Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder

The prevalence of body dysmorphic disorder in outpatient dermatology clinics: a systematic review

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric condition involving a preoccupation with physical appearance disproportionate to physical findings, which are often absent altogether. Previously published data have estimated its prevalence at approximately 11.3-11.9%, across various medical specialties. No recent systematic reviews strictly related to dermatology clinics and the prevalence of BDD have been published to the best of our knowledge.

OBJECTIVES

To gather a pooled prevalence for BDD in outpatient dermatology clinics around the world.

METHODS

A literature review was completed as per PRISMA guidelines. Studies had to meet the following inclusion criteria: (i) observational studies (either prospective, cross-sectional or case-controlled), (ii) include patients aged ≥ 13 years of age; (iii) undertaken in dermatology clinics (medical, cosmetic or specialty clinics); (iv) use validated, or translations of validated screening tools, used for BDD [such as the Body Dysmorphic Disorder Questionnaire (BDDQ), the Structured Clinical Interview for DSM-5, BDDQ-Dermatology Version (DV), the Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder]; (v) report a point prevalence for BDD; and (vi) be written in either English, French or Arabic, the three languages fluently spoken by the Lebanese researchers.

RESULTS

Twenty-one articles tackling BDD in outpatient cosmetic and general dermatology clinics were selected. Studies were graded based on the Newcastle-Ottawa Scale and a mean for the pooled prevalence was calculated, yielding a weighted mean prevalence of 12.5% among general dermatology patients (n = 1082) and 25.0% among cosmetic dermatology patients (n = 218). The mean prevalence of BDD among general dermatology patients is similar to previously reported numbers. For cosmetic dermatology patients, the findings are markedly higher than previously reported, which we postulate could be owing to dermatologists being at the forefront of noninvasive cosmetic procedures.

CONCLUSIONS

Given the high prevalence of BDD among dermatology patients, we highlight the importance of having a high index of suspicion for BDD and identifying it in the clinical setting and also emphasize the importance of psychiatric treatment for these patients to improve outcomes, all while avoiding unnecessary interventions.

An Evidence-based Pathway for Body Dysmorphic Disorder in Facial Aesthetics

Aesthetic procedures should be avoided in patients with body dysmorphic disorder (BDD) since they can negatively impact mental health and lead to further aesthetic dissatisfaction. There are no evidence-based patient pathways for BDD in facial aesthetics which can result in the failure to identify patients with BDD, leading to unsuitable treatments and suboptimal patient care. We aim to construct the first evidence-based patient pathway for BDD in surgical and nonsurgical facial aesthetics. A systematic review was performed and articles that discussed screening or patient pathways for BDD in field of facial aesthetics were included. We extracted relevant information from each article on screening tools and pathways for BDD. Data were synthesized by summarizing the data under column headings into a structured narrative and into new tables. Based on this synthesis, a practical pathway for BDD was constructed. Forty articles fulfilled the criteria for inclusion. Twenty-eight BDD screening tools were discussed in the included articles, and we provide an overview of these tools. Thirty-one articles discussed patient pathways for BDD, and we synthesized this information into a structured narrative. Combining these findings, we present an evidence-based patient pathway for BDD for patients presenting for facial aesthetic treatments. This systematic review has resulted in the first, evidence-based, patient pathway for BDD in surgical and nonsurgical facial aesthetics. This practical pathway can be used by aesthetic clinicians to identify patients with potential BDD and provide clear guidance for managing cases where BDD is suspected. It will help reduce the number of facial aesthetic procedures performed on patients with BDD, safeguard patient mental well-being, and prevent further aesthetic dissatisfaction.

Surgical Rhinoplasty in Mild Forms of Body Dysmorphic Disorder: Safety, Protocols, and Long-Term Outcomes

Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder concerning body image which negatively distorts the patient's perception of their appearance. In rhinoplasty, surgery on patients with severe BDD is considered contraindicated as patients are often dissatisfied and their BDD symptoms rarely improve. For patients with borderline to mild BDD, however, there has been some preliminary evidence to show that they can benefit from surgical rhinoplasty. In our first article on this series of BDD in rhinoplasty, we presented our two-specialist protocol using mandatory psychiatric evaluation (MPE) to assess patient's suitability. In this present article, we used this protocol to identify a group of borderline to mild BDD patients, performed surgical rhinoplasty on this group, and evaluated the outcome using a visual analog scale (VAS) and a five-point Likert scale. From 2010 to 2023, 1,602 patients attended our practice seeking cosmetic rhinoplasty, out of which, 892 were sent for MPE to the same psychiatrist. The MPE identified 2.5% (22/892) patients as having mild BDD, out of which, 15 were considered suitable for surgical intervention and underwent successful rhinoplasty (follow-up 6-95 months, M = 54.13 months). Five of 15 patients scored 10/10 on the VAS and were very happy, 8 of 15 patients scored 7 to 9/10 on the VAS and were happy, and 2 of 15 patients scored 6/10 on the VAS but were still happy. Although all patients were happier, 3 of 15 patients requested revision rhinoplasty which was not offered as was planned and discussed before the initial intervention. This study shows that in the presence of safe protocols, including a two-specialist model, safe outcomes can be expected even in the long term. Further, the request for revision surgery appears to be common in borderline to mild BDD cases, and we like to warn the patients against it before surgery.

An Audit of Outcomes in Cosmetic Rhinoplasty with the Mandatory Psychiatric Evaluation Protocol

With the high demand of rhinoplasty surgery, careful selection and management of aspirants, as well as proper assessment of outcomes after surgery, are imperative for achieving successful outcomes and learning from it. The aim of this study was to answer two important questions: (1) What is the success rate in cosmetic rhinoplasty? (2) How can we best identify candidates who would achieve good outcomes in cosmetic rhinoplasty? In this study cohort, we excluded patients with any functional concerns and confounding factors that could in any way influence patient satisfaction with a cosmetic surgery. This study is a part of the trilogy of articles on "psychology of rhinoplasty" submitted to this volume of Facial Plastic Surgery, using mandatory psychiatric evaluation (MPE) to optimize candidacy. In total, 184 patients (144 females and 40 males) aged 16 to 63 years (M = 31.09) met the inclusion criteria and were included in this study (follow-up: 3-122 months; M = 70.18 months), and outcome satisfaction was assessed using the visual analog scale (VAS) score and a 5-point Likert scale. The mean improvement between preoperative (M = 4.26) and postoperative VAS scores (M = 8.47) was 4.23. Most patients were happy or very happy (95.1%) about the surgical outcome. Patients who were very happy generally scored between 8 and 10 on the VAS (77.2%) and those who were happy generally scored between 6 and 7.9 (21.2%). Some patients, however, were neutral (3.3%) or unhappy (1.6%) about their surgical outcome, and generally scored around ≤7 on the VAS. Although the successful outcome in 95.1% patients reflects a carefully designed protocol for rhinoplasty candidacy, 4.9% patients reported poor satisfaction despite these efforts. An ever-present proportion of unhappy outcomes is a reality of this popular surgery.

The Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery: Are We Screening the Troublesome Patients?

This study aims to clarify the current concept of performing rhinoplasty in patients with possible body dysmorphic disorder (BDD). The primary objective was to investigate the validity and evolution over time of the Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery (BDDQ-AS) before and after surgery. Together with the BDDQ-AS, also the Nasal Obstruction Symptom Evaluation scale, FACE-Q nose and nostrils, and Utrecht questionnaire (UQ) were used for convergent validation. In this prospective study, 187 patients completed these patient-reported outcome measures at four time points: at the preoperative consultation and postoperatively at 3, 6 and 12 months. The preoperative BDDQ-AS positivity rate was as high as 55.1%. Postoperatively, there was a highly significant decrease in the odds of scoring positive on the BDDQ-AS. At the preoperative consultation, positively screened patients were less satisfied with the esthetics of their noses with worse scores on UQ, FACE-Q nose, and visual analog scale. The preoperative differences in outcome measure ratings disappeared postoperatively, except for the FACE-Q nostrils, which surprisingly showed better values in BDDQ-AS positive patients. Younger age and absence of nasal trauma were statistically significant covariates associated with positive BDDQ-AS screening. Due to the overwhelming decrease in positive BDDQ-AS outcomes after surgery, a positive screening result on the BDDQ-AS should not be interpreted as a formal contraindication for surgery. Collaboration with psychologists or psychiatrists remains crucial to diagnose BDD conclusively.

Body Dysmorphic Disorder: A Decade of Mandatory Psychiatric Evaluation in Cosmetic Rhinoplasty Aspirants

The aim of rhinoplasty is to make the patient happier with their nose. The patient's perception plays a substantial role in their outcome satisfaction. Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder concerning body image, which negatively distorts the patient's perception, rendering them dissatisfied with the outcome even if the results are close to the defined objectives. In this paper, we present a protocol with a two-specialist approach (rhinoplasty surgeon and a psychiatrist) to standardize BDD diagnosis using the DSM-5 criteria. The patients deemed suitable for cosmetic rhinoplasty by the rhinoplasty surgeon's first consultation were sent for Mandatory Psychiatric Evaluation (MPE) for further consultation and second opinion. MPE was employed with a semi-structured clinical interview by a psychiatrist incorporating the Cosmetic Procedure Screening Questionnaire and Appearance Anxiety Inventory. From 2010 to 2023, 1,602 patients attended our practice seeking cosmetic rhinoplasty, out of which, 892 were sent for MPE to the same psychiatrist. The MPE identified 2.5% (22/892) patients as having mild BDD; out of which, 15 were considered suitable for surgical intervention and underwent successful rhinoplasty (follow up: 1-10 years, M = 4.33 years). Although BDD is considered a contraindication in rhinoplasty, our experience shows that borderline and mild BDD can be offered surgery with good insight and support system. Moderate to severe BDD in our practice was filtered out at the first stage and was not offered surgical intervention. BDD among rhinoplasty aspirants is not as prevalent as previously reported. Standardized diagnostic protocols and studying the severity of BDD when present has clarified management of BDD in rhinoplasty aspirants in our practice. MPE is not easy to incorporate in every rhinoplasty practice, but we aim to present guidelines arising from our ongoing experience to help management of BDD in rhinoplasty.

A cross-sectional study on gender differences in body dysmorphic concerns in patients with skin conditions in relation to sociodemographic, clinical and psychological variables

BACKGROUND

Dysmorphic concern is an overconcern with an imagined or slight defect in physical appearance that can be a symptom of body dysmorphic disorder (BDD). Appearance-related concerns are frequently reported by people with dermatological conditions. However, relatively little remains known about the relationship between dysmorphic concern and other variables within persons with different skin conditions.

OBJECTIVES

The aim of this multicentre, cross-sectional study was to investigate gender differences regarding dysmorphic concern and the prevalence of BDD in a large sample of patients with skin conditions, in relation to sociodemographic, clinical and psychological variables.

METHODS

Participants aged ≥18 years with skin conditions were consecutively enrolled in dermatological clinics of 22 European centres. Dysmorphic concern and the possible presence of BDD were measured using the Dysmorphic Concern Questionnaire (DCQ) and compared between men and women in relation to sociodemographic, clinical and psychological variables, and separately for each skin condition.

RESULTS

The DCQ questionnaire was completed by 5290 dermatological patients. In all categories, mean scores were significantly higher in women than in men. Mean DCQ scores were also higher in women for most skin conditions, with the highest effect size in vitiligo. The percentage of patients who screened positive for BDD on the DCQ was 10.5%, 7.7% of men and 12.7% of women. The prevalence of BDD positive was 6.9% in patients with mild clinical severity, 11.1% for moderate and 19.1% for severe condition. In the multivariate model in patients with mild skin condition, the presence of BDD was positively associated with stress and stigma both in men and in women.

CONCLUSIONS

Dysmorphic concern and BDD were more frequent in women than in men with skin conditions. Both received and actual stigmatization might have an impact on body-related concerns, in particular in women, who may be more at risk for sociocultural reasons.

Prevalence and Characteristics Associated with Positive Body Dysmorphic Disorder Screening Among Patients Presenting for Cosmetic Facial Plastic Surgery

Background: Many patients with body dysmorphic disorder (BDD) seek out cosmetic surgery to alleviate their symptoms of distress related to a perceived defect in their appearance; however, the prevalence and risk factors for BDD among patients with cosmetic concerns have not been well characterized. Methods: We screened adult patients presenting to the clinic from June 2021 through September 2022 for BDD using the BDD Questionnaire-Aesthetic Surgery (BDDQ-AS) who were seen in consultation for rhinoplasty, aging face, and injectables. Results: Among 488 patients, the prevalence of screening positive for BDD was 41.0%. The prevalence of a positive BDD screen was highest among patients who were younger (p = 0.02), and those who had a positive self-reported psychiatric history (p = 0.02). Among rhinoplasty patients, those with aesthetic/cosmetic motivations, and those seeking revision rhinoplasty had higher rates of positive BDD screen. Higher scores on the Standardized Cosmesis and Health Nasal Outcomes Survey-Nasal Obstruction Score (SCHNOS-O) (p = 0.01) and Standardized Cosmesis and Health Nasal Outcomes Survey-Nasal Obstruction Score-Nasal Cosmesis Score (SCHNOS-C) (p < 0.0001) were predictive of a positive BDD screen, while question 5 of the SCHNOS was highly predictive of positive BDD screening (p < 0.0001). Conclusions: Our study characterizes relationships between positive BDD screening and age, gender, self-reported psychiatric history, and motivations for consultation, among patients seen for cosmetic surgery evaluation in a facial plastic and reconstructive surgery setting.

