Dysmorphic concern symptoms and personality disorders: a clinical investigation in patients seeking cosmetic surgery

Prevalence of body dysmorphic disorder: A systematic review and meta-analysis

Body dysmorphic disorder (BDD) is characterised by a preoccupation with a perceived defect in appearance. This preoccupation results in the completion of repetitive/time consuming behaviours to reduce distress. While the disorder results in considerable distress and impairment, the prevalence of the disorder is largely unknown, as BDD has not been examined in large epidemiological studies. The aim of the current study was to provide an estimate of BDD prevalence in a variety of settings using a meta-analytic approach using only studies that have made a diagnosis using a structured diagnostic interview. Twenty-two studies met criteria (n = 7159) and the pooled point-prevalence estimate for BDD was 11.3% across all studies with high levels of heterogeneity (I2 = 95.81). The pooled point-prevalence estimate was 20.0% in cosmetic/dermatology settings, 7.4% in mental health settings, and 6.7% in 'other' settings (including students and professional ballet dancers). The risk of bias assessment indicated questionable methodological quality in some of the included studies. While this study provides an important improvement on the existing literature there is a need to include BDD in epidemiological studies in order to have a more accurate understanding of the prevalence rate of this mental health condition in the community.

Prevalence of Body Somatic Deformities in Plastic Surgery Patients: A Systematic Review with Meta-analysis

BACKGROUND

Plastic surgery is a surgical specialty that focuses on restoring, reconstructing, or changing the human body. Somatic deformities (SD) are defined by a distorted impression of one's own body image and are rather frequent. The majority of people with SD have some level of social and vocational impairment, with obsessive concerns about appearance leading to compulsive behaviors and, in more severe situations, suicidal thoughts.

OBJECTIVE

The current study aims to confirm the prevalence of SD in plastic surgery patients using a systematic review of the literature and a meta-analysis.

METHODOLOGY

We have searched for electronic databases with MeSH terms, and the studies for analysis were selected based on inclusion and exclusion criteria and quality assessment. The study was conducted as per the PRISMA guidelines. The pooled prevalence was calculated using fixed and random effect model. The publication bias was assessed qualitatively (funnel plot) as well as quantitatively (Begg, Egger and Harbord tests). All analysis was done using Stats Direct (version 3).

RESULTS

The pooled prevalence of somatic deformities in plastic surgery with 95% confidence interval using random effect model was found to be 0.19 [0.12, 0.27] which indicates a significant association of somatic deformities in plastic surgery. The heterogeneity among studies was found to be high as indicated by Cochran Q (P < 0.0001) and I² tests (98.6%). The qualitative and quantitative analysis has also shown significant involvement of publication bias.

CONCLUSION

Based on available evidence, there is a significant association of somatic deformities in plastic surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prevalence of elective cosmetic surgery and its relationship with socioeconomic and mental health: A cross-sectional study in west of Iran

Background and Aims

The aim of this study was to investigate the prevalence and desire towards performing elective cosmetic surgery and its relationship with socioeconomic, mental, and spiritual health in Sanandaj, the capital of Kurdistan province in the west of Iran.

Methods

This cross‐sectional descriptive‐analytical study was performed on 492 subjects in Sanandaj using multistage sampling method. Data collection tools included two checklists and two questionnaires. Data analysis was performed using the Chi‐square test and multiple logistics regression model by the help of SPSS software version 20.

Results

The mean (standard deviation) age of participants was 32.58 (9.67) years. The prevalence of cosmetic surgery and the desire to perform it were 12.8% (n = 63) and 19.1% (n = 94), respectively. The most common type of cosmetic surgery was rhinoplasty with 5.5% (n = 27). The prevalence of symptoms of mental disorders among people with cosmetic surgery and people willing to perform cosmetic surgery was significantly higher than all subjects (p < 0.001). Female gender (odds ratio [OR] = 1.98; 95% confidence interval [CI]: 1.06–3.68) and having mild (OR = 3.01 95% CI: 1.06–3.68) and moderate to severe symptoms of mental disorder (OR = 7.59; 95% CI: 3.90–14.75) were among the influential variables on performing cosmetic surgery.

Conclusion

Both the prevalence and desire towards performing cosmetic surgery are high in Sanandaj and this needs the attention of health policy makers. Designing targeted interventions with an emphasis on the findings of this study is proposed to reduce these practices.

Body dysmorphic disorder in individuals requesting cosmetic surgery: A systematic review and meta-analysis

BACKGROUND

Body dysmorphic disorder (BDD) is known as a mental disorder in which a person suffers from concern and distress with the perceived defects in their appearance and subsequently can experience significant impairment in social, occupational, and interpersonal functioning. Various studies have reported different BDD prevalence rates in patients with cosmetic surgery. However, there has been no comprehensive study that has examined the results of these studies. Therefore, this study aims to determine BDD prevalence in individuals requesting cosmetic surgery in a systematic review and meta-analysis.

METHODS

In this review study, a search was conducted in national and international databases of Cochrane, Embase, ScienceDirect, Scopus, PubMed, and Web of Science (WoS) between 1878 and January 2020. A random-effects model was used to analyze the data, and heterogeneity of studies was examined with the I² index. Data analysis was done using comprehensive meta-analysis (Version 2).

