Body Dysmorphic Disorder - General Principles of Treatment - UpToDate

23/2/24, 14:02 Body dysmorphic disorder: General principles of treatment - UpToDate
Official reprint from UpToDate®

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Body dysmorphic disorder: General principles of

treatment
AUTHOR: Katharine A Phillips, MD, DLFAPA
SECTION EDITOR: Joel Dimsdale, MD
DEPUTY EDITOR: David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Jan 18, 2024.
INTRODUCTION
Body dysmorphic disorder (BDD) is characterized by preoccupation with nonexistent or slight

defects in physical appearance, such that patients believe that they look abnormal,
unattractive, ugly, or deformed, when in reality they look normal. The preoccupation with
perceived flaws leads to repetitive behaviors (eg, checking their appearance in mirrors),
which are usually difficult to control and not pleasurable. BDD is common but
underrecognized, causes clinically significant distress and/or psychosocial impairment, and is
often associated with suicidal ideation and behavior.
Patients with BDD may present to mental health professionals as well as other clinicians,
such as dermatologists, plastic surgeons, otolaryngologists, primary care clinicians,
pediatricians, gynecologists, and dentists. Most patients seek nonpsychiatric cosmetic
treatment (most commonly dermatologic and surgical) for their perceived physical defects;
this treatment appears to be ineffective for most patients and can be risky for clinicians to
provide. By contrast, pharmacotherapy (ie, selective serotonin reuptake inhibitors or
clomipramine) and/or cognitive-behavioral therapy tailored specifically to BDD are often
efficacious.
This topic reviews the general principles of treating BDD. Choosing treatment and the
prognosis of BDD are discussed separately, as are the epidemiology, pathogenesis, clinical
features, assessment, diagnosis, and differential diagnosis of BDD.
● (See "Body dysmorphic disorder: Choosing treatment and prognosis".)

https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/body-dysmorphic-disorder-general-principles-of-treatment/print?search=aneste… 1/17
● (See "Body dysmorphic disorder: Epidemiology and pathogenesis".)

● (See "Body dysmorphic disorder: Clinical features".)
● (See "Body dysmorphic disorder: Assessment, diagnosis, and differential diagnosis".)
DIAGNOSIS OF BODY DYSMORPHIC DISORDER
Body dysmorphic disorder (BDD) is diagnosed in patients who meet each of the following
criteria ( table 1) [1]:
● Preoccupation with at least one nonexistent or slight defect in physical appearance (eg,
thinks about the perceived defects for at least one hour per day).
● At some point during the course of the disorder, concerns about appearance lead to
repetitive behaviors (eg, mirror checking, excessive grooming, or skin picking) or
mental acts (eg, comparing one’s appearance to that of others).
● Clinically significant distress or psychosocial impairment that results from the

