Body dysmorphic disorder (dermatologic non-disease): Synonyms: Dermatologic non-disease, Body dysmorphic disease, Dysmorphophobia

Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Body dysmorphic disorder (BDD) is an alteration in perception of body image that causes preoccupation with minimal or imagined defect in appearance. The preoccupation can be markedly excessive, causing clinically significant emotional distress and impairment in social, occupational, or other important areas of functioning. Preoccupations commonly involve the face and head, with skin and hair being the most frequent areas of concern. However, any area of the body may be involved. Dermatologic preoccupations are distressing, time consuming, and difficult or impossible for patients to resist. Insight is typically poor and alterations in perception are often to delusional proportion. Most patients have ideas of reference, thinking that others take special notice or mock them for their perceived defect. Repetitive behaviors are present in almost all patients, such as excessive checking or grooming, innumerable consultations with dermatologists and plastic surgeons, constant need for reference and reassurance, and skin manipulations. Risk of suicidal ideation and attempts is high, affecting approximately one-quarter of BDD patients. BDD was reclassified in the DSM-5 under obsessive-compulsive and related disorders.

Management Strategy

BDD is common in dermatologic settings with prevalence estimated at 11.9%, 3–53% in cosmetic surgery settings, and 8–37% in those with obsessive-compulsive disorder. Recognition of these patients is extremely important because they typically have psychiatric comorbidities, diminished quality of life, and impairments in psychosocial and vocational function. They are usually poor candidates for cosmetic procedures. Dissatisfaction, anger, and even aggression directed toward the treating clinician have been reported. Patients with BDD often have associated psychiatric disorders including major depression, substance abuse and dependence, social phobia, and obsessive-compulsive disorder. Recent studies with MR imaging have suggested abnormal brain network organization, which may provide some biological basis for the characteristic distortions in self-perception. The majority of these patients also have a personality disorder. Appropriate psychiatric treatment can result in a generally favorable outcome.

Typical body areas of preoccupation include:

Face. Preoccupation with facial itching and burning or obsessive preoccupation with imagined acne, scars, wrinkles, pigmentation, oiliness, redness, paleness, facial vessels, and facial hair are common. Preoccupation with the nose, ears, and pore size is reported. Despite the fact that others do not usually see these minimal or non-existent flaws, patients can spend hours in front of mirrors, preventing them from working or socializing.
Scalp. Dysesthesias (burning or itch) and obsession with imagined hair loss are common.
Genital. Genital size, scrotal, perineal, and perianal burning, as well as vulvar redness and burning are common symptoms. Preoccupation with sexually transmitted disease or neoplastic process is common. Symptoms can be incapacitating.

Hallmarks and Flags for Diagnosis of Body Dysmorphic Disorder

Patients presenting with extreme concern that appears out of proportion to their chief complaint accompanied by a paucity of objective physical findings should raise suspicion that BDD may be present. Obsession, rumination, and extreme psychological distress are striking features. These patients usually report dissatisfaction with previous physicians and describe poor outcomes from past medical and surgical interventions. Skin picking and related behaviors such as excessive tanning, excessive grooming, and relentless need for reassurance are characteristic. Attempts to correct their perceptions are inevitably futile since their perceptual distortions and associated cognitions are deeply entrenched. It can be argued that the distorted perceptions are delusional, which by definition suggests that they are unresponsive to objective logic and persuasion. Patients often wear heavy makeup, hats, sunglasses, scarves, and other clothing to hide their imperfections and perceived ugliness ( Table 30.1 ).

Table 30.1

Screening questions

(Adapted from Veale D, Ellison N, Werner TG, et al. Development of a cosmetic procedure screening questionnaire (COPSs) for body dysmorphic disorder. J Plast Reconstr Aesthet Surg 2012; 65(4): 530–532.)

1.
How much do you currently think about your skin?
2.
On an average day, how many hours do you spend thinking about your skin? Please add up all the time that your feature is on your mind and make your best estimate.
3.
Do you feel your skin is ugly or very unattractive?
4.
How noticeable do you think your skin is?
5.
Does your skin currently cause you a lot of distress?
6.
How many times a day do you usually check your skin either in a mirror or by feeling it with your fingers?
7.
How often do you feel anxious about your skin in social situations? Does it lead to you avoiding social situations?
8.
Has your skin affected dating or an existing relationship?
9.
Has your skin interfered with your ability to work or study, or your role as a homemaker?

Patients with BDD often make unusual and excessive requests for cosmetic procedures with the belief that the procedure will transform or fix their lives. Poor psychosocial functioning with difficulties in relationships, school, and work is almost always seen. Depression is frequently evident and previous suicide attempts are not infrequent. Bear in mind that there have been instances of violent behavior toward treatment providers.

Clinical interactions and consultations with these patients are typically long, difficult, and emotionally draining. Regardless of the actual length of time spent with them, BDD patients often feel that they were not given adequate time and attention. As already stated, it is inadvisable to perform procedures on these patients since less than 10% will be satisfied with the results of medical or surgical interventions.

Selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral psychotherapy remain the treatments of choice. Fluoxetine, fluvoxamine, and citalopram are the best studied agents, but recent evidence suggests that all SSRIs are probably effective. Higher dosing regimens than those used for depression are usually required. For example, fluoxetine and citalopram should be titrated to 60 mg per day while fluvoxamine should be increased to 300 mg per day at monthly intervals. Patients should receive a trial of 12–16 weeks before efficacy is assessed. If one agent fails, another should be substituted since some patients idiosyncratically respond more favorably to one agent over another. SSRIs appear to be more effective than antipsychotic agents despite the fact that BDD can involve severe distortions in self-perception to delusional proportion. Interestingly, only about 20% of patients will become free of their delusional thinking. However, the intrusiveness of the thoughts and distress will diminish sufficiently such that many patients will be able to resume some social and vocational functioning.

Cognitive-behavioral therapy (CBT) is a reality-based, in-the-present therapy that specifically focuses on the affected individual’s cognitions and associated emotional experiences. The key elements are known as exposure, response prevention, perceptual retraining, and cognitive restructuring. Exposure consists of having patients expose the perceived defect in social and work situations. Response prevention techniques help patients avoid performance of their repetitive behaviors such as avoidance of others, excessive camouflage, picking, hyperventilating, etc. Perceptual retraining involves the development of a more holistic positive view of appearance. Cognitive restructuring helps patients challenge and eventually change their erroneous beliefs about their appearance. Ideally, treatment of BDD should encompass both CBT and an SSRI.

To initiate treatment or referral, suggest to the patient in a gentle manner that they may have a body image disorder called BDD. Convey your concern regarding the amount of their time being usurped by their preoccupation and their emotional distress. Psychiatric referral is preferable but often not feasible. Dermatologists are encouraged to align themselves, if possible, with mental health professionals who are experienced in treating this entity. Euphemisms for the psychiatric practitioner such as skin-emotion specialist may reduce the stigma of psychiatric referral and may increase patient acceptance. If referral is not possible, treating with an SSRI may be successful. If suicidal ideation or intent are present, immediate hospitalization is recommended.

Specific Investigations

Assess for potential suicide risk: emergent referral and appropriate notification if active ideation or intent
Assess for any evidence of physical or emotional abuse
Assess for evidence of substance abuse
Assess for concomitant underlying psychiatric disease, i.e., depression/anxiety/OCD/psychosis, and make an appropriate psychiatric referral
Appropriately diagnose and acknowledge genuine skin disease, i.e., hair loss, acne, rosacea, psoriasis, eczema, keratosis pilaris, seborrheic keratoses, or dyschromia, and offer legitimate therapies
Investigate perceived skin changes appropriately to rule out atypical presentations of an underlying organic process if suspicion is present. Perform bacterial, viral, fungal cultures, skin biopsy, serologies, and imaging studies when deemed appropriate

Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder

Phillips KA, Siniscalchi JM, McElroy SL. Psychiatr Q 2004; 75: 309–20.

Seventy-five patients with BDD completed a symptom questionnaire assessing depression, anxiety, somatic/somatization, and anger-hostility. Compared to normal controls, BDD subjects had markedly elevated scores on all four scales, indicating severe distress and psychopathology. When treated with fluvoxamine, all symptoms significantly improved.

Quality of life for patients with body dysmorphic disorder

Phillips KA. J Nerv Ment Dis 2000; 188: 170–5.

This is the only published study looking at quality of life (QOL) in BDD patients. These patients were found to have a poorer mental health QOL than has been reported for patients with other severe illnesses such type II diabetes, recent myocardial infarction, or depression. These findings highlight the dramatic impact of a non-disease.

Thirty-three cases of body dysmorphic disorder in children and adolescents

Albertini RS, Phillips KA. J Am Acad Child Adolesc Psychiatry 1999; 38: 453–9.

Thirty-three cases were examined. Onset was usually during adolescence but sometimes occurred in childhood. Earlier identification and treatment may avert unnecessary cosmetic and medical interventions as well as suicide.

Gender differences in body dysmorphic disorder

Phillips KA, Diaz S. J Nerv Ment Dis 1997; 185: 570–7.

This study looked at a large series of patients with DSM-4 defined BDD and found that one-quarter of patients had attempted suicide. Female patients with severe symptoms are at greater risk.

Body dysmorphic disorder

Ahmed I, Bowman D, Power A. Medscape October 3, 2019.

Excellent overview of entity and treatment strategies.

Suicide in dermatological patients

Cotterill JA, Cunliffe WJ. Br J Dermatol 1997; 137: 246–50.

Sixteen patients who had committed suicide are described. Most of these patients had acne or BDD. Females with facial complaints and men with facial scarring appeared more at risk for suicide. The authors relate these findings to the possible preventative benefits of early isotretinoin to prevent scarring in patients predisposed to BDD.

Diagnostic Aids

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here