History and exam
Key diagnostic factors
common
preoccupation with perceived flaws in one's physical appearance that appear non-existent or only slight to other people
A diagnostic criterion for BDD under DSM-5-TR (one of four diagnostic criteria, which must all be met).[1] Preoccupations (obsessions) with perceived appearance flaws that add up to about 1 hour or more a day, in total. On average, these thoughts consume 3-8 hours a day.[33][38]
Appearance preoccupations are intrusive, unwanted, and distressing, and are difficult to resist or control (telling a patient to ‘stop worrying’ does not help).[33] The nature of the preoccupation for the patient consists of ruminating, comparing, and being self-critical, and perhaps rating their ‘ugliness’.
Appearance preoccupations can focus on one or multiple body areas, most often the face or head but can be any other body area (e.g., teeth, eyes, mouth, jaw, ears, head size or shape, breasts, thighs, stomach, legs, hands, genitals, or body build). They most often focus on perceived defects of the skin (e.g., perceived acne, marks, scars, or colour), followed by hair concerns (e.g., excessive facial or body hair, hair loss), followed by nose concerns (usually nose size or shape).[33]
More than 25% of patients have at least one concern involving perceived bodily asymmetry.[41]
The other three diagnostic criteria are the presence of repetitive behaviours, significant distress, and the appearance preoccupation is not better explained by an eating disorder.
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. Use of anabolic-androgenic steroids is common in these boys and men, which may develop into an addiction and can have serious adverse physical and psychiatric effects.[42]
Whether the patient has the muscle dysmorphia form of BDD is one of the two specifiers that needs to be considered under DSM-5-TR once a diagnosis of BDD has been made. The other specifier is level of insight of the BDD belief.[1]
repetitive behaviours (compulsions, rituals)
Repetitive behaviours or mental acts in response to appearance concerns at some point during the course of the disorder is a diagnostic criterion for BDD under DSM-5-TR (one of four diagnostic criteria, which must all be met).[1] These behaviours 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 behaviours.[33][38]
Patients feel a strong urge to do them, and they are difficult to resist or control (asking a patient to simply stop the behaviour is not effective).
Common repetitive behaviours include: comparing one’s own appearance with that of other people; excessively checking mirrors or other reflecting surfaces; excessive grooming; taking excessive selfies; skin picking or hair removal; seeking reassurance about one’s appearance; searching online for information about surgery and other cosmetic treatment.[33]
BDD repetitive behaviours are not limited to these. In a study of 176 people with BDD, 45% reported lifetime pathological skin picking and 37% reported current pathological 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 behaviour that sometimes causes clearly obvious skin lesions or scarring. Even when skin lesions are more obvious than 'slight', BDD can be diagnosed if picking is triggered by concerns with the skin’s appearance and it can be ascertained that the skin preoccupation preceded the onset of picking or is present even when the skin is clear or blemishes are slight.
Repetitive behaviours aim to reduce the distress that is triggered by appearance preoccupations. If these behaviours do decrease distress, the relief is only temporary. These behaviours may immediately increase distress.
Repetitive behaviours are usually observable by others and can be a clue that a person may have BDD.[33][39]
The other three diagnostic criteria are the presence of appearance preoccupations, significant distress, and the appearance preoccupation is not better explained by an eating disorder.
poor psychosocial functioning and quality of life
On average, psychosocial functioning and quality of life are very poor in both youth and adults. Scores on 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.[32][33]
That the appearance preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning is a diagnostic criterion for BDD under DSM-5-TR (one of four diagnostic criteria, which must all be met).[1]
The other three diagnostic criteria are the presence of appearance preoccupations, repetitive behaviours, and the appearance preoccupation is not better explained by an eating disorder.
