Abstract
Importance
Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented.
Objective
To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD.
Design, Setting, and Participants
This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016.
Methods
All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE).
Results
Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE.
Conclusions and Relevance
Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care.
Level of Evidence
NA.
This prospective cohort study attempts to establish the prevalence of body dysmorphic disorder across facial plastic and oculoplastic surgery practice settings and to estimate the ability of surgeons to screen for it.
Key Points
Question
What is the prevalence of body dysmorphic disorder (BDD) and ability of facial plastic and oculoplastic surgeons to clinically diagnose this condition?
Findings
In this multicenter prospective study, 597 patients were screened for BDD. Approximately 10% of patients screened by a validated screening instrument were positive for BDD, but surgeons were only able to correctly identify approximately 5% of those patients screening positive.
Meaning
Body dysmorphic disorder is a common condition within facial plastic surgery practices, but surgeons have a low accuracy in identifying these patients when compared with validated screening instruments. Routine use of validated BDD screening tools may improve patient care.
Introduction
Body dysmorphic disorder (BDD) is a psychiatric condition that is classified as an obsessive compulsive–related disorder. Patients with BDD have an obsessive preoccupation with perceived defects of their appearance that are minuscule or nonexistent and commonly involve the nose, eyes, skin, or hair. Patients with BDD often suffer from significant emotional distress and functional impairment. Mood, anxiety, and personality disorders are common psychiatric comorbidities in these patients.
Patients with BDD exhibit compulsive or repetitive behaviors that aim to improve or hide their perceived defects. Indeed, up to 76% of patients with BDD seek consultation for cosmetic procedures, and up to 60% of patients with BDD actually undergo unnecessary surgical procedures for their perceived defects. A vast majority (84%) of cosmetic plastic surgeons report having operated on patients whom they believed had BDD, with 82% of these patients having a negative outcome. Numerous studies have shown that patients tend to have poor satisfaction following surgery and show a higher rate of aggression and litigation toward surgeons. Therefore, it is important to accurately identify patients with BDD in plastic surgery practices, because the proper treatment for these patients is psychiatric care and occasionally surgery with psychiatric care and/or intensive psychological support.
The prevalence of BDD is approximately 2.4% in the general population. The reported prevalence of BDD in patients presenting for facial plastic and oculoplastic surgery varies significantly, likely owing to varying patient populations and inconsistent screening methods. Furthermore, because formal and routine screening for BDD is uncommon in these practices, there is often an underdetection of BDD. More recent studies suggest that the prevalence of BDD is up to 13% in the facial plastic surgery setting and 6.9% in the oculoplastic surgery practice.
The Body Dysmorphic Disorder Questionnaire (BDDQ) was developed in the psychiatric setting for BDD screening. Recently, the BDDQ was validated in the facial plastic surgery patient population and was found to have a sensitivity of 100% and specificity of 90.3%. Despite the existence of this validated screening instrument for BDD, many surgeons continue to rely primarily on their intuition and intangible information gathered from the clinical encounter to determine if a patient has BDD. Whether surgeons’ suspicion of BDD based on clinical intuition correlates well with the validated BDDQ has not been investigated. In the study, we aim to establish the prevalence of BDD across multiple cosmetic and reconstructive facial plastic and oculoplastic surgery practices. Furthermore, we sought to prospectively determine surgeons’ accuracy in screening for BDD compared with the validated BDDQ.
Methods
Participants
This study was approved by the institutional review boards of the Johns Hopkins University School of Medicine and the University of Michigan Medical School. Informed consent or a waiver of informed consent for study participation was obtained for each study site. A total of 3 clinical sites participated in this study. Study site 1 represents an academic facial plastic and reconstructive surgery practice; site 2, a private facial plastic and reconstructive surgery practice; and site 3, an academic oculoplastic surgery practice. Across the 3 participating sites, a total of 597 patients that presented between March of 2015 and February of 2016 participated in this study.
Data Collection
All patients 18 years or older presenting to the participating sites for a new patient consultation were invited to complete the screening questionnaires during the registration process. Patients who agreed to participate were provided a portable electronic tablet which displayed the clinical instruments in an interactive manner. Regardless of the study site, the survey questions were presented in an identical order and had the same on-screen formatting. In addition to questions involving the primary screening instruments, patients were asked a series of background demographic questions including age, ethnicity, sex, marital status, education level, and primary category of consultation (reconstructive vs cosmetic).
