Prevalence of Body Dysmorphic Disorder Symptoms and Body Weight Concerns in Patients Seeking Abdominoplasty

Abstract

Background

Body dysmorphic disorder (BDD) is one of the most common psychiatric conditions found in patients seeking cosmetic surgery, and body contouring surgery is most frequently sought by patients with BDD.

Objectives

To estimate the prevalence and severity of BDD symptoms in patients seeking abdominoplasty.

Methods

Ninety patients of both sexes were preoperatively divided into two groups: patients with BDD symptoms (n = 51) and those without BDD symptoms (n = 39) based both on the Body Dysmorphic Disorder Examination (BDDE) and clinical assessment. Patients in the BDD group were classified as having mild to moderate or severe symptoms, according to the BDDE. Body weight and shape concerns were assessed using the Body Shape Questionnaire (BSQ).

Results

The prevalence of BDD symptoms was 57%. There were significant associations between BDD symptoms and degree of body dissatisfaction, level of preoccupation with physical appearance, and avoidance behaviors. Mild to moderate and severe symptoms of BDD were present in 41% and 59% of patients, respectively, in the BDD group. It was found that the more severe the symptoms of BDD, the higher the level of concern with body weight and shape (P < .001). Patients having distorted self-perception of body shape, or distorted comparative perception of body image were respectively 3.67 or 5.93 times more likely to show more severe symptoms of BDD than those with a more accurate perception.

Conclusions

Candidates for abdominoplasty had a high prevalence of BDD symptoms, and body weight and shape concerns were associated with increased symptom severity.

Level of Evidence: 3

Diagnostic

Body dysmorphic disorder (BDD) is one of the most common psychiatric conditions found in patients seeking cosmetic surgery,^1-7 and body contouring surgery is most frequently sought by patients with BDD^7-9 and those with eating disorders.^9,10 Sarwer and Crerand,⁹ and Grossbart and Sarwer¹¹ found that eating disorders and BDD were prevalent in plastic surgery patients and may be considered contraindications to surgery.

Recent studies have suggested a change in the expression of body dissatisfaction^7,12,13 and, therefore, concerns about weight and body contour, and disordered eating behaviors can make the diagnosis of BDD difficult.^13,14 This aspect has been identified and highlighted by the American Psychiatric Association (APA) in the diagnostic criteria for BDD described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).¹⁵

According to the DSM-5, BDD is characterized by a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others, and repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, and reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to concerns about physical appearance. BDD causes clinically significant distress or impairment in important areas of functioning, and its symptoms are not better explained by normal concerns with physical appearance or by concerns with body fat or weight in individuals meeting diagnostic criteria for eating disorders. BDD symptoms may be associated with muscle dysmorphia and patients with BDD may show different degrees of insight regarding BDD beliefs.¹⁵

Abdominoplasty is frequently performed to improve body contour after pregnancy or major weight loss.^16,17 This surgery treats the aesthetic units of the abdomen, namely, the epigastrium, lower abdomen, flanks, and mons pubis.^17-19

Physiological changes, such as aging and pregnancy, or alterations in body contour caused mainly by increases in body mass index (BMI) may lead to functional and psychological changes expressed as high levels of embarrassment in social and personal relationships.^16,17,20 However, an excessive preoccupation with appearance can conceal psychopathological traits that are not always easy to recognize and may result in iatrogenic and medico-legal problems if neglected.^21-25 Therefore, it is very important to carefully assess candidates for cosmetic procedures to identify those with this condition.^5,26

For patients with a slight perceived defect who seek cosmetic surgery, degrees of behavior impairment and emotional distress seem to be more accurate indicators of BDD.^6,26,27 Avoidance behaviors and social withdrawal have been appointed as contributors to BDD severity^6,7 and chronicity.^28-30 Therefore, the classification of BDD severity in the present study was based on this concept.

The purpose of the study was to evaluate the prevalence and severity of BDD symptoms in patients seeking abdominoplasty.

METHODS

This study was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (UNIFESP), Brazil, and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all patients prior to their inclusion in the study. Patient anonymity was assured. The study was conducted between February 2009 and August 2010.