RESULTS

BDD prevalence in individuals requesting cosmetic surgery in 48 articles with a sample size of 14,913 was 19.2% (95% CI: 15.8-23%). Regarding heterogeneity based on meta-regression, a significant difference between the sample size (p<0.001) and BDD prevalence in patients with cosmetic surgery was observed.

CONCLUSION

The results of this study showed that BDD prevalence in individuals requesting cosmetic surgery is high. Therefore, with the provision of feedback at hospitals, appropriate interventions, such as pre-screening for body image disturbance, should be mandated.

Body Dysmorphic Symptoms in Youth with Obsessive-compulsive Disorder: Prevalence, Clinical Correlates, and Cognitive Behavioral Therapy Outcome

The aims of the study were to estimate the prevalence of body dysmorphic symptoms in a sample of children and adolescents with obsessive-compulsive disorder, possible clinical correlates and whether BDD symptoms predict poorer treatment outcomes after cognitive behavioral therapy. The study included 269 children and adolescents with OCD, aged 7-17 years, from Denmark, Sweden, and Norway, who were treated with 14 weekly sessions of manualized, exposure-based CBT. Twenty-one patients (7.8%) had BDD symptoms. BDD symptoms were associated with older age (p = 0.003) and a higher prevalence of comorbid anxiety disorders (p = 0.025). In addition, patients with BDD symptoms endorsed a greater number of OCD symptoms than did those without BDD symptoms. Having symptoms of BDD did not affect the CBT outcome on OCD. The results of the study suggest that CBT for OCD is equally effective for those with and without comorbid BDD symptoms.

Validation of the Cosmetic Procedure Screening (COPS) Questionnaire in the Greek language

Practitioners in cosmetic and aesthetic treatment practices are likely to unknowingly work with patients with Body Dysmorphic Disorder (BDD). Screening questionnaires to identify the disorder in Greece are lacking. The purpose of this study was to validate a Greek version of the Cosmetic Procedure Screening (COPS) questionnaire, a self-report measure of how the respondents feel about their appearance, before an aesthetic intervention. The COPS was translated into Greek and was completed by 216 adult females from several areas of Attica (four private beauty centers, three dermatology clinics, five plastic surgery clinics, and Thriasio General Hospital of Elefsina) who pursued a cosmetic procedure. Participants also completed the Perceived Stress Scale (PSS-14). The Greek version of the COPS questionnaire demonstrated high internal consistency (Cronbach's α of 0.856) with corrected item's total range 0.468 to 0.687. Two of the factors explained 58.98% of total variance. Twenty (9.26%) women had a possible diagnosis of BDD (80% were unmarried, 95% had no children, 80% had university education). An increase in perceived stress levels was associated with an increase in the likelihood of being diagnosed with BDD (Pearson's r=0.726). The Greek version of the COPS questionnaire is a valid instrument that can be used by professionals to screen adult women for BDD.

Psychiatric Assessment and Management of Clients Undergoing Cosmetic Surgery: Overview and Need for an Integrated Approach

Background  Psychiatric disorders are more common among people undergoing cosmetic procedures than the general population and evaluating mental health can be cumbersome for plastic surgeons. We aim to summarize the available literature in this regard and propose an integrated approach to psychiatric assessment and management of mental health issues among this group. Methods  Electronic search of MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles from inception till April 2020. Generated abstracts were screened for their eligibility. Included articles were grouped according to their thematic focus under the following headings; prevalence of psychiatric morbidity among clients posted for cosmetic surgery, assessment tools, and management of psychiatric morbidity in relation to undergoing cosmetic surgery. Results  A total of 120 articles were reviewed. The prevalence of psychiatric disorder in patients undergoing cosmetic surgery was 4 to 57% for body dysmorphic disorder (BDD); the corresponding figures for depression, anxiety, and personality disorder were 4.8 to 25.8, 10.8 to 22, and 0 to 53%, respectively. A range of tools have been used to assess these disorders and specific measures are also available to assess clinical outcomes following surgery. Screening for these disorders is essential to prevent unnecessary surgical procedures, as well as to ensure timely management of the psychiatric comorbidity. Conclusion  Psychiatric morbidity is a common concomitant in cosmetic surgery. A structured and integrated approach to evaluation and management of psychiatric morbidity will help to optimize postsurgical outcomes.

Body Dysmorphic Disorder in the Perspective of the Alternative DSM-5 Model for Personality Disorder: A Study on Italian Community-Dwelling Women

To evaluate the relationships between body dysmorphic disorder (BDD) and Alternative DSM-5 Model for Personality Disorder (AMPD) criterion A and dysfunctional personality trait (i.e., criterion B) measures, 420 Italian community-dwelling women were administered three measures of BDD (i.e., the Body Dysmorphic Disorder Questionnaire, the Body Dysmorphic Disorder-Dimensional Scale, and the Appearance Anxiety Inventory), as well as the Level of Personality Functioning Scale-Brief Form (LPFS-BF) and the Personality Inventory for DSM-5-Short Form (PID-5-SF). The three BDD measures showed substantial convergent validity correlations and could be reliably cumulated to obtain the BDD Cumulative Index (BDDCI). Several significant, nonnegligible correlations were observed between the BDDCI as well as the LPFS-BF scale scores and PID-5-SF personality trait scale scores. Relative importance weight analysis results showed that LPFS-BF scale scores and PID-5-SF trait scale scores were substantial predictors of the BDDCI scores (R = 0.42, f = 0.72). In particular, AMPD criterion A impairment in self-functioning and AMPD criterion B depressivity, anhedonia, perseveration, separation insecurity, and cognitive and perceptual dysregulation were core components of the dysfunctional personality profile associated with BDD.