appearance concerns.
● Appearance preoccupations are not better explained by an eating disorder.
Additional information about the diagnosis and clinical features of BDD is discussed
separately. (See "Body dysmorphic disorder: Assessment, diagnosis, and differential
diagnosis", section on 'Diagnosis' and "Body dysmorphic disorder: Clinical features", section
on 'Clinical manifestations'.)
GENERAL PRINCIPLES
The sections below describe some general principles and issues that are involved in treating
body dysmorphic disorder (BDD). Information about choosing a specific treatment regimen
is discussed separately. (See "Body dysmorphic disorder: Choosing treatment and
prognosis".)
Approach to the patient — Before initiating treatment for BDD, it is important to lay some
essential groundwork to educate and engage patients, and to establish a therapeutic alliance
by expressing empathy and providing hope that evidence-based treatment usually helps [2].
Most patients have little to no insight regarding their appearance and may doubt whether
psychiatric treatment can help them. In addition, some find it difficult to leave their house to
see clinicians or participate in videoconferencing if they can see themselves on the screen.
Educate patients about BDD — Patients benefit from education about BDD and a rationale
for recommended treatment [2,3]. Although many patients are relieved to learn that they
have a known and treatable disorder, some may resist the diagnosis because of poor insight.
Focus of treatment — Address how concerns with appearance cause patients to obsess
about their appearance and perform repetitive BDD behaviors/rituals (eg, check mirrors)
excessively, which in turn impair psychosocial functioning and cause patients to suffer [2]. In
addition, emphasize how recommended treatment can improve these problems.
Avoid focusing on how the patient looks — It usually is not helpful to comment on the
patient’s looks. Even reassuring comments are often misinterpreted in a negative way. We do
not try to convince patients that they look normal (one cannot impose insight), nor do we
agree with them that there is something wrong with their appearance [2-4]. Instead,
clinicians might say that patients with BDD see themselves very negatively and differently
from how other people see them, for reasons that are not well understood. Clinicians can
mention that patients tend to overfocus on tiny details of their appearance and have
difficulty seeing the “big picture” of how they look. (See "Body dysmorphic disorder:
Epidemiology and pathogenesis", section on 'Pathogenesis'.)
Educate patients about effective psychiatric treatments for BDD — Patients can benefit
from education about cognitive-behavioral treatment (CBT) and pharmacotherapy, especially
the expected benefits, prognosis, and misconceptions that surround these treatments [2]. If
patients fear that CBT will be too anxiety-provoking, clinicians can reassure patients that CBT
exercises will be generated collaboratively by the patient and clinician, and that patients will
not be asked to perform CBT exercises that are intolerable.
It may also be helpful to emphasize that selective serotonin reuptake inhibitors (SSRIs) and
clomipramine are usually well tolerated, not addictive, and appear to normalize brain
functioning (rather than cause brain damage) [2,3]. Clinicians can manage negative
expectations about medications by [5]:
● Explaining the desired therapeutic effects when discussing potential side effects (eg,
“Response to just one trial of these types of medication occurs in more than one-half to
approximately three quarters of patients”). Response rates are even higher in patients
who complete the medication trial with good adherence. If the first medication that is
tried is not sufficiently helpful, other medications may be effective. It may be helpful to
elicit potential benefits that are meaningful and specific to the patient. Explain that it
may take time (eg, one to four months) for the benefits to manifest, but that symptoms
may start improving sooner than this.
● Ensuring that patients understand side effects are often transient and usually benign,
and the clinician can often minimize them (eg, by switching a medication that causes
fatigue to bedtime). In addition, side effects can be reframed as an indication that the
medication is having an effect.
● Discussing techniques for coping with side effects other than stopping the drug.
In addition, it may help to ask patients to try a medication for three to four months, with the
understanding that they will be monitored throughout treatment [6]. If the medication trial is
successful, they can (and should) continue the drug, and if not, then next step treatment will
be discussed.
The US Food and Drug Administration (FDA)’s warnings about suicidal ideation and behavior
in children, adolescents, and young adults who are treated with SSRIs should be
acknowledged, although the evidence is inadequate to conclusively establish this
association. However, studies indicate that in adults aged 18 years and older with BDD,
fluoxetine protects against worsening of suicidality more than placebo [7], and that
suicidality decreases with other SSRIs. In addition, other studies indicate that SSRIs decrease
suicidal ideation and behavior in depressed adults, and that the risk of suicidality in
depressed children and adolescents is comparable for fluoxetine and placebo [8]. Thus, it
appears that the substantial risk of suicidal ideation and behavior posed by BDD and
comorbid disorders such as depression exceeds the small potential risk posed by the use of
SSRIs for children, adolescents, and young adults [3]. (See "Effect of antidepressants on
suicide risk in adults", section on 'Reduction of existing suicidal ideation' and "Effect of
antidepressants on suicide risk in children and adolescents", section on 'Randomized trials'.)
Individualize treatment for each patient — Treatment for BDD should be individualized
for each patient. Factors to evaluate include [2]:
● Severity of illness. (See "Body dysmorphic disorder: Choosing treatment and

prognosis", section on 'Mild to moderate illness' and "Body dysmorphic disorder:
Choosing treatment and prognosis", section on 'Severe illness'.)
● History of prior treatment for BDD.
● Comorbid disorders – Although some comorbid disorders such as unipolar major

depression or social anxiety disorder may respond to the same medication used for
BDD, other comorbid disorders (eg, bipolar disorder) require different medications. In
addition, patients with comorbid substance use disorders are generally not treated with
benzodiazepines or other controlled substances.
● Medication safety and adverse effects.
● Patient preferences.
● Pregnancy and lactation status.
● Age – For children, adolescents, and some older adults, lower initial and maximum
medication doses may be efficacious and better tolerated than doses prescribed for the
general population of adults with BDD. For children, we generally do not exceed FDA
maximum medication doses. In addition, CBT that was developed for adults needs to
be adapted for children and adolescents.
Involve family members if clinically appropriate — We suggest involving the family if it is