Body Dysmorphic Disorder in Women

Body dysmorphic disorder (BDD) consists of distressing or impairing preoccupation with perceived defects in physical appearance that are actually nonexistent or only slight. This common and often-severe disorder, which affects more women than men, frequently goes unrecognized. BDD is associated with marked impairment in functioning, poor quality of life, and high rates of suicidality. Most patients seek cosmetic treatment, which virtually never improves BDD symptoms. In contrast, serotonin-reuptake inhibitors, often at high doses, and cognitive behavioral therapy that is tailored to BDD's unique clinical features are often effective. This article provides a clinical overview of BDD, including BDD in women.

The Prevalence and Clinical Features of Body Dysmorphic Disorder Among Dermatology Patients in the Eastern Province of Saudi Arabia

Background and objective Body dysmorphic disorder (BDD), which affects 1.7% to 2.4% of people worldwide, is usually encountered for the first time by nonpsychiatric physicians. Up to 37% of cases have been documented in dermatology clinics. This study aims to estimate the prevalence of BDD among Saudis attending dermatology clinics because the literature is lacking in this field, especially in the Eastern Province. Methods This is a cross-sectional study, conducted in 2023. A total of 412 Saudi Eastern Province residents, aged 18 years and older, were included in the study and given a self-administered web-based questionnaire. The study uses the Body Dysmorphic Disorder Questionnaire as one of its three primary measurements, together with sociodemographic data, and dermatological and previous psychological histories. Results A total of 412 participants were enrolled in this study. Of the total sample, 64.5% had more than one skin condition, with the rest having only one one. The most received cosmetic treatment in this study was topical agents. It was estimated that the prevalence of BDD is 9.5% among the studied population. However, it was found that there are no significantly associated factors with the prevalence of BDD. Conclusions This study reports a prevalence of 9.5% among people visiting dermatological clinics. The prevalence is alarming, which emphasizes the importance of enhancing the awareness of BDD among dermatologists and developing certain guidelines to identify and refer these patients to mental health professionals.

Arabic translation, cultural adaptation, and validation of the BDDQ-AS for rhinoplasty patients

BACKGROUND

Body Dysmorphic Disorder (BDD) is a significant aspect that compromises patient satisfaction after rhinoplasty. BDDQ-AS (Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery) is a validated, simple, reliable patient-reported outcome measure. It is a screening tool to detect body dysmorphic disorder in rhinoplasty patients. This study aimed to translate, culturally adapt, and validate BDDQ-AS to Arabic as a novel tool for screening and detecting BDD in Arabic rhinoplasty individuals.

METHODS

BDDQ-AS was translated from English to Arabic following the international consensus guidelines. We tested the translation on ten Arabic-speaking rhinoplasty patients to ensure that the final version was understandable and acceptable. The proposed Arabic version was then completed by 112 patients whose average age was 28.79 ± 9.32 years. The screening is assumed positive if the patients expressed bother and preoccupation about their appearance (questions 1 and 2 "yes"), as well as a moderately disrupted everyday life (question 7 "yes" or questions 3, 4, 5, or 6 are equal to or greater than "3''). The internal consistency, test-retest reliability, and item-response theory (IRT) were used to evaluate psychometric validations.

RESULTS

The Arabic BDDQ had a high level of internal consistency, as measured by Cronbach's alpha 0.995. The A-BDDQ-AS was deemed reliable with an Intraclass Correlation Coefficient (ICC) of 0.989. A-BDDQ had good discrimination scores (above 2.0) with adequate difficulty parameters. The overall scale content validity average was 0.83, affirming that all items were relevant, clear, and straightforward.

CONCLUSION

The Arabic version of the BDDQ-AS is reliable, culturally adapted, and psychometrically validated to be readily used and incorporated into clinical practice. It is a beneficial tool that can guide the screening of Arabic rhinoplasty patients suffering from body dysmorphic disorder and be utilized in further studies to optimize patient outcomes.

Novel Selection Tools in Rhinoplasty Patients

With no consensus document or guideline to help us compute the psychological make-up of rhinoplasty candidates and in the light of new perspectives of some key opinion leaders in the field of patient selection, the goals of this article are to offer a glimpse of the current literature together with the knowledge gaps, introduce some new tools for the preoperative consultation, help us identify who among our patients is at greatest risk for a poor outcome, and explain how childhood trauma can be linked to body shame and postoperative dissatisfaction.

Men's Experiences and Psychological Outcomes of Nonsurgical Medical Penile Girth Augmentation: A Preliminary Prospective Study

BACKGROUND

The popularity of penile augmentation procedures is increasing, but investigation into men's experiences with these procedures and their impact on psychological well-being is lacking.

OBJECTIVES

The aim of this study was to investigate men's experiences with nonsurgical medical penile girth augmentation and assess, based on valid psychological measures, the impacts these procedures have on psychological well-being.

METHODS

Men seeking to undergo a girth augmentation (n = 19) completed an online questionnaire prior to their procedure and 6 months later that contained standardized measures assessing impacts of the procedure, penile size self-discrepancy, body dysmorphic disorder, psychological distress, self-esteem, and body image-related quality of life. Girth size was also measured preprocedure and 6 months postprocedure for a subsample of men.

RESULTS

Almost half of the men reported positive impacts of "increased self-confidence" and "increased sexual pleasure" after their procedure. Despite an average girth increase of 3.29 cm, the men still perceived that their penile girth and length was less than what they should be or less than the ideal size after their augmentation procedure. However, this perceived discrepancy was significantly smaller than before their procedures. Prior to the procedure, the men who met diagnostic criteria for body dysmorphic disorder according to self-reported questionnaire (11%, n = 2/19) and clinical interview (7%, n = 1/15) lost this diagnosis at 6 months. There were no changes in psychological distress, self-esteem, or body image-related quality of life from pre- to postprocedure.

CONCLUSIONS

Men report positive impacts on their lives after penile girth augmentation, but impacts on broader psychological well-being are mixed.

LEVEL OF EVIDENCE: 4

Prevalence of Body Dysmorphic Disorder in an Otolaryngology-Head and Neck Surgery Clinic

OBJECTIVE

To analyze the prevalence of body dysmorphic disorder (BDD) in a general otolaryngology population presenting to an outpatient clinic.

STUDY DESIGN

Prospective prevalence study.

SETTING

Single tertiary academic otolaryngology clinic.

SUBJECT AND METHODS

New patients over 18 years of age who presented to an academic otolaryngology clinic between August 2018 and May 2021 completed a questionnaire including demographic questions and the validated Body Dysmorphic Disorder Questionnaire (BDDQ). Data collected from the questionnaires were analyzed to assess demographics and prevalence of BDD in an otolaryngology clinic.