A systematic review of personality temperament models related to somatoform disorder with main focus on meta-analysis of Cloninger's theory components

The systematic review aims to identify four personality temperament models related to somatoform disorder with the main focus on the meta-analysis of temperaments and characters in Cloninger's theory. The literature search was performed on PubMed (Medline), Scopus, Web of Science, Cochrane, and ProQuest for all articles published in English from January 1990 to April 2019. Due to heterogeneity, pooled estimates of the standard mean difference between cases and controls were calculated using the random-effects model. Based on our inclusion criteria, 14 studies were identified, 7 of which were included in the meta-analysis. The results show that there is a significant difference between cases and controls with regard to harm avoidance (HA) (z = 5.322, P < 0.001), self-directedness (z = -4.719, P < 0.001), and self-transcendence (z = 2.848, P = 0.004). Compared to controls, HA and self-transcendence were higher and self-directedness was lower in cases. With regard to other subscales, there was no difference between the two groups (P > 0.05). The publication bias was not seen (P > 0.05 for Egger statistics). Up to now, very few studies have been focused on the relationship between personality temperament models and somatoform disorder. Among the components of the Cloninger's model, the poor self-directedness along with the abnormally high self-transcendence and HA is the personality component related to the somatoform disorder. Thus, Cloninger's model may potentially draw a personality profile for vulnerability to somatoform disorder. Given the limited number of studies available, future studies may challenge the results of the present study.

Psychological aspects of aesthetic and cosmetic surgery: Clinical and therapeutic implications

Recently there is a surge in cosmetic and aesthetic surgery procedures. Several patient seeking various cosmetics procedures present to aesthetic surgery clinics and demanding procedures which are out of proportion. Several of these patients have under-recognized or untreated psychiatric disorders. Proper screening and evaluation of these patients could save money and resources. This brief review focuses on current trends, clinical and psychological assessment and expectations on the part of patients and recommendations regarding management of these patients.

Psychological Analysis of Non-surgical Rhinoplasty

The aim of this study is to analyze the psychological outcomes for patients undergoing non-surgical correction of nasal defects using injections of cross-linked hyaluronic acid. We assessed changes in the subjective perception of nasal appearance after non-surgical rhinoplasty using the Rhinoplasty Outcomes Evaluation (ROE) questionnaire, which is validated and widely used in the literature. One hundred adult subjects without prior history of surgical or non-surgical rhinoplasty underwent non-surgical recontouring using the hyaluronic acid filler from December 2016 to December 2018. The points of inoculation have been standardized by the authors and are divided according to the aesthetic subunits of the nose. A final 74 patients (65 females and 9 males) completed a one-year follow-up and were included in the present study. The ROE questionnaire consists of six questions and assesses the way patients perceive the appearance of their nose and the way they think the people around them view the appearance of their nose. The results of each question were analyzed for each patient, comparing the preoperative results over a 12-month time-frame. Candidates for rhinoplasty, either medical or surgical, are among the most difficult to treat and, interestingly, there is substantial literature showing that among these patients, there is a higher rate of psychiatric disorders. Many of these patients seek aesthetic surgery and are often dissatisfied with the outcome of their surgery. The authors suggest that the use of ROE is not only a valid method of assessing patient satisfaction, but it could also be used as a tool to highlight some of the psychological characteristics of patients long before performing any treatment and could help identify potentially problematic patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Body image, cosmetic surgery, and minimally invasive treatments

Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic surgery and related minimally-invasive treatments. While the earliest studies were influenced by psychoanalytic thinking, much of the work over the past several decades has been influenced by Thomas Cash's cognitive-behavioral theory of body image and has focused on the appearance concerns of patients who seek these procedures. The majority of individuals interested in the procedures report heightened dissatisfaction typically focused on the feature being considered for treatment. Studies from around the world also have suggested that between 5-15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients without the disorder do report improvement in body image. The paper reviews this literature and also discusses the role of body image in three newer areas of plastic surgery-body contouring after massive weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and vascularized composite allotransplantation, including face and hand transplantation.

Changes in the Indices of Body Image Concern, Sexual Self-Esteem and Sexual Body Image in Females Undergoing Cosmetic Rhinoplasty: A Single-Group Trial

INTRODUCTION

Psychological factors play a major role in the tendency toward cosmetic surgery. Variety seeking, making changes in one's face and reducing apparent dissatisfaction, improving body image and increasing sexual self-esteem can be considered as some psychological aspects of cosmetic surgery. The present study was conducted with the aim of evaluating the changes in the indices of body image concern, sexual self-esteem and sexual body image in patients undergoing rhinoplasty.

