Educational Disclaimer: This case study is for educational and informational purposes only. It does not constitute medical advice, clinical guidance, or a substitute for professional psychiatric evaluation. All diagnostic criteria referenced are from the DSM-5-TR (APA, 2022). Clinicians should rely on their professional training, direct patient assessment, and current evidence-based guidelines when making diagnostic and treatment decisions.

Clinical Vignette

Patient: "Mr. S," 22-year-old college student, brought by his roommate after missing 3 weeks of classes due to refusing to leave his dorm room because of his facial appearance.

Chief Concern: "My nose is grotesquely large and misshapen. Everyone stares at it. I can't go out looking like this. I needed plastic surgery years ago but no surgeon will agree because they 'don't see the problem' — which proves how delusional THEY are."

History of Present Illness: Mr. S has been preoccupied with the shape and size of his nose since age 16 (6 years). He believes his nose is 'grotesquely large' and 'obviously deformed.' Objective assessment by two otolaryngologists and his primary care physician have found his nose to be within normal anatomical variation; no structural abnormality was identified. He spends 3-4 hours daily examining his nose in mirrors (checking from multiple angles, measuring with a ruler), takes 30-50 selfies daily to compare nose appearance across lighting conditions, and applies makeup to contour his nose before leaving (or leaving not at all on 'bad nose days'). He has consulted 3 plastic surgeons, all of whom declined surgery, stating his nose is anatomically normal. He believes the surgeons are wrong. He has not attended classes in 3 weeks, avoids social gatherings, turns away from people in conversation to hide his nose, and wears hats and scarves to obscure his face. He has passive suicidal ideation: 'I can't live looking like this forever.'

Past Psychiatric History: No prior psychiatric treatment. No prior diagnosis. Suicidal ideation has been present intermittently for 2 years.

Family History: Mother: depression. No OCD-spectrum disorders in family.

Mental Status Exam: Wears baseball cap pulled low. Turns head to show left profile (avoiding frontal view). Speech normal. Mood 'hopeless.' Affect depressed, anxious. Thought content: constant preoccupation with nose appearance. Conviction that his nose is deformed is held with near-delusional intensity (does not accept that clinicians and surgeons see no defect). Passive suicidal ideation present. No hallucinations. Cognitive testing normal.

Step 1: BDD DSM-5-TR Criteria

Criterion A: Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

Six-year preoccupation with nose size/shape. Three independent clinicians have assessed the nose as anatomically normal. The perceived defect is not observable to others. MET.

Criterion B: Repetitive behaviors or mental acts in response to the appearance concerns (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking, or comparing appearance with others).

Mirror checking 3-4 hours daily, 30-50 selfies daily, makeup application to contour nose, consulting 3 plastic surgeons, ruler measurement of nose. MET — multiple repetitive behaviors.

Criterion C: Clinically significant distress or functional impairment.

Missing 3 weeks of classes, social isolation, avoiding frontal-face exposure, turning away in conversations, passive suicidal ideation. Severe impairment across academic and social domains. MET — severe impairment.

Criterion D: Not better explained by eating disorder concerns about body fat or weight.

Preoccupation is specifically about nose shape/size, not about body weight or fat. No caloric restriction, purging, or weight/shape distortion. MET.

Step 2: Insight Specifier

DSM-5-TR requires an insight specifier for BDD, identical to OCD:

Insight Level Description This Patient
Good or fair insight Recognizes BDD beliefs are probably or definitely not true Does NOT apply: believes defect is real
Poor insight Thinks BDD beliefs are probably true APPLIES: believes nose is genuinely deformed despite all professional assessments to the contrary
Absent insight / delusional beliefs Completely convinced BDD beliefs are true Borderline: believes surgeons 'don't see the problem' which 'proves they are delusional'

Insight Assessment

Mr. S demonstrates poor insight bordering on absent insight. He maintains his belief despite unanimous contradictory evidence from three surgeons and two physicians. His assertion that the surgeons are 'delusional' suggests near-delusional conviction. The poor/absent insight specifier has prognostic significance: it is associated with greater severity, higher suicidal ideation, and poorer treatment response.

Diagnostic Formulation

Diagnostic Conclusion

Body Dysmorphic Disorder, with Poor Insight (F45.22): All 4 DSM-5-TR criteria met. Six-year preoccupation with nose appearance not observed by others. Multiple repetitive behaviors (mirror checking, selfies, measurement, surgical consultations). Severe functional impairment (academic failure, social isolation). Passive suicidal ideation. Poor insight specifier. Treatment: SSRI at high dose (as for OCD) + CBT with BDD-specific exposure (going out without camouflage, looking at frontal-facing photos) and cognitive restructuring of appearance beliefs.

Teaching Points

  • BDD is classified under Obsessive-Compulsive and Related Disorders in DSM-5-TR, reflecting its phenomenological and neurobiological overlap with OCD. Both involve intrusive preoccupations and repetitive behaviors, and both respond to high-dose SSRIs.
  • BDD suicidal ideation rates are significant. Passive and active suicidal ideation should be assessed at every visit. The combination of appearance preoccupation, social isolation, and hopelessness about the perceived defect creates elevated suicide risk.
  • Cosmetic surgery is contraindicated in BDD. Patients with BDD who undergo surgery are typically dissatisfied with results, shift preoccupation to another body part, or develop worsened BDD symptoms. Dermatologists and plastic surgeons should screen for BDD before performing elective procedures.
  • The insight specifier in BDD is particularly important because poor insight (near-delusional conviction about the defect) is associated with more severe presentations, higher comorbidity, and greater treatment challenges. In DSM-IV, BDD with absent insight was coded as Delusional Disorder, Somatic Type. DSM-5-TR unified these presentations under BDD with insight specifiers.
  • BDD-specific CBT differs from standard CBT. Key components include: (1) behavioral experiments testing beliefs about others' reactions to the perceived defect, (2) exposure to avoided situations (going out without camouflage, allowing frontal photos), (3) response prevention (reducing mirror checking, selfie taking, and reassurance seeking), and (4) perceptual retraining to reduce selective attention to the perceived flaw.