearance
Skin picking
Hair removal
Touching or directly examining disliked body areas to check them
Researching information about surgery and other cosmetic treatments.
BDD repetitive behaviors are not limited to these examples.
Skin picking
In one study of 176 people with BDD, 45% reported lifetime pathologic skin picking and 37% reported current pathologic skin picking secondary to BDD.[43] The purpose of skin picking is to try to improve the appearance of the skin. However, this is a compulsive, driven behavior that sometimes causes clearly obvious skin lesions or scarring (although this is not the patient’s intent). Even when skin lesions are currently more than “slight”, BDD can be diagnosed (instead of excoriation disorder) if:[44]
Picking was initially triggered by concerns with nonexistent or minor skin flaws, or
Skin picking has been present even when the skin is clear or when blemishes are only slight.
Although repetitive behaviors in BDD aim to reduce distress that is triggered by appearance preoccupations, they may increase the patient’s distress. If they do decrease distress, the relief is only temporary. Most of these behaviors can be observed by others, and therefore they can be a clue that a person may have BDD. If they are observed, clinicians should ask the patient about other BDD symptoms.[39]
Psychosocial functioning and quality of life
Impairment in psychosocial functioning due to BDD is part of the definition of BDD.[1] For BDD to be diagnosed, the appearance preoccupations must cause clinically significant distress or clinically significant impairment in functioning.[1] Most often, both significant distress and impairment are present in both younger people and adults.[45] On average, psychosocial functioning and quality of life are very poor. Scores on health measures such as the SF-36 (36-item short-form survey) are typically several standard deviations below community norms and 0.4 to 0.7 standard deviations below norms for depression.[33][46] School dropout and difficulty maintaining a job are common complications of BDD.[33] More severe BDD symptoms are associated with poorer functioning and quality of life.[33]
Camouflaging
About 90% of people with BDD try to camouflage their perceived appearance defects.[33] For example, they may hide them with makeup, a hat, clothes, their hair or hands, or their body position.[33][39]
One goal of camouflaging is to avoid feeling self-conscious around others. Another goal is to reduce the fear of being ridiculed because of the perceived appearance flaws. Sometimes camouflaging is done repeatedly throughout the day and therefore may also qualify as a repetitive behavior. Examples are frequently reapplying makeup, adjusting one’s hat to cover a supposedly high forehead or uneven eyebrows, or repeatedly sucking in a “fat stomach”. Sometimes, camouflaging makes the patient look somewhat unusual: for example, if long bangs cover one’s face.
Camouflaging can be a clue to the presence of BDD. If it is observed, clinicians should ask about other BDD symptoms.[39]
Insight in BDD
Before effective treatment, BDD-related insight is typically poor or absent (in about 70% of patients).[47] Most people with BDD are mostly or completely certain that they really do look "ugly", "disfigured", or "unattractive", even though they do not appear this way to others. Patients who are completely convinced that their BDD belief is true (that they truly are "ugly", "deformed", or "abnormal looking") should be diagnosed with “BDD with absent insight/delusional beliefs” rather than a psychotic disorder.[1] Delusional BDD (beliefs held with complete certainty) and nondelusional BDD (the patient has some recognition that they are not actually "ugly" or "abnormal looking") are the same disorder, and thus treatments are the same for both.[47]
Referential thinking
Referential thinking, also known as ideas or delusions of reference, is common. People with BDD may mistakenly think that other people take special notice of them in a negative way because of how they look. The patient may believe, for example, that other people are staring at them, talking about them, or laughing at them because they look so strange or ugly. Referential thinking can exacerbate social avoidance, and it can trigger anger, hostility, and even aggressive behavior toward others.[39]
Negative emotions
Appearance preoccupations trigger distressing emotions. Most patients feel embarrassed and ashamed by their supposed physical deformities and the mistaken belief that other people think that they look ugly or abnormal. The appearance preoccupations also typically trigger anxiety, depression, anger, and suicidal thinking. BDD is associated with high levels of hostility, rejection sensitivity, neuroticism, and perceived stress, as well as low levels of self-esteem, extraversion, and assertiveness. Other negative emotions include disgust in response to seeing the perceived defects, guilt (for example, after cosmetic surgery with an unsatisfactory outcome), and grief (for example, over years lost to BDD symptoms).[26]
Social anxiety and avoidance
Social anxiety and avoidance are common symptoms of BDD. Social avoidance is a common way in which impairment in psychosocial functioning manifests. Social anxiety and avoidance are typically due to embarrassment, shame, and anxiety about being seen by other people. People with BDD believe that others think that they look ugly and may think that others take special notice of them because they are ugly.[33][48]
Higher global social avoidance (due to BDD or any other source) predicts poorer overall functioning in several domains of global functioning.[49]
Age at onset
BDD can begin as young as age 4 years. It most often onsets at age 12-13 years, and the mean age at onset is 16-17 years. Two-thirds of cases onset before age 18 years. It is unusual for BDD to onset in people older than 40 years.[6]
BDD in children and adolescents
The clinical features of BDD appear largely similar in youth and adults. However, youth have poorer insight regarding their perceived appearance defects and are also more likely than adults to have attempted suicide (44% vs. 24%).[50]
Ask about risk factors for BDD, such as:
Family history of BDD or obsessive-compulsive disorder (OCD)
Childhood neglect, abuse, and trauma
Teasing/bullying
Temperament/personality
Image-centric social media use.
