Introduction
Body dysmorphic disorder (BDD) is a recognized psychiatric condition characterized by a significant preoccupation with perceived flaws in one’s physical appearance that are either unnoticeable or appear minor to others. Defined within the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR), BDD is more than mere vanity; it’s a debilitating condition marked by intense focus on these perceived imperfections, leading to repetitive behaviors and, in severe cases, suicidal thoughts and actions. Often, individuals with BDD seek cosmetic procedures, believing them to be the solution, highlighting the critical need for accurate diagnosis and appropriate intervention. Given the symptom overlap with other psychiatric conditions, establishing a precise Body Dysmorphic Disorder Differential Diagnosis is paramount for effective patient management. This article will delve into the nuances of differential diagnosis for BDD, ensuring clinicians can accurately distinguish it from similar disorders and provide targeted, evidence-based care.
Etiology
The development of body dysmorphic disorder is multifaceted, arising from an interplay of psychological, social, and biological factors. Research into the precise pathogenesis of BDD is ongoing, with studies often limited by sample size. Neuroimaging studies have suggested potential etiological factors or consequences of the disorder itself. Genetic predispositions are indicated by twin studies, estimating a 43% heritability for BDD. A preliminary gene study pointed towards the GABA-A-gamma-2 (5q31.1-q33.2) receptor gene as being more prevalent in individuals with BDD. Environmental and psychological factors also play a crucial role. Experiences of physical or sexual abuse and a history of parental neglect or low perceived parental care during childhood are associated with an increased risk of developing BDD.
Epidemiology
Body dysmorphic disorder is a global concern, affecting individuals across all ages and genders, although it is slightly more prevalent in females than males. The worldwide prevalence is estimated to be between 2% and 3%. Studies in the United States and other countries have reported similar prevalence rates of approximately 2% to 3% in adults, 2% to 5% in adolescents, and around 3% among university students.
A significant portion of patients seeking cosmetic surgery, about 13% in general cosmetic surgery settings, are estimated to have BDD. This number rises to approximately 20% among those seeking rhinoplasty and about 11% for patients considering orthognathic surgery. Furthermore, 5% to 10% of individuals seeking orthodontic treatment may also be affected by BDD. The desire for surgical correction of perceived flaws can sometimes lead individuals with BDD to engage in medical tourism.
BDD frequently coexists with other psychiatric disorders, including anxiety, depression, psychotic disorders, and bipolar spectrum disorders. Comorbidity rates in inpatient psychiatric settings are around 7% and about 6% in outpatient settings. Notably, individuals with obsessive-compulsive disorder (OCD) and eating disorders may exhibit even higher rates of comorbid BDD.
Pathophysiology
Our understanding of the underlying biological mechanisms of BDD is still evolving. Currently, there are no definitive biomarkers for the disorder. However, research has identified potential biological factors and overlapping features with OCD that may offer insights. Neuroanatomical findings in BDD are not entirely consistent across studies. Magnetic resonance imaging (MRI) studies have reported findings such as increased white matter volume, altered caudate volume asymmetry, smaller orbitofrontal cortex, and anterior cingulate volume, alongside larger thalamic volumes in BDD patients compared to healthy individuals. Disorganization of white matter tracts connecting visual processing, emotion, and memory areas might contribute to the delusional level of preoccupation seen in some BDD cases, reflecting poor insight into their perceived appearance flaws.
Functional MRI (fMRI) and visual processing task studies indicate that individuals with BDD tend to have enhanced local or detail-oriented visual processing while exhibiting diminished holistic or global visual processing. fMRI studies involving facial viewing tasks revealed abnormal hyperactivity in the left orbitofrontal cortex and bilateral caudate head, coupled with hypoactivity in the occipital cortex, a region involved in visual processing. Another fMRI study noted hypoactivity in the dorsal visual and parietal networks in BDD patients compared to controls.
