Approach Considerations

No specific laboratory tests are used to diagnose body dysmorphic disorder (BDD). No specific imaging studies are indicated.

Patients undergoing cosmetic surgery should undergo a screening questionnaire to determine whether may have BDD. The Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV) and the Dysmorphic Concern Questionnaire (DCQ) have been validated for the dermatologic surgery setting.^{[66, 67]}

The Multidimensional Body-Self Relations Questionnaire is a self-reported measure of body image that assesses satisfaction with appearance and preoccupation with perceived defects. It is used in clinical trials and may not be practical in routine office settings. A study of 92 patients with BDD who took the questionnaire revealed that patients with this condition differ from population norms with respect to numerous aspects of body image, including perception of illness.^[29]

The Body Dysmorphic Disorder Examination Self-Report measures the patient’s level of dissatisfaction with respect to the perceived defect. It is another tool that is used in clinical trials and may not be practical in routine office settings.

The Body Dysmorphic Disorder Symptom Scale (BDD-SS) is another self-report measure designed to differentiate, for each group of symptoms, the number of symptoms endorsed and their severity. A study of 99 adults with BDD who completed the measure found it showed good reliability and convergent validity.^[68]

Mental Status Examination

Key findings from the mental status examination that may be associated with the experience of symptoms consistent with a diagnosis of body dysmorphic disorder (BDD) include the following:

Mood - Patients may describe feelings of depressed mood, as well as irritability and anxiousness
Thought process - Patients may demonstrate perseveration on their physical appearance, particularly in association with their perceived defect
Thought content - Patients’ thoughts about the perceived defect in their physical appearance may actually be so divorced from reality as to become delusional; assessing the presence of suicidal and homicidal ideation is crucial, especially because patients with BDD may be at particularly high risk for both after an “unsuccessful” surgery

Typical nondelusional patients with BDD display little or no insight. For a brief time, they may admit that they might be wrong about their preoccupation. Often, they have only come to see the psychiatrist because they were coerced by a family member or because they were told to do so by the plastic surgeon.

Delusional BDD patients are firmly attached to false beliefs that they cannot be talked out of, even with given adequate proof that these beliefs are mistaken. Such patients may believe that what they consider their abnormal body part is slowly worsening or that other people are always staring or know about it.

These considerations aside, findings from the mental status examination are usually within normal limits except for the amount of time and energy spent on the preoccupation. Auditory hallucinations or wide mood swings might point to additional diagnoses, such as schizophrenia or bipolar disorder.

Treatment & Management

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Media Gallery

of 0

Body Part of Concern

Women	Men
Skin	Skin
Hair	Hair
Nose	Nose
Legs	Body build
Eyes	Eyes
Weight	Genitals
Breasts	Legs
Stomach	Pectoral muscles
Teeth	Stomach
Hips	Lips
Face size/shape	Ears
Lips	Weight
Chin	Face size/shape
Cheeks	Teeth
Height	Chin
Jaw	Head size/shape
Head size/shape	Arm/wrist
Feet	Cheeks
Buttocks	Height
Ugly face	Ugly face
Forehead	Jaw
Ears	Forehead
Fingers	Fingers
Hands	Hands
Neck	Feet
Shoulders	Buttocks
Body build	Neck
Arm/wrist	Face muscles
Eyebrows	Eyebrows

Body Part of Concern

Women	Men
Skin	Skin
Hair	Hair
Nose	Nose
Legs	Body build
Eyes	Eyes
Weight	Genitals
Breasts	Legs
Stomach	Pectoral muscles
Teeth	Stomach
Hips	Lips
Face size/shape	Ears
Lips	Weight
Chin	Face size/shape
Cheeks	Teeth
Height	Chin
Jaw	Head size/shape
Head size/shape	Arm/wrist
Feet	Cheeks
Buttocks	Height
Ugly face	Ugly face
Forehead	Jaw
Ears	Forehead
Fingers	Fingers
Hands	Hands
Neck	Feet
Shoulders	Buttocks
Body build	Neck
Arm/wrist	Face muscles
Eyebrows	Eyebrows

Cutaneous Reactions Associated with SSRIs

Cutaneous Reaction
Spontaneous bruising
Pruritus
Urticaria
Angioedema
Erythema multiforme
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Erythema nodosum
Alopecia
Hypertrichosis
Leukocytoclastic vasculitis
Acneiform eruption

Typical Mean and Maximum Dosing of SSRIs ^[82]

Medication	Mean Dose	Max Dose
Fluoxetine	67 ± 24 mg	120 mg
Fluvoxamine	308 ± 49 mg	450 mg
Sertraline	202 ± 46 mg	400 mg
Paroxetine	55 ± 13 mg	90 mg
Citalopram	66 ± 36 mg	40 mg*
Escitalopram	29 ± 12 mg	60 mg
Clomipramine	203 ± 53 mg	250 mg

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Author

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American College of Psychiatrists, American Neuropsychiatric Association, American Psychiatric Association, Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

David R Bowman, MD Psychiatrist, Deputy Chief, Joint Behavioral Health Clinic, Multi-Disciplinary Outpatient Clinic, Medical Review Officer, Clinical Practice Guidelines Champion, External Behavioral Health Consultant, Department of Behavioral Health, Moncrief Army Health Clinic

David R Bowman, MD is a member of the following medical societies: American Psychiatric Association, American Society for Adolescent Psychiatry, American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Anton Power, DO Resident Physician, Department of Pyschiatry, Tripler Army Medical Center; Teaching Fellow, Uniformed Services University of the Health Sciences

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Lawrence Genen, MD, MBA Board Certified Psychiatrist; Diplomate, American Board of Psychiatry and Neurology; Founder, The Genen Group - A Multi-Specialty Psychiatry and Psychotherapy Practice

Disclosure: Nothing to disclose.

Thomas Cook, MD Resident Physician, Department of Psychiatry, University of Hawaii, John A Burns School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Carol Diane Berkowitz, MD Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center

Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology