Body dysmorphic disorder in a sample of cosmetic surgery applicants

European Psychiatry 18 (2003) 365–368 www.elsevier.com/locate/eurpsy

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Body dysmorphic disorder in a sample of cosmetic surgery applicants B. Aouizerate a, H. Pujol a, D. Grabot a, M. Faytout a, K. Suire a, C. Braud a, M. Auriacombe a, D. Martin b, J. Baudet b, J. Tignol a,* a

Service Universitaire de Psychiatrie d’Adultes, Centre Hospitalier Charles Perrens, Université Victor Segalen (Bordeaux 2), Centre Carreire, 121, rue de la Béchade, 33076 Bordeaux cedex, France b Service Universitaire de Chirurgie Plastique, Reconstructrice et Esthétique, Centre Hospitalier Pellegrin, Université Victor Segalen (Bordeaux 2), Place Amélie Raba-Léon, 33076 Bordeaux cedex, France Received 30 July 2002; revised and accepted 20 February 2003

Abstract 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. © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Somatoform disorders/*diagnosis; Surgery, plastic; France; Adult; Human; Epidemiologic/comparative studies

1. Introduction Body dysmorphic disorder (B.D.D.), originally described under the term “dysmorphophobia”, did not appear in the American diagnostic nomenclature until DSM-III-R. B.D.D. is characterised by a preoccupation with an imagined—or slight—defect in appearance [1,4,8,15,18,19,21,22,25,32]. Patients with B.D.D. usually exhibit painful concerns centred on the face or head, most often the skin, hair and nose, or on any other body parts. They perform time-consuming and repetitive behaviours such as mirror checking or avoidance, camouflaging, multiple physician visits, and often seek dermatological treatment or cosmetic surgery [1,4,8,15,18,19,21,22,25,32]. B.D.D. is associated with severe distress and impairment in functioning, a high degree of comorbidity, and is chronic [1,4,8,15,18,19,21,22,25,32]. Serotonin reuptake inhibitors [7,10,16,20,23,26] and cognitive-behavioural therapies [13,27,32,34] have been recently shown as effective treatments of B.D.D. Nevertheless, B.D.D. remains under recognised and mistreated in clinical settings. Among physicians, plastic surgeons appear to be often consulted by patients with B.D.D. Many of these patients repeatedly undergo unsuccessful cosmetic surgery pro* Corresponding author. E-mail address: [email protected] (J. Tignol). © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2003.02.001

cedures [11,18,21,24,25]. The current challenge is to clearly identify B.D.D. in non-psychiatric settings where patients seek inappropriate care, in order for them to get proper and efficient psychiatric treatment. To our knowledge, the present study is the first systematic European report on B.D.D. in a cosmetic surgery setting. Rate, demographic correlates, and body areas of appearance concerns were explored. Among cosmetic surgery applicants with no or slight defect, patients with B.D.D. were compared for appearance concerns, current psychiatric comorbidity, and functional disability to their defect-matched counterparts without B.D.D. 2. Subjects and methods The study population consisted of 132 subjects (eight males, 124 females) scheduled for a cosmetic surgery consultation over a 6-month period with one plastic surgeon at a University Hospital in Bordeaux (France). Written informed consent was obtained prior to participation. Ages ranged from 18 to 74 years (mean (S.D.): 40.6 (12.9)). The plastic surgeon examined the physical defect location and completed a 4-point defect severity scale in which score 1 represented ‘no defect’, 2 ‘minimal/slight defect’, 3 ‘defect clearly present at conversational distance’ and 4 ‘moderately severe/severe defect’. The surgeon rated the defect indepen-

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Table 1 Statistical comparison of clinical and functional correlates in patients with no or slight physical defect, with and without B.D.D Comparison of patients with no or slight physical defect with vs. without B.D.D. Variables With B.D.D. (n = 12) Number of preoccupations (mean (S.D.)) 2.4 (1.4) Subjects with current DSM-IV psychiatric 9 (75.0) disorders (N (%)) Functional disability scores (SDS) Work (mean (S.D.)) 3.7 (3.7) Social life (mean (S.D.)) 6.8 (2.9) Family life (mean (S.D.)) 3.9 (3.7)