RESULTS

Of the 242 patients queried, 15 patients screened positive for BDD. The screened prevalence of BDD was determined to be 6.2%. None of the patients had previously been diagnosed with BDD. The prevalence of prior mental health diagnoses was 34.3%. These patients had initially presented for a variety of otolaryngologic concerns and had pre-existing diagnoses of anxiety, depression, obsessive-compulsive, bipolar and eating disorders.

CONCLUSION

The prevalence of BDD in our population of new patients presenting to an academic otolaryngology practice (6.2%) is higher than that of the general population (1.9%).

Early response to cognitive behavioral therapy for body dysmorphic disorder as a predictor of outcomes

Individuals with body dysmorphic disorder (BDD) suffer from distressing or impairing preoccupations with perceived imperfections in their appearance. This often-chronic condition is associated with significant functional impairment and elevated rates of psychiatric comorbidity and morbidity, including depression, substance use disorders, and suicidality. Cognitive behavioral therapy (CBT) for BDD has been shown to be efficacious. However, this intervention is long (up to 24 weeks) relative to many manualized approaches for other related conditions, there is a significant shortage of clinicians trained in CBT for BDD, and some patients drop out of treatment and/or do not respond. Thus, there is great interest in understanding and predicting who is most likely to respond, to better allocate clinical resources. This secondary data analysis of participants enrolled in prior uncontrolled and controlled studies of CBT for BDD explored whether early response to CBT, operationalized as percentage change in symptom severity within the first four weeks and the first 12 weeks of this 24-week treatment, predicts clinical outcomes for patients with BDD (n = 90). The findings indicated that minimal early symptom change was not indicative of eventual non-response. This suggests that patients and clinicians should not be discouraged by limited early improvement but should instead continue with a full course of treatment before reevaluating progress and alternative interventions. Overall, the results support the view that treatment success is more likely if a longer CBT protocol is followed. More work is needed to understand mechanisms of change and thus match optimal interventions to patient characteristics.

Joint Report on Terminology for Cosmetic Gynecology

INTRODUCTION AND HYPOTHESIS

The current terminology used to describe cosmetic gynecologic procedures includes many nondescriptive, trademarked, or informal names, which contributes to substantial ambiguity about their aims and specific techniques. The development of clear, uniform descriptive terminology for cosmetic gynecology is needed for patients, researchers, and practitioners across multiple specialties.

METHODS

This document was developed from a collaboration of selected members from the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS). Wide-ranging literature reviews were performed to identify the breadth of currently used terms and tools for measuring efficacy and safety. After extensive internal review the adoption of each definition was ratified by group consensus.

RESULTS

A terminology report for elective cosmetic gynecology procedures, anatomical classification, outcome metrics, and reporting of complications has been developed. This document seeks to provide clear descriptive guidance for patients, researchers, and practitioners across multiple specialties. This document will be subject to internal review by IUGA and AUGS to incorporate and adopt evidence-based changes in the field.

CONCLUSIONS

A consensus-based document establishing clear terminology for cosmetic gynecology procedures has been created. Use of these terms should be encouraged to provide clarity to patients seeking these procedures and to facilitate future research to establish the safety and efficacy of these procedures.

Joint Report on Terminology for Cosmetic Gynecology

INTRODUCTION AND HYPOTHESIS

The current terminology used to describe cosmetic gynecologic procedures includes many nondescriptive, trademarked, or informal names, which contributes to substantial ambiguity about their aims and specific techniques. The development of clear, uniform descriptive terminology for cosmetic gynecology is needed for patients, researchers, and practitioners across multiple specialties.

METHODS

This document was developed from a collaboration of selected members from the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS). Wide-ranging literature reviews were performed to identify the breadth of currently used terms and tools for measuring efficacy and safety. After extensive internal review the adoption of each definition was ratified by group consensus.

RESULTS

A terminology report for elective cosmetic gynecology procedures, anatomical classification, outcome metrics, and reporting of complications has been developed. This document seeks to provide clear descriptive guidance for patients, researchers, and practitioners across multiple specialties. This document will be subject to internal review by IUGA and AUGS to incorporate and adopt evidence-based changes in the field.

CONCLUSIONS

A consensus-based document establishing clear terminology for cosmetic gynecology procedures has been created. Use of these terms should be encouraged to provide clarity to patients seeking these procedures and to facilitate future research to establish the safety and efficacy of these procedures.

"Motivations, demography and clinical features of body dysmorphic disorder among people seeking cosmetic treatments: a study of 199 patients."

BACKGROUND

Motivations for getting aesthetic medicine treatments concern not only the improvement of the physical appearance but also internal aspects such as feeling more confident or happier. Body dysmorphic disorder (BDD) is a disorder that affects from 5 to 15% of aesthetic medicine clients and characterizes by an obsessive preoccupation with a non-visible or minimal defect in appearance.

AIMS

The aim of the study was to assess the main motivations, demography, and clinical features of body dysmorphic disorder among people seeking cosmetic treatments.

METHODS

A single-center study was performed using an anonymous questionnaire on 199 patients of the private aesthetic medicine clinic in Gdansk, Poland.

RESULTS

A typical client of an aesthetic clinic is a woman aged 40 to 50, with higher education, who undergoes aesthetic treatments more than twice a year, mainly with botulinum toxin injections. The most common motivations are the desire to achieve a fresh look, the will to reduce the signs of aging, and to invest in oneself. Furthermore, over 38% of patients stated that they were having critical and recurring thoughts about their appearance, which affected their daily functioning and caused a decrease in their well-being. Almost 20% of them performed repetitive activities, such as frequently looking in the mirror or asking others for opinions about their appearance. 15.6% of patients presented at least two characteristic features of BDD.

CONCLUSIONS

Patients seeking cosmetic treatments may suffer from body dysmorphic disorder, thus the need for aesthetic medicine practitioners to be aware of this disease.

Translation, cross-cultural adaptation and validation of the Mandarin version of the BDDQ-AS for rhinoplasty patients

Background

The BDDQ-AS (Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery) is a simple and reliable patient-reported outcome measure. It can be used as a screening tool for body dysmorphic disorder (BDD) in patients undergoing aesthetic rhinoplasty. The aim of this study was to translate and culturally adapt the Mandarin version of the BDDQ-AS (M-BDDQ-AS) and evaluate its selected psychometric validation in patients after rhinoplasty.

Method

According to international guidelines, the BDDQ-AS questionnaire was translated from English to Mandarin. Twenty Mandarin-speaking rhinoplasty patients were interviewed in order to evaluate the understandability and acceptability of the translation and produce a final version. It was then administered to 137 patients with a mean age of 38.75 ± 6.24 years. Psychometric validation were evaluated using reliability (internal consistency, test–retest reliability) and item-reponse theory (IRT) test.

Result

High internal consistency of 0.823 was found using Cronbach’s α coefficient. Reliability of the M-BDDQ-AS resulted in Intraclass Correlation Coefficient (ICC) = 0.863. Besides, based on IRT analysis, the discrimination abilities of all the items were good (over 2.0), and their difficulty estimates were reasonable.