Patients of both sexes, who expressed a desire to undergo abdominoplasty, were recruited at the outpatient facility of the Abdominal Plastic Surgery Unit of the São Paulo Hospital, UNIFESP.

Patients unable to understand the interview questions and those with severe physical deformities as a result of obesity, bariatric surgery, tumors and other conditions, psychotic disorders, previous history of BDD, or who had undergone psychiatric or psychological treatment were excluded from the study.

Ninety patients who met participation criteria and agreed to participate were included in the study. The participants were divided into two groups: patients with BDD symptoms (BDD group; n = 51) and those without BDD symptoms (non-BDD group; n = 39), according to the Brazilian version of the Body Dysmorphic Disorder Examination (BDDE)³¹ and clinical assessment of BDD.¹⁵ All patients were clinically assessed by the same psychologist (first author) with expertise in BDD and screening of plastic surgery candidates, who administered the BDDE. Body weight and shape concerns were assessed using the Body Shape Questionnaire (BSQ).³² Sociodemographic (eg, name, sex, age, and ethnicity) and clinical characteristics (eg, history of previous cosmetic procedures, psychological/psychiatric treatment, and abuse) of the study participants were obtained through a clinical interview. All participants were evaluated by the authors, including two psychologists, one psychiatrist, and three plastic surgeons. The questionnaires were administered preoperatively.

The 34-item BDDE is a specific questionnaire that measures symptoms of severely negative body image.³³ The items are grouped into 6 domains assessing preoccupation and negative self-evaluation of appearance, self-consciousness and embarrassment, excessive importance given to appearance in self-evaluation, avoidance of activities (eg, avoidance of public and social situations or physical contact with other persons), body camouflaging (eg, use of camouflage strategies involving style of clothing, the wearing of accessories, use of makeup, and changes in body posture in an attempt to hide the perceived defect), and body checking (eg, self-inspection, reassurance seeking, and comparing self to others).²⁶ The items are rated on a 0 to 6 scale, with 0 indicating the absence of negative body image symptoms in the previous 4 weeks. Scores of 1 to 6 represent the frequency (number of days) or intensity (mild to severe) of symptoms. The BDDE total score ranges from 0 to 168; a cutoff score of ≥66 indicates a higher degree of dissatisfaction with appearance and is usually associated with diagnosis of BDD.³³

Besides measuring body image dissatisfaction, the BDDE includes specific items for the diagnosis of BDD and patients are required to have a score of 4 or greater on these items to meet diagnostic criteria.^31,34 Patients without BDD symptoms were defined as those who had a score of 3 or less on the specific items and those who did not meet criteria for BDD according to the DSM-5 during the clinical interview.

Patients with BDD symptoms were classified as having mild to moderate or severe symptoms,^6,7,26 based on their level of subjective distress and avoidance behavior.²⁶

The classification of the physical deformity perceived by the patient was performed independently and in person by two experienced plastic surgeons, who are not authors of this paper, and two observers, who were not plastic surgeons. The intention was to classify the degree of severity of the defect from both the point of view of plastic surgeons and that of lay persons (non-plastic surgeons). Plastic surgeons are specialists able to observe even small aesthetic defects or variations from the ideal standard of beauty valued by a given culture. Consensus between non-plastic surgeons was achieved through a review of the photographs of patients. There was no disagreement between the classifications of both plastic surgeons.

The BSQ assesses concerns of body weight and shape in the past 4 weeks. Items are rated on a 6-point Likert-type scale ranging from “never'” to “always'” and grouped into 4 domains, including self-perception of body shape, comparative perception of body image, attitude concerning body image alterations, and severe alterations in body perception.³²

Statistical Analysis

Comparisons between groups were made using t test, the Mann-Whitney test, chi-square test, and Fisher's exact test. The t-test for independent samples was used to compare the means between groups, and analysis of variance (ANOVA) was applied to compare data from more than two variables. The Brown-Forsythe test was used when variances were heterogeneous.

The Cramer's V coefficient was calculated to measure the strength of associations between categorical variables. The Kolmogorov-Smirnov test and Shapiro-Wilk W-test were used to test for normality. Levene's test was performed to test homoscedasticity of variances. Dunnett's multiple comparison test was applied to identify differences in mean values if significant differences were detected by ANOVA.