appropriate and potentially helpful (parental/guardian involvement is required for minors)
[2]. Family members often bring patients with BDD for treatment because patients usually
manifest impaired functioning, suicidal thoughts and/or behavior, and poor insight into their
illness (and thus may resist psychiatric treatment). In addition, the family can support the
patient and encourage adherence with the treatment plan, and family members generally
benefit from psychoeducation about the illness and its treatment.
Use motivational interviewing if needed — Motivational interviewing modified for BDD

may be necessary to engage and retain patients in psychiatric treatment. Patients with BDD
may be reluctant to accept psychiatric treatment due to poor insight into their illness, a wish
for cosmetic treatment rather than psychiatric treatment, the belief that psychiatric
treatment will not be helpful, and discomfort being seen by other people, including the
psychiatric clinician. (See "Overview of psychotherapies", section on 'Motivational
interviewing'.)
Monitoring — At the beginning of treatment, ill outpatients who are receiving medication
are generally seen once every few weeks, and patients receiving CBT are seen weekly or
more often. The visit frequency also depends upon clinical urgency. In patients who improve
with medication, the frequency of visits can be tapered, with visits every one to two months.
Stable remitted patients can eventually be seen once every three to six months. Patients who
receive CBT are usually seen at least weekly for approximately six months; following
improvement, as-needed “booster sessions” may be helpful to maintain gains.
We monitor BDD symptoms over time by asking the patient:
● What is the total time each day that you think about your appearance?
● How much distress is caused by these thoughts about your appearance?
● How much do concerns about your appearance interfere with daily functioning (eg,
work, school, and social)?
Clinicians can also ask about total time spent each day performing BDD repetitive behaviors
(ie, rituals, compulsions).
In addition, clinicians should monitor depressive symptoms and suicidal thinking and
behavior, which are common in patients with BDD. Options for monitoring depression and
suicidality include self-report measures such as the Patient Health Questionnaire – Nine Item
(PHQ-9) ( table 2) and Quick Inventory of Depressive Symptomatology – Self Report 16

Item (QIDS-SR16) ( table 3). Information about comorbid psychopathology in BDD and
using the PHQ-9 or QIDS-SR16 to assess depression is discussed separately. (See "Body
dysmorphic disorder: Clinical features", section on 'Comorbidity' and "Using scales to
monitor symptoms and treat depression (measurement based care)", section on 'Self-report
scales in the public domain'.)
Discourage cosmetic interventions — For patients with BDD, we suggest that clinicians not
perform surgical, dermatological, dental, or other cosmetic treatments because these
interventions usually do not help and sometimes worsen BDD symptoms [2,9-12]. This
approach is consistent with practice guidelines:
● American Academy of Otolaryngology – A 2017 guideline states that BDD is a

contraindication to elective rhinoplasty and that patients seeking surgery should be
screened for BDD [13,14].
● American College of Obstetricians and Gynecologists – A committee opinion states that

individuals younger than age 18 who request breast or labia surgery should be
screened for BDD and that if the obstetrician-gynecologist suspects an adolescent has
BDD, referral to a mental health clinician is appropriate [15]. A subsequent opinion on
elective female genital cosmetic surgery states that before surgery is considered,
patients should be referred and assessed for BDD if indicated (eg, they acknowledge
concerns about the appearance of secondary sex characteristics) [16].
However, we do not recommend avoiding cosmetic interventions in patients with skin

damage due to BDD-related skin picking that requires dermatologic treatment.
Although most patients with BDD receive cosmetic treatment in an attempt to “fix” their
perceived appearance flaws, BDD symptoms respond poorly to cosmetic procedures in the
large majority of cases and may even worsen [9,12-14]. In addition, dissatisfaction with the
outcome of cosmetic treatment may lead patients to become litigious, threatening, or violent
toward clinicians who provide such treatment [12].
We suggest that patients presenting for cosmetic treatment be assessed for BDD ( table 4)
[9]. In addition to inquiring about BDD’s diagnostic criteria ( table 1), it can be helpful to
assess patient motivations and expectations for cosmetic treatment; determine whether
patients have had past cosmetic treatment with which they have been dissatisfied; ask
whether surgeons, dermatologists, dentists, or other clinicians have recommended against
cosmetic treatment; and observe the patient’s behavior in the office (eg, making unusual
requests for appointment times so as to avoid being seen by other people).
If BDD is suspected in patients presenting for cosmetic treatment, we suggest:
● Explaining to the patient that they may or do have BDD

