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Section 19
Diagnosis: Distinguishing the Clinical Presentation of BDD

Question 19 | Test | Table of Contents

BPD is often underdiagnosed and misdiagnosed
Although BDD has been described for more than a century (Morselli, 1891; Phillips, 1991) and reported around the world (Phillips, 1991), it remains underrecognized and underdiagnosed. Reasons for its underdiagnosis include BDD's past omission from the Diagnostic and Statistical Manual of Mental Disorders (DSM), patients' seeking of nonpsychiatric treatment (e.g., surgery), and, probably most important, patients' reluctance to reveal their appearance concerns because of embarrassment and shame (Phillips, 1996a).

BDD appears to be fairly common (Perugi et al., 1998; Phillips, Nierenberg, Brendel, & Fava, 1996; Simeon, Hollander, Stein, Cohen, & Arnowitz, 1995) but is usually missed by clinicians. Several studies that investigated BDD's prevalence in clinical populations found that the patient's clinician missed the diagnosis of BDD in all cases in which it was present (Phillips et al., 1996; Zimmerman & Mattia, 1998). Not diagnosing BDD is problematic because the patient may not feel understood, the patient is not adequately informed about his or her diagnosis and treatment options, and treatment may be unsuccessful. In addition, BDD does not necessarily improve when comorbid disorders improve unless it is a focus of treatment.

BDD can be diagnosed with the following questions:
Are you very worried about your appearance in any way? If yes: What is your concern?
Does this concern preoccupy you? Do you think about it a lot and wish you could worry about it less? If you add up all the time you spend thinking about your appearance each day, how much time do you think it would be?
What effect has this preoccupation with your appearance had on your life? Has it interfered with your job (or schoolwork), your relationships or social life, other activities, or other aspects of your life?
Have your appearance concerns caused you a lot of distress?
Have your appearance concerns affected your family or friends?

BDD can be diagnosed if the person reports being preoccupied with some aspect of his or her appearance, or his or her entire appearance. A useful guideline is whether the person thinks about the appearance "flaw" for at least an hour a day, although this cutpoint is not part of BDD's definition. Clinically significant distress or impairment in functioning must also be present.

Clues to the diagnosis include mirror checking or avoidance, comparing with others, seeking reassurance about the perceived flaw, excessive grooming (e.g., hair combing or shaving), skin picking, and camouflaging. Other clues include frequent clothes changing, body measuring, excessive exercising or weight lifting, seeking unnecessary dermatological treatment or surgery, and anabolic steroid use. Most patients have ideas or delusions of reference, social anxiety, and self-consciousness, and some are housebound (Phillips et al., 1994).

In addition to being underdiagnosed, BDD is often misdiagnosed as the following disorders:
Obsessive-compulsive disorder (OCD): Because BDD and OCD both involve prominent obsessions and compulsive behaviors, BDD is often misdiagnosed as OCD. However, as discussed later, the two disorders have some important differences, and are probably distinct disorders.
Depression: Depression often coexists with BDD (Phillips et al., 1993). Often the depression is diagnosed but the BDD is missed.
Social phobia: Because social anxiety is such a common consequence of BDD, the latter is often misdiagnosed as social phobia or avoidant personality disorder.
Agoraphobia: Some patients with BDD are housebound (Phillips et al., 1993) because they think they are so ugly that they cannot tolerate being seen by others; these patients may be misdiagnosed with agoraphobia.
Panic disorder: Patients with BDD can have panic attacks, for example, when looking in the mirror and hating what they see, or when thinking others are mocking them because of how they look; these panic attacks can be misdiagnosed as panic disorder.
Trichotillomania: Some patients with BDD pluck their hair in an effort to make it look better (e.g., to make their eyebrows more even), which can be misdiagnosed as trichotillomania.
Schizophrenia or psychotic disorder not otherwise specified (NOS): Because their beliefs can be delusional and accompanied by prominent delusions of reference (Phillips et al., 1994), some patients are diagnosed with schizophrenia or psychotic disorder NOS.

The best approach to diagnosing BDD is specifically to ask every patient the questions listed earlier, and to be alert to the clues to BDD. Unless BDD is specifically asked about, the diagnosis is likely to be missed.