Emotional processing deficits are also observed in BDD, with patients demonstrating a reduced ability to recognize emotions from facial expressions. Studies suggest a tendency to misinterpret neutral facial expressions as angry. Executive function may also be compromised, particularly in areas such as response inhibition, planning, and decision-making. These neuropsychological findings, combined with neuroimaging results, suggest potential frontal lobe dysfunction in individuals with BDD.
History and Physical Examination
Patients with BDD are consumed by thoughts of personal physical defects that are either minimal or nonexistent. These persistent thoughts are difficult to manage, often occupying 3 to 8 hours of their day. While some individuals fixate on a single body area, others are concerned with multiple areas, averaging 5 to 7 different preoccupations. Any physical attribute can become a source of concern, but common areas include the skin, hair, nose, stomach, breasts, and eyes. Males are more frequently concerned about genital size and hair loss, whereas females often focus on body fat distribution, such as breasts, legs, hips, buttocks, and waist.
The intense belief in being ugly, deformed, or flawed leads to significant emotional distress. Repetitive behaviors, or compulsions and rituals, are performed in an attempt to alleviate this psychological distress. Nearly all BDD patients engage in repetitive behaviors at some point during their illness. Common rituals include camouflaging, mirror checking, excessive grooming, clothes changing, excessive exercise, seeking reassurance, and hiding or inspecting the perceived defect. Some rituals are not externally observable and are purely mental, such as comparing oneself to others, counting, or self-reassurance.
Physical findings during a mental status examination are variable. Skin or hair-picking wounds, beyond the perceived flaw, might be visible, along with attempts at camouflaging. Compulsive behaviors may be observed directly, such as skin picking, hair combing, covering the concerning body part, counting, or self-reassuring.
During a physical examination, especially in non-psychiatric settings, it is important to differentiate between a perceived flaw and an actual physical defect. The examination should focus on the areas of concern voiced by the patient.
Evaluation
BDD often goes unrecognized. Clinical clues that may suggest BDD include treatment-resistant anxiety or depression, a history of unsatisfactory cosmetic procedures, or the patient’s belief that others are mocking their appearance. Substance use, intended to alleviate distress and avoid social situations, and the pursuit of multiple cosmetic procedures should raise suspicion. Screening in mental health, substance abuse, and cosmetic surgery settings is crucial for improving detection rates. Tools such as the Body Image Disturbance Questionnaire or the Body Dysmorphic Disorder Questionnaire are available for screening purposes. Directly inquiring about BDD symptoms is essential, as patients may not spontaneously disclose them.
Suspected BDD cases warrant referral for psychiatric evaluation. The initial psychiatric assessment aims to establish trust, gather detailed historical information about the presenting problem, and conduct a mental status examination. Questions should be asked sensitively and non-judgmentally. Building rapport is especially important for patients with limited insight who may be reluctant to share their experiences or engage in treatment. The psychiatric evaluation should systematically address each of the DSM-5-TR diagnostic criteria for BDD.
Body Dysmorphic Disorder DSM-5-TR Diagnostic Criteria:
- Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear minor to others.
- Performance of repetitive behaviors (e.g., mirror checking, excessive grooming) or mental acts (e.g., comparing appearance to others) in response to appearance concerns.
- Clinically significant distress or impairment in social, occupational, or other important areas of functioning due to the appearance preoccupation.
- The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
If muscle size is the primary concern, the specifier “body dysmorphic disorder with muscle dysmorphia” is used. If panic attacks occur in relation to BDD symptoms, “body dysmorphic disorder with panic attacks” is diagnosed.
Assessing the patient’s level of insight into their condition is crucial for guiding treatment planning and expectations. Insight can range from good to absent:
- Good or fair insight: The individual recognizes that their BDD beliefs are not or probably not true.
- Poor insight: The individual believes their BDD beliefs are likely true.
- Absent insight/delusional beliefs: The individual is completely convinced their BDD beliefs are true, regardless of evidence to the contrary.
