Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population

doi:10.21203/rs.3.rs-3879165/v1

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Research Article

Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population

https://doi.org/10.21203/rs.3.rs-3879165/v1

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Background

Body dysmorphic disorder (BDD) is an impairing psychological disorder with a high prevalence in clinical and cosmetic surgery settings. In the new ICD-11, BDD is grouped with the obsessive-compulsive spectrum disorders and the diagnostic criteria are updated, largely corresponding with the DSM-5. Available diagnostic interviews and screening scales for BDD are not based on these current criteria. In this paper, a newly developed screening questionnaire (BDD-S) and structured clinical interview (BDD-CI) according to the ICD-11 and DSM-5 criteria were preliminarily validated.

Methods

The BDD-S and the BDD-CI cover all core BDD symptoms. Open-ended questions allow for the addition of qualitative information on affected body parts and behavioural and mental aspects. We determined the internal consistency and construct validity of the BDD-S and suggested a cutoff value. We assessed a subsample with the BDD-CI and estimated a prevalence. The BDD-S was translated into Farsi and applied to an Iranian sample. BDD-S scores, social anxiety symptoms, and general psychopathological impairment were compared between a German and an Iranian sample.

Results

Internal consistency of the BDD-S was excellent (ω = .92). A high correlation with the body dysmorphic concerns and moderate correlations with measures of other mental disorders supported good construct validity. We determined a cutoff value of 19 for balanced sensitivity and specificity (sensitivity = 0.92, specificity = 0.87, AUC = .94). We estimated a prevalence of 2.76% for the German sample. The cultural comparison showed that the BDD-S score was higher in the Iranian sample.

Conclusions

With the BDD-S, we developed an economic and versatile screening instrument based on current diagnostic criteria, to be followed up with the BDD-CI when applicable, to obtain a clinical diagnosis. In the next step, the measures must be validated in larger clinical samples.

Body Dysmorphic Disorder

Diagnostic Interview

Screening Scale

ICD-11

DSM-5

Culture Comparison

Body dysmorphic disorder (BDD) is characterized by an excessive preoccupation with one or more defects or flaws in one’s appearance that are not or only slightly visible to others and cause considerable suffering [1]. This may refer to one or multiple body parts, often hair, skin or facial features [2]. Individuals usually engage in ritualistic behaviours to modify or conceal the flaw, or excessively check and compare their appearance [3]. In the ICD-10, which was used from 1994 to 2022, BDD was diagnosed as hypochondriacal disorder, or, with low or missing insight, as delusional dysmorphophobia. Numerous findings over the years have provided evidence for similarities between BDD and obsessive-compulsive and related disorders (OCRD) regarding symptomatology, course of illness, comorbidity, heritability, brain function and effective treatments [e.g. 4,5–10]. Accordingly, the current conceptualizations place BDD within the OCRD in the DSM-5 [1, 8] and the ICD-11 [11, 12]. In both the DSM-5 and ICD-11 classification systems, repetitive behaviours are explicitly added to the definition of BDD. The presence of at least one out of (i) repetitive and excessive (checking) behaviours, (ii) attempts to alter or conceal the defect, and only in the ICD-11 (iii) avoidance of social situations or triggers is necessary for the diagnosis. The patients must show an excessive self-consciousness up to ideas of reference (not included in the DSM-5), and show significant distress or impairment in functioning. Both manuals include an insight specifier.

Available Diagnostic Tools

To date, BDD is still an underdiagnosed and undertreated disorder due to a lack of awareness among psychiatric and medical professionals [13, 14]. In general psychiatric care, patients often do not express body dysmorphic concerns out of shame or lack of insight [13, 15]. BDD patients often request cosmetic surgery. Although BDD is typically considered a contraindication for cosmetic procedures [16], surgeons often do not reliably recognize it in patients [17]. In general, missing or incorrect diagnoses prevent appropriate treatment according to guidelines. As weighted BDD prevalences are elevated for psychiatric inpatients (7.4%) and in cosmetic surgery settings (13.2%) compared to the general population (1.9%) [18], it is especially important to introduce routine screening procedures. Self-rated screening questionnaires can be used to identify potentially affected patients in various psychiatric and medical settings. However, none of the available self-rated screening scales for BDD conform to both the DSM-5 and ICD-11 criteria. In existing questionnaires, either newly added criteria are missing (e.g. behaviour rituals, self-consciousness) or only some specific examples of repetitive behaviours are asked for (e.g. BDD5-S [19] or COPS [20]). For some questionnaires, the conceptual focus deviates from the core construct of BDD, or the target population is limited (e.g. patients requesting aesthetic surgery). For individuals who have been screened positive, a thorough follow-up assessment must be carried out to confirm the diagnosis or rule out differential possibilities. The research version of the structured clinical interview for DSM-5 (SCID-5-RV) [21] assesses BDD according to DSM-5, however, no clinical interview pertaining to the current ICD-11 criteria has been published.

