The frequency of body dysmorphic disorder in ... - Wiley Online Library

Clinical dermatology • Original article

CED

Clinical and Experimental Dermatology

The frequency of body dysmorphic disorder in dermatology and cosmetic dermatology clinics: a study from Turkey S. Dogruk Kacar,1 P. Ozuguz,1 E. Bagcioglu,2 K. S. Coskun,2 H. Uzel Tas,3 S. Polat1 and S. Karaca4 Departments of Dermatology, 2Psychiatry and 3Public Health, Afyon Kocatepe University School of Medicine, Afyonkarahisar, Turkey; and 4Department of Dermatology, Izmir Katip Celebi University School of Medicine, Izmir, Turkey 1

doi:10.1111/ced.12304

Summary

Background. Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with a slight or imagined defect in appearance. There are few reports on the prevalence of BDD in the Turkish population. Aim. To investigate the frequency of BDD in dermatology settings, and to compare the results from cosmetic dermatology with those from general dermatology settings. Methods. This cross-sectional study recruited 400 patients from cosmetic dermatology (CD) (n = 200) and general dermatology (GD) clinics (n = 200). A mini-survey was used to collect demographic and clinical characteristics, and the dermatology version of a brief self-report BDD screening questionnaire was administered. A fivepoint Likert scale was used for objective scoring of the stated concern, which was performed by dermatologists, and patients who scored ≥ 3 were excluded from the study. Results. In total, 318 patients (151 in the CD group and 167 in the GD group) completed the study, and of these, 20 were diagnosed with BDD. The CD group had a higher rate of BDD (8.6%) than the GD group (4.2%) but this was not significant (P = 0.082). The major concern focused on body and weight (40.0%), followed by acne (25.0%). Conclusions. The number of cosmetic procedures in dermatology practices is increasing Therefore, it is becoming more important to recognize patients with BDD. Although the rates of BDD found in the present study are in agreement with the literature data, population-based differences still exist between this study and previous studies.

Introduction Body dysmorphic disorder (BDD) is a psychiatric condition, with the main symptom being an impairing preoccupation with a nonexistent or slight defect in appearance. The main difference from simple concern is the marked negative effect of BDD on the patient’s social and professional life.1 Patients with BDD are Correspondence: Dr Seval Dogruk Kacar, Afyon Kocatepe University School of Medicine, Department of Dermatology, 03200, Afyonkarahisar, Turkey E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 9 November 2013

ª 2014 British Association of Dermatologists

more likely to present to a dermatologist and/or plastic surgeon than to a psychiatrist.2 Studies report an incidence of about 2% incidence in the general population,3,4 but the rate increases with specific medical populations such as those attending dermatology and cosmetic dermatology/surgery clinics.5–9 Although BDD is increasingly being recognized and discussed in dermatology and cosmetic dermatology outpatient clinics, there are questions regarding its incidence in different communities. It is well known that cultural background may influence the understanding of patients with BDD.10 We hypothesized that the incidence of BDD in patients who are seen in dermatology and cosmetic dermatology outpatient clinics may have not received sufficient attention in Turkey.

Clinical and Experimental Dermatology (2014) 39, pp433–438

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Body dysmorphic disorder in cosmetic and general dermatology " S. Dogruk Kacar et al.

Therefore, in the present study, we aimed to evaluate the incidence of BDD patients in dermatology and cosmetic dermatology outpatient clinics.

Methods

a severity scale ranging from 1 to 5 (1 = nonexistent defect, 2 = slight defect, 3 = defect recognizable from conversational distance, 4 = moderately severe defect and 5 = severe defect). Patients who scored ≥ 3 or were excluded from the study. Each patient’s final diagnosis and the treatments they received were also noted.