METHOD

This study was a single-group pretest-posttest quasi-experimental design. The research data were collected from March 2015 to January 2016. For this purpose, of the patients seeking nose surgery who referred to beauty centers in Mashhad, 40 subjects were selected through purposive method sampling and completed a Body Image Concern Inventory, Sexual Self-Esteem Index for Women and Body Exposure during Sexual Activities Questionnaire before and after rhinoplasty. These data were collected after obtaining informed consent, conducting a structured clinical interview and completing the demographic checklist.

FINDINGS

Data analysis demonstrated that there is a significant improvement in the index of female body image concern after rhinoplasty (p < 0.05). In the indices of sexual self-esteem and sexual body image, the analyses showed no significant difference between the pretest and posttest scores (p > 0.05).

CONCLUSION

Cosmetic surgery leads to the reduced body image concern of women but has no effect on sexual self-esteem and sexual body image. It seems that the psychological function of patients does not change significantly by rhinoplasty dimensions.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prevalence of Body Dysmorphic Disorder in Plastic Surgery and Dermatology Patients: A Systematic Review with Meta-Analysis

The aim of the present study was to evaluate the prevalence of body dysmorphic disorder in plastic surgery and dermatology patients, by performing a systematic review of the literature and meta-analysis. The most relevant studies published originally in any language were analyzed. The literature search was performed using the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scielo databases. The final sample comprised 33 publications that were submitted to meta-analysis. The study verified that 15.04% of plastic surgery patients had body dysmorphic disorder (range 2.21-56.67%); patient mean age was 34.54 ± 12.41 years, and most were women (74.38%). Among dermatology patients, 12.65% (range 4.52-35.16%) had body dysmorphic disorder; patient mean age was 27.79 ± 9.03 years, and most were women (76.09%). Both plastic surgeons and dermatologists must adequately assess their patients to identify those with a higher likelihood of body dysmorphic disorder and should arrange multidisciplinary care for such individuals.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Avoiding Psychological Pitfalls in Aesthetic Medical Procedures

OBJECTIVE

To assess the prevalence of body dysmorphic disorder (BDD) in an aesthetic surgery setting in the region of Southwest China, and to ascertain the differences in terms of body images between patients in the aesthetic setting and general Chinese population. This study tracked patient satisfaction with their body image changes while undergoing aesthetic medical procedures to identify whether the condition of patients who were presenting with BDD symptoms or their psychological symptoms could be improved by enhancing their appearance. Additionally, this study explored whether there was improvement in quality of life (QoL) and self-esteem after aesthetic medical procedures.

METHODS

A total of 106 female patients who were undergoing aesthetic medical procedures for the first time (plastic surgery, n = 26; minimally invasive aesthetic treatment, n = 42; and aesthetic dermatological treatment, n = 38) were classified as having body dysmorphic disorder symptoms or not having body dysmorphic disorder symptoms, based on the body dysmorphic disorder examination (BDDE), which was administered preoperatively. These patients were followed up for 1 month after the aesthetic procedures. The multidimensional body self-relations questionnaire-appearance scales (MBSRQ-AS) and rosenberg self-esteem scale (RSE-S) were used to assess patients' preoccupation with appearance and self-esteem pre-procedure and 1 month post-procedure. Additionally, 100 female healthy control participants were recruited as a comparative group into this study and they were also assessed using BDDE, MBSRQ-AS, and RSE-S.

RESULTS

A total of 14.2 % of 106 aesthetic patients and 1 % of 100 healthy controls were diagnosed with BDD to varying extents. BDDE scores were 72.83 (SD ± 30.7) and 68.18 (SD ± 31.82), respectively, before and after the procedure for the aesthetic patient group and 43.44 (SD ± 15.65) for the healthy control group (F = 34.28; p < 0.001). There was a significant difference between the groups in subscales of MBSRQ-AS, i.e. appearance evaluation (F = 31.31; p < 0.001), appearance orientation (F = 31.65; p < 0.001), body areas satisfaction (F = 27.40; p < 0.001), and RSE-S scores (F = 20.81; p < 0.001). There was no significant difference, however, in subscales of MBSRQ-AS, i.e. overweight preoccupation (F = 1.685; p = 0.187), self-classified weight (F = 0.908; p = 0.404) between groups. All the subscales of MBSRQ-AS showed significant differences between the aesthetic patients (pre-procedure) and female adult norms from Dr. Cash's result given in Table 4 (p < 0.001). The study also showed that there were no significant differences in the scores of BDDE, MBSRQ-AS, and RSE-S of those fifteen aesthetic patients diagnosed with BDD after aesthetic procedures lasting one month.

CONCLUSION

There was a high prevalence rate (14.2 %) of body dysmorphic disorder in aesthetic procedure seekers, and it seemed that those patients suffering from BDD were more likely to be dissatisfied with the results of the aesthetic medical procedures. However, general aesthetic patients showed improvement in most assessments which indicated that aesthetic medical procedures could not only enhance patient appearance, but also patient low self-esteem and QoL. Self-satisfaction could also be promoted. A screening procedure for BDD including suitable screening questionnaires might be considered for routine use in aesthetic clinical settings to minimize dissatisfaction and complaints.