Clinical Interview for Body Dysmorphic Disorder (BDD-CI) and Body Dysmorphic Screening Scale (BDD-S)

To overcome this limitation, the working group developed a structured clinical interview BDD-CI [22] as well as an economic, self-administered questionnaire for body dysmorphic disorder BDD-S [23], which can be applied as a preliminary screening. The items of both the clinical interview and the screening scale were developed by integrating the diagnostic criteria of the DSM-5 and the ICD-11. The BDD-S is intended to identify individuals in whom clinically relevant BDD is suspected and detailed diagnostic testing is necessary. In addition, the BDD-S can provide a dimensional estimate of BDD symptomatology. The application of the BDD-S does not require any specific training and takes only five minutes, so it can be used in routine medical and psychiatric care. If the screening reveals an elevated score, the BDD-CI can be applied to obtain the formal diagnosis according to both diagnostic systems.

Research Objective.

The first aim of this study was to perform an initial validation of the BDD-S and test the feasibility of the BDD-CI. We report descriptive data and estimate the internal consistency of the BDD-S. Content validity can be assumed since the items were adapted from the established diagnostic criteria (DSM-5 and ICD-11) for BDD. To establish construct validity, we assess self-reported body dysmorphic concerns (DCQ), depressive symptomatology, general psychopathological impairment, and social anxiety. We expected a high correlation of the BDD-S with the Dysmorphic Concern Questionnaire (DCQ) [24, 25]. Previous findings have shown that BDD is strongly comorbid with depression and social anxiety disorder (SAD) [26–28]. Therefore, we expected lower, but still substantial correlations with these measures. We determined two different cutoff values to indicate from which total score further BDD diagnostic assessment is recommended. In addition, we reported data from the application of the BDD-CI based on a subsample and estimated a prevalence.

Culture Comparison

BDD prevalence is estimated to be between 0.5 and 3.2 [18, 29]. However, these estimates include only studies from Europe and the U.S., as population-level epidemiological studies have not been conducted in other cultures [29]. Three representative studies from Germany (N = 2129, N = 2552 and N = 2510) found prevalence rates ranging from 1.7–2.9% in adults [9, 30, 31]. Even though the majority of related research has been conducted in the U.S. and Western countries, research on BDD in other cultures has increased in recent years. A recent meta-review compared prevalence rates of BDD symptoms between Eastern and Western countries and found no difference [32]. Due to the lack of research, however, there is still much uncertainty as to whether prevalence rates are comparable. Generally, body image dissatisfaction is on the rise in Iran [33] and the number of cosmetic procedures, especially rhinoplastic surgery, has risen strongly [34, 35]. To date, no prevalence study of BDD has been conducted in the general population in Iran, but some subpopulations can be compared between Iran and combined samples from other countries. Prevalences seem to be higher in rhinoplastic [36–40], orthognathic [41] and dermatological [42] patients compared to a global sample [18]. In a student sample, the prevalence was somewhat greater in Iran [4.5%, 43] than in a combined sample of different nationalities [3.3%, 18]. However, methods for determining the diagnosis differ greatly, so all these comparisons can only be initial indications.

Research Objective.

It is important to establish comparability between samples from different cultural backgrounds to evaluate the extent to which findings are culturally transferable. Providing measurement tools and screening instruments in a wide range of languages will help to recognize BDD and will encourage the expansion of the research landscape outside the Western world. Therefore, the BDD-S was translated into Farsi and applied to an Iranian sample. We compared BDD-S scores between the German and the Iranian samples.