Ethics approval

The study was approved by the local ethics committee, and all the patients signed an informed consent form before recruitment. Patient selection

This cross-sectional study was conducted in Afyon Kocatepe University Hospital, and enrolled 400 consecutive patients who were seen in the general dermatology (GD group; n = 200) and cosmetic dermatology (CD group; n = 200) outpatient clinics between February and May 2013. The exclusion criteria for the study included being < 18 or > 65 years, and inability to complete a self-report questionnaire. The CD clinic of the hospital deals mainly with acne scars, hyperpigmentation, hair loss, wrinkles, body shaping and cellulite, excess body hair and vascular lesions, giving medical and supportive care, and performing minimally invasive procedures. The GD clinic deals with adults with a full range of skin complaints. The study-specific mini-survey

Patients were asked to fill in a mini-survey giving demographic information, reason for seeking treatment, any previous cosmetic procedures/surgery, and level of satisfaction with the procedures. The body dysmorphic disorder questionnaire

Next, the presence of BDD was evaluated by a selfreport BDD questionnaire, developed and validated by Dufresne et al.11 based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. This questionnaire has been shown to have 100% sensitivity and 92.3% specificity in CD practice, with a positive predictive value of 70% and a negative predictive value of 100%. Objective assessment of the existing defect

After completion of the questionnaire, the existence of any flaws reported in the questionnaire was evaluated by two independent investigators (SDK and MD), using

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Statistical analysis

Means, standard deviations, modes, medians and frequencies were calculated. Differences between the groups were investigated by v² analysis for categorical variables, and Fisher exact test wherever required. P = 0.05 was considered significant. PASW Statistics for Window (version 18; SPSS Inc., Chicago, IL, USA) was used for analyses.

Results There were 65 (16.25%) patients who refused to participate in the study (n = 38 in the CD group and n = 27 in the GD group), and 17 other patients (11 CD group and 6 GD) were excluded from the study as they scored ≥ 3 on the objective assessment. The remaining 318 patients (151 CD and 167 GD) constituted the final sample. The demographic and clinical characteristics of the groups are summarized in Table 1. Of the 318 patients, 55 (17.3%) stated presence of preoccupation with their appearance, and 20 (6.3%) were diagnosed with BDD. Similar rates of dissatisfaction with appearance were found in both groups (P = 0.97). The rate of BDD was 8.6% (n = 13) and 4.2% (n = 7) in the CD and GD groups, respectively, with no significant difference between the two groups (P = 0.11). The groups were then divided into BDD and nonBDD groups; their demographic and clinical characteristics are summarized in Table 2. Patients diagnosed with BDD were significantly younger (26.60 ! 7.84 vs. 33.39 ! 11.59, P = 0.01) than those without BDD. Although a female predominance was apparent in both of the groups, there was no gender difference between the groups (P = 0.43). A history of psychiatric admissions/diagnoses was reported by 10 patients; 2 in the BDD group and 8 in the non-BDD group (10.0% vs. 2.7%, P = 0.12). None of the patients stated a history of suicide attempt. A history of cosmetic procedures/surgery was given by 4 patients (20%) in the BDD group, whereas a significantly (P = 0.03) lower proportion (5.4%; n = 16) of the non-BDD group had undergone such procedures. All 4 BDD patients expressed dissatisfaction with the outcomes of the



Table 1 Demographic and clinical characteristics of the patients.

Group Variable

CD, n = 151

GD, n = 167

P*

Age (years), mean ! SD Female gender, n (%) Married, n (%) Good economic status, n (%) University graduate, n (%) Islamic religion, n (%) City centre residence, n (%) Lifetime psychiatric admissions/diagnoses, n (%) History of cosmetic procedures, n (%) Presence of concern, n (%) Diagnosis of BDD, n (%)

33.82 ! 10.52 123 (81.4) 93 (61.5) 148 (98.1) 102 (67.5) 150 (99.3) 146 (96.6) 1 (0.7) 19 (12.5) 26 (17.2) 13 (8.6)

32.19 ! 12.29 127 (76.0) 74 (44.3) 152 (91.0) 78 (46.7) 166 (95.8) 127 (76.0) 9 (5.3) 1 (0.6) 29 (17.3) 7 (4.2)

0.03† 0.24 0.01 0.01 < 0.001 0.72‡ < 0.001 0.01‡ < 0.001 0.97 0.10

BDD, body dysmorphic disorder; CD, cosmetic dermatology; GD, general dermatology. *Pvalues are v² test unless otherwise specified. †Mann–Whitney U-test. ‡Fisher exact test. Table 2 Demographic and clinical characteristics of the patients divided by presence or absence of body dysmorphic disorder (BDD).

