What is the diagnostic approach for body dysmorphic disorder (BDD)?

Diagnostic Approach for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is diagnosed through a structured clinical assessment focusing on the presence of excessive preoccupation with perceived appearance flaws, associated repetitive behaviors, and resulting distress or impairment. 1

Core Diagnostic Criteria Assessment

• Assess for preoccupation with perceived appearance defects that are minimal or not observable to others 1
• Evaluate repetitive behaviors performed in response to appearance concerns (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) 1
• Determine level of distress and functional impairment in social, occupational, or other important areas 1
• Assess insight level (good, poor, or absent/delusional beliefs) 1, 2
• Screen for muscle dysmorphia variant, particularly in males (preoccupation with being insufficiently muscular) 3, 1

Structured Diagnostic Interview Questions

When interviewing patients, use these specific questions aligned with DSM-5 criteria:

1. Preoccupation assessment:

   • "Do you worry about how you look from time to time in a way that takes up a lot of time and really upsets you?" 1
   • "What aspects of your appearance worry you most?" 1
   • "How much time do you spend thinking about your appearance during an average day?" 1

2. Repetitive behaviors assessment:

   • "Do you spend a lot of time doing things to try to hide, change or check your appearance?" 1
   • "Do you spend time comparing your appearance to others?" 1
   • "How much time in an average day do you spend on these behaviors?" 1

3. Distress and impairment assessment:

   • "How much do these worries about your appearance upset you?" 1
   • "Do they make you feel very sad or very anxious?" 1
   • "Do these worries get in the way of day-to-day life or cause you to avoid activities?" 1

4. Insight assessment:

   • "If you had to describe your appearance in a single word, what word would you choose?" 1
   • "How convinced are you that you look [use patient's descriptor]?" 1
   • "Do you think other people see you the same way?" 1

Differential Diagnosis

BDD must be distinguished from several conditions with overlapping features:

• Obsessive-compulsive disorder: In OCD, grooming rituals are driven by contamination fears or "just right" urges, not by attempts to correct perceived appearance flaws 1
• Social anxiety disorder: Social anxiety involves fear of embarrassing oneself through actions, while BDD involves fear of rejection based on appearance 1
• Depression: While depression may include negative self-concept, appearance concerns are not the primary preoccupation and lack associated repetitive behaviors 1
• Eating disorders: Appearance concerns in eating disorders focus specifically on body weight/shape and lead to dysfunctional eating behaviors 1
• Psychotic disorders: Unlike psychotic disorders, BDD involves appearance preoccupations without hallucinations, disorganized thought, or disorganized speech 1, 4
• Gender dysphoria: In gender dysphoria, body concerns relate to features not being appropriate for gender identity rather than being perceived as ugly 1

Assessment Considerations and Pitfalls

• Be vigilant for behavioral clues during assessment (wearing hood/hat/sunglasses indoors, heavy makeup, frequent mirror checking, keeping camera off during telehealth) 1
• Avoid challenging beliefs about appearance or providing reassurance about perceived flaws, as this may be interpreted as dismissive or fuel reassurance-seeking 1
• Screen for comorbidities as approximately 70% of young people with BDD have at least one additional diagnosis (especially depression, social anxiety, eating disorders) 1
• Assess suicide risk as BDD is associated with high rates of suicidality (11-44% of clinical BDD patients have history of suicide attempts) 1
• Evaluate family accommodation (parents/family members facilitating avoidance, providing reassurance, or supplying cosmetic products) 1

Common Diagnostic Challenges

• BDD is frequently under-detected and under-diagnosed due to patients' reluctance to disclose symptoms spontaneously 1
• Patients often present with other symptoms (depression, anxiety) rather than their core appearance concerns 1
• Appearance concerns may be dismissed as normal developmental issues in adolescents 1
• Patients may seek cosmetic procedures rather than mental health support 2, 5
• Poor insight is common, with patients often believing their appearance concerns are justified rather than disproportionate 2, 6

By following this structured diagnostic approach and being aware of common pitfalls, clinicians can more accurately identify BDD and direct patients to appropriate mental health treatment rather than unnecessary cosmetic interventions 2, 5, 7.