How do you know whether you or someone you know has BDD?

Psychiatric diagnoses—
including BDD—are made primarily by asking questions to determine if an individual “meets
the criteria” for the disorder, as determined by the DSM-5. [1] There are as yet no blood tests,
brain-scanning techniques, or other tools sufficient to diagnose psychiatric disorders, although
such tools are being developed.

How BDD is Diagnosed
A mental health professional — preferably a BDD specialist — will look for the following in
order to make a diagnosis of BDD:

Preoccupation with appearance: People with BDD are preoccupied with one or more aspects
of their physical appearance, believing that these body areas look ugly, abnormal, deformed, or
disfigured. People with BDD obsess about the disliked body areas, usually for at least an hour a
day (and typically much more).

Insight Regarding BDD Beliefs: Most people with BDD are mostly convinced or completely
convinced that they look ugly or abnormal, even though other people don’t see them this way.

Repetitive Compulsive Behaviors: BDD preoccupations fuel repetitive compulsive behaviors

that are intended to fix, hide, inspect, or obtain reassurance about the disliked body parts. On
average, these behaviors consume from 3–8 hours a day. They are usually difficult to control or
stop. These behaviors may include the following:

 Camouflaging (trying to hide or cover up the disliked body areas)

 Comparing (comparing the disliked features to those of other people)
 Mirror checking, or checking other reflective surfaces (such as windows or cell phone
screens)
 Excessive grooming
 Reassurance seeking/questioning of others about appearance
 Skin picking to try to improve the skin’s appearance
 Changing clothes frequently
 Excessive tanning
 Excessive exercising or weight lifting
 Excessive shopping
 Seeking cosmetic surgery, dermatologic treatment, or other cosmetic procedures
 Social anxiety and avoidance

Significant Distress or Impairment in Functioning: These preoccupations with appearance

and repetitive compulsive behaviors cause significant emotional distress (e.g. sadness, anxiety,
irritability/anger, self-consciousness), and/or get in the way of day-to-day functioning.  BDD
symptoms usually interfere with one’s ability to engage in valued life activities such as working,
going to school, or spending time with family/friends.

A Self-Test for BDD

The BDD Questionnaire (BDDQ) [2] is a “self-test” that an individual fills out him/herself. Only
a trained mental health professional can diagnose BDD, but this test may serve as a helpful guide
for whether you should seek help. You may consider bringing your responses on this test with
you to your visit with a therapist or psychiatrist to discuss the results and what they mean.

BDD Questionnaire (BDDQ)

This questionnaire assesses concerns about physical appearance. Please read each question
carefully and select the answer that best describes your experience.

1. Are you worried about how you look? Examples of areas of concern include: your skin (for
example, acne, scars, wrinkles, paleness, redness); hair; the shape or size of your nose, mouth,
jaw, lips, stomach, hips, etc.; or defects of your hands, genitals, breasts, or any other body part.
Yes / No

IF YES: Do you think about your appearance problems a lot and wish you could think about
them less?   Yes / No

NOTE: If you answered “No” to either of the above questions, you are finished with this
questionnaire. Otherwise, please continue.

2. Is your main concern with how you look that you aren’t thin enough or that you might get too
fat?   Yes / No

3. How has this problem with how you look affected your life?

 Has it often upset you a lot?   Yes / No

 Has it often gotten in the way of doing things with friends, dating, your relationships with
people, or your social activities?   Yes / No
 Has it caused you any problems with school, work, or other activities?  Yes / No
 Are there things you avoid because of how you look?  Yes / No

4. On an average day, how much time do you usually spend thinking about how you look? (Add
up all the time you spend in total in a day)

 a. Less than 1 hour a day

 b. 1-3 hours a day
 c. More than 3 hours a day

You’re likely to have BDD if you give the following answers on the BDDQ:

 Question 1: Yes to both parts

 Question 3: Yes to any of the questions
 Question 4: Answer b or c
Screening Measures
 Body Dysmorphic Disorder Questionnaire (BDDQ): This is a brief self-report screening
measure for BDD; a follow-up in-person interview is needed to confirm the diagnosis.
The BDDQ has had high sensitivity (100%) and specificity (89-93%) for the BDD
diagnosis in psychiatric, cosmetic surgery, and dermatology samples.
 Body Image Disturbance Questionnaire (BIDQ): This brief self-report measure is a
slightly modified self-report version of the BDDQ that uses continuous response scaling.
It has strong psychometric properties in a non-clinical population, but sensitivity and
specificity data are needed. A follow-up in-person interview is needed to confirm the
diagnosis.

Diagnostic Measures
 Structured Clinical Interview for DSM-5 (SCID): The SCID’s BDD module is a brief
semi-structured clinician-administered measure.
 BDD Diagnostic Module: This brief semi-structured clinician-administered measure is
similar to and predated the SCID. A DSM-5 version is available for both adults and
youth.
 Body Dysmorphic Disorder Examination (BDDE): This semi-structured interview is
fairly lengthy, and is of limited usefulness for patients with more severe BDD symptoms.
A self-report version has been used in some studies, but its psychometric properties have
not been established.
 NOTE: It is NOT recommended that clinicians use the MINI Plus tool. This semi-
structured rater-administered measure, based on ICD-10 diagnostic criteria, is not
recommended for BDD; it likely under-diagnoses BDD.