Participants

Data from the N = 650 participants were collected as convenience samples from the general population in a German (n = 486) and an Iranian subsample (n = 164). In the German sample, the average age was M = 31.39 (SD = 13.52), and 75.93% of participants were female. The German subsample that also completed the diagnostic interview (n = 40) had a mean age of M = 31.10 (SD = 13.51). In the all-female Iranian sample, 53.66% of participants were between 29 and 40, 31.10% were younger (18 to 28), and 17.68% were older than 40 years. A full comparison of sociodemographic data can be found in Table 1.

Table 1

Sociodemographic data of the complete sample and the subsamples
	Complete Sample	German Sample	German Interview Subsample	Iranian Sample
N	650	486	40	164
Age		M = 31.39, (SD = 13.52)	M = 31.1, (SD = 13.51)	18–28: 31.1%, 29–40: 53.66%, 41–55: 17.68%
Gender Female (%)	82	75.93	60	100
No Education (%)	25.38	0.21	0
Secondary Education Completed (%)	57.69	43.42	50	14.63
Vocational Education completed (%)	43.69	24.69	17.5
University degree (%)	47.38	29.63	27.5	83.54
Doctorate degree (%)	26.77	2.06	5	7.93
In Education (%)	51.54	51.23	65	5.49
(Self-)Employed (%)	38.46	35.19	30	64.63
Other Occupation (%)	10.31	13.58	5

Measures

In both samples, the BDD-S was administered in combination with another measure of BDD symptoms, depressive symptoms, general psychopathological distress, social anxiety disorder symptoms and demographic questions. From the German sample, a subsample of participants was contacted for a follow-up with the diagnostic interview BDD-CI. For the follow-up interview, we contacted participants who indicated agreement (at least 2 = “quite true”) with at least one of 4 items (Item 1: Preoccupation, Item 7: Repetitive behaviours, Item 9: Mental behaviours, or Item 12: Impairment) of the Body Dysmorphic Screening Scale and agreed to be contacted. N = 381 of our sample fulfilled these criteria, of which N = 40 were interviewed. In the German study, we used established questionnaires with good psychometric qualities. For the Iranian sample, validated questionnaire versions were used where available. Unavailable questionnaires were translated and back-translated from German to Farsi by a native speaker (FT).

Body Dysmorphic Disorder Screening (BDD-S).

The proposed 15-item BDD-S [23] intends to distinguish patients with BDD from healthy persons. Eight quantitative items measure concern over the imagined flaw, subjective impairment, avoidance and increased self-consciousness, as well as mental and behavioural preoccupation on a scale from 0 (“not at all true”) to 4 (“very much true”). The numerical items are summed up to calculate the total score (range 0–32). Additional items ask for the body region(s) that are the focus of preoccupation (item 2; e.g. skin, hair, face, etc.), the type of disorder-specific behaviours (item 8; e.g. checking rituals) and mental preoccupation (item 10; e.g. comparison of one’s own appearance with that of others), as well as specific life domains of impairment (item 13; e.g., couple relationship/sexuality). All qualitative items allow the selection of multiple answers and the addition of own answers, providing additional information. Item 3 is used to exclude participants whose concerns relate only to body weight and items 14 and 15 assess insight into the excessiveness of the belief.

Structured Clinical Interview for Body Dysmorphic Disorder (BDD-CI).

With the structured clinical interview for BDD (BDD-CI) [22], the BDD diagnosis can be obtained corresponding to ICD-11 and DSM-5 by evaluating the respective relevant criteria. The interview guideline assesses the core criteria preoccupation (item 1), self-consciousness and ideas of reference (item 2), repetitive behaviours and mental acts (item 3), avoidance (item 4) and impairment (item 5). Additional items for the insight (item 8) and muscle dysmorphia (item 7) specifiers, and eating disorder exclusion (item 6) are provided. Interview questions are supplemented by guidelines for the assessment of each criterion. Qualitative information is recorded about the body parts, the performed behaviours, and the impaired areas of life. For the ICD-11 diagnosis, the questions regarding preoccupation (Item 1), self-consciousness (Item 2) and suffering or impairment (Item 5) have to be answered positively, and either repetitive (mental) behaviours (Item 3) or avoidance (Item 4) are indicated. For the DSM-5 diagnosis, items 1, 3 and 5 have to be affirmed. For both, the exclusion of an eating disorder (Item 6) has to be considered.

Dysmorphic Concern Questionnaire (DCQ).