dently, and blindly toward the psychopathological assessment. All subjects were administered with the B.D.D. Diagnostic Module [17,18]. This instrument based on the Structured Clinical Interview for DSM-IV is used for B.D.D. diagnosis according to DSM-IV criteria [17,18]. Subjects with a score of 1 or 2 on the defect severity scale, which is required to meet B.D.D. diagnosis, were assessed for associated psychopathology with the Mini-International Neuropsychiatric Interview (MINI) (version 4.4) [31]. This short structured diagnostic interview, of demonstrated validity and reliability, is compatible with DSM-IV criteria [31]. These subjects also completed the Sheehan Disability Scale (SDS) to evaluate their functional impairment in three separated domains (work, social and family life) [30]. All these assessments were made by a trained research assistant, independently of the cosmetic surgery screening procedure. 2.1. Statistical analyses Non-parametric comparisons were performed on subjects having no or minimal physical defect, with and without B.D.D., by using Wilcoxon signed-rank for continuous data and Fisher’s exact test, two-tailed, for categorical data. 3. Results Of the 132 cosmetic surgery applicants, 30 (22.7%) had no (n = 2) or minimal (n = 28) physical defect, 12 of these (9.1%) met DSM-IV criteria for B.D.D. (95% confidence interval (CI), 4.2–14.0%) and 18 (13.6%) did not (95% CI, 7.8–19.5%). Among subjects with no or minimal defect, the rate of B.D.D. was 40% (95% CI, 22.0–58.0%). The mean age of the 12 subjects with B.D.D. was 35.0 years (S.D. = 10.8). Two (16.6%) were male (25.0% of all male subjects) and 10 (83.4%) were female (8.1% of all female subjects). The main sites of concern in the 12 subjects with B.D.D. were the skin for five (41.7%), the nose for four (33.4%), the breasts for three (25.0%), the legs/knees for three (25.0%). Other locations of appearance concerns, such as head/face (shape) or hair, were found in only one (8.3%) case while no case (0%) was preoccupied with the eyes. High current rates of psychiatric comorbidity appeared to be associated with B.D.D. Four (33.4%) of the 12 subjects with B.D.D. had major depressive disorder, four (33.4%) agora-

Without B.D.D. (n = 18) 1.0 (0.9) 5 (27.7)

P

0.1 (0.5) 1.2 (1.9) 0.8 (1.8)

0.001 0.0001 0.01

0.009 0.02

phobia without history of panic disorder, three (25.0%) social phobia and three (25.0%) generalised anxiety disorder. Obsessive–compulsive disorder (O.C.D.) was only reported in one (8.3%) case. Comparison analyses of both groups of subjects defined as having no or slight physical defect, with and without B.D.D., revealed significant differences. The B.D.D. group showed: (1) a larger number of appearance preoccupations; (2) a higher percentage of subjects with at least one current psychiatric disorder other than B.D.D.; and (3) a more severe functional distress on the SDS (Table 1). 4. Discussion The results of the present study emphasise the high rate of B.D.D. (9.1%) in subjects seeking cosmetic surgery, especially in men (25.0%). This percentage even reached 40.0% in subjects with no or a slight physical defect. Rates from 6% to 15% have been found in Japanese or American plastic surgery populations [12,28,29] or in an aesthetic medicine setting [2]. Our findings are concordant with the prevalence rates ranging from 5.3% in a non-clinical sample [5] to 13.1% in a psychiatric inpatient setting [6]. However, a lower rate of 0.7% has been reported in a recent study conducted on a large female community sample [14]. More women were seen in our B.D.D. sample, as reported by other investigators [2,5,6,27,35], although a male-to-female ratio of 1:1 or a higher rate of B.D.D. in men was also seen [3,9,12,15,18]. Differences in study setting probably account for these discrepancies. Our data support earlier observations performed in cosmetic surgery settings [2,12,28,29], or in other populations [5,9,15,18], with respect to concern locations mostly focused on skin, nose, breasts or legs/knees, but not on hair, head/face (shape) or eyes. Consistent with previous reports of series of patients with B.D.D. [9,15,18,36], major depression was the most frequent current comorbid condition in our study, followed by social phobia. Rate of generalised anxiety disorder was also in relative agreement with a recent work [36]. In contrast, important differences were observed regarding the comorbidity with O.C.D. or agoraphobia, respectively, of 20–50% and 1–6% in the literature [2,9,15,18,36]. This may be related to discrepancies in the male-to-female ratio. For example, rate of O.C.D. in our study is very close to that


observed in a previous work that showed a large preponderance of women among patients with B.D.D. [35]. Comorbidity with O.C.D. tends to increase with the percentage of men in the B.D.D. sample [9]. Our results confirmed that B.D.D. is associated with multiple appearance preoccupations and frequent psychiatric comorbidity reflected in functional impairment [1,4,8,15,18,19,21,22,25,32]. This is what differentiates patients with B.D.D. from their defect severity-matched counterparts without B.D.D. Our large number of cosmetic surgery applicants with no or slight defect, and without B.D.D., probably refers to what has been termed a “normative discontent” to qualify the non-pathological dissatisfaction with appearance felt by many women [33]. It also underlines the social status given to physical appearance, and to its correction through cosmetic surgery. Overall, it complicates the recognition of B.D.D., which needs identification of patient characteristics, other than no or slight defect, by plastic surgeons. Our study suggests that surgeons could rely on number of appearance concerns, psychiatric comorbidity, and level of disability, to identify subjects with probable B.D.D. among their consultants with no or slight defect. As usual in French University Hospitals, the Plastic Surgery Department, where the study was carried out, recruits not only tertiary care patients, but also secondary care patients for medical student training purposes. Despite the relatively small size of the sample, our study population potentially represents the average population applying for cosmetic surgery in France. Nevertheless, our results need confirmation by further studies in other cosmetic surgery settings in France. Thus, B.D.D. seems relatively common in French cosmetic surgery settings, as seen in Japan or the United States. Its clinical and functional correlates require thorough attention on the part of plastic surgeons to improve recognition and shift patients with B.D.D. to specific and effective psychiatric treatment.

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Acknowledgements This work was supported in part by a grant from GlaxoSmithKline.

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