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BDD is severely distressing and has one of the highest suicide rates in psychiatry, and so it is critical that a risk assessment forms part of your assessment. Furthermore, this station requires empathy and gentle questioning, given the nature of the concerns and association with shame, and level of distress experienced by the patient.
Key Knowledge
●BDD involves persistent preoccupation with one or more perceived defects in physical appearance which are either not observable to others or appear only slight, resulting in clinically significant distress and/or functional impairment
●There are high rates of co-morbidity including depression and other anxiety disorders and it is associated with a high suicide risk.
What is Body Dysmorphic Disorder?
ICD-11 defines body dysmorphic disorder (6B21) as a persistent preoccupation with one or more perceived defects or flaws in appearance that are either not observable or appear only slight to others, accompanied by repetitive behaviours or mental acts in response to the appearance concerns.
The preoccupation causes significant distress and/or impairment in functioning and is not better accounted for by another diagnosis e.g. concerns about body fat or weight secondary to an eating disorder.
Core features include:
●Persistent preoccupation with perceived appearance defects (time-consuming, difficult to resist or control)
●The defects are not observable or appear slight to others
●Repetitive behaviours in response: mirror checking, excessive grooming, skin picking, reassurance seeking, comparing appearance with others, camouflaging
●Mental acts: comparing oneself mentally to others, reviewing perceived defects
●Significant distress or impairment in social, occupational, or other important functioning
●Duration of at least several months
●Common areas of concern include skin, nose, hair, eyes, teeth, lips, chin, or overall facial appearance, although it can involve any body part. There may be multiple perceived defects. Sometimes individuals have a preoccupation which is vague and they may have a general perception of ‘ugliness’ or ‘not being right’.
●Muscle dysmorphia is a specifier where the preoccupation is that the individual’s body build is too small or insufficiently muscular, even when objectively muscular.
●Level of insight varies but is often poor, with some individuals holding beliefs with delusional intensity.
Differential Diagnosis for Body Dysmorphic Disorder
Differential Diagnosis for Body Dysmorphic Disorder
1. Eating disorders (e.g. anorexia nervosa, bulimia nervosa)
Key distinctions: In eating disorders, concerns focus specifically on body weight and shape, with fear of weight gain. In BDD, concerns are about specific perceived defects (e.g., nose, skin, hair). If both weight concerns and other appearance concerns are present, consider whether criteria for both disorders are met.
2. Obsessive-compulsive disorder (OCD)
Key distinctions: In OCD, obsessions and compulsions are not limited to appearance. However, some overlap may exist. Both BDD and OCD involve intrusive thoughts and repetitive behaviours. The key is whether appearance preoccupation dominates the clinical picture.
3. Social anxiety disorder
Key distinctions: In social anxiety, fear relates to being negatively evaluated in social situations generally (e.g., saying something foolish), not specifically to physical appearance. However, they commonly coexist, and people with BDD may frequently avoid social situations because of appearance concerns.
4. Delusional disorder, somatic type
Key distinctions: When appearance beliefs are held with complete, fixed conviction and cannot be shaken by evidence (absent insight/delusional BDD), this can resemble delusional disorder. In practice, this is a severity specifier within BDD rather than a separate condition.
5. Normal appearance concerns
Key distinctions: Most people have some concerns about their appearance. BDD is distinguished by the severity and persistence of preoccupation, the degree of distress, time spent on related behaviours, and functional impairment.
6. Trichotillomania or excoriation disorder
Key distinctions: These involve hair pulling or skin picking. If the behaviour is driven by appearance concerns (e.g., picking to remove perceived imperfections), consider BDD. If it’s driven by tension relief or gratification without appearance preoccupation, consider trichotillomania or excoriation disorder.
7. Gender dysphoria
Key distinctions: In gender dysphoria, distress relates to incongruence between experienced gender and assigned gender, not to perceived defects within one’s body. However, they can coexist.
8. Depression
Key distinctions: Depression can include appearance-related negative thoughts, but these are usually part of broader low self-esteem rather than focused preoccupation with specific defects.