Ordered logistic regression was used to analyze the relationship between the four BSQ domains and BDD symptoms. The level of significance was set at a P-value of ≤ .05, and BSQ domains showing statistical significance were included into the final logistic regression model. The Mantel-Haenszel method was used to test for trends between BDD symptoms and the BSQ total score.

The Statistical Package for the Social Sciences (SPSS) 20.0 (SPSS Inc., Chicago, IL) and Stata 12 (StatCorp, College Station, TX) were used for data analysis. All statistical tests were performed at a significance level of 5% (P < .05). Data are expressed as mean ± SD.

RESULTS

Most patients were women (women, n = 84, 93.3%; men, n = 6, 7%), had a mean age of 38 ± 11 years (range, 20-66 years), a mean BMI of 26 ± 4 kg/m² (range, 18.3-41.3 kg/m²), and secondary or higher education (n = 72, 80%). No significant differences in sociodemographic characteristics were found between groups (Table 1).

Table 1.

Sociodemographic Characteristics of Patients According Group Distribution

Characteristics	Groups			P Value
	Non-BDD Group (n = 39)	BDD Group (n = 51)	Test Statistics
Age (years)	39 ± 11	37 ± 10	t = 0.76	.451
BMI (kg/m2)	26 ± 5	25 ± 4	t = 0.61	.545
Education Level	N (%)	N (%)
Incomplete primary education	2 (5)	1 (2)	χ2 = 1.297	.523
Complete primary education	5 (13)	10 (20)
Secondary education	17 (43)	24 (47)
Some higher education	10 (26)	11 (21)
College degree	5 (13)	5 (10)

SD, standard deviation; BMI, body mass index.

There were significant differences in mean BDDE total score and number of patients scoring >66 between groups, showing a significant association between BDD symptoms and body dissatisfaction (Table 2).

Table 2.

Comparison of Clinical Characteristics of Patients Between Groups

Variable	Non-BDD Group (n = 39)	BDD Group (n = 51)	Test Statistics	P Value
Dissatisfaction with appearance
BDDE total score (mean ± SD)	83 ± 33	120 ± 26	t = 5.87	<.001*
	N (%)	N (%)
BDDE scores >66	26 (67)	50 (98)	χ2 = 16.559	<.001*
Level of preoccupation (obsessive characteristics)a
Defect severitya
Real	5 (13)	__
Exaggerated	30 (77)	42 (82)	χ2 = 7.456	.024*
Non-observable	4 (10)	9 (18)
Perception of self-reference	14 (36)	48 (94)	χ2 = 34.952	<.001*
Types of behaviors (compulsive characteristics)a
Checking
Comparing self to others	28 (72)	43 (84)	χ2 = 2.080	.149
Reassurance seeking	18 (46)	24 (47)	χ2 = 0.007	.932
Mirror checking	35 (90)	49 (96)	χ2 = 1.425	.233
Body inspection	39 (100)	50 (98)	Fisher's test	.999
Avoidance and Inhibition
Mirror avoidance	12 (31)	31 (61)	χ2 = 7.980	.005*
Camouflage strategies	32 (82)	47 (92)	χ2 = 2.104	.147
Avoidance of public situations	13 (33)	27 (53)	χ2 = 3.441	.064
Avoidance of social situations	12 (31)	30 (59)	χ2 = 6.989	.008*
Avoidance of physical activities	21 (54)	27 (53)	χ2 = 0.007	.932
Avoidance of physical contact	15 (38)	46 (90)	χ2 = 27.084	<.001*
Inhibition of sexuality	28 (72)	51 (100)	χ2 = 16.388	<.001*

^aData obtained using the Body Dysmorphic Disorder Examination (BDDE). ^bAccording to the psychologist's assessment based on the BDDE. *Statistical significance (P < .05).

Mild to moderate (without avoidance behavior) and severe (with avoidance behavior) symptoms of BDD were present in 41% and 59% of patients, respectively, in the BDD group.

Significant differences in patient perception of the defect severity (P = .024) and perception of self-reference (P < .001) were found between groups, revealing an association between level of preoccupation with physical appearance and BDD symptoms (Table 2).