We used the German version [25] of the Dysmorphic Concern Questionnaire (DCQ) [24]. In the DCQ, participants rate dysmorphic worries on a 7-item scale with 0 = ‘not at all’, 1 = ‘like most other people’, 2 = ‘more than other people’ and 3 = ‘much more than other people’. The aggregated score ranges from 0 to 21 with higher scores representing more pronounced dysmorphic worries. A cutoff value of 14 achieved an 84.6% accuracy in classifying BDD patients [25]. A solid body of research indicates that the DCQ is a valid and reliable screening instrument [25, 44–46]. A recent study confirmed a good internal consistency of $\alpha$ = .81 and good convergent validity for a representative German sample [47].

Brief Symptom Inventory.

General psychopathological distress was examined using a German version [48] of the 18-item short form of the Brief Symptom Inventory (BSI-18) [49]. The short version encompasses the three symptom areas Anxiety, Depression, and Somatization, each represented by six items that are rated on a scale from 0 (“not at all”) to 4 (“very much”). Sum scores (ranging from 0 to 24) can be calculated for each syndrome. Taken together, the three syndromes constitute the Global Severity Index (GSI, range 0–72) as a measure of general psychological distress. A representative German sample showed good internal consistency for each of the syndromes and very good internal consistency for the GSI, as well as favourable estimates of convergent validity [50]. In the Iranian sample, the 53-item version of the BSI [51] was used, for which psychometric quality is empirically supported [52]. However, in order to enable a comparison with the German sample, only the corresponding items of the BSI-18 were evaluated for the Iranian sample.

Beck Depression Inventory.

The German version of the BDI-Fast Screening (BDI-FS) [53, 54], a short form of the BDI-II [55], was applied to measure depressive symptoms. For each item, one out of four statements is selected, resulting in a rating between 0 and 3. The total score ranges from 0 to 21, with higher values indicating more severe depressive symptoms. In a representative German sample, the one-factor structure and good internal consistency ($\alpha$ = .84) along with good convergent and satisfying discriminant validity could be supported [54]. For the Iranian sample, the BDI-V [56] was translated into Farsi. The BDI-V is a simplified version of the BDI that applies a standard Likert scale (0–5) to 20 items (sum score ranging from 0 to 100). This scale showed a good psychometric quality in a German sample [57].

Social Phobia Inventory.

Symptoms of social anxiety disorder (SAD) were assessed with the Social Phobia Inventory (SPIN) [58] in the German [59] and Iranian versions [60]. In the 17-item self-report screening instrument, participants rate social anxiety, avoidance and physiological aspects of social anxiety on a Likert scale between 0 and 4 (total score ranging from 0 to 68). In the German version of the SPIN, a very high internal consistency, good retest reliability, good validity and change sensitivity were shown [59]. For the Iranian version, internal consistencies of $\alpha$ = .66 in a clinical and $\alpha$ = .89 in a non-clinical sample were found [60].

Data analysis

Reliability of the BDD-S was assessed by estimating the internal consistency with McDonald’s $\omega$. To determine construct validity, correlations with another BDD measure and related constructs were calculated. We expected correlations > .70 for convergent measures, and lower values for divergent measures. We performed a ROC analysis on the German sample (n = 486), using the DCQ score categorization based on the cutoff value of > = 14 provided by Stangier et al. [25]. A first cutoff value was determined based on maximizing the sum of sensitivity and specificity. An alternative, more sensitive cutoff value was calculated by maximization of the sensitivity. From the BDD-CI, we estimated the prevalence in the German sample. Given that the interview was not conducted in the total sample due to limited resources, the prevalence could only be estimated indirectly. We first preselected eligible participants from the total German sample with a very liberal criterion to exclude people who did not confirm any relevant item. For these N = 105 people, we assumed that the BDD diagnosis was not fulfilled. Among the N = 381 eligible participants, 40 interviews were ultimately conducted. For the 341 people who were eligible, but not interviewed for various reasons (accessibility, no consent to interview), we assumed that the prevalence was comparable to that of the sample that was interviewed. In this way, we estimated a prevalence value for the entire German sample.

Descriptive Statistics, Reliability and Item Analysis

The means, standard deviations and McDonald’s $\omega$ values for the measured scales are given in Table 2. Internal consistency for the BDD-S was high. All items had a discriminatory power of 0.69 or higher, except item 15, which was still within the acceptable range (discrimination 0.31).