Severity Measures
 BDD-YBOCS:This semi-structured rater-administered measure is similar to the Y-BOCS
for OCD with the exception that it includes two additional items (insight and avoidance).
All 12 items should be rated; it is not intended for use as a 10-item scale. It assesses BDD
severity during the past week. Scale scores range from 0-48. The cutpoint for the
presence of the BDD diagnosis is 20. It is intended for use only with people who have
already been diagnosed with BDD (it should not be used to diagnose BDD). The BDD-
YBOCS should be administered by a trained clinician or rater; a self-report version
should not be used, because its reliability and validity has not been demonstrated.
 BDD-PSR: This brief measure provides a global rating of BDD severity. It maps onto
DSM diagnostic criteria for BDD. The BDD-PSR is especially well suited for tracking
BDD severity in longitudinal course of illness studies. It identifies full criteria BDD and
subthreshold BDD, and it is well suited for tracking remission and relapse of BDD over
time.
  Body Dysmorphic Disorder Examination (BDDE): This measure (see above) also
assesses BDD severity.

Insight Measures
 Brown Assessment of Beliefs Scale (BABS):  This 7-item semi-structured rater-
administered measure assesses insight/delusionality in BDD and other disorders that are
characterized by false beliefs. It assesses insight/delusionality both dimensionally and
categorically. Items assess conviction, perception of others’ views of the belief,
explanation of differing views, fixity of the belief, attempts to disprove the belief, insight
(whether the belief has a psychiatric/psychological explanation), and ideas/delusions of
reference.
 Overvalued Ideas Scale (OVIS): The OVIS measures the current severity and extent of
overvalued ideas by considering their strength, reasonableness, fluctuation, accuracy,
degree to which others hold the same beliefs, attribution, insight, and degree of resistance
of the belief.
Diagnosing BDD

To diagnose BDD, the DSM-5 [1] diagnostic criteria should be followed. DSM-5 classifies BDD in the
chapter of “Obsessive-Compulsive and Related Disorders,” along with OCD and several other 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 (adding up all the time that is
spent throughout the day). Note that distressing or impairing preoccupation with obvious
appearance flaws (for example, those that are easily noticeable/clearly visible at conversational
distance, such as obesity) is not  diagnosed as BDD; rather, such preoccupation is diagnosed as
“Other Specified Obsessive-Compulsive and Related Disorder.”

 Repetitive behaviors:To qualify for a diagnosis of BDD, at some point during the course of the
disorder, 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 diagnostic 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).

 Specifiers:  Once BDD is diagnosed, clinicians should assess the two DSM-5 BDD specifiers to
identify meaningful subgroups of individuals with BDD:

o Muscle dysmorphia:The muscle dysmorphia form of BDD is diagnosed if the individual is

preoccupied with concerns that that his or her body build is too small or insufficiently
muscular. Many individuals with muscle dysmorphia are additionally preoccupied with
other body areas; the muscle dysmorphia specifier should still be used in such cases.
 Individuals with the muscle dysmorphia form of BDD have been shown to have even
higher rates of suicidality and substance use disorders, as well as poorer quality of life,
than individuals with other forms of BDD. In addition, the treatment approach may
require some modification.

o Insight specifier: This specifier indicates degree of insight regarding BDD beliefs (for
example, “I look ugly” or “I look deformed”) – that is, how convinced the individual is
that his/her belief about the appearance of the disliked body parts is true. Levels of
insight are “with good or fair insight,” “with poor insight,” and “with absent
insight/delusional beliefs.” Note that absent insight/delusional beliefs are diagnosed as
BDD, not as a psychotic disorder.

Differential Diagnosis

BDD is often misdiagnosed as another disorder. If it is misdiagnosed, patients may not receive
appropriate care or improve with treatment that is provided.

BDD is commonly misdiagnosed as one of the following disorders:

 Obsessive Compulsive Disorder:  If preoccupations and repetitive behaviors focus on appearance

(including symmetry concerns), BDD should be diagnosed rather than OCD.

 Social anxiety disorder (social phobia):  If social anxiety and social avoidance are due to
embarrassment and shame about perceived appearance flaws, and diagnostic criteria for BDD
are met, BDD should be diagnosed rather than social anxiety disorder (social phobia).

 Major depressive disorder:  Unlike major depressive disorder, BDD is characterized by

prominent preoccupation and excessive repetitive behaviors. BDD should be diagnosed in
individuals with depression if diagnostic criteria for BDD are met.

 Trichotillomania (hair-pulling disorder):  When hair tweezing, plucking, pulling, or other types of
hair removal is intended to improve perceived defects in the appearance of body or facial hair,
BDD should be diagnosed rather than trichotillomania (hair-pulling disorder).

 Excoriation (skin-picking disorder):  When skin picking is intended to improve perceived defects
in the appearance of one’s skin, BDD should be diagnosed rather than excoriation (skin-picking
disorder).

 Agoraphobia:  Avoidance of situations because of fears that others will see a person’s perceived
appearance defects should count toward a diagnosis of BDD rather than agoraphobia.

 Generalized anxiety disorder:  Unlike generalized anxiety disorder, anxiety and worry in BDD
focus on perceived appearance flaws.

 Schizophrenia and schizoaffective disorder:  BDD-related psychotic symptoms – i.e., delusional

beliefs about appearance defects or BDD-related delusions of reference – reflect the presence of
BDD rather than a psychotic disorder.
  Olfactory reference syndrome:  Preoccupation with emitting a foul or unpleasant body odor is a
symptom of olfactory reference syndrome, not BDD (although these two disorders have many
similar characteristics).

 Eating disorder:  If a normal-weight person is excessively concerned about being fat or their
weight, meets other diagnostic criteria for BDD, and does not meet diagnostic criteria for an
eating disorder, then BDD should be diagnosed.

 Dysmorphic concern:  This is not a DSM diagnosis, but it is sometimes confused with BDD. It
focuses on appearance concerns but also includes concerns about body odor and non-
appearance related somatic concerns, which are not BDD symptoms.

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 with psychiatric medication and/or
therapy. 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).