Laboratory tests and radiographic imaging are typically not necessary unless there are concerns about physical health due to extreme behaviors.
Treatment and Management
Cosmetic surgery is not a recommended treatment for BDD, as it is ineffective and can exacerbate the condition. Effective treatment strategies involve a combination of medications and cognitive-behavioral therapy (CBT). Selective serotonin reuptake inhibitors (SSRIs) and clomipramine, a tricyclic antidepressant, are considered first-line pharmacotherapeutic options, drawing from their efficacy in treating obsessive-compulsive disorder. There is no direct comparative data on the effectiveness of pharmacotherapy versus CBT.
Psychotherapeutic Interventions
Establishing a strong therapeutic relationship is foundational to BDD treatment. While supportive psychotherapy alone is unlikely to alleviate BDD symptoms, patient education about the disorder, active listening, and guidance on treatment options are crucial for building trust. It is important to acknowledge the patient’s distress without focusing excessively on their perceived appearance. Instead, the focus should shift to how these preoccupations impact daily functioning, such as psychological suffering, suicidal thoughts, social avoidance, impaired work or academic performance, and interpersonal conflicts. Discouraging cosmetic procedures is essential, as they rarely resolve BDD symptoms and can lead to financial strain and symptom worsening.
CBT, particularly BDD-specific CBT, is a primary treatment intervention. CBT aims to identify and modify maladaptive beliefs central to BDD. Techniques include psychoeducation, relaxation exercises, coping skills development, and stress management. While access to CBT therapists may be limited compared to medication, telehealth CBT has shown efficacy and can improve treatment accessibility. Motivational interviewing can be helpful for patients hesitant to engage in treatment, especially in severe BDD cases.
Psychotropic Medication Interventions
Pharmacotherapy is often more readily accessible than psychotherapy. SSRIs are superior to placebo in treating BDD and are generally well-tolerated. While no specific SSRI is proven to be superior, higher doses than typically approved are often necessary. Fluoxetine, sertraline, and escitalopram are often preferred choices. Escitalopram may be favored in patients on multiple medications due to a lower risk of drug-drug interactions. Citalopram is generally not recommended due to FDA dosing limits that may be too low for effective BDD treatment and the risk of QT prolongation at higher doses. Paroxetine may be less well-tolerated than other SSRIs.
For patients who do not respond adequately to SSRIs, augmenting with clomipramine, a tricyclic antidepressant with FDA approval for OCD, can be considered. Clomipramine is generally a second-line treatment due to its potential side effects compared to SSRIs. Doses exceeding 250mg/day can cause significant adverse effects. Monitoring for serotonin syndrome and QT prolongation is important. The mechanism of action for SSRIs and clomipramine in BDD is thought to involve alterations in serotonin turnover and neuropeptide expression in brain circuits. These medications help reduce body dysmorphic preoccupations and compulsive behaviors. SSRIs and TCAs are also effective for comorbid depression and anxiety, which are common in BDD.
Evidence for other pharmacological treatments is limited. Buspirone, glutamate modulators like memantine, or second-generation antipsychotics may be considered as augmentation agents to SSRIs. Venlafaxine monotherapy has shown some efficacy in small studies. Bupropion augmentation of SSRIs has also been reported to be beneficial in case reports. Monoamine oxidase inhibitors are generally not recommended due to potential adverse effects and limited evidence of efficacy.
Given the high risk of suicidal ideation and behavior in BDD, patients with active suicidal thoughts or recent suicidal behavior require inpatient hospitalization.
Body Dysmorphic Disorder Differential Diagnosis
Distinguishing BDD from other psychiatric disorders and normal appearance concerns is crucial due to symptom overlap and common psychiatric comorbidities. Accurate body dysmorphic disorder differential diagnosis is essential to avoid misdiagnosis and ensure appropriate treatment.
