Course and Prognosis
Symptoms of BDD typically begin in early adolescence and follow a chronic course, although reports indicate that symptoms often wax and wane over time. For those who develop BDD prior to the age of 18, suicidal ideation and attempts are more common. Symptoms have been shown to improve significantly through evidence-based treatments.
Differential Diagnosis (or, When Is It Really BDD?)
It is extremely important that BDD not be mistaken for other psychiatric illnesses which often mimic the symptoms seen in BDD.
Misinterpreting BDD for a delusional disorder or schizophrenia, for example, and subsequently treating the patient with atypical antipsychotics will likely result in minimal to no symptom improvement, and could actually do harm to the patient. Likewise, misdiagnosing BDD in someone with psychosis could be disastrous, as risks are likely to be missed and treatments are unlikely to be effective.
Bear in mind the following types of psychiatric or medical conditions in which the clinician may mistake BDD as the primary condition:
- • Eating Disorders. The BDDQ screens for eating disorders by asking, “Is your main concern with your appearance that you aren’t thin enough or that you might become too fat?” Given the obsessive preoccupation with appearance noted in both eating disorders and BDD, ruling out eating disorders is of vital importance. If the individual is solely concerned with weight, an eating disorder would be the proper diagnosis.
- • Agoraphobia. Patients with BDD often isolate themselves in their home and may be seen as agoraphobic. It is important to address the motivation for remaining housebound or limiting their interactions with the world in order to differentiate other anxiety disorders such as agoraphobia from BDD.
- • Schizophrenia or Delusional Disorder. Many of the signs and symptoms of BDD mirror the positive and negative symptoms of schizophrenia or delusional disorder. In BDD, however, disorganized behaviors are generally absent and the delusions are typically very specific and isolated.
- • Psychotic depression. Like eating disorders, the obsessive preoccupation with a perceived defect can, at times, border on being delusional. The person with BDD is convinced that a particular area of the body is grossly unattractive. Significant depressive symptoms may accompany obsessions over bodily defects. Psychotic depression can be associated with somatic delusions (e.g., that a part of the body does not exist or does not function properly).
• Social anxiety disorder. Social anxiety disorder is common in BDD and patients with BDD will often isolate themselves from social interaction or become reclusive in their home. Unlike social anxiety disorder, however, BDD is based upon a central preoccupation with defects in appearance and the belief that others will reject or laugh at them due to their physical defect(s).