An increasing need for early detection of body dysmorphic disorder by all specialties

Body dysmorphic disorder (BDD) is a relatively new term for a well-established phenomenon also termed dysmorphophobia or ‘imagined ugliness’. It is characterized by a preoccupation with a slight or imagined defect in appearance. The British Association of Aesthetic Plastic Surgeons (BAAPS) reports over 22 000 cosmetic surgical procedures being performed in the UK in 2005. This is a 34.6% increase in cases from 2004 to 2005 with an increasing number being undertaken in men (11% of the total). As cosmetic procedures become increasingly accessible and in demand so does the likelihood of presentation of this condition to both general practitioners and other specialties, particularly aesthetic/plastic surgeons and dermatologists. Failure to recognize BDD can result in both poor physical and psychiatric outcomes—there is a need for education about this debilitating condition within all specialties (Box 1).

Although widely recognized, BDD is not found within the World Health Organization International Classification of Mental and Behavioural Disorders¹ (the current classification system of mental illness used in the UK), though the criteria for the BDD are listed in the American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)² which provides a generally accepted definition of the disorder (Box 2). Current opinion is that the preoccupations or overvalued ideas associated with the disorder span a continuum between rational beliefs and delusions with those who present with delusions having a more severe form of illness and less insight.

BDD is a relatively common disorder with a prevalence of around 1% in the community and an equal incidence in both sexes. Indications are: that it usually begins during adolescence; typically involves numerous body areas and related behaviours; and is characterized by poor insight, marked functional impairment and high rates of suicidal ideation and suicide attempts. Although often assumed to present to mental health services, it is now presenting with increasing frequency to other specialties—most commonly primary care, plastic surgery and dermatology, with up to 12% of patients seen by dermatologists, and up to 15% of patients seeking cosmetic surgery meeting the criteria for BDD. As cosmetic procedures increase so, it can be assumed, will presentations of BDD, thus making recognition and appropriate management increasingly important.

In the largest study to date, 76% of 250 adults with BDD sought, and 66% received, non-psychiatric treatment for their perceived appearance defect, most commonly dermatological and surgical. Evidence suggests that the skin, hair and nose are the most common areas of concern and that outcomes from physical interventions are poor. Patients report a high degree of dissatisfaction with cosmetic surgery and frequently an increase in symptoms of BDD. Those who are satisfied tend to transfer their preoccupation to a different area of the body and continue to be disabled by the symptoms of BDD. BDD occurs with high levels of psychiatric comorbidity, including depression, suicidality and personality disorders. If the diagnosis remains undetected, comorbid mental illness may remain untreated and the risks of future self harm are heightened. Detection of BDD is by clinical suspicion and, as such, knowledge of the DSM-IV criteria provides a good reference point for clinicians. The DSM-IV criteria have been adapted to a self-report questionnaire with good sensitivity and specificity for detection of the disorder⁰ and clinicians likely to be in frequent contact with BDD could consider this simple and effective identification measure.

Box 1 Summary points

• Failure to detect BDD can lead to poor physical and psychiatric outcomes

• BDD can present to all specialties and is most commonly seen in psychiatry, dermatology and plastic surgery

• Attempts to treat the perceived abnormality do not lessen the symptoms of BDD and may worsen outcomes

• Current evidence suggests the best treatment for BDD is a combination of cognitive behavioural therapy and adjunctive psychotropic medication

Current evidence for the best treatment of BDD is limited and few interventions have been systematically evaluated, but the most convincing supports treatment by psychiatric intervention consisting of a combination of pharmacotherapy with an antidepressant (specifically SSRIs [selective serotonin reuptake inhibitors]) and cognitive behavioural therapy. Antipsychotic use appears to be of limited benefit, but can be considered as an adjunct to antidepressant therapy in some cases psychiatric assessment also enables treatment of comorbid psychiatric conditions.

Whilst highlighting the need for all specialties to be aware of BDD, it is also important to recognize the difficulty of objectifying and quantifying physical defects. Many clinicians may be faced with the dilemma of what is a reasonable amount of concern for a patient to have with regard to their appearance. Physical perfection is now seen as achievable by the general population, with ideals of aesthetic beauty becoming increasingly uniform. This makes it difficult to follow the DSM-IV criteria with regards to whether a defect is imagined or slight. If unclear, clinicians should focus on other aspects of the criteria such as degree of distress and functional impairment. They should also look at what actions patients have taken to rid themselves of the defect (for example, ‘do it yourself [DIY]’) surgery. A thorough history may reveal previous unsuccessful contacts with plastic surgery or dermatology due to concern over other body areas, Psychiatric comorbidity or a past psychiatric history should also increase the index of suspicion for BDD. The number of cosmetic procedures is likely to continue to rise and raising awareness of BDD is vital in order to provide expedient diagnosis and appropriate further management for these patients.

Box 2 Diagnostic criteria from DSM-IV for Body Dysmorphic Disorder (Ref ²)

• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive

• The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning

• The preoccupation is not better accounted for by another mental disorder.