Diagnosis and differential diagnosis

BDD can be diagnosed using the following questions.

• Have you ever been very worried about your appearance in any way? If yes: what was your concern?

• Did this concern/preoccupy you? Did you think about it a lot and wish you could worry about it less?

• What effect has this preoccupation with your appearance had on your life? Has it caused you a lot of distress or significantly interfered with your social life, school work, job, or other activities? Has it affected your family or friends?

Clues to the diagnosis include mirror-checking or avoidance, comparing with others, reassurance seeking, excessive grooming, skin picking, camouflaging, frequent clothes changing, body measuring, excessive exercising or weightlifting, anabolic steroid use, ideas or delusions of reference, social anxiety and self-consciousness, being housebound, panic attacks, depression, anxiety, suicidal ideation, or unnecessary surgical or dermatological treatment. (4)

ICD-10's definition of BDD, which requires that patients refuse to accept the advice and reassurance of several different doctors, is likely to result in underdiagnosis, as many patients do not seek medical help because of shame, limited access to health care, or for other reasons.

BDD can be difficult to diagnose because sufferers often keep their symptoms secret due to embarrassment and shame. They may volunteer only depression, anxiety, or discomfort in social situations. Consequently, BDD may be misdiagnosed as social phobia or agoraphobia (due to secondary social anxiety and isolation), panic disorder (because situational panic attacks may occur, e.g. after looking in the mirror), trichotillomania (in patients who cut or pluck their hair for the sake of appearance), or obsessive-compulsive disorder (due to obsessional preoccupations and compulsive behaviours). Delusional patients are sometimes misdiagnosed with schizophrenia or psychotic depression. To diagnose BDD, the symptoms typically need to be asked about directly.

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