LEVEL OF EVIDENCE IV

This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence

Our aim was to systematically review the prevalence of body dysmorphic disorder (BDD) in a variety of settings. Weighted prevalence estimate and 95% confidence intervals in each study were calculated. The weighted prevalence of BDD in adults in the community was estimated to be 1.9%; in adolescents 2.2%; in student populations 3.3%; in adult psychiatric inpatients 7.4%; in adolescent psychiatric inpatients 7.4%; in adult psychiatric outpatients 5.8%; in general cosmetic surgery 13.2%; in rhinoplasty surgery 20.1%; in orthognathic surgery 11.2%; in orthodontics/cosmetic dentistry settings 5.2%; in dermatology outpatients 11.3%; in cosmetic dermatology outpatients 9.2%; and in acne dermatology clinics 11.1%. Women outnumbered men in the majority of settings but not in cosmetic or dermatological settings. BDD is common in some psychiatric and cosmetic settings but is poorly identified.

Identification and management of mental health issues by dermatologic surgeons: a survey of American Society for Dermatologic Surgery members

BACKGROUND

Dermatologists have long been interested in mental health issues of their patients. Some psychosocial distress likely motivates the pursuit of cosmetic dermatologic treatments. However, a percentage of patients seeking treatment suffer from significant psychopathology, such as body dysmorphic disorder (BDD), which may contraindicate treatment.

OBJECTIVE

To assess dermatologic surgeons' strategies for identification and management of mental health issues among patients seeking cosmetic procedures.

MATERIALS AND METHODS

A survey was sent to 2,855 practicing members of the American Society for Dermatologic Surgery by e-mail.

RESULTS

Two hundred sixty members completed the survey (9.1%). Approximately, 60% of respondents indicated that they ask new patients about psychiatric treatment history, and 92% reported that they have declined to provide a cosmetic treatment because of concerns about mental health status. Most (94%) indicated that they were aware of BDD, and 62% indicated that they refused to treat a patient believed to have BDD. Respondents estimated that 13% of new patients had BDD and 63% considered BDD to be a contraindication to treatment.

CONCLUSION

Approximately 60% of dermatologic surgeons inquire about the mental health issues of their cosmetic patients. Most are aware of BDD, but less than two-thirds consider it a contraindication to treatment.

Prevalence of Body Dysmorphic Disorder Among Patients Seeking Breast Reconstruction

BACKGROUND

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a slight or imagined defect in physical appearance. It has significant implications for patients who desire breast reconstruction, because patient satisfaction with the aesthetic outcome is a substantial contributor to the success of the procedure.

OBJECTIVES

The authors estimated the prevalence of BDD among women seeking breast reconstruction by surveying patients with the previously validated Dysmorphic Concerns Questionnaire (DCQ).

METHODS

One hundred eighty-eight women who presented for immediate or delayed breast reconstruction completed the DCQ anonymously, during initial consultation with a plastic surgeon. Two groups of respondents were identified: those who desired immediate reconstruction and those who planned to undergo delayed reconstruction. The prevalence of BDD among breast reconstruction patients was compared between the 2 groups, and the overall prevalence was compared with published rates for the general public.

RESULTS

Body dysmorphic disorder was significantly more prevalent in breast reconstruction patients than in the general population (17% vs 2%; P < .001). It also was much more common among patients who planned to undergo delayed (vs immediate) reconstruction (34% vs 13%; P = .004).

CONCLUSIONS

Relative to the general public, significantly more women who sought breast reconstruction were diagnosed as having BDD. Awareness of the potential for BDD will enable clinicians to better understand their patients' perspectives and discuss realistic expectations at the initial consultation. Future studies are warranted to examine the implications of BDD on patient satisfaction with reconstructive surgery.

LEVEL OF EVIDENCE

3.

Body dysmorphic disorder in aesthetic rhinoplasty candidates

Objective: Body Dysmorphic Disorder (BDD) is a psychiatric disorder defined as obsessive ideas about distorted physical appearance, leading to social, professional and personal dysfunction. Many of these patients seek aesthetic surgery and are generally dissatisfied with the outcome of their surgery. In the present study patients coming to the otolaryngology clinic of Thaleghani Hospital in Tehran seeking rhinoplasty were evaluated.

Methodology: Between October 2010 and October 2011, 130 patients seeking rhinoplasty were recruited in a cross-sectional study. These patients were consecutively interviewed in the otolaryngology clinic of Taleghani Hospital, Tehran, Iran. Questionnaires were filled containing demographic data. BDD was evaluated by a separate questionnaire. Hospital Anxiety and Depression Scale (HADS) questionnaire was filled to evaluate depression and anxiety. Data were analyzed by using SPSS software. The frequency and standard deviations were calculated. Differences between groups were evaluated by using the chi-square, and t-tests.

Results: Ninety nine (76.2%) of rhinoplasty candidates were female and thirty one (23.8%) were male. Eighty five (65.4%) were single and thirty eight (29.2%) were married while seven were divorced. About 63.8% were University students or University graduates. Mean age was 26.43±6.29 years old. 41 patients (31.5%) had BDD. Among BDD patients 12 (29.3%) had concurrent depression and 11 (26.8%) had concurrent anxiety. No statistically significant correlation was found between the presence or severity of BDD and age, gender, marital status, level of education and profession.

Conclusion: Considering the high prevalence of Body Dysmorphic Disorder (BDD) among rhinoplasty candidates, psychiatric evaluation is advisable before surgery to avoid unnecessary operations and patient dissatisfaction.