● Educating patients about BDD
● Conveying concern that cosmetic treatment appears very unlikely to be helpful
● Discussing the potential for pharmacotherapy (eg, SSRIs) and CBT to improve BDD
symptoms
● Referring the patient to a mental health clinician who is knowledgeable about BDD
If the patient insists upon receiving cosmetic treatment, psychiatric clinicians can
recommend delaying it until after the patient has tried psychiatric treatment, which may
improve BDD symptoms to the point that the patient no longer desires a cosmetic
intervention. However, some patients receive cosmetic treatment regardless of the clinician’s
recommendations, in which case efforts should be made to have the patient receive mental
health treatment concurrently.
Additional information about the prognosis and course of illness of BDD following cosmetic
procedures is discussed separately. (See "Body dysmorphic disorder: Clinical features",
section on 'Cosmetic interventions'.)
Referral — Patients with BDD should be referred to mental health clinicians who preferably
have experience treating the disorder. Although primary care clinicians may be able to treat
mild BDD (eg, mild distress and no suicidal ideation or behavior), most patients are referred
for management, especially those with moderate to severe symptoms and those who require
psychotherapy or are suicidal.
CHOOSING TREATMENT
Choosing a specific treatment regimen for body dysmorphic disorder is discussed separately.
(See "Body dysmorphic disorder: Choosing treatment and prognosis".)
INFORMATION FOR PATIENTS
Many patients can benefit from reading about their illness at websites such as those
maintained by the International OCD Foundation and the author of this topic at her
website.
SUMMARY
● Diagnosis – Body dysmorphic disorder (BDD) is diagnosed according to the American

Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition-Text Revision (DSM-5-TR) criteria ( table 1). (See "Body dysmorphic disorder:
Assessment, diagnosis, and differential diagnosis", section on 'Diagnosis'.)
● Approach to the patient – Before initiating treatment for BDD, it is important to