Table 2

Descriptive data of all measured constructs
	Complete Sample			German Sample		Iranian Sample
	$\omega$	M	SD	M	SD	M	SD
BDD Screening	0.92	13.39	8.12	12.72	7.96	15.88	8.25
BSI-GSI (18)	0.93	14.37	12.72	12.64	11.67	19.91	14.30
SPIN	0.95	14.61	12.97	15.65	13.41	11.28	10.84
DCQ	0.87	/	/	6.55	4.24	/	/
BDI-FS	0.91	/	/	3.88	3.82	/	/
BDI-V	0.94	/	/	/	/	28.29	20.27
Note. Complete sample: n = 650, German sample: n = 486, Iranian sample: n = 164. McDonald $\omega$ is calculated for the complete sample where possible, or for the respective subsample that completed each measure.

Validity

As expected, we found high correlations (> .70) with BDD symptom severity assessed by the DCQ and medium to large correlations with depression, general psychopathology and SAD symptoms for the German sample. In the Iranian sample, however, correlations of the BDD-S with the BDI, BSI and SPIN were considerably lower (Table 3).

Table 3

Correlations of the BDD Screening with other measured constructs
	Complete Sample		German Sample		Iran Sample
	r	p	r	p	r	p
Expected high correlation
DCQ	/	/	0.76	< .001	/	/
Expected medium correlation
BDI	0.32	< .001	0.57	< .001	0.29	.001
BSI-GSI (18)	0.46	< .001	0.52	< .001	0.20	.024
SPIN	0.49	< .001	0.56	< .001	0.33	< .001
Note. DCQ: Dysmorphic Concerns Questionnaire, BDI: Beck Depression Inventory, BSI-GSI: Brief Symptom Inventory Global Severity Index, 18-item version, SPIN: Social Phobia Inventory. In the German sample, the BDI-FS was used. In the Iranian sample, the BDI-V was used.

Cutoff Value

The cutoff based on maximizing the sum of sensitivity and specificity was 19. This cutoff value reached a sensitivity of 0.92 and a specificity of 0.87. The area under the curve was 0.94. N = 110 (22.63%) of the German sample and N = 41 (25.00%) of the Iranian sample reached this value.

An alternative cutoff point that maximizes sensitivity was 14. This cutoff value reached a sensitivity of 1.00 and a specificity of 0.64. The area under the curve was 0.94. This cutoff value was reached by N = 199 (40.95%) of the German sample and N = 70 (42.68%) of the Iranian sample.

Prevalence

Based on the ICD-11 criteria, four people (10.00%) fulfilled the diagnosis of BDD. Using the DSM-5 criteria, instead, five participants (12.50%) from the assessed sample fulfilled the diagnostic criteria for BDD. Among the diagnosed participants, one showed good to fair insight (two for DSM-5), and for three participants, insight was rated poor. Based on the ICD-11 criteria we estimated a prevalence of 2.76% for the whole sample. The N = 105 participants who did not fulfil our interview eligibility criteria showed a mean BDD-S value of M = 4.33. The mean score of the interviewed patients was M = 14.85 (SD = 7.80), which was not significantly different to that of the eligible patients who were not interviewed (M = 15.05, SD = 7.24, t = 0.15, p = .878).

Cultural Comparison

The BDD-S total score of the German (M = 12.72, SD = 7.96) and the Iranian sample (M = 15.88, SD = 8.25) differed significantly (t = -3.92, p = < .001) (Fig. 1).

Considering that the Iranian sample included only female participants, we also examined gender differences for the BDD-S score. In the German sample, the difference between female (M = 13.49, SD = 7.95) and male participants M = 10.09 SD = 7.30) was significant (t = 4.26, p = < .001). Comparing only female participants from the German and Iranian samples, the difference in BDD-S scores remained significant, however (t = -2.88, p = .004).

The BSI value was greater in the Iranian sample (M = 19.91, SD = 14.30) than in the German sample (M = 12.64, SD = 11.67 t = -5.67, p = < .001). However, SAD symptoms were significantly greater in the German sample (M = 15.65, SD = 13.41) than in the Iranian sample (M = 11.28, SD = 10.84, t = 4.04, p = < .001).