Risk Assessment in Body Dysmorphic Disorder
Risk Assessment in Body Dysmorphic Disorder
As with every risk assessment, you must consider risk to self, to others and from others.
To self:
●Suicide risk – BDD has one of the highest suicide rates among psychiatric disorders
●Self-harm – Often related to appearance concerns (skin picking, attempts to “fix” perceived defects)
●Social isolation – Severe avoidance of social situations, education, or employment
●Cosmetic procedures – Seeking repeated procedures, which rarely relieve preoccupation and may worsen distress
●Substance misuse – Using alcohol or drugs to cope with distress
●Self-neglect – Severe cases may involve inability to leave home or complete self-care
To others:
●Low, though irritability and relationship strain are common
●Rarely, anger towards others perceived as causing or commenting on appearance
From others:
●Vulnerability to exploitation by cosmetic surgery providers
●Risk of bullying or teasing, which may have precipitated or worsened BDD
Communication Tips
Communication Tips
Think CASC: BDD requires a great deal of sensitivity. People often feel ashamed and may not disclose concerns readily, despite severe distress and functional impairment. Avoid dismissing or reassuring about appearance; focus on distress and impact.
Opening gently:
●”I’d like to understand what’s been troubling you. Can you tell me what’s been on your mind?”
●”Sometimes people have concerns about their appearance that really bother them. Is that something you experience?”
Exploring the preoccupation:
●”What aspect of your appearance concerns you most?”
●”How much time each day would you say you spend thinking about this?”
●”When did you first start worrying about this?”
●”Has anyone else commented on what you’re concerned about?”
Exploring behaviours:
●”Do you find yourself checking your appearance, for example in mirrors, windows, phone cameras?”
●”Do you try to hide or camouflage the area you’re concerned about?”
●”Do you compare yourself to other people?”
●”Have you asked others for reassurance about how you look?”
●”Do you spend a lot of time grooming or trying to fix this?”
Impact on functioning:
●”How do these concerns affect your daily life?”
●”Do you avoid certain situations e.g. social events, photos, dating?”
●”Has this affected school, work, or relationships?”
●”Do you find it hard to leave the house?”
Cosmetic procedures and help-seeking:
●”Have you thought about or tried cosmetic treatments, surgery, or dermatology?”
●”If you’ve had treatments, did they help with how you feel?”
Insight:
●”How do other people react when you mention your concern?”
●”Do you think your view of this might be different from how others see it?”
Screen for comorbidities:
●Depression: mood, hopelessness, anhedonia, sleep, appetite
●Social anxiety: fear of negative evaluation beyond appearance
●OCD: other obsessions or compulsions
●Eating disorders: weight and shape concerns, dietary restriction, purging behaviours
●Suicidal ideation and self-harm: particularly important in BDD
Avoid:
●Reassuring about appearance (“you look fine”). This is ineffective and invalidates their experience
●Agreeing with their negative evaluation
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the adult SpR in the community mental health team. Daniel, a 24-year-old postgraduate student, has been referred by his GP with suspected depression. He has been increasingly isolating himself over the past eighteen months and has stopped attending university. His GP prescribed sertraline 50mg daily six weeks ago, which Daniel stopped after two weeks due to side effects. He lives alone in university accommodation.
Please take a psychiatric history and perform a risk assessment.
Scenario Summary:
Daniel is a 24-year-old PhD student who has been preoccupied with his nose for the past three years, believing it is grossly misshapen and deformed. He spends several hours daily checking mirrors, comparing himself to others, and researching rhinoplasty. He has seen two private cosmetic surgeons, both of whom declined to operate. His preoccupation has led to near-total social isolation; he wears a mask constantly, avoids seminars and social events, and is impacting his competition of his PhD. He is profoundly depressed secondary to BDD, with passive suicidal ideation. He has poor insight, believing his appearance is objectively abnormal. He tried sertraline briefly but stopped due to sexual side effects.
