Body dysmorphic disorder: Assessment, diagnosis, and differential diagnosis
- Katharine A Phillips, MD
Katharine A Phillips, MD
- Professor of Psychiatry and Human Behavior
- Warren Alpert Medical School of Brown University
Body dysmorphic disorder (BDD) is characterized by preoccupation with nonexistent or slight defects in physical appearance, such that patients believe that they look abnormal, unattractive, ugly, or deformed, when in reality they look normal. The preoccupation with perceived flaws leads to repetitive behaviors (eg, checking their appearance in mirrors), which are difficult to control and are not pleasurable. BDD is common but usually under-recognized, causes distress and/or impaired functioning, and is often associated with suicidal ideation and behavior.
Patients with BDD may present to mental health professionals as well as other clinicians, such as dermatologists, plastic surgeons, primary care physicians, pediatricians, and dentists. Most patients seek nonpsychiatric treatment (most commonly dermatologic or surgical) for their perceived physical defects; this treatment appears to be ineffective for most patients and can be risky for clinicians to provide. By contrast, pharmacotherapy (eg, selective serotonin reuptake inhibitors or clomipramine) and/or cognitive-behavioral therapy tailored specifically to BDD are often efficacious.
This topic reviews the assessment, diagnosis, and differential diagnosis of BDD. The epidemiology, pathogenesis, clinical manifestations, treatment and prognosis of BDD are discussed separately. (See "Body dysmorphic disorder: Epidemiology, pathogenesis, and clinical features" and "Body dysmorphic disorder: Treatment and prognosis".)
The initial clinical evaluation of patients with a possible diagnosis of body dysmorphic disorder (BDD) includes a general psychiatric history, general medical history, and mental status examination, with emphasis upon suicidal ideation and behavior, delusional BDD symptoms, and depressive symptoms [1-3]. As with all psychiatric patients, a physical examination is indicated and typically is performed by the patient’s primary care clinician or an internal medicine consultant; however, many patients refuse examinations because they do not want their bodies seen by others. Laboratory tests are obtained on the basis of the history and examination.
Screening instruments — Screening instruments can facilitate diagnosis, but are not intended to diagnose BDD by themselves. For patients who screen positive, a clinical interview is required to establish the diagnosis.
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- Screening instruments
- Clinical interview
- - Avoiding pitfalls
- Diagnostic clues
- Diagnostic criteria
- DIFFERENTIAL DIAGNOSIS
- Normal appearance concerns
- Obvious bodily defects
- Dysmorphic concern
- Eating disorders
- Unipolar major depression
- Social anxiety disorder
- Avoidant personality disorder
- Panic disorder
- Generalized anxiety disorder
- Obsessive-compulsive disorder
- Trichotillomania (hair-pulling disorder)
- Skin picking (excoriation) disorder
- Illness anxiety disorder
- Factitious disorder
- Psychotic disorders
- Gender dysphoria
- Olfactory reference syndrome
- Body identity integrity disorder
- INFORMATION FOR PATIENTS