Body Dysmorphic Disorder: Screening Patients and Associated Algorithms

Fig. 11.1
Body Dysmorphic Disorder Questionnaire (BDDQ) [44]. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder by Phillips (2005) Fig “BDDQ for Adolescents” p. 380. By permission of Oxford University Press, USA

When compared to a structured psychiatric interview, the BDDQ exhibited 100 % sensitivity and 89 % specificity as a screening measure for body dysmorphic disorder in 66 psychiatric outpatients [45], and similarly demonstrated 100 % sensitivity and 93 % specificity in a psychiatric inpatient sample [36, 46]. The BDDQ has been validated in a community-based sample [36] and used to estimate prevalence of body dysmorphic disorder among college students [5, 40].

The BDDQ has been used in two studies of individuals seeking cosmetic rhinoplasty [35, 38, 47]. Veale et al. administered the BDDQ as a screening measure in conjunction with a self-report version of the BDD-YBOCS to assess symptom severity before and after rhinoplasty. Six of 29 patients had a positive screening result indicating “possible body dysmorphic disorder” pre-rhinoplasty, and had significantly higher scores on the self-report BDD-YBOCS than the patients with a negative screening result. However, at the 9th month post-rhinoplasty, no patient out of the 29 patients had a positive screening result on the BDDQ and the overall mean BDD-YBOCS scores were low, indicating mild symptom severity in the total patient group. Given the study findings, Veale et al. suggested that the BDDQ had identified false positives in their sample [38]. In the second study, the BDDQ was used to identify features of body dysmorphic disorder to correlate body dysmorphic disorder traits with self-esteem, personality, and quality of life [47]. Of note, neither studies compared the BDDQ to a gold standard, diagnostic measure (psychiatric interview) to validate the BDDQ as a screening tool for body dysmorphic disorder in a cosmetic patient population [35].

Body Dysmorphic Disorder Questionnaire—Dermatology Version (BDDQ-DV)

A modified version of the BDDQ, called the Body Dysmorphic Disorder Questionnaire—Dermatology Version (BDDQ-DV), was created by Dufresne et al. and Phillips et al. for the dermatology setting [13, 14]. Alterations included removal of questions 2 and 4 and the addition of five-point scale to response elements of question 3 (Fig. 11.2). Similar to the BDDQ, patients indicating preoccupation with an aspect of their appearance and at least moderate distress or disturbances in functioning screen positive for body dysmorphic disorder [13].


Fig. 11.2
Body dysmorphic Disorder Questionnaire—Dermatology Version (BDDQ-DV) [14]

The BDDQ-DV was validated in a sample of 46 cosmetic dermatology patients as compared to the Body Dysmorphic Disorder-Diagnostic Module (BDD-DM), a semi-structured interview instrument based on DSM-IV criteria for body dysmorphic disorder. Nine (19.6 %) of the 46 patients screened positive using the BDDQ-DV and 7 (15.2 %) were diagnosed with body dysmorphic disorder by BDD-DM. This resulted in 100 % sensitivity and 92 % specificity with a positive predictive value of 70 % and a negative predictive value of 100 % [14]. Limitations included a small sample size and administration of the BDD-DM by a physician without formal psychometric training [35].

Three additional studies have used the BDDQ-DV to estimate the prevalence of body dysmorphic disorder in dermatology patients. Phillips et al. administered the BDDQ-DV to 268 patients presenting to a general dermatology community practice and a university-based dermatologic cosmetic surgery practice, and found a positive screening result in 11.9 % of patients. This estimate was increased to 15.2 % in individuals with nonexistent or minimal defects [13]. Bowe et al. used the BDDQ-DV as a screening tool in patients with acne vulgaris [16], and Conrado et al. used this instrument to evaluate 300 patients presenting to general and cosmetic dermatology practices [41]. These studies reported positive screening results in 14.1  and 9.1 % respectively [16, 41]. None of the three studies used a psychiatric interview to confirm the diagnosis of body dysmorphic disorder [35].