Group Variable

BDD, n = 20

Non-BDD n = 298

Age (years), mean ! SD Female gender, n (%) Married, n (%) Good economic status, n (%) University graduate, n (%) Islamic religion, n (%) City centre residence, n (%) Lifetime psychiatric admissions/diagnoses, n (%) History of cosmetic procedures, n (%)

26.60 ! 7.83 15 (75.0) 7 (35.0) 19 (95.0) 11 (55.0) 19 (95.0) 20 (100.0) 2 (10.0) 4 (20.0)

33.39 ! 11.58 235 (78.9) 163 (54.7) 281 (94.3) 169 (58.5) 297 (99.7) 253 (84.9) 8 (2.7) 16 (5.4)

P* 0.01† 0.43‡ 0.13 0.99 0.45 0.12‡ 0.18 0.01‡ 0.03‡

*P-values are v² test unless otherwise specified. †Mann–Whitney U-test. ‡Fisher exact test.

previous procedures, whereas only 2 of the 16 nonBDD patients expressed dissatisfaction. In question 3, the patients were asked which parts of the body caused them concern (Table 3). Nine patients (45%) reported more than one area of concern. Question 4 asked about the effects of the preoccupation on the patient’s life. Three patients reported that there wee no effects. The others stated effects such as low self-esteem, absence of work, and avoiding friends, leaving the house, wearing particular clothing, or marriage.

Discussion To our knowledge, this is the first study to investigate the frequency of BDD in a Turkish population in dermatology and cosmetic dermatology settings. Similar to western populations, there has been increasing interest in cosmetic procedures in the Turkish population over the past decade, and thus it has become more important to recognize patients with BDD. The frequency of BDD in the Turkish population has been investigated in


Table 3 Major areas of concern in the body in 20 patients diagnosed with BDD. Area of concern*

n (%)

Body asymmetry† or weight Acne Cellulite Facial asymmetry (nose) Facial pigmentation Facial hair Hair thinning/loss Skewed teeth Aging/wrinkles Broad shoulders Hand eczema Varicose veins

8 5 4 4 2 2 2 2 1 1 1 1

(40.0) (25.0) (20.0) (20.0) (10.0) (10.0) (10.0) (10.0) (5.0) (5.0) (5.0) (5.0)

*Patients may have had concerns about more than one area. †Hip, stomach and/or thigh.

only a few studies.12–14 The study by Cansever et al.,12 which enrolled healthy female college students, reported a 4.8% frequency of BDD. Another study by Kaymak et al.,13 which recruited university students with/without skin disease, found that patients with