In this study, we presented a new screening questionnaire (BDD-S) and a structured clinical interview guide (BDD-CI) for body dysmorphic disorder that incorporate the current diagnostic criteria from both the DSM-5 and the ICD-11. Content validity, as secured by up-to-date criteria, is crucial as the absence of important components or a diverging construct focus can lead to both under- and overrecognition. If BDD is not recognized, or misdiagnosed e.g. as mood disorder, the resulting inappropriate treatment, or lack thereof, leads to persisting psychopathology. Underrecognition also poses the risk of performing cosmetic surgery which is usually ineffective at reducing distress for BDD patients [61, 62]. Mitigating the underrecognition of BDD in the German psychiatric and medical care landscape will help to ensure that patients receive appropriate treatment according to relevant clinical guidelines. Screenings that lack recently added criteria (e.g. repetitive behaviours or avoidance) might instead cause overrecognition, causing a waste of resources, as performing diagnostic procedures is time-consuming. In a large representative German sample, the addition of the criterion of ritualistic behaviours did not lead to a difference in caseness determined by a clinical interview [9]. However, this would likely be different in self-report questionnaires. Appearance-related concerns are common in the population [63], and it is difficult for affected persons to assess whether their preoccupation with a flaw is clinically significant. Therefore, in self-report questionnaires, the inclusion of the more objective behaviour criterion is much more important for specificity. A lack of content validity can also cause difficulties in distinguishing common differential diagnoses, such as eating disorders. Accordingly, by providing a screening instrument with good content validity, the present investigation is an important contribution to the appropriate care of this patient population. Despite its relative prevalence in psychiatric and cosmetic surgery settings [15, 18], medical staff and surgeons often lack knowledge about BDD [16, 17]. As patients usually do not report appearance-related concerns spontaneously out of shame or lack of insight [13, 15], it is important to screen for BDD in routine assessments. Due to its quick and easy application, the BDD-S is a practical and useful tool intended to screen for BDD in all psychiatric, psychotherapeutic and medical settings. With the query of the relevant body parts and the existing control behaviours, individual qualitative information for therapy planning is also recorded here in a very economical way. The total BDD-S score can be interpreted as a dimensional estimate of symptom severity and can be used for monitoring therapy success. When an elevated BDD-S score indicates the need for further diagnostics, the BDD-CI can be used as a follow-up by trained professionals to obtain the BDD diagnosis. It enables the determination of a valid diagnosis according to ICD-11 and DSM-5, by evaluating the appropriate criteria. The screening questionnaire was translated into Farsi, as the dissemination of adequate and validated measurement instruments is lacking, and the rapidly increasing field of research can benefit from this.

Psychometric quality of the BDD-S

We found an excellent internal consistency of the BDD-S. Content validity is assured because the items were derived from the diagnostic criteria in the ICD-11 and the DSM-5. As shown by the high correlation with the DCQ, the construct validity of the BDD-S is good. The moderate to high correlations with other psychopathological constructs reflect the expected relationship to comorbid disorders and psychopathological burden [64, 65]. We suggested two different cutoff values that prioritize different criteria. The choice of the appropriate cutoff value may vary depending on the setting. The recommended value for general screening in a low-risk population or routine mental health care is 19. This value balances a high sensitivity of 0.92 and specificity 0.87, to combine a good recognition with time efficiency. As cosmetic surgery-seeking patients show a high prevalence of BDD [17, 18], the more sensitive cutoff value (14) might be appropriate here, as well as in specific clinical settings and other high-risk populations.

Prevalence Estimate

The prevalence in the German sample was estimated to be 2.76%, applying the ICD-11 criteria. This value is in line with previous findings, which estimated the prevalence in German adults between 1.7% and 2.9% [9, 30, 31], and somewhat higher than the weighted estimate (1.9%) from a cross-national study [18]. However, it is important to note here that our prevalence estimate is based only on a subsample (N = 40), from which the value was extrapolated to the entire sample. Possible biases in the selection of samples and thereby limited generalizability cause uncertainty and the estimate should therefore be interpreted with caution. If the criteria according to DSM-5 are evaluated, a slightly higher number of cases is obtained. The ICD-11 criteria allow for avoidance to be the only behavioural consequence of the appearance preoccupation but require self-consciousness or ideas of reference to be present. This might explain the difference in caseness in our sample.