Actor Brief:
You are Daniel, a 24-year-old PhD student in biochemistry at Imperial College London. You live alone in a studio flat in South Kensington. About three years ago, you became increasingly aware that your nose is misshapen; it’s crooked, bulbous at the tip, and the nostrils are asymmetrical. You can’t understand how you didn’t notice it before. It’s all you can think about now.
You spend at least three to four hours every day checking your nose in mirrors, your phone camera, reflective surfaces and anywhere else you can catch a glimpse. You take dozens of selfies each day, analysing every angle. You constantly compare your nose to other people’s noses, both in person and online. You’ve researched rhinoplasty extensively and consulted two private cosmetic surgeons in Harley Street, Mr. Peterson and Dr. Ellis, both of whom told you surgery wasn’t appropriate. You were angry and frustrated by this because they clearly didn’t understand how bad it is.
You wear a face mask all the time now, even though COVID restrictions have lifted. You tell people it’s for allergy reasons. You can’t bear the thought of people looking at your nose. You’ve stopped attending your PhD supervision meetings and seminars. You defer via email, citing illness. You order all your food online and only leave your flat late at night when fewer people are around. You’ve lost contact with most of your friends because you keep declining invitations. Your supervisor, Professor Allen, has emailed several times expressing concern about your progress.
You feel desperately low and hopeless. You sleep poorly and lie awake thinking about your nose and whether you’ll ever be able to fix it. Your appetite is reduced and you’ve lost about a stone over the past few months, though you weren’t really trying to lose weight. You have no energy and can’t concentrate on your research anymore. You feel worthless and like your life is ruined. You’ve thought vaguely that you’d be better off dead, but you haven’t made any plans. You haven’t harmed yourself.
Your GP started you on sertraline six weeks ago, but you stopped after two weeks because it made you feel nauseous and you had difficulty reaching orgasm when masturbating, which added to your distress. You don’t drink much, maybe one or two beers a week. You do not take recreational drugs. You have no past psychiatric history, though you were bullied a bit at secondary school for being “nerdy,” which knocked your confidence.
You’re initially quite guarded and embarrassed about discussing your appearance concerns. You might say you’ve been “stressed about uni” or “not feeling great” but avoid specifics until asked directly. When the topic of your nose comes up, you become more animated and distressed. You might ask the doctor if they notice anything wrong with your nose. If they say it looks normal, you feel frustrated and disbelieved. You have very poor insight and you genuinely believe your nose is objectively deformed and that others must see it too, even if they’re being polite.
Your presentation is flat and low in energy. You make limited eye contact (partly because you’re self-conscious). You speak quietly and hesitantly. You’re wearing a face mask pulled up high. If asked to remove it for the assessment, you’re very reluctant and might refuse or only briefly lower it before quickly covering your face again.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
●Recognise the core features of BDD through systematic exploration: preoccupation with a perceived defect in appearance, repetitive behaviours (mirror checking, reassurance seeking, camouflaging), and significant functional impairment.
●Differentiate BDD from other conditions (social anxiety, OCD, eating disorders, psychotic disorders) by focusing on the specific nature of appearance-related cognitions and the presence or absence of other defining features
●Assess insight carefully, recognising that BDD exists on a spectrum from good insight to absent insight/delusional beliefs, and adjust formulation and management accordingly
●Screen comprehensively for comorbidities, particularly depression and suicidal ideation (BDD has one of the highest suicide rates of any psychiatric disorder), as well as social anxiety, OCD, and substance use
●Explore cosmetic treatment-seeking behaviour.
Communication
A good candidate will:
●Create a safe environment for disclosure by normalising appearance concerns initially before exploring the severity and impact in detail, recognising that patients often feel ashamed
●Demonstrate cultural awareness and avoid assumptions, acknowledging that body image concerns exist across all cultures and genders, though the specific focus may vary.
●Build a therapeutic alliance despite poor insight by validating distress and functional impairment even if not agreeing with the patient’s beliefs about their appearance
Video
All our videos can be found here! CASC Scenario Videos – PsychPanda
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Phillips, K. A. (2009). Understanding body dysmorphic disorder: An essential guide. Oxford University Press.
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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