White matter water diffusion changes in primary Sjögren syndrome

BACKGROUND AND PURPOSE

Histopathologic studies have demonstrated WM damage in primary Sjögren syndrome. The purpose of this study was to evaluate WM microstructural changes by use of DTI-derived parameters in patients with primary Sjögren syndrome.

MATERIALS AND METHODS

DTI was performed in 19 patients with primary Sjögren syndrome (age, 64.73 ± 9.1 years; disease duration, 11.5 ± 7.56 years) and 16 age-matched control subjects. Exclusion criteria were a history of major metabolic, neurologic, or psychiatric disorder and high risk for cardiovascular disease. Data were analyzed by use of tract-based spatial statistics, for which the WM skeleton was created, and a permutation-based inference with 5000 permutations was used with a threshold of P < .01, corrected for multiple comparisons to enable identification of abnormalities in fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity.

RESULTS

Tract-based spatial statistics showed decreased fractional anisotropy in multiple areas in patients with primary Sjögren syndrome compared with control subjects, located mainly in the corticospinal tract, superior longitudinal fasciculus, anterior thalamic radiation, inferior fronto-occipital fasciculus, uncinate fasciculus, and inferior longitudinal fasciculus. Increased mean diffusivity and radial diffusivity and decreased axial diffusivity were observed in most of the fiber tracts of the brain in patients with primary Sjögren syndrome, compared with control subjects.

CONCLUSIONS

Patients with primary Sjögren syndrome show loss of WM microstructural integrity, probably related to both Wallerian degeneration and demyelination.

Support system for decision making in the identification of risk for body dysmorphic disorder: a fuzzy model

PURPOSE

To develop a fuzzy linguistic model to quantify the level of distress of patients seeking cosmetic surgery. Body dysmorphic disorder (BDD) is a mental condition related to body image relatively common among cosmetic surgery patients; it is difficult to diagnose and is a significant cause of morbidity and mortality. Fuzzy cognitive maps are an efficient tool based on human knowledge and experience that can handle uncertainty in identifying or grading BDD symptoms and the degree of body image dissatisfaction. Individuals who seek cosmetic procedures suffer from some degree of dissatisfaction with appearance.

METHODS

A fuzzy model was developed to measure distress levels in cosmetic surgery patients based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), diagnostic criterion B for BDD. We studied 288 patients of both sexes seeking abdominoplasty, rhinoplasty, or rhytidoplasty in a university hospital.

RESULTS

Patient distress ranged from "none" to "severe" (range=7.5-31.6; cutoff point=18; area under the ROC curve=0.923). There was a significant agreement between the fuzzy model and DSM-IV criterion B (kappa=0.805; p<0.001).

CONCLUSION

The fuzzy model measured distress levels with good accuracy, indicating that it can be used as a screening tool in cosmetic surgery and psychiatric practice.

Body Image Concern Inventory (BICI) for identifying patients with BDD seeking rhinoplasty: using a Persian (Farsi) version

BACKGROUND

Dissatisfaction with appearance is most pronounced in rhinoplasty patients compared to candidates for other aesthetic procedures. We aimed to test and introduce the Body Image Concern Inventory (BICI) as a self-report screening tool for identifying body dysmorphic disorder (BDD) among patients seeking rhinoplasty.

METHODS

The surgeon completed a two-point defect severity scale in which a score of 1 represented no defect or one defect and a score of 2 represented more than one defect. Each of the 117 subjects with a score of 1 answered a questionnaire that was designed to obtain demographic data and completed the Persian version of the BICI. The psychiatrist, considering the patient's demographic data and blind to the BICI score, interviewed him/her using a semistructured diagnostic tool for BDD based on DSM-IV.

RESULTS

The validity of the Persian version of the BICI was calculated at 85%. The reliability of the Persian BICI items was tested and Cronbach's alpha was 0.90. The results of ROC analysis for the ideal cutoff point of the Persian BICI, based on the Youden index method and optimum sensitivity and specificity, revealed that the ideal cutoff point for positive or negative criterion of that questionnaire's result may be the total score of 42 (sensitivity, 93.5%; specificity, 80.8%) The diagnostic accuracy of the Persian BICI in comparison with the gold standard (psychiatric interview), according to the area under the ROC curve (AUC), was 91.4% (95% CI = 86-97%, P < 0.0001). The agreement of the results of the Persian BICI questionnaire with the psychiatric interview for diagnosis of BDD, according to kappa index, was 61.7% (P < 0.001), and the odds ratio (OR) of being diagnosed with BDD in a psychiatric interview for those with overall scores ≥42 for the Persian BICI was 47.7 (95% CI = 43-52).

CONCLUSION

The results of the present study emphasize the high rate of BDD (12.2%) in subjects seeking rhinoplasty. The BICI appears to be an internally consistent and valid brief multiple-choice instrument for assessing dysmorphic concern. To our knowledge, this is the first time that this measure has ever been used for identifying BDD patients in a rhinoplasty setting; it is also the first time that ROC analysis has been used for calculating and analyzing the results of BICI. Our study suggests that rhinoplasty surgeons could rely on the scores of the BICI to identify subjects with probable BDD among their consultants with no or one slight defect.

