Rhinoplasty takes a unique position in the COSMETIC. High Prevalence of Body Dysmorphic Disorder Symptoms in Patients Seeking Rhinoplasty

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1 COSMETIC High Prevalence of Body Dysmorphic Disorder Symptoms in Patients Seeking Rhinoplasty Valerie A. Picavet, M.D. Emmanuel P. Prokopakis, M.D., Ph.D. Lutgardis Gabriëls, M.D., Ph.D. Mark Jorissen, M.D., Ph.D. Peter W. Hellings, M.D., Ph.D. Leuven, Belgium; and Heraklion, Greece Background: Nasal aesthetic deformities may be associated with significant body image dissatisfaction. The only diagnostic category in the current list of psychiatric disorders that directly addresses these concerns is body dysmorphic disorder. This large-scale study determined the prevalence of body dysmorphic disorder and its symptoms in patients seeking rhinoplasty and evaluated the clinical profile of these patients. Methods: Two hundred twenty-six patients were given questionnaires including demographic characteristics, visual analogue scales for nasal shape, the Yale- Brown Obsessive Compulsive Scale modified for body dysmorphic disorder to assess severity of symptoms, a generic quality-of-life questionnaire, and the Derriford Appearance Scale 59, to assess appearance-related disruption of everyday living. Independent observers scored the nasal shape. Results: Thirty-three percent of patients showed at least moderate symptoms of body dysmorphic disorder. Aesthetic goals (p 0.001), revision rhinoplasty (p 0.003), and psychiatric history (p 0.031) were associated with more severe symptoms. There was no correlation between the objective and subjective scoring of the nasal shape. Yale-Brown scale modified for body dysmorphic disorder scores correlated inversely with the subjective nasal scoring (n 210, p 0.001), without relation to the objective deformity of the nose. Body dysmorphic disorder symptoms significantly reduced the generic quality of life (n 160, p 0.001) and led to significant appearance-related disruption of everyday living (n 161, p 0.001). Conclusions: The prevalence of moderate to severe body dysmorphic disorder symptoms in an aesthetic rhinoplasty population is high. Patients undergoing revision rhinoplasty and with psychiatric history are particularly at risk. Body dysmorphic disorder symptoms significantly reduce the quality of life and cause significant appearance-related disruption of everyday living. (Plast. Reconstr. Surg. 128: 509, 2011.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III. Rhinoplasty takes a unique position in the field of facial aesthetic surgery. The morphology of the nose and its central position in the face seem to be crucial not only for facial harmony, but also for normal psychological From the Department of Otorhinolaryngology and the Psychiatric Department, University Hospitals Leuven, and the Department of Otorhinolaryngology, University Hospital Heraklion. Received for publication November 12, 2010; accepted February 3, Presented at the 33rd Annual Conference of the European Academy of Facial Plastic Surgery, in Antalya, Turkey, September 1 through 5, 2010; and the 23rd Conference of the European Rhinologic Society, in Geneva, Switzerland, June 20 through 24, Copyright 2011 by the American Society of Plastic Surgeons DOI: /PRS.0b013e31821b631f function. 1 The nasal shape is frequently one of the factors that disturb, consciously or unconsciously, our personality development and body image. 2 The latter is believed to motivate the pursuit of cosmetic surgery. 3 5 The only diagnostic category in the current list of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), that directly addresses body image concerns is body dysmorphic disorder. Therefore, this well-established psychiatric disorder seems to be of particular relevance in appearanceenhancing medical treatments. 4 According to its Disclosure: The authors have no financial interest to declare in relation to the content of this article. No outside funding was received

2 Plastic and Reconstructive Surgery August 2011 current definition, body dysmorphic disorder is defined as an excessive concern with an imagined or slight defect in physical appearance, leading to significant distress and/or impairment in one or more important areas of functioning. 6 Despite the suspected high prevalence, the increased availability of literature and the increased awareness of aesthetic surgeons regarding this disorder, there is still no standardized approach or guideline for proper identification of these patients in a cosmetic surgery setting. 7 Body dysmorphic disorder is often present in a hidden state Patients are often too ashamed to seek help from their general practitioner or mental health practitioner. Moreover, they frequently show impaired judgment regarding the psychiatric origin of their problems and often seek cosmetic treatment because they are convinced they warrant medical rather than psychiatric attention Large-scale studies reported body dysmorphic disorder rates of 0.7 to 3 percent in community samples and 2.5 to 5.3 percent in college students The prevalence of the disorder in an aesthetic surgery population is still unclear. Initially, it was thought that in this setting, it occurred in approximately 2 percent, a rate similar to that in the general population. 