Conclusion

The M-BDDQ-AS is a reliable and valid self-reported questionnaire that can be used in rhinoplasty patients. The very good psychometric validation of the M-BDDQ-AS indicates that it can be used in clinical practice and scientific research.

Graphical Abstract

Body dysmorphia in common skin diseases: Results of an observational, cross-sectional multi-centre study among dermatological out-patients in 17 European countries

BACKGROUND

Body dysmorphic disorder (BDD) is a common psychiatric disorder associated with high costs for healthcare systems as patients may repeatedly ask for different, often not effective interventions. BDD symptoms are more prevalent in patients with dermatological conditions than the general population, but there are no large sample studies comparing the prevalence of BDD symptoms between patients with dermatological conditions and healthy skin controls.

OBJECTIVES

To compare the prevalence of BDD symptoms between patients with different dermatological conditions and healthy skin controls and to describe sociodemographic, physical and psychological factors associated with BDD symptoms to identify patients who may have a particularly high chance of having this condition.

METHODS

This observational cross-sectional, comparative multi-centre study included 8295 participants: 5487 consecutive patients with different skin diseases (56% female) recruited among dermatological out-patients at 22 clinics in 17 European countries and 2808 healthy skin controls (66% female). All patients were examined by a dermatologist. BDD symptoms were assessed by the Dysmorphic Concern Questionnaire (DCQ). Sociodemographic data, information on psychological factors and physical conditions were collected. Each patient was given a dermatological diagnosis according to ICD-10 by a dermatologist.

RESULTS

The participation rate of invited dermatological patients was 82.4% on average across all centres. BDD symptoms were five times more prevalent in patients with dermatological conditions than in healthy skin controls (10.5% vs. 2.1%). Patients with hyperhidrosis, alopecia and vitiligo had a more than eleven-fold increased chance (adjusted Odds Ratio (OR) > 11) of having BDD symptoms compared to healthy skin controls, and patients with atopic dermatitis, psoriasis, acne, hidradenitis suppurativa, prurigo and bullous diseases had a more than six-fold increased chance (adjusted OR > 6) of having BDD symptoms. Using a logistic regression model, BDD symptoms were significantly related to lower age, female sex, higher psychological stress and feelings of stigmatisation.

CONCLUSIONS

This study reveals that clinical BDD symptoms are significantly associated with common dermatological diseases. As such symptoms are associated with higher levels of psychological distress and multiple unhelpful consultations, general practitioners and dermatologists should consider BDD and refer patients when identified to an appropriate service for BDD screening and management.

The relationship between body dysmorphic disorder symptoms and 'not just right' experiences in a sample of individuals seeking cosmetic surgery and aesthetic medicine procedures

BACKGROUND

Body dysmorphic disorder (BDD) is characterized by concerns for perceived defects in physical appearance that appear to others as mild or unobservable. Individuals with BDD frequently refer concerns with their physical appearance being 'not right' (not just right experiences; NJREs), and BDD-related behaviours may be performed until their appearance is perceived as 'right'. The aim of the study was to explore the relationship between BDD and NJREs in cosmetic surgery and aesthetic medicine settings.

METHODS

Individuals requesting cosmetic procedures with BDD symptoms (BDD-symptoms group; n = 24), without BDD symptoms (cosmetic intervention [CI] group; n = 45), and individuals that have never required these procedures (no cosmetic intervention [NCI] group; n = 53) entered the study.

RESULTS

Results showed a greater number of past-month NJREs, higher NJREs severity, higher drive for thinness, and greater general distress in the BDD-symptoms group. Pertaining to features associated with NJREs (perfectionism and obsessive-compulsive disorder symptoms) and ED core features, the BDD-symptoms group scored higher only with respect to NCI. Regression analyses showed that BDD symptoms were predicted by age, NJREs severity, and drive for thinness above and beyond general distress, perfectionism, obsessive-compulsive disorder symptoms, bulimia, and body dissatisfaction related to weight and shape in the BDD-Symptoms group (in comparison with the CI and NCI groups).

CONCLUSIONS

NJREs may represent a potential vulnerability factor for BDD symptoms in cosmetic settings.

Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder

Body dysmorphic disorder (BDD), characterized by a distressing or impairing preoccupation with nonexistent or slight defects in appearance, is associated with markedly poor quality of life and high rates of suicidality. Onset of BDD is usually in childhood or adolescence and, unless appropriately treated, tends to be chronic. The first-line pharmacologic approach for both delusional and non-delusional BDD is serotonin reuptake inhibitors (SRIs), often at high doses. SRI augmentation and switching strategies can be effective. The first-line psychotherapy is cognitive-behavioral therapy (CBT) tailored to BDD's unique clinical features. Cosmetic treatment (such as surgery or dermatologic treatment), although received by a majority of patients with BDD, is not recommended. BDD has many similarities to obsessive-compulsive disorder (OCD) and appears closely related to OCD but also has some important differences. This article, which updates a 2015 article on BDD that we published in this journal, provides a clinically focused overview of BDD and its relationship to OCD.

Emotion Regulation Difficulties and Depression Among Individuals With Dermatological and Body Dysmorphic Concerns

ABSTRACT

Existing literature demonstrates strong links between emotion regulation (ER) difficulties and depression. Although high rates of depression are observed among individuals with body dysmorphic disorder and skin disease, little is known about these co-occurring syndromes. To advance our understanding of a vulnerable population, this study examined facets of ER difficulties in relation to depression among adults with skin disease symptoms and body dysmorphic concerns (N = 97). Participants were recruited online and completed self-report measures. The overall hierarchical regression model accounted for 61.6% of the variance in depression. After controlling for anxiety and stress, ER difficulties added 9.9% unique variance. In particular, limited access to ER strategies was the only ER dimension significantly associated with depression. This study integrates divergent literatures and suggests the important role of ER difficulties in depression in this unique sample, thereby highlighting directions for future investigation.

Comparison of Reconstructive Plastic Surgery Rates and 30-Day Postoperative Complications Between Patients With and Without Psychiatric Diagnoses

BACKGROUND

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery.

OBJECTIVES

The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses.

METHODS

This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression.

RESULTS

Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67).

CONCLUSIONS

Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

LEVEL OF EVIDENCE: 4

Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived appearance flaw or flaws that are not observable to others. BDD is associated with distress and impairment of functioning. Psychiatric comorbidities, including depression, social anxiety, and obsessive-compulsive disorder are common and impact treatment. Treatment should encompass psychoeducation, particularly addressing the dangers associated with cosmetic procedures, and may require high doses of selective serotonin reuptake inhibitors* (SSRI*) and protracted periods to establish full benefit. If there is an inadequate response to SSRIs, various adjunctive medications can be employed including atypical antipsychotics*, anxiolytics*, and the anticonvulsant levetiracetam*. However, large-scale randomized controlled trials are lacking and BDD is not an approved indication for these medications. Oxytocin* may have a potential role in treating BDD, but this requires further exploration. Cognitive-behavioural therapy has good evidence for efficacy for BDD, and on-line and telephone-assisted forms of therapy are showing promise. CBT for BDD should be customized to address such issues as mirror use, perturbations of gaze, and misinterpretation of others' emotions, as well as overvalued ideas about how others view the individual.