What is the relationship between BDD and OCD? A commonly asked question is whether BDD is a symptom of OCD. Similarities between BDD and OCD have been noted over the past century (Janet, 1903; Morselli, 1891), and BDD is currently widely considered an OCD-spectrum disorder--that is, a disorder with similarities to OCD in a variety of domains (Hollander, 1993; Hollander & Phillips, 1993; McElroy, Phillips, & Keck, 1994). As a reflection of this hypothesis, BDD is included in the Symptom Checklist of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, et al., 1989a, 1989b) as a disorder that may be related to OCD. In addition, consideration was given to transferring BDD from the somatoform to the anxiety disorders section of DSM-IV (American Psychiatric Association, 1994), alongside OCD (Phillips & Hollander, 1996).  Indeed, available data suggest that BDD and OCD have many similarities. A study that compared 53 patients with BDD to 53 patients with OCD found no significant differences in sex ratio, employment status, most course and impairment variables, illness severity, and most comorbid disorders (Phillips, Gunderson, Mallya, McElroy, & Carter, 1998). In addition, two neuropsychological studies found that BDD subjects had deficits similar to those reported for OCD (Deckersbach et al., 1998; Hanes, 1998), although BDD and OCD subjects were directly compared in only one of these studies (Hanes, 1998). In one study (Deckersbach et al., 1998), BDD subjects had impaired verbal and nonverbal memory that appeared mediated by deficits in organizational encoding strategies. This finding indicates that executive dysfunction underlies memory deficits in BDD and suggests the presence of frontal-striatal system dysfunction, as appears to be the case for OCD. The other study (Hanes, 1998) also found impaired executive functioning in patients with BDD, similar to patients with OCD. In addition, BDD's treatment response appears largely similar to that for OCD (as described later), although treatment data for BDD are still preliminary.

However, BDD and OCD also appear to have some notable differences. In the BDD-OCD comparison study (Phillips, Gunderson, et al., 1998), patients with BDD were significantly less likely to be married (13% vs. 39%) and significantly more likely to have had suicidal ideation (70% vs. 47%) or to have made a suicide attempt (22% vs. 8%) due to their disorder. They also had earlier onset of major depression (18.8 +/- 6.5 vs. 25.3 +/- 10.$ years) and higher lifetime rates of major depression (85% vs. 55%), social phobia (49% vs. 19%), and psychotic disorder diagnoses (30% vs. 8%). Their first-degree relatives had a higher rate of substance use disorders. In a study that used the Brown Assessment of Beliefs Scale (Eisen et al., 1998), 20 BDD subjects had significantly poorer insight and a higher rate of ideas/delusions of reference than 20 OCD subjects (Eisen, Phillips, Rasmussen, & Luce, 1997). One way to conceptualize these findings is that BDD is a more depressed, socially phobic, and psychotic "relative" of OCD. BDD and OCD may also have some treatment differences, as described later.

Clinical observations suggest that there are additional differences between BDD and OCD, although these characteristics have not been directly compared in these disorders. Patients with BDD often have profound feelings of shame, embarrassment, and humiliation. Low self-esteem (Rosen & Ramirez, 1998), rejection sensitivity (Phillips et al., 1996), and feeling unlovable also appear more characteristic of persons with BDD than OCD. Another possible difference is less anxiety relief with rituals in BDD; in fact, BDD behaviors (such as mirror checking) often increase rather than decrease anxiety (Phillips, 1996a). In addition, available data suggest that mental health-related quality of life may be poorer in persons with BDD (Phillips, in press) than OCD (Koran, Thienemann, & Davenport, 1996), although comparison studies have not been done.

Until the etiology and pathophysiology of BDD and OCD are elucidated, the exact nature of their relationship will remain unknown. These disorders' etiology and pathophysiology are likely to be multifactorial and complex, involving both genetic (most likely, multiple genes of small effects) and environmental factors. It is likely that some of these disorders' etiological and pathophysiological factors will be shown to overlap and others will be shown to be distinct. More research is clearly needed. In the meantime, the apparent differences between BDD and OCD have some clinical implications: Patients with BDD need to be thoroughly assessed for depressive symptoms, which are common in this disorder and more common than in OCD. Patients with BDD should be carefully assessed and monitored for suicidal ideation and suicidal behavior, which are also common in this disorder. The poorer insight of patients with BDD may have implications for treatment compliance and response (which is discussed further later in this article). Cognitive-behavioral therapy may be less effective for delusional BDD than for OCD (discussed later), although this issue, too, needs to be studied. It is also possible that BDD is less responsive than OCD to exposure and response prevention alone (i.e., without a cognitive component; discussed later), although this question has received little investigation.

The relationship between BDD and depression: BDD has also been postulated to be a symptom of (Carroll, 1994), or related to (Phillips et al., 1994), depression. During the past century, many case descriptions have noted depressive symptoms, suicidal ideation, and suicide attempts in patients with BDD. Hay (1970), for example, in his classic article quotes a 20-year-old women who was obsessed with lines under her eyes and thoughts of suicide: "I am constantly thinking about them, about my face and how I have changed. Make-up is just a waste of time. Life is not worth living" (p. 402).