distressing emotions
The appearance preoccupations trigger a range of distressing emotions, such as embarrassment, shame, anxiety, and depression, which can lead to self-consciousness and even suicidal thinking. Anger and hostility are also common. Other negative emotions include guilt (for example, after having cosmetic surgery with an unsatisfactory outcome), disgust, and grief (for example, over years lost to BDD symptoms).[26]
That the appearance preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning is a diagnostic criterion for BDD under DSM-5-TR (one of four diagnostic criteria, which must be met).[1]
The other three diagnostic criteria are the presence of appearance preoccupations, repetitive behaviours, and the appearance preoccupation is not better explained by an eating disorder.
appearance concerns not better explained by an eating disorder
The final of the four diagnostic criteria under DSM-5-TR (all of which must be met) 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 non-facial 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.
The other three diagnostic criteria are the presence of appearance preoccupations, repetitive behaviours, and significant distress.
social anxiety and social avoidance
Social anxiety and social avoidance are common due to inaccurate fears that other people are thinking that the person looks ugly or are taking special notice of them because they are ugly.[33][48]
This may also be seen in other disorders (unrelated to appearance concerns).
Social avoidance typically causes impairment in functioning. That the appearance preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning is a diagnostic criterion for BDD under DSM-5-TR (one of four diagnostic criteria, which must be met).[1]
Other diagnostic factors
common
absence of BDD-related insight
BDD-related insight is typically poor or absent. Most individuals with BDD are mostly or completely certain that they really do look ugly, deformed, or unattractive, even though they look normal or even attractive to others.[47]
Level of insight is one of the two specifiers that needs to be considered under DSM-5-TR once a diagnosis of BDD has been made. The other specifier is whether the patient has the muscle dysmorphia form of BDD.[1]
referential thinking (ideas or delusions of reference)
Referential thinking (i.e., ideas or delusions of reference) is common. Most people with BDD mistakenly think that other people take special notice of them in a negative way because of how they look (for example, talk about them, stare at them, or laugh at them). Some patients are completely convinced of this, whereas others are less certain.[39]
Referential thinking may be seen in other disorders, but unrelated to appearance concerns.
onset <18 years of age
BDD can begin as young as age 4 or 5. It most often onsets at age 12-13; the mean age at onset is 16-17. Two-thirds of cases onset before age 18. BDD only occasionally begins after age 40.[6]
Risk factors
strong
heritability/genetics
weak
visual processing aberrations
Individuals with BDD exhibit a bias for encoding and analysing details of faces and non-face objects, such as houses. In addition, holistic visual processing, which emphasises a global and more integrated view of objects, appears disrupted.[17][18] Therefore, details of the face and body override the big picture, gestalt view of one’s appearance. These visual processing aberrations are similar to those of individuals with anorexia nervosa; however, they also differ from and are more severe than visual processing aberrations in anorexia nervosa.[19] It is unclear whether visual processing aberrations in BDD precede the development of BDD and are a risk factor for BDD, or whether they are simply a co-occurring characteristic of BDD.
neurocognitive dysfunction and emotional processing deficits
BDD is associated with neurocognitive dysfunction (for example, executive functioning deficits) and emotional processing deficits, such as deficits in recognising emotions conveyed by the facial expressions of other people.[23] However, it is not known whether these abnormalities precede the development of BDD and are a risk factor for BDD, or whether they are simply a co-occurring feature of BDD.
childhood abuse, neglect, and trauma
teasing/bullying
BDD has been associated with a history of teasing or bullying about appearance and competence, but it is unclear whether teasing and bullying are risk factors for the development of BDD.[16]
characteristic temperament/personality
image-centric social media use
Numerous studies suggest that use of image-centric social media is associated with, and might increase the risk of developing, more general body image dissatisfaction.[30] Regarding BDD specifically, one cross-sectional study found an association between BDD and greater use of Snapchat and Instagram.[31] It is not known whether use of social media platforms that extol physical perfection, sow dissatisfaction with one’s appearance, or enable or encourage alteration of one’s appearance are risk factors for the development of BDD, although this seems plausible in the opinion of the author.
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