Correlation of the Standardized Cosmesis and Health Nasal Outcomes Survey With Psychiatric Screening Tools

BACKGROUND

Identifying mental health disorders, including body dysmorphic disorder (BDD), is important prior to rhinoplasty surgery; however, these disorders are underdiagnosed, and screening tools are underutilized in clinical settings.

OBJECTIVES

The authors sought to evaluate the correlation of a rhinoplasty outcomes tool (Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]) with psychiatric screening tools.

METHODS

Patients presenting for rhinoplasty consultation were prospectively enrolled and administered mental health instruments to assess depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and BDD (BDD Questionnaire-Aesthetic Surgery [BDDQ-AS]) as well as the SCHNOS rhinoplasty outcomes scale. Convergent validity of SCHNOS scores with these mental health instruments was assessed as well as calculation of an optimal SCHNOS-C score to screen for BDD.

RESULTS

A total 76 patients were enrolled in the study. The average SCHNOS-O score (standard deviation) was 46.1 (34.0) and the average SCHNOS-C score was 61.1 (27.0). Five (7%) patients screened positive for depression, and 24 (32%) patients screened positive for mild, 5 (7%) for moderate, and 4 (5%) for severe anxiety. Twenty-four (32%) patients screened positive for BDD by BDDQ-AS scores. SCHNOS-O and SCHNOS-C did not correlate with Patient Health Questionnaire-9 or Generalized Anxiety Disorder-7 scores; SCHNOS-C did correlate with BDDQ-AS. A score of 73 or greater on SCHNOS-C maximized the sensitivity and specificity of also screening positive for BDD with BDDQ-AS. This score correlated with a sensitivity of 62.5%, specificity of 80.8%, and number needed to diagnose of 2.3, meaning for every 2 patients with a score of ≥73 on SCHNOS-C, 1 will have a positive BDDQ-AS score.

CONCLUSIONS

SCHNOS-C correlates with BDDQ-AS and may help screen rhinoplasty patients at higher risk for BDD.

LEVEL OF EVIDENCE: 2

Unhappy Patients Can Turn into Angry Patients: How to Deal with Both

Patient satisfaction is the ultimate measure of success in cosmetic facial plastic surgery. A successful outcome depends on patient selection, technical performance, and postoperative care. Patient perception can be influenced by physician-patient interactions. Surgical training focuses on diagnosis-identifying variations in physical condition and treatment. Although these skills are essential to a well-trained and successful facial plastic surgeon, the importance of proper patient selection, management of expectations, and empathetic communication in cosmetic surgery are often overlooked in education and cannot be understated. This article outlines the contributing factors to difficult physician-patient relationships and strategies for mitigating these situations.

Screening for body dysmorphic disorder among patients pursuing cosmetic surgeries in Saudi Arabia

OBJECTIVES

To determine the prevalence of positive screening of body dysmorphic disorder (BDD) among patients seeking cosmetic surgeries in plastic surgery and oculoplastic surgery clinics.

METHODS

The survey of this cross-sectional study was self-administrated and distributed among adults pursuing cosmetic surgeries in plastic surgery and oculoplastic surgery clinics at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between March 2019 and March 2020. The BDD questionnaire was validated, and a highly sensitive and specific tool was used to identify patients with BDD. Ethical approval was granted by the Research Ethics Committee. All analytic studies were performed using IBM SPSS, version 24. Results: A total of 344 patients participated in this study with a mean age of 39.66 ± 13.76 years. Of these, 296 (86%) were women and 298 (86.6%) were Saudi. The prevalence of positive screening for BDD was 19.2%. The most commonly requested procedures were abdominoplasty (21.2%) and skin lesion removal (21.2%). Smoking was found to be significantly associated with BDD with 21.2% of smokers having it (p less than 0.010).

CONCLUSION

Body dysmorphic disorder was unrecognized among patients pursuing cosmetic surgeries. One-fifth of patients requesting cosmetic procedures are potential cases of BDD requiring psychiatric evaluation and treatment. We recommend implementing screening protocols to identify cases before surgical plans.

A case of body dysmorphic disorder in an adolescent with hypohidrotic ectodermal dysplasia

We report the case of an adolescent with hypohidrotic ectodermal dysplasia, who had obsessive-compulsive disorder and was later diagnosed with body dysmorphic disorder (BDD). BDD is a highly distressing, adolescent-onset disorder that may lead to social isolation, the development of comorbid mental health disorders and suicidality. Patients typically lack insight into their BDD and frequently present to dermatologists for medical treatment. In this paper, we address the challenges faced when working with patients with BDD.

More than just filler: an empirically informed ethical analysis of non-surgical cosmetic procedures in body dysmorphic disorder

OBJECTIVES

To identify and analyse ethical considerations raised when individuals with body dysmorphic disorder (BDD) consult for non-surgical cosmetic procedures.

METHODS

Ethical analysis was conducted addressing the issues of best interests and capacity to consent for non-surgical cosmetic procedures in individuals with BDD. Analysis was informed by the findings of semistructured interviews with non-surgical cosmetic practitioners and mental health professionals.

FINDINGS

Non-surgical cosmetic interventions were viewed not to be in the best interests of individuals with BDD, as they fail to address core psychological issues, result in dissatisfaction post-procedure, and risk harm. Referral to mental health services was advocated, however numerous obstacles to this were perceived. The issue of capacity to consent to non-surgical cosmetic procedures raised questions regarding whether standard capacity assessment is sensitive to the manner in which BDD may influence decision-making processes. In addition, concerns were voiced that decisions made by individuals with BDD in this context may be judged foolish, and thus wrongly equated with lack of capacity.

DISCUSSION/CONCLUSIONS

Ethical analysis, informed by the available evidence base, suggests that it is generally not in the best interests of individuals with BDD to undergo non-surgical cosmetic intervention, and referral to mental health services is indicated. Analysis of capacity draws parallels between BDD and anorexia nervosa, as decision-making capacity in both conditions can be impaired by pathological values derived from the disorder. Means of differentiating clinical assessment of pathological values from inappropriate value judgements are advocated, in order to safeguard against the latter encroaching into capacity assessment.

Body dysmorphic disorder and cosmetic surgery: Evolution of 24 subjects with a minimal defect in appearance 5 years after their request for cosmetic surgery

Objectives

To evaluate the effect of cosmetic surgery and the stability of body dysmorphic disorder (BDD) diagnosis in patients with a minimal defect in appearance, with and without BDD, 5 years after their request for plastic surgery.

