A young female patient comes to the clinic with concerns of depression. Her symptoms, however, are not characteristic of depression and she is wearing heavy, concealing clothing – including gloves – despite the warm weather. Such presence and dress could suggest a stronger than usual concern about one’s appearance, a defining characteristic of body dysmorphic disorder (BDD). BDD is a psychiatric disorder characterized by an intense and persistent preoccupation of perceived physical defects that are not observable or would appear minor to others. BDD is most common in female adolescents, and more prevalent in cosmetic surgery, dermatology, and inpatient psychiatric settings.
People with BDD spend hours every day fixating on their appearance. They tend to cope with this preoccupation by trying to hide their bodies and mask perceived imperfections, sometimes attempting to “fix” themselves with unsafe cosmetic procedures or even self-harm. This behavior can lead to avoidance of social interaction that negatively affects work, school, and social life. In fact, nearly one-third of individuals with BDD become housebound. Most have at least one psychiatric comorbidity, including suicidality, with an estimated 10-35 percent attempting suicide more than once. Despite its far-reaching negative consequences most people with BDD do not seek treatment. When they do, clinical features of BDD often overlap or co-occur with other psychiatric conditions, making it difficult to diagnose.
Diagnosing Body Dysmorphic Disorder (BDD)
People with BDD usually do not discuss concerns about their appearance out of fear, shame, or embarrassment. Diagnosis of this complicated disorder requires a thorough, nonjudgmental assessment using motivational interviewing techniques modified for BDD and clinical exam based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). For younger patients, it may be helpful to have a parent or caregiver involved as they may disclose additional symptoms or may be accommodating BDD-related behaviors.
The first step is to ask questions about BDD’s core features, including:
- Whether the patient worries about their appearance and wishes they could think about it less.
- Observing how the patient presents themselves during the exam, which may reveal subtle behaviors that telegraph concerns such as wearing a hood, hat, or sunglasses inside, or frequently checking their appearance in a window or on their phone.
- Which aspects of their appearance elicit concern, starting from head to toe and observing the patient’s answers and physical reactions.
- Whether their appearance concerns relate to body shape, which could indicate an eating disorder.
- Whether their concerns cause significant distress or impairment in daily life.
- The extent to which they believe their appearance concerns are true/accurate (known as insight). Many people with BDD have poor insight, where they perceive defects that others do not or would not.
Additionally, look for repetitive behaviors such as spending extended time hiding, changing, or checking their appearance.
A physical exam may reveal signs of repeated injury from trying to alter their appearance. Look for evidence of abrasions caused by needles, razors, or knives on the skin, skin-picking, or unsafe cosmetic procedures such as skin bleaching or injection of saline solution into the lips.
A validated rating scale, such as the Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS) is helpful to confirm the diagnosis and assess symptom severity.
After determining BDD as a diagnosis, assess for comorbid conditions such as eating disorders, depression or anxiety, substance use disorders, obsessive-compulsive disorder, suicidality, and non-suicidal self-injury.
Our current patient came to the clinic to seek help with depression. But her clothing and thick gloves were inappropriate for the season, prompting a work-up for BDD. Although reluctant to reveal her appearance concerns, she eventually took off her gloves and revealed that she thought her hands were ugly. She feared that others were judging how she looked. She self-isolated and bleached her hands in order to “correct” the perceived imperfection. Cases like this one highlight the importance of identifying overlapping symptoms to develop a treatment plan that incorporates comprehensive management of BDD, depression, and self-harm.
Establishing a Treatment Plan for BDD with Frequent Follow-up
After confirming the diagnosis of body dysmorphic disorder, treatment for BDD typically involves counseling designed for BDD and medications (such as selective serotonin reuptake inhibitors [SSRIs]), but this may vary depending on symptom severity and comorbidities. The treatment plan should include a safety plan for patients prone to suicidality or self-harm. Since relapses are common and treatments may not always be effective, frequent follow-up should be offered to assess response to treatment and consider the need for more intensive management. Treatment strategies and resources for obsessive-compulsive disorder may also be helpful in complex cases.
BDD is often a severe psychiatric disorder, and multiple attempts may be required to find an effective treatment plan. During each follow-up, consider using validated rating scales such as the Yale-Brown Obsessive-Compulsive Scale Modified for BDD for adults (BDD-YBOCS) and adolescents (BDD-YBOCS-A) to assess response to treatment. With proper treatment, most patients with BDD are reported to show improvement.