Also supporting a connection between BDD and depression is the high comorbidity between them. Studies that used structured assessment instruments have found that major depression is the most common comorbid disorder in patients with BDD. In clinical settings, current major depression has been reported in approximately 60% of patients with BDD, and lifetime major depression in approximately 80% (Phillips et al., 1994). Conversely, BDD appears relatively common in patients with major depression. Although one study found that none of 42 patients diagnosed with major depression had BDD (Brawman-Mintzer et al., 1995), larger studies have reported rates of BDD in depressed patients of 8% (of 334 patients; Nierenberg et al., 1995), 14% (of 80 patients; Phillips et al., 1996), and 42% (of 86 patients; Perugi et al., 1998). In one of the studies, BDD was more than twice as common as OCD (Phillips et al., 1996), and in another study (Perugi et al., 1998), it was more common than many other disorders, including OCD, social phobia, simple phobia, generalized anxiety disorder, bulimia nervosa, and substance abuse or dependence.

A number of similarities between BDD and depression also support the theory that they may be related disorders. For example, patients with BDD often report feelings of low self-esteem (Rosen & Ramirez, 1998), shame, rejection sensitivity (Phillips et al., 1996), unworthiness, and defectiveness--feelings often experienced by depressed patients. Such feelings are consistent with the core ideational content of BDD, which involves the belief that one is unattractive, defective, and unappealing. Furthermore, some patients with BDD have prominent feelings of guilt based on the belief that they are responsible for ruining their appearance (for example, due to sun exposure or cosmetic surgery) (Phillips, 1996a).  However, such feelings (e.g., guilt, rejection sensitivity) are not specific to depression. In addition, BDD and depression have some notable differences, such as the presence of prominent obsessional preoccupations and repetitive compulsive behaviors. Depressed patients often focus less on their appearance, even neglecting how they look, rather than becoming overfocused on it. And those depressed patients who dislike their appearance are unlikely to selectively and obsessionally focus on this aspect of themselves or to spend hours a day performing compulsive appearance-related behaviors, such as mirror checking and reassurance seeking. Other apparent differences between BDD and depression include a 1:1 gender ratio (Phillips Sc Diaz, 1997), earlier age of onset (Phillips et al., 1993), and often-chronic course (Phillips et al., 1993) for BDD. In addition, in the author's series of 260 BDD patients, onset of BDD usually preceded onset of major depression, suggesting that BDD is not simply a symptom of depression.

BDD and depression do not always respond to treatment concurrently (Phillips, Dwight, Sc McElroy, 1998). Unlike depression, BDD appears to respond to cognitive-behavioral therapy (CBT) but not to other types of psychotherapy alone (Phillips et al., 1993).

Studies of BDD's etiology and pathophysiology are needed to clarify the nature of its relationship to depression. The differences noted suggest that BDD is not simply a symptom of depression, although BDD and depression may be related disorders (Phillips, McElroy, et al., 1995). In some, if not many, patients with BDD, depression appears "secondary" to (i.e., due to) BDD. These conclusions have the following treatment implications: Simply treating depression will often not effectively treat BDD; both BDD and depressive symptoms need to be targeted for treatment. Longer treatment trials (up to 12 or 16 weeks) are often needed to successfully treat BDD and comorbid depressive symptoms (Phillips, Dwight, & McElroy, 1998).
- Phillips, Katharine A., Body dysmorphic disorder: Diagnostic controversies and treatment challenges; Bulletin of the Menninger Clinic, 00259284, Winter2000, Vol. 64, Issue 1

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Body Dysmorphic Disorder

- Veale, D. (2004). Body dysmorphic disorder. Postgrad Med j, 80. p. 67-71. doi: 10.1136/pmj.2003.015289

Personal Reflection Exercise #1
The preceding section contained information regarding distinguishing the clinical presentation of BDD from depression and OCD.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Body Dysmorphic Disorder

- Nicewicz, H. R., & Boutrouille, J. F. (2022). Body Dysmorphic Disorder. In StatPearls. StatPearls Publishing.


Peer-Reviewed Journal Article References:
Baker, J. H., Higgins Neyland, M. K., Thornton, L. M., Runfola, C. D., Larsson, H., Lichtenstein, P., & Bulik, C. (2019). Body dissatisfaction in adolescent boys. Developmental Psychology, 55(7), 1566–1578.

Ferguson, C. J. (2018). The devil wears stata: Thin-ideal media’s minimal contribution to our understanding of body dissatisfaction and eating disorders. Archives of Scientific Psychology, 6(1), 70–79.

Giraldo-O'Meara, M., & Belloch, A. (2019). The Appearance Intrusions Questionnaire: A self-report questionnaire to assess the universality and intrusiveness of preoccupations about appearance defects. European Journal of Psychological Assessment, 35(3), 423–435.

QUESTION 19
According to Phillips, when can Body Dysmorphic Disorder be diagnosed? To select and enter your answer go to Test.

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