There were also significant associations of BDD symptoms with some avoidance behaviors, including avoidance of mirrors (P = .005), social situations (P = .008) and physical contact (P < .001), and inhibition of sexuality (P < .001) (Table 2).

The majority of participants (90%) expressed the desire to undergo not only abdominoplasty, but also other cosmetic surgeries.

All patients with BDD symptoms (n = 51) reported extreme dissatisfaction with their abdominal region and desired to undergo additional cosmetic surgery in other parts of the body. The most common complaints were body weight and deformities of the nose, breast, and face.

Complaints of dissatisfaction with different parts of the body were not normally distributed in both the BDD group (S-W = 0.835; P < .001) and non-BDD group (S-W = 0.880; P < .001). Patients with BDD symptoms showed dissatisfaction with a significantly (Z = −2.337, P = .019) greater mean number of parts of the body (2.36 ± 1.19) compared with those without BDD symptoms (2.36 ± 1.01).

Patients in both groups reported that dissatisfaction with their body image began before the age of 40 years, especially during adolescence and early adulthood (P = .460; χ² = 1.555). A higher proportion (49%) of patients in the BDD group experienced the onset of BDD symptoms during adolescence.

Patients in the BDD (69%) and non-BDD (33%) groups reported some experience of being teased and bullied, with a significant difference between groups (P = .001; χ² = 11.061).

No significant association was found between history of substance abuse (alcohol and other drugs) and BDD symptoms (P = .061). However, a higher proportion (20%) of patients with BDD reported substance abuse compared with that (5%) of patients without BDD.

Dissatisfaction With Body Image Associated With Body Weight and Shape

There were significant differences in the distribution of BSQ total scores across the levels of body image concern measured by the BDDE, and in mean BSQ domain scores between groups (Table 3). BSQ total scores for patients without body image concerns were significantly lower than those of patients with mild to moderate concerns, which in turn were significantly lower than the scores of patients with severe body image concerns (Table 3).

Table 3.

Distribution of BDDE Total Scores According to Levels of Body Image Concern and BSQ Domain Scores in Both Groups

Scores	Mean	SD	Median	N
BDDE total	104.9	32.8	110.0	90
BSQ total
Absent	81.4a	30.4	80.0	39
Mild	106.4b	19.2	103.0	15
Moderate	121.5b	18.2	117.0	19
Severe	138.9c	13.1	144.0	17
F3,80 = 37.74; P < .001
BSQ domains
Self-perception of body shape
Non-BDD group	83.8	30.5	81.0	43
BDD group	124.2	20.7	127.0	47
t = −7.28; P < .001
Comparative perception of body image
Non-BDD group	88.9	31.1	88.5	52
BDD group	126.8	20.0	131.5	38
t = −7.02; P < .001
Attitude concerning body image
Non-BDD group	98.8	32.4	100.5	74
BDD group	132.9	15.8	134.0	16
t = −6.26; P < .001
Severe alterations in body perception
Non-BDD group	98.2	32.3	100.5	72
BDD group	131.7	17.8	134.0	18
t = −5.90; P < .001

^a,b,cdifferent letters indicate significant differences between mean values (P < .05).

A significant association was found between presence of BDD symptoms and both the BSQ total and domain scores, with the comparative perception of body image (V = 0.570; P < .001) and self-perception of body shape (V = 0.520; P < .001) domains showing the strongest association. The higher the level of concern with body weight and shape, the more severe were the BDD symptoms (P < .001; Mantel-Haenszel test).

Logistic regression showed that patients having distorted self-perception of body shape or distorted comparative perception of body image were respectively 3.67 (odds ratio (OR) = 3.670; P = .011; 95% IC, 1.35-9.94) or 5.93 (OR = 5.932; P = .001; 95% IC, 2.15-16.39) times more likely to show more severe symptoms of BDD than those with a more accurate perception when the effects of the other variables were controlled (Tables 4 and 5).

Table 4.