engage patients and establish a therapeutic alliance by expressing empathy and
providing hope that evidence-based treatment usually helps. Educate patients about
BDD and effective psychiatric treatments for the disorder, focus on the patient’s
excessive preoccupation and impaired functioning, avoid focusing on how the patient
looks, individualize treatment, and involve family members if clinically appropriate. (See
'Approach to the patient' above.)
● Monitoring – We monitor BDD symptoms over time by asking patients how much time
each day they think about their appearance and how much distress is caused by these
thoughts. We also ask about the effects of appearance concerns on daily functioning
(eg, work and social interactions), the time spent performing BDD rituals (eg, mirror
checking), and monitor depressive symptoms, anxiety, and suicidal thinking and
behavior. (See 'Monitoring' above.)
● Discourage cosmetic interventions – For patients with BDD, clinicians should not
perform surgical, dermatological, or other cosmetic treatments. In the large majority of
cases, BDD symptoms respond poorly to cosmetic procedures and may even worsen.
(See 'Discourage cosmetic interventions' above.)
● Referral – Patients with BDD are typically referred to mental health clinicians. (See
'Referral' above.)
● Choosing treatment – Several effective treatments are available for BDD. (See "Body
dysmorphic disorder: Choosing treatment and prognosis".)
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REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition, Text Revision (DSM-5-TR), Washington, DC 2022.
2. Phillips KA. Pharmacotherapy and other somatic treatments for body dysmorphic disord
er. In: Body Dysmorphic Disorder: Advances in Research and Clinical Practice, Phillips KA
(Ed), Oxford University Press, New York 2017. p.333.
3. Phillips KA, Hollander E. Treating body dysmorphic disorder with medication: evidence,
misconceptions, and a suggested approach. Body Image 2008; 5:13.
4. Phillips KA. Pharmacotherapy for Body Dysmorphic Disorder. Psychiatr Ann 2010;
40:325.
5. Bingel U, Placebo Competence Team. Avoiding nocebo effects to optimize treatment
outcome. JAMA 2014; 312:693.
6. Veale D, Phillips KA, Neziroglu F. Challenges in assessing and treating patients with body
dysmorphic disorder and recommended approaches. In: Body Dysmorphic Disorder: Ad
vances in Research and Clinical Practice, Phillips KA (Ed), Oxford University Press, New Yo
rk 2017. p.313.
7. Phillips KA, Kelly MM. Suicidality in a placebo-controlled fluoxetine study of body
dysmorphic disorder. Int Clin Psychopharmacol 2009; 24:26.
8. Gibbons RD, Brown CH, Hur K, et al. Suicidal thoughts and behavior with antidepressant
treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and
venlafaxine. Arch Gen Psychiatry 2012; 69:580.
9. Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder in patients who seek
appearance-enhancing medical treatments. Oral Maxillofac Surg Clin North Am 2010;
22:445.
10. Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures
among persons with body dysmorphic disorder. Ann Plast Surg 2010; 65:11.
11. Crerand CE, Sarwer DB, Ryan M. Cosmetic medical and surgical treatments and body dys
morphic disorder. In: Body Dysmorphic Disorder: Advances in Research and Clinical Prac
tice, Phillips KA (Ed), Oxford University Press, New York 2017. p.431.
12. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic
surgeons: results of a survey of american society for aesthetic plastic surgery members.
Aesthet Surg J 2002; 22:531.
13. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical Practice Guideline: Improving Nasal Form
and Function after Rhinoplasty. Otolaryngol Head Neck Surg 2017; 156:S1.
14. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical Practice Guideline: Improving Nasal Form
and Function after Rhinoplasty Executive Summary. Otolaryngol Head Neck Surg 2017;
156:205.
15. Committee Opinion No. 686 Summary: Breast and Labial Surgery in Adolescents. Obstet
Gynecol 2017; 129:235. Reaffirmed 2019.
16. Elective Female Genital Cosmetic Surgery. The American College of Obstetricians and Gy
necologists. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opi
nion/articles/2020/01/elective-female-genital-cosmetic-surgery (Accessed on January 26,
2021).
Topic 117786 Version 5.0
GRAPHICS
DSM-5 diagnostic criteria for body dysmorphic disorder
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not
observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors
(eg, mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (eg,
comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or othe
important areas of functioning.
D. 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.
Specify if:
With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is
too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with
other body areas, which is often the case.
Specify if:
Indicate degree of insight regarding body dysmorphic disorder beliefs (eg, "I look ugly" or "I look
deformed").
With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs
are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably
true.
With absent insight/delusional beliefs: The individual is completely convinced that the body
dysmorphic disorder beliefs are true.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).
American Psychiatric Association. All Rights Reserved.
Graphic 96646 Version 5.0
https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/body-dysmorphic-disorder-general-principles-of-treatment/print?search=anest… 10/17
PHQ-9 depression questionnaire
Name: Date:
Over the last 2 weeks, how often have you been Not at Several More Nearly
bothered by any of the following problems? all days than every
half day
the
days
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too 0 1 2 3

much
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself, or that you are a failure, 0 1 2 3

or that you have let yourself or your family down
Trouble concentrating on things, such as reading the 0 1 2 3

newspaper or watching television
Moving or speaking so slowly that other people could 0 1 2 3

have noticed? Or the opposite, being so fidgety or
restless that you have been moving around a lot
more than usual.
Thoughts that you would be better off dead, or of 0 1 2 3