Clinical Instruments
Several instruments were used in this study. The BDDQ was the primary instrument used to determine whether a patient exhibited symptoms consistent with BDD. This instrument was originally developed and validated in the psychiatric setting but has since been validated in a number of patient populations including the facial plastic and reconstructive surgery patient population. Within the facial plastic and reconstructive surgery population, it was found to have a very high sensitivity (100%) and high specificity (90.3%). Instruments that were used to assess patient satisfaction with their appearance include the FACE-Q (Overall Facial Appearance Scale), Rhinoplasty Outcomes Evaluation (ROE), Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), and the Skin Rejuvenation Outcomes Evaluation (SROE). All patients completed the FACE-Q instrument. Depending on the patients’ reasons for presentation, they also completed any relevant outcomes evaluation surveys. After completing the screening instruments, patients proceeded to their surgical consultation. At the end of the encounter, surgeons completed a short series of questions to determine whether they believed each patient met diagnostic criteria for BDD and their certainty in the diagnosis (Figure 1). Surgeons were blinded to the results of the BDDQ instrument throughout the study.
Figure 1. Surgeon BDD Screening Form.
BDD indicates body dysmorphic disorder.
Statistical Analysis
Descriptive statistics were used to assess baseline demographic variables. For categorical variables, the Fischer exact test or χ2 test was used to test for differences across study sites. Analysis of variance (ANOVA) methods were used to compare continuous demographic variables (age) across study sites. Simple logistic regression was used to assess for differences in baseline patient-rated satisfaction scores based on BDDQ status. Surgeon diagnostic accuracy was compared with the validated BDDQ screening instrument. Sensitivity, specificity, positive predictive value, negative predictive value, prevalence, receiver operating curve (ROC) area, and positive and negative likelihood ratios were calculated from frequency tables. Our primary performance metric—our surgeon’s ability to classify BDD—were the positive and negative likelihood ratios. We generated the pretest vs posttest probability curves using Mathematica 10.0 (Wolfram). These curves illustrate how much a surgeon’s diagnostic ability changes the likelihood that a patient is diagnosed or not diagnosed as a BDD case. Missing data were assumed to be missing at random and a sensitivity analysis of our results to missing data was performed using multiple imputation; 200 imputations were used for this analysis. All tests were 2-sided and P values less than .05 were considered statistically significant. Besides what was otherwise noted, all remaining statistical analyses were performed using Stata Data Analysis and Statistical Software, version 14.0 (StataCorp LP).
Results
Study Population
A total of 597 patients completed the surveys and were included in the study population. Baseline demographic variables are shown in Table 1. Patients presenting to each study site had similar age. Across study sites, there was a difference in the distribution of gender (χ2 [2, N = 595] = 17.36; P < .001), education (χ2 [10, N = 595] = 21.13; P = .049), self-reported race (χ2 [10, N = 595] = 25.81; P = .004), and marital status (χ2 [4, N = 594] = 34.08; P < .001). Furthermore, the proportion of patients presenting primarily for cosmetic concerns differed across sites (χ2 [2, N = 597] = 58.21; P < .001).
Table 1. Demographics of Participants by Study Site.