Complete Logistic Regression Model Measuring the Relationship Between BDD Symptoms and the Four BSQ Domains

BSQ domains	OR	SE	Z	P > |Z|	95% CI
Self-perception of body shape	3.153	1.665	2.17	.030*	[1.120-8.875]
Comparative perception of body image	4.123	2.289	2.55	.011*	[1.389-12.241]
Attitude concerning body image alterations	3.377	3.144	1.31	.191	[.545-20.938]
Severe alterations in body perception	1.082	.875	0.10	.923	[.221-5.284]

OR, odds ratio; SE, standard error; CI, confidence interval. *Statistical significance (P ≤ .05).

Table 5.

Final Logistic Regression Model Measuring the Relationship Between BDD Symptoms and Two BSQ Domains

BSQ domains	OR	SE	Z	P > |Z|	95% CI
Self-perception of body shape	3.670	1.866	2.56	.011*	[1.355-9.944]
Comparative perception of body image	5.932	3.076	3.43	.001*	[2.147-16.388]

OR, odds ratio; SE, standard error; CI, confidence interval. *Statistical significance (P ≤ .05).

Only patients in the BDD group (n = 51; 57%) had concerns about body weight and shape, with 17%, 21%, and 19% of them having mild, moderate, and severe levels of concern, respectively.

It also was found that 53%, 42%, and 20% of all participants reported high levels of concern on the self-perception of body shape, comparative perception of body image, and attitude concerning body image domains of the BSQ, respectively.

Overall, significant associations were found between dissatisfaction with body image and BSQ total scores (P < .001), self-perception of body shape (P < .001; χ² = 16.61), and comparative perception of body image (P < .006; χ² = 7.46) scores. There was no association between attitude concerning body image (P = .114) and severe alterations in body perception (P = .063).

DISCUSSION

The high prevalence of BDD symptoms (57%) in the study population shows the importance of the abdomen in the assessment of body image and its impact on mental health.¹⁶ The prevalence rate was different and greater than those of previous studies on cosmetic surgery.^1,4,35,36 This may be attributed to sociocultural factors, which may affect the onset and progression of this condition. The results also indicated that the social importance of physical appearance, which can be corrected with plastic surgery, can make diagnosis of BDD difficult.

In this study, patients with BDD symptoms reported dissatisfaction with a significantly greater number of parts of the body compared with patients without BDD symptoms, indicating an overall dissatisfaction with body image. This also indicates that an overlap of clinical symptoms of BDD and body dissatisfaction with body areas (size of the stomach, hips, and thighs) may occur, representing a challenge for the differential diagnosis of BDD and eating disorders.¹³ Fontenelle et al³⁷ suggested that systematic investigations should be performed to determine the impact of sociocultural factors on body image concerns in Brazil, such as the estimate of prevalence of BDD symptoms obtained in this study. Veale³⁸ highlighted that, in a culture that values appearance, increased levels of preoccupation with body image based on an ideal body model may stimulate individuals to seek cosmetic procedures. Cansever et al³⁹ observed that the prevalence of BDD may be affected by differences in physical appearance among different cultures, suggesting that complaints of dissatisfaction with different parts of the body in patients with BDD may be specific, but also show diversity, as found in the present study.

A significant association was found between severity of BDD symptoms and level of preoccupation (P = .009; χ² = 9.425), which was excessive for all patients in the BDD group. A negative self-perception of body image may have increased the perception of self-reference in these patients. Mood disturbances and excessive preoccupation with appearance may not always be associated with changed behavior.^13,26 Thus, distress is not always clearly expressed in the behavior of patients with BDD.²⁶ The observation of this phenomenon allowed us to assess the degree of global functioning impairment and to classify patients in the BDD group as having mild to moderate (41%) or severe (59%) BDD symptoms.

Concerns with body weight and shape were associated with severity of BDD symptoms, which is in agreement with the findings of other investigators.⁴⁰ No eating disorder symptoms were found among the participants, as measured by the attitude concerning body image domain (assessing appearance-related behaviors, which may help detect extreme cases of eating disorders) and severe alterations in the body perception domain (assessing negative feelings toward body-image disturbance, such as anorexia nervosa) of the BSQ. Both domains were not associated with severity of BDD symptoms.