18 However, more recent studies suggest that the disorder is much more frequent in a cosmetic setting, with rates ranging from 6 to 15 percent. 8,19,20 Some, mostly smaller sampled studies even mentioned rates of 54 percent. 10,21 The wide variety in prevalence rates of body dysmorphic disorder in a cosmetic setting is attributable to difference in interpretation and application of the diagnostic criteria for the disorder. This raises questions regarding the utility of the present criteria for body dysmorphic disorder in a cosmetic surgery setting. 3 The vast majority of clinical reports and retrospective studies reveal that patients with body dysmorphic disorder show a low degree of satisfaction and a deterioration of disorder symptoms and even become violent toward themselves and their surgeon. 11,22 26 Therefore, there is a growing consensus that body dysmorphic disorder should be considered a contraindication for aesthetic surgery. Any part of the body may be the focus of concern in body dysmorphic disorder, but the most common areas involved are the skin, hair, and nose Cosmetic rhinoplasty is one of the most requested aesthetic procedures by patients with the disorder. 9,10,29,30 However, to our knowledge, there is only one small-scale (n 29) study evaluating the prevalence of body dysmorphic disorder in patients seeking cosmetic rhinoplasty, revealing a prevalence of 20.7 percent. 10 In addition, the clinical profile of patients with symptoms of the disorder seeking rhinoplasty is unclear. The aims of the present study were to determine the prevalence of body dysmorphic disorder, according to its definition in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), and its symptoms in patients seeking rhinoplasty in a tertiary university center using validated questionnaires for the disorder and to determine the clinical profile (demographic characteristics, nasal deformity, and quality of life) of patients according to the severity of their symptoms. PATIENTS AND METHODS Patient Recruitment The study was conducted at the Ear, Nose, and Throat Department of the University Hospitals Leuven, a tertiary referral center for nasal disease. Approval by the Hospitals Ethical Committee was obtained. All patients aged 16 years or older seeking rhinoplasty for aesthetic and/or functional reasons between February of 2009 and June of 2010 were asked to participate. Only patients with a good knowledge of Dutch were included, as the questionnaires were in Dutch. Questionnaires All patients were given questionnaires at the preoperative consultation. This questionnaire was developed in collaboration with the psychiatric department of our university hospital and consisted of the following: 1. Questions related to demographic issues (Table 1). 2. Patient s evaluation of his or her nasal shape using a visual analogue scale, with 0 meaning very bad and 10 meaning perfect. 3. The Yale-Brown Obsessive Compulsive scale modified for body dysmorphic disorder for assessing the severity of symptoms of the disorder, consisting of 10 items rating body dysmorphic disorder related thoughts and behaviors. The modified scale has acceptable psychometric properties, with adequate interrater and test-retest reliability and internal consistency. 31 Total scores on the modified scale are significantly correlated with global measures of illness severity A generic quality-of-life measurement, the Sheehan Disability Scale. This is a widely used, fully validated, brief self-report tool 510

3 Volume 128, Number 2 Prevalence of Body Dysmorphic Disorder Table 1. Demographic Characteristics of the Rhinoplasty Population and the Control Group Demographic Characteristics Rhinoplasty Controls No. of patients Age, years Sex (female/male), % 55/45 57/43 Marital status, % Married/cohabiting Divorced 4 3 Single With parents Other, not known 3 0 Ethnicity, % Belgian Referral pattern, % General practitioner ENT Plastic surgeon 6 0 No Other/not known 7 1 Previous aesthetic operations other than rhinoplasty, % 14 3 One/two/three or more, % 11/2/1 1/0/1 Previous rhinoplasty, % 20 0 One/two/three or more, % 11/5/4 0 Reason for surgery, % Only aesthetic 10 Mainly aesthetic 13 Aesthetic and functional 42 Mainly functional 19 Only functional 10 Not known 6 Motivation for surgery, % Only patient 51 Mainly patient 13 Both patient and others 8 Mainly others 1 Only others 0 Not known 27 ENT, ear, nose, and throat. consisting of three 10-point visual analogue scales that assess functional impairment in work/school, social, and family life. A higher score indicates more impairment in daily functioning. 5. The Derriford Appearance Scale 59. This 59-item self-report questionnaire has been designed to assess the disruption of everyday living, difficulties with personal relations, lowering of self-esteem, and emotional distress in individuals with problems of appearance. 33 It was developed specifically for use in a cosmetic surgery population and therefore is of great value in this setting. 