| Patient Characteristic | No. (%) | P Value | ||
|---|---|---|---|---|
| Site 1 (n = 342) | Site 2 (n = 158) | Site 3 (n = 97) | ||
| Age, mean (SD), y | 44.2 (16.5) | 46.0 (16.2) | 56.3 (15.5) | .56 |
| Sex | <.001 | |||
| Male | 128 (37.4) | 31 (19.6) | 38 (39.2) | |
| Female | 214 (62.6) | 126 (79.8) | 58 (59.8) | |
| Unknown | 0 (0) | 1 (0.6) | 1 (1.0) | |
| Race | .004 | |||
| White | 223 (65.2) | 125 (79.1) | 81 (83.5) | |
| African American | 54 (15.8) | 11 (7) | 6 (6.2) | |
| Asian | 24 (7) | 8 (5.1) | 6 (6.2) | |
| Hispanic | 15 (4.4) | 8 (5.1) | 2 (2.1) | |
| Other | 17 (5) | 2 (1.3) | 0 (0) | |
| Prefer not to answer | 8 (2.3) | 3 (1.9) | 2 (2.1) | |
| Unknown | 1 (0.3) | 1 (0.6) | 0 (0) | |
| Marital Status | <.001 | |||
| Single | 140 (40.9) | 68 (43) | 12 (12.4) | |
| Married | 164 (48) | 69 (43.7) | 60 (61.9) | |
| Separated/divorced/widow | 38 (11.1) | 19 (12) | 24 (24.7) | |
| Unknown | 0 (0) | 2 (1.3) | 1 (1) | |
| Education | .049 | |||
| Less than high school | 4 (1.2) | 4 (2.5) | 1 (1) | |
| High school/GED | 36 (10.5) | 9 (5.7) | 15 (15.5) | |
| Some college | 66 (19.3) | 26 (16.5) | 17 (17.5) | |
| 2 y college | 26 (7.6) | 10 (6.3) | 14 (14.4) | |
| 4 y college | 108 (31.6) | 54 (34.2) | 27 (27.8) | |
| Masters degree | 68 (19.9) | 44 (27.8) | 17 (17.5) | |
| Doctoral degree | 34 (9.9) | 10 (6.3) | 5 (5.2) | |
| Unknown | 0 (0) | 1 (0.6) | 1 (1) | |
| Visit type | <.001 | |||
| Reconstructive | 207 (59.5) | 43 (27.2) | 69 (69.0) | |
| Cosmetic | 141 (40.5) | 115 (72.8) | 31 (31.0) | |
Abbreviation: SD, standard deviation.
BDDQ Screening
A total of 58 patients (9.7%) across study sites screened positive for BDD based on the BDDQ instrument. The proportion of patients screening positive at each study site is shown in Table 2. There was no significant difference in the proportion of patients screening positive across the 3 study sites (χ2 [2, N = 597] = 1.11; P = .57). Patients presenting primarily for cosmetic purposes (37 of 283 patients [13.1%]) were more likely than those presenting for reconstructive reasons (21 of 314 patients [6.7%]) to screen positive on the BDDQ (odds ratio [OR], 2.10; 95% CI, 1.20-3.68; P = .01).
Table 2. Participants Screening Positive for Body Dysmorphic Disorder as Determined by the Body Dysmorphic Disorder Questionnaire by Study Site.
| Response | No. (%) | P Valuea | ||
|---|---|---|---|---|
| Site 1 (n = 342) | Site 2 (n = 158) | Site 3 (n = 9) | ||
| Body Dysmorphic Disorder Questionnaire | .57 | |||
| Positive | 37 (10.8) | 13 (8.2) | 8 (8.2) | |
| Negative | 305 (89.2) | 145 (91.8) | 89 (91.8) | |
P value for heterogeneity in prevalence across sites.
Surgeon Diagnostic Accuracy
The diagnostic accuracy of surgeons in performing clinical screening for BDD was compared with that of the validated BDDQ screening instrument. A total of 402 patients completed the baseline screening surveys and were also screened by a surgeon. Independent of BDDQ status, a total of 16 patients (4.0%) were suspected by surgeons as having BDD. While 43 out of the 402 patients (10.7%; 95% CI, 7.8%-14.1%) screened positive on the BDDQ instrument, only 2 of these patients (4.7%) were correctly identified by surgeons as having BDD. The sensitivity of surgeon diagnosis of BDD when compared with the BDDQ was 4.7% (95% CI, 0.6%-15.8%) with a specificity of 96.1% (95% CI, 93.5%-97.9%). The positive predictive value was found to be 12.5% (95% CI, 1.6%-38.3%) and negative predictive value was 89.4% (95% CI, 85.9%-92.3%). The positive and negative likelihood ratios for surgeon diagnosis were 1.19 (95% CI, 0.3-5.1) and 1.0 (95% CI, 0.9-1.1), respectively, and both 95% CIs contain one suggesting that little additional information is gained for discriminating BDD status of a patient based on clinical diagnosis of a surgeon. The ROC area was 0.50 (95% CI, 0.47-0.54). Plots of pretest and posttest probability for surgeon diagnosis are shown in Figure 2. Despite poor ability to predict BDD status, surgeons had a mean (SD) certainty of 89.0% (15.3%) (median, 90%) of the accuracy of their ability to screen for BDD. The multiple imputation results are all within the presented 95% CIs presented suggesting these results are robust to missing data.
