List of Clinical Disorders
Perhaps the most important thing to keep in mind is that many patients with BDD do not spontaneously reveal their BDD symptoms to their clinician because they are too embarrassed and ashamed, fear being negatively judged (e.g., considered vain), feel the clinician will not understand their appearance concerns, or do not know that body image concerns are treatable. Yet, research has shown that patients want their clinician to ask them about BDD symptoms. It is especially important to inquire about BDD symptoms in mental health settings, substance abuse settings, and settings where cosmetic treatment is provided (e.g., surgical, dermatologic, dental).
To diagnose BDD, the DSM-5 criteria should be followed. DSM-5 classifies BDD in the chapter of “Obsessive-Compulsive and Related Disorders.” The DSM-5 diagnostic criteria for BDD require the following:
- Appearance preoccupations: The individual must be preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance. “Preoccupation” is usually operationalized as thinking about the perceived defects for at least an hour a day. Note that distressing or impairing preoccupation with obvious appearance flaws (for example, those that are easily noticeable/clearly visible at conversational distance) is not diagnosed as BDD; rather, such preoccupation is diagnosed as “Other Specified Obsessive-Compulsive and Related Disorder”).
- Repetitive behaviors: At some point, the individual must perform repetitive, compulsive behaviors in response to the appearance concerns. These compulsions can be behavioral and thus observed by others – for example, mirror checking, excessive grooming, skin picking, reassurance seeking, or clothes changing. Other BDD compulsions are mental acts – such as comparing one’s appearance with that of other people. Note that individuals who meet all diagnostic criteria for BDD except for this one are not diagnosed with BDD; rather, they are diagnosed with “Other Specified Obsessive-Compulsive and Related Disorder.”
- Clinical significance: The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This criterion helps to differentiate the disorder BDD, which requires treatment, from more normal appearance concerns that typically do not need to be treated with medication or therapy.
- Differentiation from an eating disorder: If the appearance preoccupations focus on being too fat or weighing too much, the clinician must determine that these concerns are not better explained by an eating disorder. If the patient’s only appearance concern focuses on excessive fat or weight, and the patient’s symptoms meet diagnostic criteria for an eating disorder, then he or she should be diagnosed with an eating disorder, not BDD. However, if criteria for an eating disorder are not met, then BDD can be diagnosed, as concerns with fat or weight in a person of normal weight can be a symptom of BDD. It is not uncommon for patients to have both an eating disorder and BDD (the latter focusing on concerns other than weight or body fat).