For some risk factors, it is not known whether they precede the development of BDD and are truly a risk factor for BDD, whether they are simply a co-occurring feature of BDD, or whether they are caused by BDD.
Physical examination
By definition, the physical defects that people with BDD perceive are nonexistent or only slight in the eyes of others.[1] Although this can be a subjective judgment, one way to operationalize it is to assess whether the defects are clearly present at conversational distance and without the patient pointing them out. If a patient has a very obvious physical difference (for example, an amputation), “other specified obsessive compulsive and related disorder” is the more accurate diagnosis, according to DSM-5-TR.[1] See Differentials.
The clinician can usually determine the degree of physical deformity by directly looking at the patient, because the face and head are the most common areas of concern. Consider asking the patient to fully or partially remove camouflage (for example, take a hat off). If removal of camouflage is too difficult for the patient, BDD can often be diagnosed on the basis of other, uncovered body areas, because patients are often preoccupied with more than one area. It may be appropriate for certain specialists to ask patients to remove clothing so they can observe the body area that the patient believes looks abnormal.
An exception to the rule that people with BDD do not have flaws or defects in physical appearance that are observable or appear more than slight to others is that compulsive skin picking can cause clearly visible physical defects, such as skin lesions and scarring. Some patients pick their skin for hours a day. Some use their fingers to pick, whereas others use sharp implements, such as pins, needles, staple removers, razor blades, and knives. Even if the patient has clearly visible skin defects (more than “slightly” noticeable), BDD can nonetheless be diagnosed if the clinician can ascertain that picking occurs in response to worries about the skin’s appearance (for example, minor skin blemishes), appearance concerns preceded onset of picking, and/or preoccupations are present even when the skin is clear or blemishes are minor.[51]
Confirming the diagnosis
BDD is often a hidden disorder, because patients are too ashamed or embarrassed to mention it.[52] They may worry that the clinician will think they are vain or fear that the clinician will otherwise negatively judge them or not understand their concerns. If clinicians do not ask patients about BDD, the diagnosis is likely to be missed.[7]
The Structured Clinical Interview for DSM-5 (SCID-5) is a semi-structured diagnostic instrument that can be used to determine whether a patient meets DSM-5 diagnostic criteria for BDD. It includes other disorders as well.[37]
The Body Dysmorphic Disorder Diagnostic Module (BDD Module) is a semi-structured diagnostic instrument that can be used to determine whether a patient meets DSM-5-TR diagnostic criteria for BDD (listed above in the History section).[44]
Several self-report screening questionnaires are available for use in specialist settings (alongside clinician interview), including the Body Dysmorphic Disorder Questionnaire, the Body Dysmorphic Disorder Questionnaire, Dermatology Version, the Dysmorphic Concern Questionnaire, and the Cosmetic Procedure Screening Questionnaire.[53][54][55][56]
Assessing severity
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.[57]
BDD-related insight
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 are:
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.
The Brown Assessment of Beliefs Scale (BABS) is the most widely used measure of insight in BDD (as well as OCD and eating disorders). It assesses insight in a range of disorders, such as BDD, OCD, anorexia nervosa, bulimia nervosa, olfactory reference disorder, and illness anxiety disorder (hypochondriasis). The BABS provides a dimensional score of current insight/delusionality and also categorizes beliefs according to different levels of insight.[58]
Assessment of BDD in youth
Some of the screening, diagnostic, severity, and insight measures discussed above have separate versions for youth that use simpler, age-appropriate language.
Assessment of suicidality
Suicidality is common in patients with BDD and appears more common in BDD than in a range of other psychiatric disorders, including unipolar depression, bipolar depression, OCD, eating disorders, and PTSD. Therefore, it is important to screen all patients with BDD for suicidal ideation.[52][59][60] Ask questions about suicidality and/or use a measure of suicidal ideation. Also ask about a history of suicide attempts and risk factors for suicide. It is important to monitor patients with BDD for suicidality. Safety planning is needed with higher-risk patients. See Complications.
Distinguishing between BDD and other disorders
Keep differential diagnoses in mind so that BDD is not misdiagnosed as another disorder, for example:[61]
Eating disorders
Major depressive disorder
Obsessive-compulsive disorder
Olfactory reference disorder (olfactory reference syndrome)
Trichotillomania (hair-pulling disorder)
Excoriation (skin-picking) disorder
Social anxiety disorder (social phobia)
Agoraphobia
Panic disorder
Generalized anxiety disorder
Illness anxiety disorder (hypochondriasis)
Schizophrenia and other psychotic disorders
Gender dysphoria
Avoidant personality disorder
Bipolar disorder.
See Differentials.
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