Subjects and methods

Thirty patients requesting cosmetic surgery with minimal defect in appearance, of whom 12 had BDD and 18 did not, were re-evaluated 5 years later by telephone interview regarding their cosmetic surgery interventions, satisfaction with the intervention, BDD diagnosis, handicap, and psychiatric comorbidity.

Results

Of the 30 patients, we were able to re-evaluate 24 subjects (80%), 10 with BDD and 14 non-BDD. Seven BDD subjects had undergone cosmetic surgery vs 8 non-BDD. Patient satisfaction with the intervention was high in both groups. Nevertheless at follow-up, 6 of the 7 operated BDD patients still had a BDD diagnosis and exhibited higher levels of handicap and psychiatric comorbidity compared to their non-BDD counterparts. Moreover, 3 non-BDD patients had developed a BDD at follow-up.

Conclusion

This prospective study confirms that cosmetic surgery is not efficient on BDD despite declared patient satisfaction. Cosmetic surgery had no significant effects on BDD diagnosis, handicap or psychiatric comorbidity in BDD patients at 5-year follow-up. Furthermore, BDD appeared at follow-up in some initially non-BDD diagnosed subjects. Patients' declared satisfaction with surgery may contribute to explain why some plastic surgeons may not fully adhere to the contraindication of cosmetic surgery in BDD.

Body dysmorphic disorder in a sample of cosmetic surgery applicants

Body dysmorphic disorder (B.D.D.) consists of a preoccupation with an imagined or slight physical defect. This study is the first European report on prevalence and several clinical and functional characteristics of patients with B.D.D. in a cosmetic surgery setting. Comparisons with defect- and severity-matched subjects without B.D.D. were also performed.

Störungseinsicht bei körperdysmorpher Störung, Zwangsstörung und sozialer Angststörung

Hintergrund

Die körperdysmorphe Störung (KDS) geht mit einer geringen Störungseinsicht bis zu wahnhaft anmutenden Überzeugungen bezüglich wahrgenommener körperlicher Makel einher, die für andere nur leicht oder nicht sichtbar sind. Während die Einsicht bei der KDS bereits vielfach untersucht wurde und obwohl sie ein transdiagnostisch relevantes Merkmal ist, gibt es kaum vergleichende Studien.

Ziel der Arbeit

Es wird untersucht, inwiefern sich Personen mit einer KDS von Personen mit einer Zwangsstörung (ZS) und einer sozialen Angststörung (SAS) dimensional und kategorial hinsichtlich der Einsicht unterscheiden.

Material und Methode

Personen mit KDS (n = 36), ZS (n = 38) und SAS (n = 36) beantworteten diagnostische Interviews und Fragebogen. Die Einsicht wurde mithilfe eines teilstrukturierten Interviews, das verschiedene Facetten und Grade von Einsicht erfasst, beurteilt (Brown Assessment of Beliefs Scale).

Ergebnisse

In allen Gruppen lagen unterschiedliche Einsichtsgrade im gesamten Spektrum von exzellent bis fehlend vor. Bei den Betroffenen mit einer KDS entsprach der Gesamtmittelwert einer schlechten (M = 13,25, SD ± 6,32), bei Betroffenen mit einer SAS einer ausreichenden (M = 10,39, SD ± 5,70) und bei Betroffenen mit einer ZS einer guten Einsicht (M = 4,74, SD ± 5,49). Abgesehen von einer stärkeren Fixiertheit der Überzeugung bei KDS war die Einsicht bei KDS und SAS dimensional und kategorial nicht signifikant voneinander verschieden, jedoch bei beiden Störungen schlechter als bei ZS.

Diskussion

Die Ergebnisse bestätigen, dass die KDS mit geringer Einsicht einhergeht, dies jedoch fast gleichermaßen auf die SAS zutrifft. Die Störungseinsicht erscheint bei allen untersuchten Störungen relevant und sollte in der Psychotherapie von Beginn an diagnostisch und psychotherapeutisch berücksichtigt werden.

Body Dysmorphic Disorder, Psychiatric Symptoms, and Quality of Life in Female Dermatological Patients

PURPOSE

To examine the relationships of body dysmorphic disorder (BDD) with psychiatric symptoms and quality of life in dermatological patients.

PATIENTS AND METHODS

A total of 154 female patients with dermatological disease underwent a comprehensive clinical assessment that included the Body Dysmorphic Disorder Examination-Self Report (BDDE-SR), Symptom Checklist 90-Revised (SCL-90-R), and Skindex-29. Dermatological disease was categorized as follows: inflammatory dermatoses (reference category), isolated lesions, and unclassified dermatoses. The BDDE-SR and SCL-90-R scores were used to evaluate BDD and psychiatric symptoms, respectively. Dermatological quality of life was measured with the Skindex-29.

RESULTS

The BDDE-SR score was significantly associated with the SCL-90-R and Skindex-29 total and subscores, even after controlling for age, body mass index, and dermatological diagnosis. The variables that contributed most to the BDDE-SR score were the SCL-90-R depression score and Skindex-29 emotion scores. Additional analyses revealed that the BDDE-SR score was higher in participants with unclassified dermatoses, but neither the SCL-90-R score nor Skindex-29 score was related to any dermatological diagnosis.

CONCLUSION

The BDD symptoms were especially prominent in the unclassified dermatoses group and were highly related to psychiatric symptoms and a poor quality of life in our dermatological patients. Further research including studies involving psychiatric interviews to confirm the BDD diagnosis and symptoms will improve our understanding of BDD in dermatological patients.

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.

Body dysmorphic disorder and facial aesthetic treatments in dental practice

There is a relatively high prevalence of body dysmorphic disorder (BDD) and it is known that this patient group regularly and frequently visit dental practitioners, especially those who advertise themselves as cosmetic or aesthetic practices. The market for facial aesthetics is hugely increasing both generally and within dental practices making it ever more likely that dentists will encounter this patient group frequently. Moreover, due to the nature of their concerns individuals within this group are likely to have contact with dentists (or other medical professionals in the physical health field) prior to any contact with mental health professionals. The aim of this paper is to give an overview of the presentation of BDD, to discuss the changing climate of facial aesthetic treatments and to highlight a care pathway for general dentists. Identification of patients with potential BDD is far more predictable with the use of a validated questionnaire, and the BDD Questionnaire and Dysmorphic Concern Questionnaire are described. A flowchart approach for the management of patients requesting aesthetic improvements is presented as the ideal method for identifying, referring and managing the aesthetic treatment desires of potential BDD patients.

Trichotillomania comorbidity in a sample enriched for familial obsessive-compulsive disorder

BACKGROUND

This study addresses the strength of associations between trichotillomania (TTM) and other DSM-IV Axis I conditions in a large sample (n = 2606) enriched for familial obsessive-compulsive disorder (OCD), to inform TTM classification.