Body Dysmorphic Disorder Examination—Self Report (BDDE-SR)

The Body Dysmorphic Disorder Examination (BDDE) is a 34 question semi-structured clinical interview devised as a diagnostic and symptom severity tool. It has been shown to be a valid and reliable instrument for diagnosing body dysmorphic disorder; however, its administration is very time-intensive [48]. The Body Dysmorphic Disorder Examination-Self Report (BDDE-SR) is a written, patient-completed version of the BDDE. The BDDE-SR asks patients to rank the five physical features that bother them the most and then answer several questions as they relate to the highest ranked feature. These questions evaluate diagnostic criteria and symptoms of body dysmorphic disorder, such as frequently checking the feature, seeking reassurance from others, emotional distress, avoiding public places, work, and social situations, and camouflaging [7, 48]. Each question is answered on a scale of 1–6, and all answers are summed to produce a total score. No set cutoff score is considered diagnostic, though higher scores are associated with greater severity of body dysmorphic disorder symptoms [48]. The BDDE-SR has been used as a screening tool in cosmetic surgery patients [7, 49]. It has also been used to measure body image dissatisfaction and body dysmorphic disorder symptoms in obese women [50], women undergoing breast reduction and breast augmentation surgery [51, 52], women seeking rhytidectomy and blepharoplasty [53], and women with eating disorders [54].

Sarwer et al. applied the BDDE-SR as a screening and diagnostic instrument in 100 female cosmetic surgery patients and reported a statistically significant higher BDDE-SR mean score in the cosmetic surgery patient population than in that of a normative age comparable sample (47.76 vs. 27.8 respectively, p < 0.005). Using the BDDE-SR, seven patients were diagnosed with body dysmorphic disorder [50]. In a smaller study, Pertschuk et al. administered the BDDE-SR to 30 men seeking cosmetic surgery and reported an average BDDE-SR score of 37.52, which was statistically significantly higher than an age-comparable sample of men [49]. Neither of the two studies used a psychiatric interview to confirm the diagnosis [35].

Body Dysmorphic Symptoms Scale (BDSS)

The Body Dysmorphic Symptoms Scale (BDSS) is a 10-item questionnaire developed at the Institute of Psychiatry at the University of Pisa [55]. Yes–No questions are directed at assessing key behaviors associated with body dysmorphic disorder such as frequent mirror-checking, camouflaging, and avoidance [56]. The Modified Pisa BDSS is a slightly different version of the BDSS in which question 6 has been altered to detect unrealistic expectations from an intervention (Fig. 11.3) [25, 57]. Scoring is calculated by summing the questions answered as “yes” for a maximum score of 10. Muhlbauer et al. proposed interpretation of the score as follows: positive response to questions 1 through 5 might by candidates for surgical/dermatologic intervention but further workup is needed, positive response to questions 1 through 7 indicates likely body dysmorphic disorder, and positive response to question 1 through 10 contraindicates an intervention [57]. A practical algorithm using the Modified Pisa BDSS is described in Fig. 11.4.


Fig. 11.3
Modified Pisa Body Dysmorphic Symptoms Scale (BDSS) [25, 55, 57]


Fig. 11.4
Practical algorithm for use with Modified Pisa Body Dysmorphic Symptoms Scale (BDSS) as a screening questionnaire [25, 57]

The BDSS has been used as a screening tool in a university-based dermatology practice. The questionnaire was completed by 107 dermatology patients with a variety of skin diseases as well as 109 age- and sex-matched university students. Mean BDSS score was statistically significantly higher in the skin disease group than in the control group. The authors chose a score of greater than 4 to signify increased risk for body dysmorphic disorder and found that a higher number of patients with skin disease (17.8 %) scored greater than 4 on the BDSS as compared to healthy controls (2.8 %) [56]. Diagnosis of body dysmorphic disorder was not confirmed by psychiatric evaluation in this study [35].

Dysmorphic Concern Questionnaire (DCQ)

The Dysmorphic Concern Questionnaire (DCQ) is a seven-question screening instrument developed Oosthuizen et al. (Fig. 11.5) [58]. Questions are directed towards assessing symptomology and overconcern with physical appearance rather than trying to establish a diagnosis of body dysmorphic disorder. Response to each question is either “no concern (0)” or, as compared to most other people, graded as “the same (1)” “more (2)” or “much more (3)” and summed for a total score. In validation studies with psychiatric patients, the DCQ demonstrated good internal consistency, a unidimensional factor structure, and strong correlation with distress and work and social impairment [58, 59].