Figure 2. Pretest and Posttest Probabilities for Physician Diagnosis of Body Dysmorphic Disorder.
Shaded areas within bounds denote 95% CIs.
Factors Associated With BDDQ Status
Logistic regression analysis revealed that age and category of consultation (cosmetic consultation vs reconstructive or functional) were associated with BDDQ status (Table 3). Specifically, patients who were younger (OR, 0.98; 95% CI, 0.96-0.99; P = .04) or who presented for primarily cosmetic concerns (OR, 2.10; 95% CI, 1.20-3.68; P = .01) were more likely to screen positive on the BDDQ. Sex was not significantly associated with BDDQ status (OR, 1.8; 95% CI, 0.95-3.43; P = .07). Patients screening positive for BDD on the BDDQ also had lower baseline (preoperative) satisfaction with their appearance as measured by the FACE-Q (OR, 0.93; 95% CI, 0.91-0.95; P < .001), ROE (OR, 0.95; 95% CI, 0.92-0.98; P = .002), BOE (OR, 0.94; 95% CI, 0.90-0.97; P < .001), FOE (OR, 0.89; 95% CI, 0.85-0.94; P < .001), and SROE (OR, 0.92; 95% CI, 0.87-0.97; P = .003).
Table 3. Summary of Simple Logistic Regression Analysis for Baseline Factors Associated With Screening Positive on the Body Dysmorphic Disorder Questionnaire.
| Independent Variable | β Coefficient (SE) | Z Ratio | Odds Ratio (95% CI) | P Value |
|---|---|---|---|---|
| Sex | ||||
| Female | 0.59 (0.327) | 1.8 | 1.8 (0.95-3.43) | .07 |
| Male | [Reference] | |||
| Age | −0.017 (0.009) | −2.03 | 0.98 (0.96-0.99) | .04 |
| Consultation type | ||||
| Cosmetic | 0.741 (0.287) | 2.59 | 2.10 (1.20-3.68) | .01 |
| Reconstructive | [Reference] | |||
| FACE-Q | −0.073 (0.010) | −0.073 | 0.93 (0.91-0.95) | <.001 |
| ROE | −0.054 (0.017) | −3.04 | 0.95 (0.92-0.98) | .002 |
| BOE | −0.065 (0.018) | −3.55 | 0.94 (0.90-0.97) | <.001 |
| FOE | −0.113 (0.026) | −4.30 | 0.89 (0.85-0.94) | <.001 |
| SROE | −0.082 (0.027) | −2.98 | 0.92 (0.87-0.97) | .003 |
Abbreviations: BOE, blepharoplasty outcomes evaluation; FOE, facelift outcomes evaluation; ROE, rhinoplasty outcomes evaluation; SE, standard error; SROE, skin rejuvenation outcomes evaluation.
Discussion
Patients with BDD frequently seek plastic surgery to address their perceived defects in appearance. Yet, data suggest that these patients most commonly have poor satisfaction and may not benefit from surgery. Therefore, it is of critical importance that surgeons accurately identify patients with BDD who present seeking surgery and manage them appropriately. Many plastic surgeons do not formally screen for BDD. This may be owing to surgeons’ underestimation of the prevalence of BDD in their practice setting or a lack of familiarity with validated screening tools. Indeed, when members of the American Society of Aesthetic Plastic Surgery were surveyed, a majority of respondents believed that the prevalence of BDD was only 2% in their practice. In this prospective multicenter study, we aimed to determine the prevalence of patients screening positive for BDD across multiple facial plastic and oculoplastic surgery settings in a standardized fashion. This is also the first study to determine the accuracy of surgeons at identifying patients with BDD.
