“Are you very worried about your appearance in any way?” or, “Are you unhappy with how you look?” If the patient replies affirmatively, proceed as you would with any other illness, asking the patient to tell you about his or her concern, eg, “What don’t you like about how you look?” or, “What is your concern?” Ask if there are other body areas they do not like, eg, “Are you unhappy with any other aspects of your appearance? Some people are worried about the appearance of their face, skin, hair, nose, or the shape or size of other body areas. Are these or any other body areas a concern for you?” Next, determine whether the patient is preoccupied with the perceived appearance 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 during the entire day?” or, “Do these concerns preoccupy you?” Thinking about the perceived flaws for a total of at least 1 hour per day is consistent with the diagnosis of BDD. Ask “How much distress do these concerns cause you?” After the patient replies, ask more specifically whether the concerns cause anxiety, anxiety around other people, anger, depression, panic, or suicidal thinking. -
Ask about effects of the appearance preoccupations on the patient’s life, eg, “Do these concerns interfere with your life or cause problems for you in any way?” After the patient replies, ask more specifically about effects on:
Work: eg, being late, missing work, poor concentration or productivity, being unemployed or underemployed School: eg, being late, missing school, poor concentration or productivity, poor grades, dropping out of school, or not pursuing academic goals Social aspects of one’s life: eg, avoiding relationships, not dating, interference with intimacy or sexual functioning, avoiding social situations or events, becoming withdrawn from family or friends Other types of interference: eg, not caring for children, maintaining a household, paying bills, buying groceries, going shopping, or doing other household tasks Any other aspect of one’s life
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While BDD behaviors are not required for the diagnosis, most patients perform at least one of them (usually many), so these behaviors may be a clue that a patient has BDD. Ask, “Do you do things to check, try to fix, or hide the body areas you dislike?” Ask specifically about the most common behaviors:
Camouflaging with clothing, sunglasses, hair, or body position Comparing their appearance with that of other people Checking the perceived flaws in mirrors or other reflecting surfaces Excessive grooming, eg, makeup application; face cleansing routines; or hair styling, combing, shaving, or plucking Seeking reassurance about how they look Touching the body areas Frequent clothes changing Skin picking to remove blemishes or other skin imperfections, or to “even out” one’s skin Tanning Dieting, excessive exercise, or excessive weightlifting
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