Inference-based therapy for body dysmorphic disorder

Body dysmorphic disorder (BDD) is a debilitating disorder characterized by an excessive pre-occupation with an imagined or very slight defect in one's physical appearance. Despite the overall success of cognitive behavioural therapy (CBT) in treating BDD, some people do not seem to benefit as much from this approach. Those with high overvalued ideation (OVI), for instance, have been shown to not respond well with CBT. The purpose of this study was to evaluate the efficacy of an inference-based therapy (IBT) in treating BDD. IBT is a cognitive intervention that was first developed for obsessive-compulsive disorder with high OVI, but whose focus on beliefs can also apply to a BDD population. IBT conceptualizes BDD obsessions (e.g., 'I feel like my head is deformed') as idiosyncratic inferences arrived at through inductive reasoning processes. Such primary inferences represent the starting point of obsessional doubt and the treatment focuses on addressing the faulty inferences that maintain the doubt. Thirteen BDD participants, of whom 10 completed, underwent a 20-week IBT for BDD. The participants improved significantly over the course of therapy, with large diminutions in BDD and depressive symptoms. OVI also decreased throughout therapy and was not found to be related to reduction in BDD symptoms. Although a controlled-trial comparing CBT with IBT is needed, it is proposed that IBT constitutes a promising treatment alternative for BDD especially in cases where OVI is high.

Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments

Most patients who seek appearance-enhancing medical treatments report some degree of body image dissatisfaction, which is believed to motivate the pursuit of these treatments. However, patients with extreme body image dissatisfaction may be suffering from a psychiatric disorder known as body dysmorphic disorder (BDD). This article reviews BDD, including its clinical features and prevalence in medical settings. Although patients with BDD frequently seek cosmetic treatments to address their appearance-related distress, such treatments are rarely beneficial. The article concludes with recommendations for patient and provider safety.

Body dysmorphic traits and personality disorder patterns in rhinoplasty seekers

The purpose of the study was to examine symptoms of body dysmorphic concerns, mental health indices and certain specific personality disorder patterns in seekers of cosmetic rhinoplasty. A sample of 100 consecutive female patients scheduled for esthetic rhinoplasty was recruited for the study. Findings reveal body dysmorphic concerns in 22% of the sample, though individual traits are observed in 5-85% of the sample. Appearance evaluation, but not preoccupation with appearance, correlates with anxiety and depression. Furthermore, dissatisfaction with appearance and body parts decrease, while preoccupation with appearance increases after the surgical intervention. Positive appearance evaluations are associated with histrionic and narcissistic traits, while dissatisfaction with body parts correlates positively with obsessive-compulsive traits. Overall, results imply that body dysmorphic concerns are better conceived of either as an obsessive-compulsive spectrum disorder or as morbid manifestations of inflexible perfectionistic tendencies seen in obsessive-compulsive personality disorders.

Personality disorders in patients seeking appearance-altering procedures

The practice of psychological risk assessment (PRA) is an indispensable component of the screening process for patients seeking elective appearance-altering procedures (AAPs). Despite the need for more literature in PRA, some risk factors for psychological adverse outcomes have been established. Among these risk factors are personality disorders. This article provides some background regarding psychological risk factors associated with personality disorders for patients seeking AAPs and a brief introduction to personality disorders for the surgeons to be better prepared to identify these conditions while conducting a PRA.

Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder

Persons with body dysmorphic disorder (BDD) frequently seek surgical and minimally invasive (MI) treatments to improve their appearance, but few studies have evaluated patient characteristics and outcomes. Surgical/MI treatment histories of 200 persons with BDD were cross-sectionally/retrospectively evaluated. Clinical and demographic characteristics of persons who received such treatments (n = 42) were compared to those who had not (n = 158). Outcomes and reasons for nonreceipt of requested procedures were examined. Receivers of surgical/MI treatments reported less severe current BDD symptoms and delusionality than persons who did not receive such treatments. Surgical/MI treatments were more likely than other cosmetic procedures to decrease preoccupation with the treated body part; however, overall BDD severity improved with only 2.3% of treatments. Cost and physician refusal were the most common reasons requested treatment was not received. However, physicians were more likely to provide requested surgical/MI treatment than other types of requested cosmetic treatment, despite the poor longer-term outcome.

Tract-based analysis of magnetization transfer ratio and diffusion tensor imaging of the frontal and frontotemporal connections in schizophrenia

BACKGROUND

In the pathophysiology of schizophrenia, aberrant connectivity between brain regions may be a central feature. Diffusion tensor imaging (DTI) studies have shown altered fractional anisotropy (FA) in white brain matter in schizophrenia. Focal reductions in myelin have been suggested in patients using magnetization transfer ratio (MTR) imaging but to what extent schizophrenia may be related to changes in MTR measured along entire fiber bundles is still unknown.

METHODS

DTI and MTR images were acquired with a 1.5-T scanner in 40 schizophrenia patients and compared with those of 40 healthy participants. The mean FA and mean MTR were measured along the genu of the corpus callosum and the left and right uncinate fasciculus.

RESULTS

A higher mean MTR of 1% was found in the right uncinate fasciculus in patients compared with healthy participants. A significant negative correlation between age and mean FA in the left uncinate fasciculus was found in schizophrenia patients but not in healthy participants.

