Body dysmorphic disorder

INTRODUCTION
or other important areas of functioning.
Contraindications to cosmetic procedures fall (3) It cannot be better explained by another into several categories. Obvious medical issues mental disorder (eg dissatisfaction in size and such as bleeding disorders or allergies soon body shape in anorexia nervosa, chronic pain become apparent as the history is taken. Poor surgical candidates in terms of unrealistic BODY DYSMORPHIC DISORDER IN
physically (“like I was when I was 21”) and COSMETIC PRACTICE
emotionally (“to fix my marriage”) may be Many sufferers of body dysmorphic disorder do uncovered as the consultation progresses and not seek psychiatric treatment as they either do likely photographic results are perused.
not see their problem in psychiatric terms or However, a patient suffering body dysmorphic are too embarrassed to discuss their concerns.5 disorder, a secretive psychiatric disorder and an Rather, patients with this psychiatric disorder absolute contraindication to any cosmetic are more likely to seek help in a cosmetic procedure may pass through the consultation process undetected resulting in an undesirable dermatological practice.6, 7 A physical feature outcome for both patient and physician. The that appears to be in the range of normal literature regarding this syndrome is largely variation to the untrained eye may be judged as published in psychiatric and dermatological an observable and correctable defect by the journals.1, 2 The aim of this article is to review cosmetic practitioner. Indeed, despite the high and summarize the information, including the likelihood of treatment failure, these patients use of the BDDQ (Body Dysmorphic Disorder will most often receive dermatological or cosmetic treatment for their defect. A US relevance of the disorder to modern cosmetic study published in 2001 of 289 patients with that nonpsychiatric treatment was sought by76% and received by 66% of patients.8 WHAT IS BODY DYSMORPHIC
DISORDER?
received (45%) followed by surgery (23%). This Body dysmorphic disorder (also called beauty is despite a high level of awareness of body dysmorphic disorder by aesthetic surgeons.23 psychiatric disorder where patients think they Any non-psychiatric treatment that may be are ugly or deformed despite an objectively offered to the patient, including not only normal appearance.3 Characteristics of the rejuvenating creams, dermal fillers and laser century. In the DSM-IV, the diagnostic manual typically result in no improvement or more for psychiatric disorders, body dysmorphic disorder is described with the somatoform Additionally, many of these patients have disorders where the patient displays physical multiple concerns about their appearance and symptoms but there is no organic pathology to be found. The diagnosis for body dysmorphic remains significantly handicapped and has (1) A preoccupation with an imagined defect, or markedly excessive concern about a slight (2) This imagined defect causes significant competence may occur in the setting of body distress or impairment in social, occupational dysmorphic disorder particularly as the illness AU S T R A L A S I A N J O U R N A L O F C O S M E T I C S U R G E RY dissatisfaction with the entire body image.13 patient has little insight into the condition.5 Their concerns usually involve multiple body parts rather than one body area and are mostly consultation, the nature of the procedure and specific in nature (e.g. a bumpy nose) but some its potential risks, the availability of nonsurgical are vague (e.g. facial asymmetry, atrophied options and the ability of the patient to view facial muscles). The preoccupations usually prospective surgical results is an important part involve any part of the body including body size and body shape. Other features of Body psychiatric evaluation but even seeking expert Dysmorphic Disorder may include repetitive opinion may not offer adequate protection in behaviours such as frequent mirror checking, excessive grooming, seeking reassurance fromfamily and friends and comparisons with BODY DYSMORPHIC DISORDER
The patient’s insight into their disorder can Prevalence of the disorder is generally regarded as 1-2% of the general population however insight into their disorder. Patients with this increases to 6-15% in the context of preoccupations associated with delusions have presentation to cosmetic practice of which the poorer outcomes than those patients with mild but perceivable defects. The patient may be dermatology.9,10 The clinical course of the employing camouflage techniques which may disorder is varied but common average age of onset is in early adulthood between 15 and 20 years of age. The majority of patients will wait about 6 years before seeking treatment and the Psychiatric comorbidity often exists with nature of the symptoms of the disorder tend to be continuous rather than episodic and may obsessive compulsive disorder, bipolar disorder Veale et al studied the frequency of body Contrary to previous thought, rates of BDD dysmorphic disorder in patients requesting do not differ between the sexes.11 Men and cosmetic rhinoplasty in the UK and compared them with body dysmorphic disorder patients psychiatric treatment for their perceived defect in a psychiatric clinic.16 Of patients requesting and are equally likely to receive cosmetic rhinoplasty 20.7% had a possible diagnosis presenting to cosmetic practices tend to be women, it would therefore follow that men in dysmorphic disorder who had a good outcome after cosmetic rhinoplasty were found to be dysmorphic disorder. In addition, some male quite a distinct group from body dysmorphic patients with body dysmorphic disorder have patients seen in psychiatric clinics where patients were younger, more depressed and behaviour as a result of an unsatisfactory anxious, more preoccupied by their nose and check their nose more frequently and are more Although the preoccupation can involve likely to conduct “D.I.Y” surgery and have any part of the body, women suffering from multiple concerns about their body. They are more likely to be significantly handicapped in preoccupations associated with skin picking, their occupation, social life and in intimate waist and hip size and hair abnormalities.