hurting yourself in some way
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
5 to 9: mild
10 to 14: moderate
15 to 19: moderately severe
≥20: severe
If you checked off any problems, how difficult Not Somewhat Very Extremel
have these problems made it for you to do your difficult difficult difficult difficult
work, take care of things at home, or get along at all
___ ___ ___
with other people? ___
PHQ: Patient Health Questionnaire.
Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer,
Inc. No permission required to reproduce, translate, display or distribute.
The Quick Inventory of Depressive Symptomatology
Name or ID: ________________________________ Date: _____________
Check the one response to each item that best describes you for the past seven days.
During the past seven days...
1. Falling asleep
____ 0 I never take longer than 30 minutes to fall asleep.
____ 1 I take at least 30 minutes to fall asleep, less than half the time.
____ 2 I take at least 30 minutes to fall asleep, more than half the time.
____ 3 I take more than 60 minutes to fall asleep, more than half the time.
2. Sleep during the night
____ 0 I do not wake up at night.
____ 1 I have a restless, light sleep with a few brief awakenings each night.
____ 2 I wake up at least once a night, but I go back to sleep easily.
____ 3 I awaken more than once a night and stay awake for 20 minutes or more, more than half
the time.
3. Waking up too early
____ 0 Most of the time, I awaken no more than 30 minutes before I need to get up.
____ 1 More than half the time, I awaken more than 30 minutes before I need to get up.
____ 2 I almost always awaken at least one hour or so before I need to, but I go back to sleep
eventually.
____ 3 I awaken at least one hour before I need to, and can't go back to sleep.
4. Sleeping too much
____ 0 I sleep no longer than 7-8 hours/night, without napping during the day.
____ 1 I sleep no longer than 10 hours in a 24-hour period including naps.
____ 2 I sleep no longer than 12 hours in a 24-hour period including naps.
____ 3 I sleep longer than 12 hours in a 24-hour period including naps.
5. Feeling sad
____ 0 I do not feel sad.
____ 1 I feel sad less than half the time.
____ 2 I feel sad more than half the time.
____ 3 I feel sad nearly all of the time.
Please complete either 6 or 7 (not both).
6. Decreased appetite
____ 0 There is no change in my usual appetite.
____ 1 I eat somewhat less often or lesser amounts of food than usual.
____ 2 I eat much less than usual and only with personal effort.
____ 3 I rarely eat within a 24-hour period, and only with extreme personal effort or when others
persuade me to eat.
OR
7. Increased appetite
____ 0 There is no change from my usual appetite.
____ 1 I feel a need to eat more frequently than usual.
____ 2 I regularly eat more often and/or greater amounts of food than usual.
____ 3 I feel driven to overeat both at mealtime and between meals.
Please complete either 8 or 9 (not both).
8. Decreased weight (within the last two weeks)
____ 0 I have not had a change in my weight.
____ 1 I feel as if I have had a slight weight loss.
____ 2 I have lost 2 pounds or more.
____ 3 I have lost 5 pounds or more.
OR
9. Increased weight (within the last two weeks)
____ 0 I have not had a change in my weight.
____ 1 I feel as if I have had a slight weight gain.
____ 2 I have gained 2 pounds or more.
____ 3 I have gained 5 pounds or more.
10. Concentration/decision making
____ 0 There is no change in my usual capacity to concentrate or make decisions.
____ 1 I occasionally feel indecisive or find that my attention wanders.
____ 2 Most of the time, I struggle to focus my attention or to make decisions.
____ 3 I cannot concentrate well enough to read or cannot make even minor decisions.
11. View of myself:
____ 0 I see myself as equally worthwhile and deserving as other people.
____ 1 I am more self-blaming than usual.
____ 2 I largely believe that I cause problems for others.
____ 3 I think almost constantly about major and minor defects in myself.
12. Thoughts of death or suicide
____ 0 I do not think of suicide or death.
____ 1 I feel that life is empty or wonder if it's worth living.
____ 2 I think of suicide or death several times a week for several minutes.
____ 3 I think of suicide or death several times a day in some detail, or I have made specific plans
for suicide or have actually tried to take my life.
13. General interest
____ 0 There is no change from usual in how interested I am in other people or activities.
____ 1 I notice that I am less interested in people or activities.
____ 2 I find I have interest in only one or two of my formerly pursued activities.
____ 3 I have virtually no interest in formerly pursued activities.
14. Energy level
____ 0 There is no change in my usual level of energy.
____ 1 I get tired more easily than usual.
____ 2 I have to make a big effort to start or finish my usual daily activities (for example, shopping,
homework, cooking, or going to work).
____ 3 I really cannot carry out most of my usual daily activities because I just don't have the
energy.
15. Feeling slowed down
____ 0 I think, speak, and move at my usual rate of speed.
____ 1 I find that my thinking is slowed down or my voice sounds dull or flat.
____ 2 It takes me several seconds to respond to most questions and I'm sure my thinking is
slowed.
____ 3 I am often unable to respond to questions without extreme effort.
16. Feeling restless
____ 0 I do not feel restless.
____ 1 I'm often fidgety, wringing my hands, or need to shift how I am sitting.
____ 2 I have impulses to move about and am quite restless.
____ 3 At times, I am unable to stay seated and need to pace around.
Reproduced with permission from the UT Southwestern Medical Center at Dallas. For more information, please visit www.ids-
qids.org. Copyright © 2011. All rights reserved.
Questions to diagnose body dysmorphic disorder
Questions to diagnose body dysmorphic disorder
1. "Are you very worried about your appearance in any way?" or "Are you unhappy with how you
look?"
2. Ask the patient to describe their concern by asking a question like "What don't you like about
how you look?" or "Can you tell me about your concern?"
3. Ask if there are other disliked body areas; for example, "Are you unhappy with any other aspects
of your appearance, such as your face, skin, hair, nose, or the shape or size of any other body
area?"
4. Ascertain that the patient is preoccupied with these perceived flaws by asking "How much time
would you estimate that you spend each day thinking about your appearance if you add up all
the time you spend?" or "Do these concerns preoccupy you?"
5. Ask if at some point during the course of the disorder, the patient has performed repetitive
behaviors in response to the appearance concerns (eg, mirror checking, excessive grooming,
skin picking, or reassurance seeking) or mental acts (eg, comparing one's appearance with that
of others).
6. "How much distress do these concerns cause you?" Ask specifically about resulting anxiety, socia
anxiety, depression, and suicidal thinking.
7. Ask about effects of the appearance preoccupations on the patient's life; for example, "Do these
concerns interfere with your life or cause problems for you?" Ask specifically about effects on
school, work, other aspects of role functioning (eg, managing a household), relationships,
intimacy, family and social activities, household tasks, and other activities and responsibilities.

