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ICD-11 Criteria for Body Dysmorphic Disorder

ICD-11 Criteria for Body Dysmorphic Disorder

6B21 Dysmorphic Disorder

Description

Body Dysmorphic Disorder is characterised by persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others. Individuals experience excessive self-consciousness, often with ideas of reference (i.e., the conviction that people are taking notice, judging, or talking about the perceived defect or flaw). In response to their preoccupation, individuals engage in repetitive and excessive behaviours that include repeated examination of the appearance or severity of the perceived defect or flaw, excessive attempts to camouflage or alter the perceived defect, or marked avoidance of social situations or triggers that increase distress about the perceived defect or flaw. The symptoms are sufficiently severe to result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Exclusions

Anorexia Nervosa (6B80)

Bodily distress disorder (6C20)

Concern about body appearance (QD30-QD3Z)

Diagnostic Requirements

Essential (Required) Features:

Persistent preoccupation with one or more perceived defects or flaws in appearance, or ugliness in general, that is either unnoticeable or only slightly noticeable to others.

Excessive self-consciousness about the perceived defect(s) or flaw(s), often including ideas of self-reference [i.e., the conviction that people are taking notice, judging, or talking about the perceived defect(s) or flaw(s)].

The preoccupation or self-consciousness is accompanied by any of the following:

Repetitive and excessive behaviours, such as repeated examination of the appearance or severity of the perceived defect(s) or flaw(s) (e.g., by checking in reflective surfaces) or comparison of the relevant feature with that of others;

Excessive attempts to camouflage or alter the perceived defect (e.g., specific and elaborate forms of dress, undergoing ill-advised cosmetic surgical procedures);

Marked avoidance of social or other situations or stimuli that increase distress about the perceived defect(s) or flaw(s) (e.g., reflective surfaces, changing rooms, swimming pools).

The symptoms are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects.

The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Insight specifiers:

Individuals with Body Dysmorphic Disorder vary in the degree of insight they have about the accuracy of the beliefs that underlie their symptoms. Although many can acknowledge that their thoughts or behaviours are untrue or excessive, some cannot, and the beliefs of some individuals with Body Dysmorphic Disorder may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (e.g., an individual is convinced that others think he is hideously ugly). Insight may vary substantially even over short periods of time, for example depending on the level of current anxiety or distress, and should be assessed with respect to a time period that is sufficient to allow for such fluctuation (e.g., a few days or a week). The degree of insight that an individual exhibits in the context of Body Dysmorphic Disorder can be specified as follows:


6B21.0 Body Dysmorphic Disorder with fair to good insight

Much of the time, the individual is able to entertain the possibility that their disorder-specific beliefs may not be true and they are willing to accept an alternative explanation for their experience. This specifier level may still be applied if, at circumscribed times (e.g., when highly anxious), the individual demonstrates no insight.

6B21.1 Body Dysmorphic Disorder with poor to absent insight

Most or all of the time, the individual is convinced that the disorder-specific beliefs are true and they cannot accept an alternative explanation for their experience. The lack of insight exhibited by the individual does not vary markedly as a function of anxiety level.

6B21.Z Body Dysmorphic Disorder, unspecified

Additional Clinical Features:

Any part of the body may be the focus of the perceived flaw(s) or defect(s), but the most common area is the face (especially the skin, nose, hair, eyes, teeth, lips, chin, or overall facial appearance). However, there are frequently multiple perceived defects. Usually the focal feature is regarded as flawed, defective, asymmetrical, too big/small or disproportionate, or the complaint may be of thinning hair, acne, wrinkles, scars, vascular markings, pallor or ruddiness of complexion, or insufficient muscularity. Sometimes the preoccupation is vague or consists of a general perception of ugliness or being ‘not right’ or being too masculine/feminine.

Muscle dysmorphia, a form of Body Dysmorphic Disorder, can place affected individuals, usually males, at increased risk for complications requiring medical attention (e.g., muscle tears, strains, side effects of steroid use).

There is a high risk of suicide in adolescents and adults with Body Dysmorphic Disorder, particularly when depressive symptomatology co-occurs. Due to the low base rate of occurrence of attempted and completed suicide, it is difficult to predict suicidal behaviours. Factors to consider in assessing risk include previous attempts, lack of perceived psychosocial supports, perception of burdensomeness, and hopelessness. It is also important to consider that identification of Body Dysmorphic Disorder may be especially challenging because the increased occurrence of shame and perceived stigma among affected individuals often leads them to conceal their difficulties or present with symptoms of Depressive Disorders, Social Anxiety Disorder, or Obsessive-Compulsive Disorder rather than Body Dysmorphic Disorder.

The diagnosis of Body Dysmorphic Disorder is typically made based on direct observation or physical examination of the perceived body flaw(s) or defect(s). If this is not possible because it is inappropriate or the individual refuses to remove their camouflage, then it may be difficult to make a judgment about how noticeable or abnormal a perceived defect is. In such cases corroborative evidence may be required from a knowledgeable informant or physician who has conducted a physical examination of the individual.

