Questions to Help Uncover Hidden Body Dysmorphic Disorder

While persons with body dysmorphic disorder (BDD) are preoccupied with their imagined defects in appearance, they often hide their concerns from the outside world, making detection of the disorder a real challenge.

BDD affects an estimated 1% to 2% of the general population, and symptoms can be severe and their distressing and impairing preoccupation with imagined defects in appearance interferes with work and relationships. Comorbidity with major depressive disorder, substance use disorder, obsessive-compulsive disorder (OCD), and social phobia is common. For patients with eating disorders, shape, or weight preoccupation that is consistent with the disorder doees not constitute BDD. Criteria C for BDD states, “the preoccupation is not better accounted for any another mental disorder, such as dissatisfaction with shape and weight in Anorexia Nervosa.”

Nearly all patients with BDD have few or no friends and often avoid social interactions; some studies have reported that these patients’ quality of life is poorer than that of patients with OCD alone. In addition, 80% of patients with BDD report a history of suicidal ideation and about a fourth have attempted suicide. Results of one study noted that the rate of successful suicide among these patients is higher than in nearly all other mental disorders (Am J Psychiatry 2006; 163:1280).

Barriers to the diagnosis

Patients with BDD usually are embarrassed and ashamed about BDD and thus hide their symptoms. In addition, many BDD patients believe their problems are physical and do not recognize that their beliefs are caused by an underlying psychological or psychiatric problem. Thus, clinicians need to specifically ask about symptoms, using focused questioning, according to the authors. Also, BDD symptoms need to be differentiated from other disorders with similar symptoms. For example, social phobia and avoidant personality disorder share the symptoms of self-consciousness and anxiety in social settings—in BDD, fears of negative feedback are due to concerns about physical appearance.

Dr. Katherine A. Phillips of Brown University, Providence, RI, and colleagues at UCLA School of Medicine and Harvard Medical School recently offered some key questions to help clinicians diagnose BDD (Am J Psychiatry 165:9, 2008).

According to the authors, an important first step is engaging the patient and establishing an alliance, so that he or she is willing to consider psychiatric treatment. Often patients think cosmetic treatment is all they need, and would rather see a surgeon or dermatologist than a psychiatrist. However, patients with BDD usually eventually recognize that their quality of life is not good. Empathizing with their concerns about finding a better quality of life may help them make the decision to seek psychiatric help.

Questions to help make the diagnosis

Dr. Phillips and colleagues suggest a series of questions that may help lead clinicians to make a diagnosis of hidden  BDD.

• “Are you very worried about your appearance in any way? Or “Are you unhappy with the way you look?”
• “What don’t you like about the way you look?” or “Can you tell me about your concerns?”
• “Are you unhappy about any other aspects of your appearance?”
• “About how much time do you spend each day thinking about your appearance?”
• “How much distress do these concerns cause you?” It is helpful to ask specifically about any resulting anxiety, social anxiety, depression, and feelings of panic, as well as any suicidal ideas.
• “Do these concerns interfere with your life or cause problems in any way?” Note effects on work, caring for children, intimacy, social activities and other types of interference in the person’s life.

The researchers also suggest that although the absence of compulsive behaviors does not rule out the diagnosis, it’s helpful to ask patients about behaviors such as: frequently comparing oneself to others, checking oneself in the mirror, excessive grooming, frequently touching the disliked body area(s), changing clothing often, skin-picking, tanning, dieting, excessive exercise or excessive weight-lifting.