Culture Comparison

We found a higher total BDD-S score for the Iranian sample. This is consistent with the fact that comparatively high prevalences were found in cosmetic surgery settings [36–42] and student samples [43] in Iran, compared to global studies from the same subpopulations [18]. However, there are no direct comparison studies between Germany and Iran that can be used as a reference. Notably, the BSI values are significantly greater in the Iranian sample, as well, while SAD symptom severity is greater in the German sample. Due to the different BDI questionnaire versions used, it is not possible to compare the depression values of the two samples, which is a limitation of our study. Overall, our findings support earlier research showing that BDD might be more prevalent in the Iranian population, in connection with high psychopathological distress (BSI). However, selection effects may be involved and must be taken into account as possible alternative explanation for the higher BDD-S values.

Strength and Limitations, Future Studies

A strength of this study was the size of the complete sample (N = 650). Since the smaller Iranian sample consisted only of women, results can of course only be generalized to the female population. As only part of the German sample (N = 40) completed the interview, the prevalence stated is only a preliminary estimate and must be checked on further samples. The study was conducted using convenience samples from the general population, therefore an important limitation is the lack of clinical data. The next step is therefore the validation of the screening scale and the clinical interview in patient populations. Future studies with clinical and healthy populations should reassess the proposed cutoff values, and provide more data to evaluate the construct validity.

To summarize, in this article we preliminarily validated a new screening instrument and clinical interview for BDD. These are the first measurement instruments to reflect the currently valid criteria from both ICD-11 and DSM-5. It is of great value to provide questionnaires that assess BDD according to the current criteria, as many older screening questionnaires have a different focus in terms of content, which can lead to over- or underrecognition. The proposed instruments therefore contribute to the correct identification of patients with BDD and thus to improved psychiatric and medical care.

• AUC

• Area Under the Curve

• BDD

• Body Dysmorphic Disorder

• BDD-CI

• Clinical Interview for Body Dysmorphic Disorder

• BDD-S

• Body Dysmorphic Disorder Screening Scale

• BDD5-S

• Body Dysmorphic Disorder Screener for DSM-5

• BDI

• Becks Depression Inventory

• BSI

• Brief Symptom Inventory

• COPS

• Cosmetic Procedure Screening Questionnaire

• DCQ

• Dysmorphic Concerns Questionnaire

• DSM

• Diagnostic and Statistical Manual of Mental Disorders

• GSI

• Global Severity Index

• ICD

• International Statistical Classification of Diseases and Related Health Problems

• OCRD

• Obsessive-Compulsive and Related Disorders

• SAD

• Social Anxiety Disorder

• SCID-5-RV

• Structured Clinical Interview for DSM-5, Research Version

• SPIN

• Social Phobia Inventory

Ethics approval and consent to participate

The ethics committee of the Department of Psychology and Sports Science at the Goethe University Frankfurt approved the procedures (Reference number 2021-04). Participants provided informed consent to all study procedures.

Consent for publication

Not applicable

Availability of data and materials

As the data sets analysed in the current study are clinical data they are not made publicly available.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was used for this project outside of university funds.

Authors’ contributions

JS was involved in the conceptualization of the study design, administered the project, collected data for the German sample, curated, analyzed and interpreted the data, and created the first draft of the manuscript. ME collected data for the German sample, contributed to the formal analysis and with the first draft of the manuscript. FT collected data for the Iranian sample and reviewed the manuscript. VR was involved in the conceptualization of the study design, and administration of the project, provided supervision and reviewed and edited the manuscript. US was involved in the conceptualization of the study design and administration of the project, provided supervision and reviewed and edited the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank Anna Chlup and Sophia Jacqueline Pieronczyk for their support in conducting the interviews.

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Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population

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	Complete Sample			German Sample		Iranian Sample
	\(\omega\)	M	SD	M	SD	M	SD
BDD Screening	0.92	13.39	8.12	12.72	7.96	15.88	8.25
BSI-GSI (18)	0.93	14.37	12.72	12.64	11.67	19.91	14.30
SPIN	0.95	14.61	12.97	15.65	13.41	11.28	10.84
DCQ	0.87	/	/	6.55	4.24	/	/
BDI-FS	0.91	/	/	3.88	3.82	/	/
BDI-V	0.94	/	/	/	/	28.29	20.27
Note. Complete sample: n = 650, German sample: n = 486, Iranian sample: n = 164. McDonald \(\omega\) is calculated for the complete sample where possible, or for the respective subsample that completed each measure.