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23/2/24, 14:02 Body dysmorphic disorder: General principles of treatment - UpToDate

Official reprint from UpToDate®

Body dysmorphic disorder: General principles of

Literature review current through: Jan 2024.

Body dysmorphic disorder (BDD) is characterized by preoccupation with nonexistent or slight

● (See "Body dysmorphic disorder: Choosing treatment and prognosis".)

● (See "Body dysmorphic disorder: Epidemiology and pathogenesis".)

DIAGNOSIS OF BODY DYSMORPHIC DISORDER

● Clinically significant distress or psychosocial impairment that results from the

● Appearance preoccupations are not better explained by an eating disorder.

● Severity of illness. (See "Body dysmorphic disorder: Choosing treatment and

● History of prior treatment for BDD.

● Comorbid disorders – Although some comorbid disorders such as unipolar major

● Medication safety and adverse effects.

● Pregnancy and lactation status.

Involve family members if clinically appropriate — We suggest involving the family if it is

Use motivational interviewing if needed — Motivational interviewing modified for BDD

We monitor BDD symptoms over time by asking the patient:

● How much distress is caused by these thoughts about your appearance?

(PHQ-9) ( table 2) and Quick Inventory of Depressive Symptomatology – Self Report 16

● American Academy of Otolaryngology – A 2017 guideline states that BDD is a

● American College of Obstetricians and Gynecologists – A committee opinion states that

However, we do not recommend avoiding cosmetic interventions in patients with skin

If BDD is suspected in patients presenting for cosmetic treatment, we suggest:

● Explaining to the patient that they may or do have BDD

INFORMATION FOR PATIENTS

● Diagnosis – Body dysmorphic disorder (BDD) is diagnosed according to the American

● Approach to the patient – Before initiating treatment for BDD, it is important to

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1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

DSM-5 diagnostic criteria for body dysmorphic disorder

Graphic 96646 Version 5.0

PHQ-9 depression questionnaire

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too 0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself, or that you are a failure, 0 1 2 3

Trouble concentrating on things, such as reading the 0 1 2 3

Moving or speaking so slowly that other people could 0 1 2 3

Thoughts that you would be better off dead, or of 0 1 2 3

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

15 to 19: moderately severe

PHQ: Patient Health Questionnaire.

Graphic 59307 Version 12.0

The Quick Inventory of Depressive Symptomatology

Name or ID: ________________________________ Date: _____________

During the past seven days...

____ 0 I never take longer than 30 minutes to fall asleep.

2. Sleep during the night

____ 0 I do not wake up at night.

____ 2 I wake up at least once a night, but I go back to sleep easily.

3. Waking up too early

4. Sleeping too much

____ 1 I sleep no longer than 10 hours in a 24-hour period including naps.

____ 2 I sleep no longer than 12 hours in a 24-hour period including naps.

____ 3 I sleep longer than 12 hours in a 24-hour period including naps.

____ 0 I do not feel sad.

____ 1 I feel sad less than half the time.

____ 2 I feel sad more than half the time.

Total _ = _ + _ + _ + ___

Name or ID: ____________________ Date: _