1. Normal Appearance Concerns vs. BDD:
Most individuals have concerns about their appearance, which are considered normal and non-pathological. The key differentiator is the absence of obsessive preoccupations, compulsive behaviors, significant psychological distress, and functional impairment in normal appearance concerns. These concerns are fleeting and do not dominate daily life.
2. Obvious Bodily Defects vs. BDD:
When an individual is preoccupied with a bodily defect that is clearly visible to others, and they meet all other DSM-5-TR criteria for BDD, the diagnosis is “other specified obsessive-compulsive and related disorder (body dysmorphic-like disorder with actual flaws)”. It is important to note that BDD-related compulsive behaviors like skin picking can actually lead to visible bodily defects. In such cases, comorbid excoriation disorder should be considered.
3. Skin Picking (Excoriation) Disorder vs. BDD:
While skin picking can occur in BDD, the primary motivation in excoriation disorder is not to improve a perceived appearance flaw. Excoriation disorder is characterized by repetitive skin picking resulting in skin lesions, driven by urges or in response to emotions, not primarily focused on appearance perfection.
4. Trichotillomania (Hair-Pulling Disorder) vs. BDD:
Trichotillomania involves the compulsive urge to pull out one’s hair. If hair-pulling is primarily aimed at improving a perceived bodily defect, and other BDD criteria are met, BDD is the more appropriate diagnosis. However, if the hair pulling is driven by tension and relief, irrespective of appearance concerns, trichotillomania is the primary diagnosis.
5. Isolated Dysmorphic Concern vs. BDD:
If a patient presents with a dysmorphic concern but lacks compulsive, repetitive behaviors or rituals, they do not meet BDD criteria. An example is isolated concern about body odor. Isolated dysmorphic concerns are not a formal diagnostic category in DSM-5-TR or ICD-11 but may warrant clinical attention.
6. Obsessive-Compulsive Disorder (OCD) vs. BDD:
Both BDD and OCD fall under obsessive-compulsive and related disorders and share features like obsessions and compulsions. Both involve intrusive, persistent thoughts causing distress and functional impairment, and often involve secrecy due to shame. The critical distinction lies in the content of the obsessions. In BDD, obsessions and compulsions are specifically centered on perceived physical appearance flaws. If a patient meets criteria for both BDD and OCD, both diagnoses should be given.
7. Gender Dysphoria vs. BDD:
Both gender dysphoria and BDD involve a desire to change physical appearance and result in distress and functional impairment. However, in gender dysphoria, the focus is on primary or secondary sex characteristics and the distress stems from incongruence between assigned sex and experienced gender identity. The desire for change in BDD is not related to gender identity but to perceived flaws in appearance.
8. Eating Disorders vs. BDD:
Anorexia nervosa, bulimia nervosa, and BDD can all involve distorted body image and behaviors to alter appearance, such as dieting, compensatory behaviors, and excessive exercise. In eating disorders, the primary concern is body weight and shape, while in BDD, it’s perceived flaws in specific body features, which may or may not be related to weight or shape. If a patient meets criteria for both an eating disorder and BDD, both diagnoses should be assigned, ensuring symptoms are not solely attributable to one disorder.
9. Major Depressive Disorder vs. BDD:
Comorbid major depressive disorder is common in BDD. Patients meeting criteria for both should be diagnosed with both. However, BDD itself can present with depressive symptoms like anhedonia, concentration difficulties, guilt, low mood, sleep disturbances, and appetite changes, even without meeting full criteria for major depressive disorder. The depressive symptoms in BDD are often secondary to the distress caused by appearance preoccupations.
10. Social Anxiety Disorder (SAD) vs. BDD:
Social withdrawal can occur in both BDD and SAD. In BDD, avoidance is driven by fear of being judged based on perceived appearance flaws. In SAD, the primary fear is negative evaluation of behavior or speech content. BDD also involves repetitive behaviors, which are not characteristic of SAD. If criteria for both are met, both diagnoses should be considered.