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skin disease scored higher on the body dysmorphic symptoms scale than those without. In populationbased studies worldwide, the prevalence of BDD has been reported to be 0.7–2.2%3,4 whereas it is 2.5–9%5– 9 in dermatology settings, and 2.9–53.6%5–9,15 among those seeking cosmetic treatment. We expected similar results, with a significantly higher rate of BDD in the CD group; however, although our results were in agreement with the reported data, the higher rate of BDD in the CD group was not statistically significant. Several factors may account for this difference. Firstly, in our study, the patients who refused to participate constituted about 16% of our total sample, which might have influenced the findings, but it was not possible to assess this probability. Secondly, many studies have reported that body image might be profoundly affected by sociocultural differences, which was why we chose to perform this study.16 The present study was conducted in Afyonkarahisar, a small city to the west of Turkey, and thus the sociocultural differences between Turkish and western populations may account for this difference in results. Thirdly, there is the likely difference in the measures used for diagnosis. There are many screening instruments for BDD, which were developed mainly for CD settings.17 One such validated tools was used in this study.11 However, collaboration between psychiatrists, psychologists and dermatologists may be required for an accurate diagnosis of BDD, as was the case in the study by Conrado et al.,5 but it is not easy to convince patients diagnosed with BDD to consult a psychiatrist. The symptoms of BDD usually begin in early childhood,18 but establishment of an accurate diagnosis may take 10–15 years. Although it is believed that BDD more commonly affects women, there are reports indicating equal frequency in both genders.2 BDD is more common among single and divorced people, as opposed to married people, as found in many studies.4 Our results seem to be in agreement with the literature data with regard to age, gender and marital status. Preoccupation was with more than one part of the body was present in 45% of the patients with BDD in this study, which is similar to previous studies.7,19 However, in the previous studies, patients’ concerns frequently focused on the head/face,19 whereas in the present study, the most frequent area of concern was body weight and disproportion. This result is similar to the findings of other studies conducted in Turkey.12,14 The characteristic physical appearance of many Turkish women, who tend to carry excess weight on the hips and thighs, along with media-induced factors that establish role models of beauty and attractiveness,

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may predispose these women to BDD. In a study by Kittler, 29% of the patients with BDD had weight concerns, and most of these were young women.20 Another study from Brazil in a cosmetic setting found that 61.9% of the patients with BDD had concerns about dyschromia, followed by acne.5 In a study of patients with acne, the rate of BDD was found to be 14.1% in patients with minimal acne and 21.1% in those with mild acne,21 while patients requiring systemic isotretinoin therapy were twice as likely to have BDD than those who never had this therapy. In our study, even when patients requiring isotretinoin were excluded, acne was still a common concern. The effect of BDD concerns on life may vary. For instance, people may spend a great deal of time constantly reviewing their defects.1 Others may avoid marriage, as was the case for two patients in the present study, and some may avoid working, as one of our patients did. BDD is often accompanied by other psychiatric conditions.1 Two of our patients with BDD had previously been referred to a psychiatrist; however, the diagnoses were unknown to us. Both patients rejected our suggestions for referral to another psychiatrist. Seeking a nonpsychiatric treatment such as dermatological/ cosmetic treatment is quite common among patients with BDD.22 It may be the fear of stigma that makes people prefer to receive treatment for a physical disorder rather than a mental one.23 Phillips reported a lifetime suicidal ideation in 80% of the patients with BDD and a suicide attempt in 24–28%.24 None of the patients in the present study reported an attempted suicide, although it is possible that some did have suicidal ideation, but were unwilling to report this. The major limitation of this study was the use of a self-report questionnaire to establish the diagnosis of BDD. The questionnaire, although validated in a dermatology setting, has not been validated in the Turkish translation. Therefore, establishing the validity and reliability of the Turkish version is likely to maximize the accurate self-reporting of BDD. A nonresponse bias was also possible, as the patients who refused to participate in the study might have caused underestimation or overestimation of the prevalence of BDD. However, despite these limitations, the present study included a relatively a large sample size, thus the results of this study can be generalized on a national scale until replication studies are performed. The frequency of BDD and BDD-related concerns may vary around the world because of populationspecifiic characteristics. Although the rate of BDD was in agreement with the results of the previous studies,



the most common concern focused on the body, unlike in previous studies. Further crosscultural studies are required to investigate the relevance of such factors as gender, age, culture, beliefs and media influence in patients with BDD.

Conclusion Dermatologists are the physicians most likely to encounter BDD. As minimally invasive cosmetic procedures have become more popular, hospital visits by patients with BDD for such procedures are expected to increase, but the question of whether patients with BDD really benefit from these procedures is unanswered. Indeed, as the presence of BDD is a contraindication for cosmetic procedures, there is curently no prospective study assessing the satisfaction of patients with BDD with the outcomes of these procedures. Physicians practising CD should be qualified both in training and experience, and should know the possible complications of the procedures and how to manage them. It is also crucially important that the physician should be aware of the symptoms of BDD symptoms and how best to treat this disorder.