METHODS

We identified participants with TTM in the Johns Hopkins OCD Family Study (153 families) and the OCD Collaborative Genetics Study, a six-site genetic linkage study of OCD (487 families). We used logistic regression (with generalized estimating equations) to assess the strength of associations between TTM and other DSM-IV disorders.

RESULTS

TTM had excess comorbidity with a number of conditions from different DSM-IV chapters, including tic disorders, alcohol dependence, mood disorders, anxiety disorders, impulse-control disorders, and bulimia nervosa. However, association strengths (odds ratios) were highest for kleptomania (6.6), pyromania (5.8), OCD (5.6), skin picking disorder (4.4), bulimia nervosa (3.5), and pathological nail biting (3.4).

CONCLUSIONS

TTM is comorbid with a number of psychiatric conditions besides OCD, and it is strongly associated with other conditions involving impaired impulse control. Though DSM-5 includes TTM as an OCD-related disorder, its comorbidity pattern also emphasizes the impulsive, appetitive aspects of this condition that may be relevant to classification.

Nonsurgical Medical Penile Girth Augmentation: A Retrospective Study of Psychological and Psychosexual Outcomes

BACKGROUND

Although interest in penile augmentation procedures is increasing, there is a significant lack of research into the psychological and psychosexual outcomes of these procedures.

OBJECTIVES

To investigate the psychological and psychosexual outcomes of nonsurgical medical penile girth augmentation.

METHODS

This retrospective study involved a mixed method approach. Twenty-five men who had undergone a nonsurgical medical penile girth augmentation between 1 and 12 months prior (mean, 6.6 months) completed an online questionnaire containing measures of procedure motivation, procedure satisfaction, genital self-image, penile-focused body dysmorphic disorder symptoms, self-esteem, and sexual relationship satisfaction. Six of these men elected to complete in-depth one-to-one semi-structured phone interviews to further explore the psychological impacts of the procedure.

RESULTS

In the online questionnaire, most men were satisfied with their penile size, appearance, and function after penile girth augmentation. The men also reported statistically significant improvements in their genital self-image (P < 0.001) and self-esteem (P = 0.008), and a reduction in penile-focused body dysmorphic disorder symptoms (P = 0.002) at the time of completing the questionnaire compared to recalled pre-procedural levels. The in-depth interviews yielded 3 themes surrounding penile augmentation outcomes: (1) high satisfaction with increased penis girth; (2) increased self-confidence, particularly in situations in which the penis would be seen, such as a locker room; and (3) increased sexual confidence, but some mixed impacts on sexual relationships.

CONCLUSIONS

Most men appear to be satisfied with their nonsurgical medical penile girth augmentation results, and they also seem to experience improvements in their overall self-esteem.

LEVEL OF EVIDENCE: 4

Body dysmorphia in dentistry and prosthodontics: A practice based study

The prevalence of Body Dysmorphic Disorder (BDD) and dysmorphic concern in dentistry and prosthodontics have not been properly assessed, yet the mouth and the teeth are amongst the top preoccupation for these individuals.

OBJECTIVES

To evaluate the prevalence of dysmorphic symptoms and BDD using validated tools in patients presenting to general and specialist prosthodontic practice.

METHODS

Patients were recruited by two prosthodontics practices and three general dentist practices. Patients were given a Dysmorphic Concern Questionnaire (DCQ) integrated into a medical history form. Treating clinicians also completed a Baseline Rating Form assessing the patients´ reason for presentation. Two DCQ score cut-offs were used (9 and 12).

RESULTS

Two hundred and thirteen patients were recruited, the majority of patients showed DCQ scores below 9 (84%). The prevalence of BDD was 7% (cut-off ≥ 9) or 4% (cut-off ≥12). Women were more likely to present with high DCQ scores as well as people with a history of mental health problems. The cosmetic practice, the implant clinic, and the prosthodontic practice received a higher proportion of patients with high DCQ scores when compared with the general family practice. The type of procedure was not related to DCQ scores. The defect severity assessment and whether this was amenable to correction was moderately correlated with DCQ scores.

CONCLUSIONS

The DCQ seems to be a suitable tool to be used by dentists as part of history taking and patient examination due to its brevity, simplicity and the good sensitivity/specificity reported in the literature.

CLINICAL SIGNIFICANCE

Identifying patients with dysmorphia is important before irreversible treatment is carried out due to high levels of dissatisfaction, poor patient centred outcomes and the question of whether these individuals have the capacity to consent.

New perspectives in the treatment of body dysmorphic disorder

Body dysmorphic disorder (BDD) is a disabling illness with a high worldwide prevalence. Patients demonstrate a debilitating preoccupation with one or more perceived defects, often marked by poor insight or delusional convictions. Multiple studies have suggested that selective serotonin reuptake inhibitors and various cognitive behavioral therapy modalities are effective first-line treatments in decreasing BDD severity, relieving depressive symptoms, restoring insight, and increasing quality of life. Selective serotonin reuptake inhibitors have also recently been shown to be effective for relapse prevention. This review provides a comprehensive summary of the current understanding of BDD, including its clinical features, epidemiology, genetics, and current treatment modalities. Additional research is needed to fully elucidate the relationship between BDD and comorbid illnesses such as obsessive–compulsive-related disorders and depression and to develop therapies for refractory patients and those who have contraindications for pharmacological intervention.

Treatment utilization and barriers to treatment among individuals with olfactory reference syndrome (ORS)

OBJECTIVE

Olfactory reference syndrome (ORS) is characterized by a preoccupation that one is emitting a foul or offensive odor. Despite the profound psychosocial impact of ORS, many patients do not receive appropriate treatment, and there is no empirical research on treatment-seeking behavior in ORS. This study investigated treatment utilization patterns and barriers to treatment in individuals with ORS.

METHOD

253 subjects completed an online survey between January-March 2010. Data were obtained from the Yale-Brown Obsessive Compulsive Scale Modified for ORS (ORS-YBOCS), Depression Anxiety Stress Scales (DASS), Work and Social Adjustment Scale (WSAS), and questionnaires specific to treatment utilization and barriers.

RESULTS

The sample was ethnically diverse, predominately male (67%), with an average age of 33.7years, and moderately severe ORS symptoms. Most participants first sought care from a medical specialist (44%), and mental health services were underutilized (14%). Higher functional impairment was significantly correlated with seeking care from a mental health provider, compared to a medical specialist. Nearly all participants endorsed multiple barriers to treatment, including (a) logistical/financial, (b) stigma/discrimination, and (c) treatment perception barriers. ORS symptom severity was significantly, positively correlated with number of logistical/financial and stigma/discrimination barriers. Treatment barriers were significantly influenced by ethnic group, ORS symptom severity, and source of odor.

CONCLUSION

Results highlight the importance of increasing awareness and enhancing access to care for individuals with ORS.