11. Delusional Disorder vs. BDD:
Severe BDD with poor insight can present with delusional beliefs about appearance. In BDD, preoccupation doesn’t have to be delusional but can be an exaggeration of a minor flaw. Compulsions are also characteristic of BDD but not delusional disorder. If the appearance belief is held with delusional conviction and without significant compulsive behaviors, delusional disorder, somatic type, might be considered, although BDD with absent insight can also present with delusional intensity beliefs. Careful assessment of insight and the presence of compulsions is key to differentiating these conditions.
Pertinent Studies and Ongoing Trials
While psychopharmacology and psychotherapy are the main treatment modalities for BDD, neuromodulation techniques are being explored. Deep brain stimulation (DBS), effective in OCD, is being investigated for BDD. A case study reported successful BDD symptom reduction with DBS of the ventral capsule/ventral striatum. Further research is needed to establish the role of neuromodulation in BDD treatment.
Prognosis
With treatment, including medication, psychotherapy, or both, 50% to 80% of BDD patients show a positive response within 4 to 16 weeks. Maintenance treatment is generally recommended to prevent relapse, but the optimal duration is not yet established.
Complications
BDD significantly impairs social relationships, emotional processing, and work/school performance, leading to a poor quality of life. Comorbid psychiatric disorders are common, with major depressive disorder affecting nearly 75% of BDD patients. Other frequent comorbidities include social anxiety disorder, substance use disorders, OCD, personality disorders, and eating disorders.
Suicidal ideation is present in approximately 50% of BDD patients, and suicide attempts are estimated to occur in about 25%.
Consultations
Recognizing the prevalence of BDD among individuals seeking cosmetic procedures, several medical organizations recommend screening for BDD in relevant settings. The American College of Obstetricians and Gynecologists recommends screening adolescents seeking breast or labial surgery and considering screening adults seeking female genital cosmetic surgery. The American Academy of Otolaryngology lists BDD as a contraindication for elective rhinoplasty and advises screening patients seeking this procedure.
Deterrence and Patient Education
Patient education is crucial for deterrence and management of BDD. Emphasize that BDD is a psychiatric condition characterized by overwhelming preoccupation with perceived physical defects, commonly involving skin, hair, nose, genitalia, breasts, and body shape. Highlight that these thoughts are intrusive, difficult to control, cause distress, and consume significant time daily. Explain that repetitive behaviors are attempts to manage distress but are ultimately unhelpful. Crucially, educate patients that cosmetic surgery is not an effective treatment and can be harmful. Promote seeking help from mental health professionals, emphasizing that CBT and medication can significantly improve symptoms.
Pearls and Other Issues
Optimizing the clinician-patient relationship is vital, especially with patients who have limited insight. Careful language and tone during assessment are essential. Avoid using terms like “imagined” defects, which can be dismissive. Empathy is key to encouraging patients to share their experiences and explore the impact of their symptoms. Balance is needed to acknowledge patient distress without validating inaccurate perceptions of defects. Avoid arguing about physical appearance; instead, focus on treating the underlying psychiatric symptoms.
Enhancing Healthcare Team Outcomes
Effective BDD management relies on early recognition across healthcare settings. Clinicians in dermatology, plastic surgery, primary care, and dentistry are often the first point of contact for BDD patients. Screening and identification by these professionals are crucial, followed by appropriate referrals to psychiatry and collaboration between psychiatric clinicians and psychologists to develop comprehensive treatment plans. Given potential poor insight in BDD, a strong therapeutic alliance is paramount for treatment adherence and positive outcomes.
Review Questions
(Original article links to review questions online)
References
(Same references as original article)
Disclosure: Holly Nicewicz declares no relevant financial relationships with ineligible companies.
Disclosure: Tyler Torrico declares no relevant financial relationships with ineligible companies.
Disclosure: Jacqueline Boutrouille declares no relevant financial relationships with ineligible companies.