relationships and to avoid social situations Men present with different concerns including because of their nose. They are also more likely thin or balding hair, small or slight stature and to believe that dramatic life changes will occur genital size insufficiency. Women may have comorbid eating disorders, and men often have Body dysmorphic disorder can be associated issues with alcohol dependence. Both sexes are with significant morbidity. Patients with BDD have been found to have a poorer quality of Patients suffering from the disorder also tend life than patients suffering from a recent heart to focus on specific body features rather than AU S T R A L A S I A N J O U R N A L O F C O S M E T I C S U R G E RY eye may see a correctable defect within the range of normal variation. Patients presenting nonexistent defects should prompt further functional impairment where they are unable questions such as difficulty in functioning, to work, socialize or attend school because of camouflaging, repeated reassurance seeking, the perceived ugliness of the defect, the It is undesirable to dispute patients concerns existence of psychiatric illnesses like major – these patients undergo much suffering depression. Patients with body dysmorphic disorder have high rates of lifetime suicidal ideation (78%) and suicide attempts (27.5%).18 concerns, establish suicide risk and educate thepatient that they appear to have a body image TREATMENT OF BODY DYSMORPHIC
problem known as body dysmorphic disorder, DISORDER
which is treatable with proper therapy.
Effective treatment for body dysmorphicdisorder consists of pharmacological and BODY DYSMORPHIC DISORDER
behavioural interventions.14 Selective serotonin QUESTIONNAIRE (Dufresne et al)
reuptake inhibitors such as fluvoxamine are The Body Dysmorphic Disorder Questionnaire effective in treating both non-delusional (BDDQ) (Table 1), is a questionnaire filled in by (where the defect is mild, but perceivable) and the patient. This brief self-report questionnaire has shown to be a highly sensitive and specific publications have utilized bupropion with (respectively 100% and 93% in some studies) good effect.19 Cognitive Behavioural Therapy screening tool for BDD.20 To screen positivelyis also effective – the patient undergoes the patient must demonstrate the presence of a exposure of the perceived defect in a stressful preoccupation as well as at least moderate setting and response-prevention techniques distress or impairment in functioning. The aim to avoid behaviours such as repetitive components of the BDDQ ask questions about mirror checking, excessive grooming time, the preoccupation itself, the impact on the camouflaging and reassurance seeking. Unlike patient’s life and any avoidance behaviours. To patients with obsessive-compulsive disorders, the checking behaviours of sufferers of body dysmorphic disorder are not associated with paperwork a new patient to the practice must fill out, or could be selectively given, forexample, to dermatology or rhinoplasty DIAGNOSTIC ISSUES, SCREENING
patients. Other self-report questionnaires, AND REFERRAL.
