Body Dysmorphic Disorder is sometimes just seen as normal appearance worries in teenagers and this means that their distress or concerns about the way they look may be dismissed. Very often, people with BDD are also embarrassed to admit their body image concerns due to fears of coming across as vain or drawing attention to their perceived flaw. This makes it incredibly difficult for them to disclose their worries to others and can mean a delay in accessing treatment. 

BDD may not be well known by professionals and can often be mistaken for other difficulties such as Depression, Eating Disorders or Social Anxiety due to some overlap in symptoms. It is important to explore BDD as a possible issue and to do so by directly asking the person about appearance concerns.

Early diagnosis is key. But why is BDD missed?

• Patients seek non-psychiatric treatment, including cosmetic surgery
• Misinterpretation of BDD as ‘normal’
• Patients do not feel able to disclose concerns unless asked directly (embarrassment, shame, fearing being judged as vain or attracting more attention)
• Clinicians are unfamiliar with BDD
  • No systemic screening
  • Comorbid diagnosis

Questions to ask if you suspect a patient may have BDD:

1. Do you spend an hour or more everyday worrying about your appearance?
2. Do you find yourself carrying out lots of behaviours (e.g. mirror checking, grooming) and/or mental acts (e.g. comparing your appearance with others) in an effort to cope with your appearance worries?
3. Do your appearance worries make you feel miserable (e.g. anxious, depressed, ashamed) and/or get in the way of daily activities (e.g. socialising, going to school or leisure activities)?
4. Are your appearance concerns focussed on being too fat or weighing too much?

If they answer “yes” to questions 1) – 3) and “no” to question 4), it is possible that they are experiencing BDD and you should support them to speak to see support (see ‘how to get help’).

Clinicians have created a questionnaire to help identify whether someone might have BDD. Find out more >

Ask the right questions:

People with BDD have reported that unless they are asked directly, they would not talk about their symptoms due to shame or fear that people may think they are vain. Therefore, do not be afraid to ask the questions above whilst assuring them you do not think they are being vain or self-conceited.

• Do not get into conversations about aspects of their appearance; just ask in a neutral and matter of fact way without giving opinions on their appearance.
• Do not challenge the person’s perception of their appearance and explain that you are actively maintaining a neutral approach and will not. It is important to remember that poor insight is very common in BDD. 
• It is good to highlight that people are often concerned about multiple areas of their body and that this can often include embarrassing areas such as genitalia, this will support the person to disclose as much as they can.
• Keep the focus on the preoccupation, distress and interference this is causing them.

If the person discloses that they are preoccupied by a perceived appearance concern which is slight or cannot be seen by others and engage in behaviours which cause distress and interference in their lives, this is an indication that this is BDD.

The ultimate goal of exploring this with them is to understand what may be driving their distress and facilitate them in accessing the right support. If you are a mental health professional, you may wish to read ‘Treatment for BDD’ to guide you in offering and delivering an evidence-based treatment for BDD.

It is important, that risk assessment and management are central to the support you offer given this is a common issue in BDD.

Finally, you may wish to find out more on the scales routinely used in BDD – see below.

Treatment Guidelines

The UK has produced best practice guidelines for treating BDD.The NICE Clinical Guidelines for Obsessive Compulsive and Body Dysmorphic Disorder (2005).

Specialist Services for BDD in the UK

In the UK, if treatment is less effective than hoped for in secondary care, then the care of an adult patient in the NHS can be stepped up to a specialist service – for example out-patient treatment at the Centre for Anxiety Disorders and Trauma (CADAT) or the Anxiety Disorders Residential Unit (ADRU) or in-patient care at the Nightingale Hospital.

Children and Adolescents with BDD can be referred to the OCD Young People’s Service for OCD and BDD. After assessment, out-patient treatment maybe provided at the Maudsley or  if in-patient care is required at the Priory Hospital North London.

There are two levels of specialist care funding – the local Clinical Care Commissioning group funds the first level and the NHS England  funds the second level. (This is called the “Highly Specialised Service for severe treatment refractory OCD and BDD”). It consists of a consortium of hospitals including the Maudsley (for out-patients), the Bethlem (a residential unit) & the Priory North London (for in-patients) (Consultant Dr David Veale), Adolescent at the Maudsley (Consultant Dr Bruce Clark), Adults at the Queen Elizabeth II (out-patients and in-patients under Professor Naomi Fineberg) and Springfield Hospitals (mainly in-patients under Dr Lynne Drummond) who will assess and advise on your particular circumstances.

The type of funding for a client will depend on whether he/she meets certain criteria. For the HSS criteria, sufferers need to be in the severe range on the BDD-YBOCS (36 or above out of 48) and have failed at least two trials of CBT for BDD and 2 trials of SSRI medication at the required dose and duration.

Both levels of funding will require a referral from the local Community Mental Health Team (CMHT) team and a record of treatments that your client has received.