Despite dissatisfaction with their body weight and shape, only 18% of patients reported performing regular physical activities. Similarly, Javo and Sørlie⁴¹ found that women seeking abdominoplasty were the most dissatisfied with appearance, but at the same time considered their appearance as less important compared to those seeking different cosmetic procedures. This may predict weight gain after abdominoplasty in these patients.^42,43

Patients with BDD symptoms had a changed relationship with their body, especially expressed as avoidance of physical contact with other people, as also reported by Constantian and Lin.² Changed and negative self-perception of body shape may have led these patients to an extreme dissatisfaction with their physical appearance. Self-perception of the body is an indicator of mental health and changes in this parameter may indicate severe BDD symptoms, as observed in this study.

The comparative perception of body image domain of the BSQ was used to assess levels of inhibition and embarrassment when exposing the body. Results showed the extent to which avoidance behaviors may interfere with the severity of BDD symptoms and a behavior pattern in patients seeking abdominoplasty similar to that identified in a previous study.¹⁶ All patients with BDD symptoms experienced inhibition of sexuality, which is in agreement with other investigators.¹⁴ Patients reported avoiding close contact with other persons due to shame and embarrassment about the perceived defects,² reducing possible affective relationships and social interactions, which increase the severity of symptoms.

In this study, complaints about the shape of the abdomen and breast were associated with body weight and shape, and with pregnancy in some cases; requests for rhinoplasty were associated with ethnicity, and for facial cosmetic procedures were associated with concerns about aging. Complaints about body weight suggested that BDD symptoms may also be associated with weight concerns.⁴⁰ We found that 28% of patients with BDD symptoms and who were dissatisfied with their body weight had a normal weight (BMI range, 18.5-24.99 kg/m²), showing that their concern was not real. Recent studies have included clinically significant concerns with body weight as symptoms of BDD.^12,40 This result may also be related to the fact that most of the candidates for abdominoplasty are women.¹⁰

Previous studies have emphasized the role of adverse childhood experiences in the development of BDD.^2,3,44 In the BDD group, 69% of patients reported some experience of being teased and bullied. Dissatisfaction with physical appearance as a reaction to environmental interference, such as the phenomenon of teasing and bullying, has been observed by other authors.^2,3,38,45,46 It has been suggested that an insecure style of interpersonal attachment might result in body dissatisfaction⁴⁰ and therefore be also a motivation for cosmetic surgery,⁴¹ as observed by the association of teasing and bullying experiences with BDD symptoms. The mean age (38 ± 11 years) of the participants at the time of the interview was not significantly associated with the onset of BDD symptoms, but this does not mean that the desire for aesthetic improvement has not been considered before.

Patients were classified as having or not having BDD symptoms using the BDDE as a screening tool. The Brazilian version of the BDDE in the interview format has been validated in a population sample of candidates for cosmetic surgery.³¹ Although it requires time to be administered⁴⁶ and an experienced examiner,³⁴ the instrument allows accurate evaluation of patients with BDD, who usually complain of great difficulty in being understood and often hide their symptoms, unless directly questioned. The BDDE covers a broader spectrum of symptoms and aspects of body image, and has been used in several studies.^40,46 Some studies have observed that specific screening instruments are able to detect BDD symptoms and criticized the DSM-IV, Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and Mini International Neuropsychiatric Interview-Plus (MINI-Plus) because they fail to diagnose the disorder.^14,47

Our study has limitations, including a small sample size, the fact that most patients were women, and that the Structured Clinical Interview for DSM (SCID) was not included. Further studies with a larger number of patients and involving multiple centers are necessary to evaluate and compare the prevalence of BDD symptoms in patients seeking abdominoplasty to allow the development of care and treatment strategies for this population.

CONCLUSIONS

This was the first study exclusively assessing BDD symptoms in patients seeking abdominoplasty. A high prevalence of BDD symptoms was found among candidates for abdominoplasty, and body weight and shape concerns were significantly associated with severity of BDD symptoms. Systematic studies on the diagnosis of psychopathological symptoms in all specialties of plastic surgery are important and necessary. A careful screening of candidates for cosmetic surgery may contribute to patient satisfaction after surgery and improvement in their quality of life.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.