In some cases, individuals may be persistently preoccupied with one or more perceived defects or flaws in appearance, or ugliness in general, of another person, generally a child or a romantic partner, that is either unnoticeable or only slightly noticeable to others. This phenomenon is often referred to as Body Dysmorphic Disorder by proxy. If the other diagnostic requirements for the disorder are met with reference to the perceived bodily flaw(s) or defect(s) of the other person (e.g., excessive self-consciousness, repetitive and excessive examination or checking, marked camouflaging or alteration of the perceived defect, avoidance of relevant social situations or triggers, distress or functional impairment), a diagnosis of Body Dysmorphic Disorder may be assigned to the individual experiencing the preoccupation.

Boundary with Normality (Threshold):

Body image concerns are common in many cultures, especially during adolescence. Body Dysmorphic Disorder is differentiated from body dissatisfaction or body image concerns by the degree of preoccupation, frequency of related recurrent behaviours performed, as well as the degree of distress or interference the individual experiences as a consequence of these symptoms.

Course Features:

The onset of Body Dysmorphic Disorder commonly occurs during adolescence with two thirds of individuals reporting onset before age 18. Subclinical symptoms may appear during early adolescence (at 12 or 13 years of age).

Although the typical course of Body Dysmorphic Disorder involves a gradual worsening of symptoms from subclinical to full symptomatic presentation, some individuals may experience an acute onset of symptoms.

Among individuals with onset before age 18, Body Dysmorphic Disorder is associated with gradual onset of symptoms and co-occurring disorders. These individuals are also at greater risk of attempting suicide.

Body Dysmorphic Disorder is generally considered a chronic disorder.

Developmental Presentations:

Notwithstanding a relatively early age of onset of Body Dysmorphic Disorder, it typically takes 10-15 years before affected individuals seek help. New onset may occur among the elderly, though research with this age group is very limited.

Onset of Body Dysmorphic Disorder symptoms tends to be gradual. The disorder is recurrent, chronic, and likely to persist without intervention.

Prevalence of Body Dysmorphic Disorder among adolescents is estimated at approximately 2%, with higher prevalence among female adolescents. Prevalence rates are likely an underestimate because shame, embarrassment and stigma about symptoms frequently interfere with help-seeking behaviours.

Symptom presentation is similar across all age groups. However, differentiating between normality and Body Dysmorphic Disorder in adolescence may be complicated by the emergence of developmentally-normative concerns about body image that occur during this stage.

The course and severity of the disorder tends to be worse among individuals with an earlier onset (prior to age 18). Specifically, these individuals are at increased risk for suicide, present with more co-occurring mental disorders, have poorer insight, and are more likely to have experienced a gradual progression of symptom onset than individuals who develop Body Dysmorphic Disorder in adulthood. Youth with Body Dysmorphic Disorder are also at increased risk for school drop-out, potentially impacting their academic and social development.

Culture-Related Features:

The symptoms of Body Dysmorphic Disorder are similar across cultures, but specific concerns are shaped by cultural standards regarding what is considered attractive, acceptable, normal, or desired. For example, populations in East Asia might be focused on epicanthal folds and concerns about skin colour may be associated with racialized conceptions of desirable body characteristics.

Within more collectivistic cultures, or cultures that emphasize shame, the nature of the concern about bodily deformities may be focused on anxiety about causing offense to others.

There are cultural concepts of distress that focus on perceptions of abnormal bodily features and may shape the symptoms of Body Dysmorphic Disorder. For example, the shubo-kyofu (“fear of a deformed body”) subtype of taijin kyofusho has been reported primarily in Japan; it is characterized by intense fear of offending, embarrassing or hurting others through the person’s appearance, which is perceived as deformed. Insight is typically poor to absent.

Sex- and/or Gender-Related Features:

Although prevalence rates are similar for both genders, differences in presentation have been described. Women are more likely to experience co-occurring Eating Disorders; whereas men are more likely to be concerned with the appearance of their genitalia and their overall physique (i.e., muscle dysmorphia).

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

Boundary with Hypochondriasis (Health Anxiety Disorder): Hypochondriasis is characterized by persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses, whereas in Body Dysmorphic Disorder the preoccupation is with perceived flaws or defects in the individual’s appearance.

Boundary with Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking) Disorder: Skin picking and hair pulling can occur as symptoms of Body Dysmorphic Disorder when there is a preoccupation with the skin or hair appearing defective and the intended aim is to improve its appearance. In contrast, when the behaviour is a body-focused repetitive behaviour with no clear relationship to a perceived defect on the skin or hair, then it is better classified as Trichotillomania or Excoriation Disorder.