although not specific for body dysmorphic Standard of care in body dysmorphic disorder disorder, can also be a valuable tool to assess is psychiatric referral and every attempt should be made to this end. Body dysmorphic disorder Dysmorphic Concern Questionnaire (DCQ) is is difficult to diagnose for several reasons. It is a 7-item questionnaire measuring extent of a secretive disorder that patients try to hide concern with appearance (each item rated 0-3, with 3 being most concerned). The items cover: (preoccupation with the slight or nonexistent concern with physical appearance; belief in defect that causes distress and impairment in being misshapen or malformed; belief in bodily important areas of functioning and cannot malfunction (e.g. malodour); consultation with better be explained by another psychiatric cosmetic specialists; having been told by others that you are normal looking, but not believing interpretation. Presentation is varied and them; spending excessive time worrying about patients may appear to be functional even though they may be doing so at less than their covering up ‘defects’ in appearance.21 potential. Also, the trained cosmetic surgeon’s AU S T R A L A S I A N J O U R N A L O F C O S M E T I C S U R G E RY BODY DYSMORPHIC DISORDER
a concern that may reasonably be expected QUESTIONAIRE Table 1
from a particular population. For example,many women are concerned with their body Are you concerned about the appearance
shape and similarly many men are concerned of some part of your body, which you with their stature.
consider particularly unattractive?
If no, thank you for your time and attention.
general population in Australia22 and the US You are finished with this questionnaire.
If yes, do these concerns preoccupy you: that 43% of men are dissatisfied with their overall is, you think about them a lot and they’re hard appearance.23 This increasing dissatisfaction, coupled with greater awareness, and perhapsacceptance, of aesthetic procedures via internet What are these concerns?
and reality television shows is concomitant What specifically bothers you about the
with the increases in aesthetic procedures seen appearance of these body parts?
in Australia and the US. Figures from the What effect has your preoccupation with
American Society of Aesthetic Plastic Surgery your appearance had on your life?
(ASAPS) show an increase of 66% in cosmetic Has your defect often caused you a lot of
procedures from 1998 – 2002. Whilst most distress, torment or pain? How much?
studies reveal patients to be happy with the results of their cosmetic procedures, some are not despite good procedural outcomes.
Patients more likely to be dissatisfied with the result include those with unrealistic 4 – severe and very disturbing; 5 – extreme, undergoing “type change” procedures (e.g.
rhinoplasty) compared with “restorative” Has your defect caused you impairment in
procedures (e.g. facelift) and those with body social, occupational or other important
dysmorphic disorder.22 Factors associated with areas of functioning? How much?
poor psychosocial outcome (impaired level of functioning in social and work/study) include 2 – mild interference but overall performance unrealistic expectations of the procedure, 3 – moderate, definite interference but still previous unsatisfactory cosmetic surgery, 4 – severe, causes substantial impairment; relationship issues and a history of depression, anxiety or personality disorder and bodydysmorphic disorder.
Has your defect often significantly
interfered with your social life?
procedure does not mean it will be effective in every patient. The cosmetic practitioner mustalways bear in mind the definition of body Has your defect often significantly dysmorphic disorder and the distinguishing
interfered with your school work, your job,
features of the disorder, that is, the intensity of or your ability to function in your role?
the preoccupation, its non-coherence with the Are there things you avoid because of your slightness of the defect, the existence of any comorbid psychiatric disorders and the degreeof functional impairment being experienced by The Body Dysmorphic Disorder Questionnaire the patient. Any patient suspected of having is a self-report tool with a high sensitivity and BDD needs psychiatric evaluation prior to any specificity for detecting body dysmorphic intervention including ‘less invasive’treatments disorder. This could be administered to patients like microdermabrasion or rejuvenating creams along with routine practice paperwork prior to perceived or slight defect will not be effective There will always be difficulty in separating a patient with a borderline or well-concealed that these patients are already at high suicide body dysmorphic disorder from a patient with risk. Educating the patient that they might AU S T R A L A S I A N J O U R N A L O F C O S M E T I C S U R G E RY body dysmorphic disorder in dermatology patients. Journal focusing on the negative impact it is having on of the American Academy of Dermatology. 42:436-41, their lives and encouraging and arranging psychiatric referral is the best way to deal with 10. Sarwer DB, Wadden TA, Pertschuk MJ and Whitaker LA. Body image dissatisfaction and body dysmorphic disorder Finally, the use of simple screening tools in 100 cosmetic surgery patients. Plastic and such as the BDDQ in our practices or a few Reconstructive Surgery. 101(6):1644-9, 1998. directed questions in the routine medical 11. Phillips KA and Diaz SF. Gender differences in body history may save us, our staff and the patient of Nervous and Mental Disease. 185(9):570-7, 1997. 12. Lucas P. Violence may be serious in men with body dysmorphic disorder. [Letter] The British Medical Journal. • BDD is a psychiatric illness but patients seek and receive treatment from cosmetic 13. Kisely S, Morkell D, Allbrook B, Briggs P, Jovanovic J.
