Differential Diagnosis
Unlike normal concerns about appearance, the preoccupation with appearance in Body Dysmorphic Disorder is excessively time consuming and associated with significant distress or impairment in social, occupational, or other areas of functioning. However, Body Dysmorphic Disorder may be underrecognized in settings in which cosmetic procedures are performed. The excessive exercising (e.g., weight lifting) that can occur in Body Dysmorphic Disorder to correct a perceived appearance flaw should be differentiated from healthy exercising and from excessive exercising that may occur as part of an Eating Disorder.
The diagnosis of Body Dysmorphic Disorder should not be made if the preoccupation is better accounted for by another mental disorder. Body Dysmorphic Disorder should not be diagnosed if the excessive preoccupation is restricted to concerns about “fatness” in Anorexia Nervosa, if the individual’s preoccupation is limited to discomfort with or a sense of inappropriateness about his or her primary and secondary sex characteristics occurring in Gender Identity Disorder, or if the preoccupation is limited to mood-congruent ruminations involving appearance that occur exclusively during a Major Depressive Episode. However, depression often occurs secondary to Body Dysmorphic Disorder, in which case Body Dysmorphic Disorder should be diagnosed.
Individuals with Avoidant Personality Disorder or Social Phobia may worry about being embarrassed by real defects in appearance, but this concern is usually not prominent, persistent, distressing, time consuming, and impairing. Although individuals with Body Dysmorphic Disorder have obsessional preoccupations about their appearance and may have associated compulsive behaviors (e.g., mirror checking), a separate diagnosis of Obsessive-Compulsive Disorder is given only when the obsessions or compulsions are not restricted to concerns about appearance. Some individuals with Body Dysmorphic Disorder remove body hair or pick their skin in an attempt to improve their appearance; these behaviors should be distinguished from hair pulling in Trichotillomania, which does not occur in response to appearance concerns, and from skin picking that may be associated with other mental disorders.
Individuals with Body Dysmorphic Disorder can receive an additional diagnosis of Delusional Disorder, Somatic Type, if their preoccupation with an imagined defect in appearance is held with a delusional intensity.
Koro is a culture-related syndrome that occurs primarily in Southeast Asia that may be related to Body Dysmorphic Disorder. It is characterized by the preoccupation that the penis (or labia, nipples, or breast in women) is shrinking or retracting and will disappear into the abdomen. This preoccupation is often accompanied by a belief that death will result. Koro differs from Body Dysmorphic Disorder by its usually brief duration, different associated features (primarily acute anxiety and fear of death), positive response to reassurance, and occasional occurrence as an epidemic.