Fig. 11.5
Dysmorphic Concern Questionnaire (DCQ) [58]

A study exploring the cutoff scores as a screening tool for body dysmorphic disorder showed a cutoff score of 9 provided the best balance of sensitivity and specificity [60]. Stangier et al. used the DCQ as a screening tool in 65 female dermatology patients as compared to the BDD-DM and BDD-YBOCS. The sample consisted of 22 patients with body dysmorphic disorder, 21 patients with mild dermatological disorders, and 22 patients with disfiguring dermatological conditions. A DCQ cutoff score of 11 captured 100 % of those with body dysmorphic disorder, 100 % of those with mild disorders, and 59 % of those with disfiguring conditions. A DCQ cutoff score of 14 optimized sensitivity and specificity by accurately classifying 72 % of those with body dysmorphic disorder and 90.7 % of those without body dysmorphic disorder [60, 61].

Cosmetic Procedure Screening Questionnaire (COPS)

Veale et al. developed the Cosmetic Procedure Screening Questionnaire (COPS) in 2012 with the goal of designing a brief-screening questionnaire for body dysmorphic disorder that would also be sensitive to change after an intervention. Two groups of individuals seeking a cosmetic procedure, a community group and a group of patients diagnosed with body dysmorphic disorder by psychiatric interview, were asked several questions regarding their appearance and distress or impaired functioning related to their physical feature(s). In question 1, the individual is asked to describe the feature(s) of his or her body which is disliked or the individual would like to improve. After this, the patient is asked to draw within a pie chart the estimated the percentage of concern allocated to each feature. This is followed by a series of nine questions that were included in the final version of the COPS questionnaire after showing a significant difference between the two groups and meeting criteria for effect size (see manuscript by Veale et al. for full questionnaire). Each question is rated on a scale of 0–8 with a maximum achievable score of 72. The authors recommend referring patients with an initial score of 40 or higher for further evaluation. The questionnaire demonstrated adequate internal consistency and test–retest reliability with a high sensitivity for detecting body dysmorphic disorder in patients seeking cosmetic procedures [39].

Body Image Concern Inventory (BICI)

The Body Image Concern Inventory (BICI) was developed by Littleton et al. as a 19-item questionnaire (possible score 19–95) for use in research and clinical settings as a measure of dysmorphic concern [62]. The survey has been validated in multiple studies with undergraduate students [62], an ethnically diverse Spanish-speaking community population [63] and an Italian community sample [64]. The BICI demonstrated 96 % sensitivity and 67 % specificity in distinguishing clinical disorders from subclinical symptoms in 40 undergraduate students diagnosed with body dysmorphic disorder and eating disorders [62]. The BICI was administered to 117 individuals seeking cosmetic rhinoplasty who were also interviewed by a psychiatrist to evaluate for a diagnosis of body dysmorphic disorder. It detected the disorder with 93.5 % sensitivity, 80.8 % specificity, 63.4 % positive predictive value, and 96.5 % negative predictive value at a cutoff score of 42 [65].


Although only three (BDDQ-DV, DCQ, BICI) of the current surveys have been authenticated by psychiatric evaluation when used in dermatology and plastic surgery settings, all report similar prevalence of body dysmorphic disorder in these patient populations. It appears there is relevance in each of these surveys depending on the practice milieu. In addition, it is important not to neglect the significance of the face-to-face interaction between the proceduralist, the staff, and the patient. There are limitations to the use of these questionnaires, and, as indicated above, many to date have not yet been updated to include DSM-5 criterion pertaining to the recognition of repetitive behaviors or mental acts in response to appearance concerns. One recent study used an additional question incorporating the new criterion in a population telephone survey to compare the prevalence of BDD using DSM-IV vs. DSM-5 criteria. In this study, BDD diagnosis was not authenticated by psychiatric interview, and it was not used as a screening tool for patients seeking cosmetic procedures; however, it did show that the revised criteria did not seem to have an impact on prevalence rates [66]. From this very limited data, for the time being, it appears that current questionnaires can still be adequately used to diagnose BDD. As there are no fully up-to-date questionnaires and no universal consensus on the most appropriate questionnaire, more research is needed in this area for efficient diagnosis of BDD in those who present to the dermatology, cosmetic, and plastic surgery clinics.

Apr 26, 2017 | Posted by in Dermatology | Comments Off on Body Dysmorphic Disorder: Screening Patients and Associated Algorithms

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