physicians and surgeons.
Factors associated with dysmorphic concern and psychiatric morbidity in plastic surgery outpatients. Australian and New Zealand Journal of Psychiatry. • The key issues involve a slight or imagined 14. Castle DJ, Morkell D. Imagined ugliness: a symptom defect, the disproportionate distress and which can become a disorder. Medical Journal of Australia. associated impairment of social functioning.
• Screening methods may aid detection of 15. Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family • Psychiatric referral is the treatment of choice.
history in 200 individuals with body dysmorphic disorder.
Psychosomatics. 46(4):317-25, 2005. REFERENCES
16. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in 1. Castle DJ, Molten M, Hoffman K, Preston NJ, Phillips KA. body dysmorphic disorder. British Journal of Plastic Correlates of dysmorphic concern in people seeking cosmetic enhancement. Australia and New Zealand 17. Phillips KA. Quality of life for patients with body Journal of Psychiatry: 38(6):439-44, 2004. dysmorphic disorder. Journal of Nervous and Mental 2. Mackley CL. Body dysmorphic disorder. Dermatologic 18. Phillips KA, Coles ME, Menard W, Yen S, Fay C, 3. Phillips KA and Castle DJ. Body dysmorphic disorder. In: Weisberg RB. Suicidal ideation and suicide attempts in Castle DJ, Phillips KA (eds) Disorders of Body Image. body dysmorphic disorder. Journal of Clinical Psychiatry. UK:Wrightson Biomedical, 101-20, 2002. 4. American Psychiatric Association. Diagnostic and 19. Nardi AE, Lopes FL, Valenca AM. Body dysmorphic dis- Statistical Manual of Mental Disorders (DSM-IV). 4th order treated with bupropion: case report. Australian and edn. Washington:American Psychiatric Press, 1994. New Zealand Journal of Psychiatry. 39(1-2):112, 2005. 5. Phillips KA. Body dysmorphic disorder: the distress of 20. Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A imagined ugliness. American Journal of Psychiatry. screening questionnaire for body dysmorphic disorder in cosmetic dermatologic surgery practice. Dermatologic 6. Sarwer DB, Crerand CE, Didie ER. Body dysmorphic disorder in cosmetic surgery patients. Facial Plastic 21. Oosthuizen P, Lambert T, Castle DJ. Dysmorphic concern: Prevalence and association with clinical variables. 7. Wilson JB and Arpey CJ. Body dysmorphic disorder: Australian and New Zealand Journal of Psychiatry. suggestions for detection and treatment in a surgical dermatology practice. Dermatologic Surgery. 22. Castle DJ, Honigman RJ, Phillips KA. Does cosmetic surgery improve psychosocial wellbeing? Comment in: 8. Phillips KA, Grant J, Siniscalchi J, Albertini RS. Surgical The Medical Journal of Australia. 176(12):601-4, 2002. and nonpsychiatric medical treatment of patients with 23. Sarwer DB. Awareness and identification of body body dysmorphic disorder. Psychosomatics. 42(6): dysmorphic disorder by aesthetic surgeons : results from a survey of American Society of Aesthetic Plastic Surgery 9. Phillips KA, Dufresne RG, Wilkel C, Vittorio C. Rate of members. Aesthetic Surgery Journal. 22:531-535, 2002. AU S T R A L A S I A N J O U R N A L O F C O S M E T I C S U R G E RY

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