The overall prevalence of patients screening positive for BDD by BDDQ in our study population was 9.7%. The prevalence was higher in patients with primarily cosmetic concerns (13.1%) than those presenting for noncosmetic reconstruction (6.7%). The gold standard for diagnosing patients with BDD is the structured clinical interview for diagnosis (SCID), which is time-consuming and challenging to implement in a busy cosmetic surgery practice. However, the BDDQ is a validated screening instrument in the facial plastic surgery setting with a very high sensitivity and specificity. Of patients who screen positive on the BDDQ, approximately two-thirds of cosmetic patients and one half of reconstructive patients are expected to have BDD by SCID. Thus, the BDD prevalence in our study population can be estimated to be 9.9% in the cosmetic population and 3.4% in the reconstructive population. These findings are consistent with those that were recently reported elsewhere. There was no significant difference in the proportion of patients screening positive on BDDQ across the various practice settings (academic vs private practice, facial plastic vs oculoplastic surgery). The BDDQ-positive patients were also shown to have significantly lower baseline satisfaction on all outcome measures tested (FACE-Q, ROE, BOE, FOE, SROE).
Surgeons commonly determine whether or not a patient has BDD based on interaction with the patient and clinical intuition. Interestingly, our results show that surgeons are poor at screening for BDD when compared with the standardized BDDQ, with the former having sensitivity of only 4.7% and a positive likelihood ratio (1.2; 95% CI, 0.3-5.1) that indicates that little additional useful information is gained by surgeon screening—that is, out of 100 patients with BDD, surgeons could identify less than 5 of them. This point is most clearly illustrated by the positive and negative posttest vs pretest probability curves that show that the chance a patient would screen positive or negative does not change appreciably based on the surgeon’s opinion. Nevertheless, surgeons were extremely confident of their ability to identify patients with BDD, with an average 89% certainty of the accuracy of their judgement. Not surprisingly, in the same American Society of Aesthetic Plastic Surgery survey discussed above, 84% of plastic surgeons said they had unknowingly performed surgeries on patients with BDD. Taken together, these findings point to the need for a validated, standardized, objective method to screen for BDD in the plastic surgery practice.
While the performance metrics are specific to the study, this study had a broad geographic pool and sampled both academic and private practices. In addition, the likelihood ratios and the corresponding posttest vs pretest probability curves can be used to estimate surgeon’s performance based on local prevalence, which should be globally poor.
The BDDQ is a self-administered, brief (1-2 minutes), validated screening instrument that patients can easily complete as they wait for the surgeon. It was successfully used in high volume facial plastic and oculoplastic surgery practices in our study, without impeding clinic flow. Patients screening positive on the BDDQ should alert surgeons to the possibility that a patient may have BDD, and prompt surgeons to ask additional questions as part of the clinical interview. Surgeons should pay special attention to BDDQ-positive patients to determine if there is a true indication for surgery since most patients with BDD have been shown to not benefit from cosmetic surgery and have poor satisfaction after surgery.
To our knowledge this is the largest prospective study undertaken to estimate the prevalence of patients screening positive for BDD in the facial plastic and oculoplastic surgery setting. Our inclusion of a variety of practice settings (private and academic; cosmetic and reconstructive), and geographic locations, lends to the generalizability of our findings.
Limitations
One limitation of our study is that not every patient that was screened by the BDDQ was also screened for BDD by their surgeon (402 of 597 patients [67.3%] were screened by their surgeon and with the BDDQ). It is possible that this may have introduced bias to the analysis of surgeons’ accuracy in identification of patients with BDD. Nonetheless, the extremely poor ability of surgeons to clinically identify patients with BDDQ underscores the value of routine screening for BDD with validated screening instruments in facial plastic and oculoplastic surgery practices.
Conclusions
Body dysmorphic disorder is a common condition in patients who present for facial plastic and oculoplastic surgery. The BDDQ is a validated, 100% sensitive, and efficient method to screen for patients with BDD. Patients who screen positive by the BDDQ appear to have lower baseline satisfaction with their facial appearance. Surgeons have a poor ability to screen for BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated screening instruments into the clinical workflow of facial plastic and oculoplastic surgery practices may result in improved patient care.
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