CONCLUSIONS

Decreased FA in the left uncinate fasciculus may be more prominent in patients with longer illness duration. The increased mean MTR in the right uncinate fasciculus could reflect a compensatory role for myelin in these fibers or possibly represent aberrant frontotemporal connectivity.

[Body dysmorphic disorder in dermatology: diagnosis, epidemiology and clinical aspects]

Cosmetic concerns are becoming increasingly common in view of the obsession with the perfect body and skin. Dermatologists are often seen to evaluate and treat these conditions. Therefore, it is important to acknowledge the existence of Body Dysmorphic Disorder, also known as dysmorphophobia. Despite being relatively common, this disorder has not been well researched. Sometimes causing impairment, the disease involves a distorted body image perception characterized by excessive preoccupation with a perceived defect. Most of the patients experience some degree of impairment in social or occupational functioning and, as a result of their obsessive concerns, they may develop compulsive behaviors. In severe cases, there is a risk of suicide. Most individuals do not acknowledge that their defect is minimal or nonexistent and seek out cosmetic treatments for a psychiatric disorder. The prevalence of this disorder among the general population ranges from 1 to 2 % and in dermatological and cosmetic surgery patients, from 2.9 to 16%. The training of professionals to systematically investigate, diagnose, and refer these patients to adequate psychiatric treatment is essential, considering the high prevalence of Body Dysmorphic Disorder in dermatological patients and the fact that cosmetic treatments rarely improve their condition.

Tract-specific and region of interest analysis of corticospinal tract integrity in subcortical ischemic stroke: reliability and correlation with motor function of affected lower extremity

BACKGROUND AND PURPOSE

TS analysis has been suggested as a useful method to evaluate the fiber integrity of white matter tracts. This study investigated the intrarater and interrater reliability and validity of a TS analysis for the CST and compared the results with those of a ROI-based analysis.

MATERIALS AND METHODS

Diffusion spectrum imaging was performed on 7 patients with subcortical ischemic stroke on a 3T MR imaging system. For the TS analysis, seed regions were placed at the cerebral peduncle and the medial portion of the primary motor cortex to reconstruct the tracts of the CST for motor control of the lower extremity. The mean GFA was measured at the PLIC by calculating the weighted sum of the GFAs sampled by the CST tracts at this segment. For the ROI-based analysis, the posterior two-thirds of the PLIC were enclosed on the GFA maps, and the mean GFA in this ROI was calculated.

RESULTS

The results showed good-to-excellent intrarater and interrater reliability on the seed region/ROI placement (mean kappa values >0.80) and mean GFA values (ICCs >0.90) for both the TS and ROI-based analyses. Both the GFA(PLIC-TS) and GFA(PLIC-ROI) values were highly correlated with the motor function of the affected lower extremity (r = 0.76 and 0.80, respectively; P < .05).

CONCLUSIONS

We demonstrated good reliability and validity of the TS and ROI-based analyses of the CST corresponding to lower extremity motor control in patients with subcortical ischemic stroke.

Obsessive-compulsive disorder and related disorders: a comprehensive survey

Our aim was to present a comprehensive, updated survey on obsessive-compulsive disorder (OCD) and obsessive-compulsive related disorders (OCRDs) and their clinical management via literature review, critical analysis and synthesis. Information on OCD and OCRD current nosography, clinical phenomenology and etiology, may lead to a better comprehension of their management. Clinicians should become familiar with the broad spectrum of OCD disorders, since it is a pivotal issue in current clinical psychiatry.

Body dysmorphic disorder and appearance enhancing medical treatments

This article reviews the literature on body dysmorphic disorder (BDD) in persons who seek appearance enhancing medical treatments such as cosmetic surgery and dermatological treatment. We begin with a discussion of the growing popularity of cosmetic surgical and minimally invasive treatments. The literature investigating the psychological characteristics is briefly highlighted. Studies investigating the rate of BDD among persons who seek appearance enhancing treatments are detailed and, collectively, suggest that approximately 5-15% of individuals who seek these treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments. The clinical management of patients with BDD who present for these treatments is briefly described and directions for future research are provided.

High prevalence of personality abnormalities in patients seeking rhinoplasty

OBJECTIVE

To assess the effect of the patient's personality on his/her satisfaction with rhinoplasty.

STUDY DESIGN

Personalities of 66 rhinoplasty candidates and 50 persons who served as control were evaluated using questionnaires. The results were validated using the Minnesota Multiphasic Personality Inventory (MMPI) test. Six months after the surgery, the rate of satisfaction was evaluated using another questionnaire based on a visual scale. The results were statistically analyzed to assess the relationship between personality traits and rate of satisfaction.

RESULTS

The average age of participants was 25.3 +/- 5.12 years; 79% were females. Obsessiveness was the most frequently noted personality trait; being antisocial was the least mentioned. Personality type and level of satisfaction were statistically related (P < 0.001). The satisfaction rate of rhinoplasty was 55.1%. Candidates with "good faking" trait followed by those who were"depressed" had the highest satisfaction.

CONCLUSION

Identification of patient's personality can be a major factor influencing satisfaction results after rhinoplasty.