Boundary with other Obsessive-Compulsive or Related Disorders: Recurrent thoughts and repetitive behaviours occur in other Obsessive-Compulsive or Related Disorders but the foci of apprehension and form of repetitive behaviours are distinct for each diagnostic entity. In Obsessive-Compulsive Disorder, the intrusive thoughts and repetitive behaviours are not limited to concerns about appearance but rather encompass a variety of obsessions (e.g., of contamination, of causing harm) and compulsions (e.g., excessive washing, counting, checking) intended to neutralize these obsessions. In Olfactory Reference Disorder individuals are preoccupied exclusively with emitting a perceived foul or offensive body odour. However, Obsessive-Compulsive or Related Disorders can co-occur, and multiple diagnoses from this grouping may be assigned if warranted.

Boundary with Delusional Disorder and other Primary Psychotic Disorders: Many individuals with Body Dysmorphic Disorder lack insight about the irrationality of their thoughts and behaviours to such an extent that convictions that their appearance is flawed may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (see Insight specifiers, page __). If these beliefs are restricted to the fear or conviction of having a flawed appearance or bodily defect in an individual without a history of other delusions, that is, these beliefs occur entirely in the context of symptomatic episodes of Body Dysmorphic Disorder and are fully consistent with the other clinical features of the disorder, Body Dysmorphic Disorder should be diagnosed instead of Delusional Disorder. Individuals with Body Dysmorphic Disorder do not exhibit other features of psychosis (e.g., hallucinations or formal thought disorder).

Boundary with Mood Disorders: Individuals experiencing a Depressive Episode with psychotic symptoms may occasionally become preoccupied with perceived physical flaws or defects, which can be differentiated from Body Dysmorphic Disorder on the basis of the absence of such symptoms outside of the Mood Episode. However, individuals with a history of Body Dysmorphic Disorder commonly experience co-occurring depressive symptoms as a consequence of the distress and impairment of their Body Dysmorphic Disorder symptoms. If depressive symptoms consistent with a Mood Disorder are present in an individual with Body Dysmorphic Disorder, both disorders may be diagnosed.

Boundary with Generalized Anxiety Disorder: In Generalized Anxiety Disorder, recurrent thoughts or worries are focused on potential negative outcomes that might occur in a variety of everyday aspects of life (e.g., family, finances, work). Although some individuals with Generalized Anxiety Disorder may worry excessively about their appearance, these preoccupations occur together with worries about other aspects of life, are rarely delusional, and are not typically accompanied by the recurrent checking behaviour associated with Body Dysmorphic Disorder.

Boundary with Social Anxiety Disorder: In Social Anxiety Disorder, symptoms are in response to feared social situations and the primary concern is about the person’s own behaviour or manifestations of anxiety (e.g., fear they may blush) being negatively evaluated by others. In contrast, individuals with Body Dysmorphic Disorder believe their appearance or a specific feature of their appearance (e.g., belief that skin appears permanently red) looks flawed. Some individuals with Body Dysmorphic Disorder experience significant anxiety in social situations and fear they will be seen as ugly and therefore be rejected. If their concerns are broader than the exclusive focus on their perceived flaws or defects in appearance and other symptoms of Social Anxiety Disorder are present, both conditions may be diagnosed.

Boundary with Eating Disorders: Body Dysmorphic Disorder can be distinguished from Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder because preoccupations in Body Dysmorphic Disorder are not limited to body image concerns (i.e., idealized low body weight). Rather, the preoccupations can encompass a variety of idealized aspects of appearance. Some individuals with Body Dysmorphic Disorder exhibit muscle dysmorphia such that they are preoccupied about being insufficiently muscular or lean and in response, may exhibit unusual eating behaviours (e.g., excessive protein consumption) or engage in excessive exercise (e.g., weight lifting). In these cases, behaviours related to diet and exercise are motivated by a desire to be more muscular rather than to attain or maintain a low body weight. However, if low body weight idealization is central to the clinical presentation and all other diagnostic requirements are met, a diagnosis of Anorexia Nervosa instead of Body Dysmorphic Disorder should be assigned.

Boundary with Body Integrity Dysphoria: The persistent preoccupation and excessive self-consciousness experienced by individuals with Body Dysmorphic Disorder derives from their concerns that an aspect of their body or appearance is perceived by others to be ugly or deformed. In contrast, the persistent discomfort or intense negative feelings about a particular body part (most commonly one or both arms or legs) experienced by individuals with the rare condition of Body Integrity Dysphoria derives from their sense that a part of their body is alien or the way their body is configured is wrong or unnatural. This leads to a desire to amputate or be rid of the particular body part, rather than wishing to improve its appearance.

Boundary with Gender Incongruence of Adolescence and Adulthood and Gender Incongruence of Childhood: Gender Incongruence of Adolescence and Adulthood as well as Gender Incongruence of Childhood differ from Body Dysmorphic Disorder in that in these conditions the preoccupation with aspects of bodily appearance centres exclusively on the individual’s experience of a marked incongruence between their expressed or experienced gender and their biological sex. A common consequence is that individuals will clearly state a desire to alter their primary and secondary sex characteristics such that they align with their experienced gender. 

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