What’s already known about this topic? " BDD is a psychiatric condition, and patients

often seek non-psychiatric treatments such as dermatological and cosmetic treatments. " Minimally invasive cosmetic procedures, often performed by dermatologists, have become increasingly popular. " High rates of BDD in GD and higher rates in CD settings are expected.

What does this study add? " We carried out a study in a Turkish population,

as there are few studies regarding BDD in Turkey.

" The frequency of BDD was within the reported

rates in our study sample, with concerns mainly focused on weight and body shape. " The symptoms with which patients present may not be those of their BDD concern. " Awareness of BDD is important in cosmetic dermatology practice.


References 1 Mackley CL. Body dysmorphic disorder. Dermatol Surg 2005; 31: 553–8. 2 Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 1997; 185: 570–7. 3 Rief W, Buhlmann U, Wilhelm S et al. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 2006; 36: 877–85. 4 Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr 2008; 13: 316–22. 5 Conrado LA, Hounie AG, Diniz JB et al. Body dysmorphic disorder among dermatologic patients: prevalence and clinical features. J Am Acad Dermatol 2010; 63: 235–43. 6 Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance—enhancing medical treatments. Body Image 2008; 5: 50–8. 7 Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol 2000; 42: 436–41. 8 Castle DJ, Phillips KA, Dufresne RG. Body dysmorphic disorder and cosmetic dermatology: more than skin deep. J Cosmet Dermatol 2004; 3: 99–103. 9 Hsu C, Ali Juma H, Goh CL. Prevalence of body dysmorphic features in patients undergoing cosmetic procedures at the National Skin Centre, Singapore. Dermatology 2009; 219: 295–8. 10 Bohne A, Keuthen NJ, Wilhelm S et al. Prevalence of symptoms of body dysmorphic disorder and its correlates: a cross-cultural comparison. Psychosomatics 2002; 43: 486–90. 11 Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27: 457–62. 12 Cansever A, Uzun O, Donmez E, Ozsahin A. The prevalence and clinical features of body dysmorphic disorder in college students: a study in a Turkish sample. Compr Psychiatry 2003; 44: 60–4. 13 Kaymak Y, Taner E, Sims!ek I. Body dysmorphic disorder in university students with skin diseases compared with healthy controls. Acta Derm Venereol 2009; 89: 281–4. 14 Uzun O, Bas!o! glu C, Akar A et al. Body dysmorphic disorder in patients with acne. Compr Psychiatry 2003; 44: 415–9. 15 Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg 2006; 118: 167–80. 16 Kronenfeld LW, Reba-Harrelson L, Von Holle A et al. Ethnic and racial differences in body size perception and satisfaction. Body Image 2010; 7: 131–6.


437


17 Picavet V, Gabri€els L, Jorissen M, Hellings PW. Screening tools for body dysmorphic disorder in a cosmetic surgery setting. Laryngoscope 2011; 121: 2535–41. 18 Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics 2005; 46: 317–25. 19 Phillips KA, McElroy SL, Keck PE et al. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150: 302–8. 20 Kittler JE, Menard W, Phillips KA. Weight concerns in individuals with body dysmorphic disorder. Eat Behav 2007; 8: 115–20.

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21 Bowe WP, Leyden JJ, Crerand CE et al. Body dysmorphic disorder symptoms among patients with acne vulgaris. J Am Acad Dermatol 2007; 57: 222–30. 22 Veale D, Boocock A, Gournay K et al. Body dysmorphic disorder: a survey of fifty cases. Br J Psychiatry 1996; 169: 196–201. 23 Woodruff PW, Higgins EM, du Vivier AW, Wessely S. Psychiatric illness in patients referred to a dermatology-psychiatry clinic. Gen Hosp Psychiatry 1997; 19: 29–35. 24 Phillips KA. Suicidality in body dysmorphic disorder. Prim Psychiatry 2007; 14: 58–66.