Diagnostic Scales used for BDD

The following scales are routinely used in BDD. Please send us details of any further validated scales used for BDD.

Yale Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS)

The BDD-YBOCS is an observer rated scale to assess the severity of BDD symptoms. It was developed by Katherine Phillips and colleagues and consists of 12 items and the range is from 0 to 48. It is widely used as an outcome measure in controlled trials.

Reference: Phillips, K. A., Hollander, E., Rasmussen, S. A., Aronowitz, B. R., DeCaria, C., & Goodman, W. K. (1997). A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin, 33(1), 17-22.

The Brown Assessment of Beliefs Scale (BABS)

The BABS is an observer rated scale designed to measure the strength of conviction in beliefs (for example about “being as ugly as the Elephant Man”).

Reference: Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., Atala, K. D., & Rasmussen, S. A. (1998). The Brown Assessment of Beliefs Scale: reliability and validity. American Journal of Psychiatry, 155(1), 102-108.

The Cosmetic Procedure Screening Scale (COPS)

The COPS is a self-report scale designed to screen for symptoms of BDD in cosmetic settings. The score is achieved by summing the 9 items. Item numbers 2, 3, and 5 are reverse scored. Scores of 40 or above are strongly suggestive of a diagnosis of BDD. The scale may also be repeated during treatment and used as a measure of outcome. It is available to complete on this website. It is free to use but should be cited in any publication.

Reference: Veale, D, Ellison, N, Werner, T, Dodhia, R, Serfaty, M & Clarke, A. (2012) Development of a cosmetic procedure screening questionnaire (COPS) for Body Dysmorphic Disorder. Journal of Plastic Reconstructive and Aesthetic Surgery, 65 (4), 530-532.

The Appearance Anxiety Inventory (AAI)

The AAI is a self-report scale designed to be used weekly during therapy to help decide which processes and behaviours to target during therapy. The questionnaire has 10 items and the range is 0 to 40. It is free to use but should be cited in any publication. It is available to complete on this website by following this link.

Reference: Veale, D, Eshkevari, E, Kanakam, N, Ellison, N, Costa, A, Werner, T. (2013). The Appearance Anxiety Inventory. Behavioural and Cognitive Psychotherapy.

BDD Dimensional Scale (BDD-D)

The BDD-D is a self-report scale can be used as an outcome measure during therapy. It has just 5 items and the range is 0 to 20. It is modelled on the Florida Obsessive Compulsive Inventory but has not yet been validated in BDD.  There are 5 items with a range of 0- 20. We are not sure if the scale is that sensitive to change during treatment but this needs to be formally evaluated.

Reference: LeBeau R, Mischel, E, Simpson, H, Mataix-Cols, D, Phillips, K, Stein, D, Craske, M (2013) Preliminary assessment of obsessive–compulsive spectrum disorder scales for DSM-5. Journal Of Obsessive Compulsive and Related Disorders 2:114-118

The Body Image Disturbance Questionnaire (BIDQ)

The BIDQ is a self-report scale developed by Professor Tom Cash derived from Katherine Phillips BDD Questionnaire. It contains seven items and is used for screening for BDD. It is available for a nominal fee or may be used for free in research (write to Professor Cash).

References:

Cash, T. F., Phillips, K. A., Santos, M. T., & Hrabosky, J. I. (2004). Measuring “negative body image”: Validation of the Body Image Disturbance Questionnaire in a non-clinical population. Body Image, 1(4), 363-372.

Cash, T.F., & Grasso, K. (2005). The norms and stability of new measures of the multidimensional body image construct. Body Image: An International Journal of Research, 2, issue 2.

The Body Image Quality of Life Inventory (BIQLI)

The BIQLI was developed by Professor Tom Cash. It measures the quality of life related to body image and has been validated in BDD. It is available for a nominal fee or for free if used in research (write to Professor Cash) and is available from his website.

References:

Cash, T.F., & Fleming, E.C. (2002). The impact of body-image experiences: Development of the Body Image Quality of Life Inventory. International Journal of Eating Disorders, 31, 455-460.

Hrabosky, J.I, Cash, T. F, Veale, D, Neziroglu, F, Soll, E.A, Garner, D. M, Strachan-Kinser, M, Bakke, B, Clauss, L.J & Phillips, K.A (2009) Multidimensional body image comparisons of eating disorders, body dysmorphic disorder and clinical controls: A multisite study. Body Image, 6 (3), 155-163.

The Dysmorphic Concern Questionnaire (DCQ)

The DCQ is a self-report questionnaire, which can be used to screen for BDD. A score of 9 is used as a cut off for BDD.

Reference: Mancuso SG, Knoesen NP, Castle DJ. The Dysmorphic Concern Questionnaire: A screening measure for body dysmorphic disorder. Aust N Z J Psychiatry. 2010 Jun;44(6):535-42. doi: 10.3109/00048671003596055.

Treatment Manuals

Here are some treatment manuals that you might find useful if you have a patient who is presenting with BDD symptoms >