34 In addition to a full-scale score, the Derriford scale gives five factorial subscale scores: (1) general self-consciousness of appearance (17 items), (2) social self-consciousness of appearance (20 items), (3) self-consciousness of sexual and bodily appearance (nine items), (4) negative self-concept (five items), and (5) self-consciousness of facial appearance (four items). A higher score is associated with a greater degree of appearance-related distress and dysfunction. The scale has demonstrated excellent validity, reliability, and internal consistency in both clinical and general populations. 35 Objective Scoring of Nasal Deformities The patient s nasal shape was scored by two independent observers (V.A.P. and E.P.P.), based on standard photographs in frontal, profile (two sides), and inferior views. The scoring system was developed in our department and has already been shown to be very useful for preoperative and postoperative scoring of the nasal shape in rhinoplasty patients. 36 The frontal, profile, and inferior views of the tip and the frontal and profile views of the dorsum are each scored on a scale from 1 to 5, with 1 being a very severe deformity and 5 being no deformity. A total score is obtained, with a score of 25 of 25 indicating a perfect nasal shape. The agreement between the two observers was measured with the Spearman correlation and Bland-Altman plot. The lower and upper limits of agreement were 2.2 and 4.81, respectively. The Spearman correlation coefficient was high (0.94), indicating a high level of agreement. There was a systematic difference in observers, with one observer giving a systematically higher score (p 0.001, signed rank test), resulting in a lower interclass correlation (0.844). Statistical Analysis The relation between severity of body dysmorphic disorder symptoms as measured by the Yale- Brown Obsessive Compulsive Scale modified for body dysmorphic disorder and demographic variables was verified using Spearman correlations, Mann-Whitney U tests, Kruskal-Wallis tests, and Fisher s exact tests. The Yale-Brown score was considered continuous. The same analyses were used to relate severity of body dysmorphic disorder symptoms to patients generic quality of life and appearance-related disruption of daily life, as measured by the Sheehan Disability Scale and the Derriford Appearance Scale 59, respectively, and to the objective and subjective scoring of the nose. Values of p 0.05 were considered significant. All analyses were performed using SAS software, version 9.2 of the SAS System for Windows (SAS Institute, Inc., Cary, N.C.). 511

4 Plastic and Reconstructive Surgery August 2011 RESULTS Patient Characteristics Three hundred ten patients sought an aesthetic and/or functional rhinoplasty in our Ear, Nose, and Throat Department between February of 2009 and June of 2010, of whom 239 met the inclusion criteria and 226 agreed to participate in the study (95 percent). A control group was selected from patients, aged 16 years or older, consulting because of an otologic or general ear, nose, and throat problem. Demographic characteristics of our rhinoplasty population and the control group are summarized in Table 1. Both had comparable demographic characteristics as measured by the Fisher s exact test and the Mann-Whitney U test. Prevalence of Body Dysmorphic Disorder According to its definition in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), patients with a Yale-Brown Obsessive Compulsive Scale score greater than 15, indicating at least moderate preoccupation, and with no or minimal defect in appearance (e.g., an objective nasal score greater than 19 of 25) were considered to meet the diagnostic criteria for body dysmorphic disorder. Five subjects met these criteria (2 percent). Prevalence and Severity of Body Dysmorphic Disorder Symptoms Patients were categorized into five groups, according to their score on the modified Yale-Brown scale (Table 2). In the overall rhinoplasty population, 33 percent scored 16 or higher, indicating at least moderate symptoms of body dysmorphic disorder. In the group of patients who requested rhinoplasty for (mainly or only) functional reasons, this was only 12 percent, whereas in the group of patients who requested rhinoplasty for (partly, mainly, or only) aesthetic reasons, this increased to 43 percent. In the control group, only one patient (2 percent) scored 16 or higher on the modified scale. Prevalence of Body Dysmorphic Disorder Symptoms in Relation to Patients Characteristics Table 3 provides an overview of the influence of the investigated demographic factors on the severity of body dysmorphic disorder symptoms. There was no significant correlation between the score on Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder and age (p 0.283), sex (p 0.069), marital status (p 0.191), ethnicity (p 0.162), referral pattern (p 0.072), previous aesthetic surgery other than rhinoplasty (p 0.135), and motivation for surgery (p 0.056). There was a significant correlation between the modified Yale-Brown score and previous rhinoplasty (p 0.003), psychiatric history (p 0.031), and reason for surgery (aesthetic versus functional) (p 0.001). Twenty percent of our population had a history of previous rhinoplasty. There was a positive correlation between the number of previous rhinoplasties and the score on the modified Yale-Brown (Spearman 0.22, p 0.003). Nine patients had a psychiatric history (4 percent). Four patients noted a history of depression, and one patient had an autistic spectrum disorder. In the four remaining patients, no further information was available. Correlation between Subjective and Objective Evaluation of the Nasal Deformity There was no significant correlation between the objective and subjective evaluation of the nose (n 218, p 0.263, Spearman 0.08). Correlation between Body Dysmorphic Disorder Symptoms and Nasal Deformity There was no significant correlation between the objective evaluation of the nasal shape and the severity of body dysmorphic disorder symptoms as measured with the Yale-Brown Obsessive Compul- Table 2. Prevalence and Severity of Body Dysmorphic Disorder Symptoms in the Overall, Aesthetic, and Functional Rhinoplasty Populations and in a Control Group BDD Symptoms Overall RP (%) Aesthetic RP (%) Functional RP (%) Controls (%) No. of patients BDD-YBOCS score 0 7 No 72 (32) 30 (20) 42 (53) 45 (69) 8 15 Mild 80 (35) 52 (35) 28 (35) 19 (29) Moderate 58 (26) 52 (35) 6 (8) 1 (2) Severe 16 (7) 13 (9) 3 (4) Extreme BDD-YBOCS, Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder; RP, rhinoplasty. 512

5 Volume 128, Number 2 Prevalence of Body Dysmorphic Disorder Table 3. Correlation between Severity of Body Dysmorphic Disorder Symptoms as Measured by the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder and Demographic Characteristics* Demographic Characteristic p Age Sex Marital status Ethnicity Referral pattern Psychiatric history Previous rhinoplasty Previous aesthetic surgery (other than RP) Reason for surgery (aesthetic vs. functional) Motivation for surgery RP, rhinoplasty. *There is a significant correlation between Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder score and psychiatric history, previous rhinoplasty, and reason for surgery (functional vs. aesthetic). Kruskal-Wallis test. sive Scale modified for body dysmorphic disorder (n 204, Spearman 0.1, p 0.137). In contrast, there was a significant inverse correlation between Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder score and the subjective evaluation of the nasal shape by the patient (n 210, Spearman 0.41, p 0.001) (Fig. 1). Correlation between Body Dysmorphic Disorder Symptoms and Daily Functioning Patients with a higher score on the modified Yale-Brown scale scored significantly higher on the Sheehan Disability Scale (i.e., a lower generic quality of life; n 160, Spearman 0.43, p 0.001) (Fig. 2) and on the Derriford Appearance Scale 59 (i.e., more appearance-related distress and dysfunction; n 161, Spearman 0.65, p 0.001) (Fig. 3). The correlation was significant for all the subscales of the Derriford scale: global self-consciousness (n 161, Spearman 0.68, p 0.001), social self-consciousness (n 161, Spearman 0.55, p 0.001), sex/bodily selfconsciousness (n 161, Spearman 0.38, p 0.001), negative self-concept (n 161, Spearman 0.47, p 0.001), and facial self-consciousness (n 161, Spearman 0.3, p ). DISCUSSION The central role of the nose in the face and the psychological impact of any deformity make the nose one of most prevalent areas of concern in patients with body dysmorphic disorder. 1,9,22,28 30 In addition, Veale et al. showed in their study of 25 patients with the disorder who underwent aesthetic surgery that rhinoplasty had the worst outcome after cosmetic surgery. 10 Despite the estimated high prevalence and potential impact of the disorder on the outcome after rhinoplasty, large-scale studies investigating its prevalence and symptoms in this particular population are missing. Moreover, the clinical profile of patients with symptoms of the disorder seeking rhinoplasty is unclear. According to its present definition, body dysmorphic disorder represents an excessive concern Fig. 1. Significant inverse correlation between subjective scoring of the nasal shape by the patient and the score on the Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder (BDD-YBOCS)(n 210, Spearman 0.41, p 0.001). 513

6 Plastic and Reconstructive Surgery August 2011 Fig. 2. Patients with a higher score on the Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder (BDD-YBOCS) had a significantly higher score on the Sheehan Disability Scale (i.e., a lower generic quality of life; n 160, Spearman 0.43, p 0.001). Fig. 3. Patients with a higher score on the Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder (BDD-YBOCS) had a significantly higher score on the Derriford Appearance Scale 59 (i.e., more appearance-related distress and dysfunction; n 161, Spearman 0.65, p 0.001). with an imagined or slight defect in physical appearance, leading to significant distress and/or impairment in daily life. 6 Only 2 percent of our population met these diagnostic criteria. This rate is lower compared with rates reported in the literature, probably because of the difference in interpretation and application of the diagnostic criteria for the disorder. Cosmetic surgery patients often present with relatively slight defects in appearance that are, however, frequently judged as observable and correctable by the plastic surgeon. As a result, judgment of a slight defect in appearance seems to be highly subjective in this population. It has therefore been suggested that the 514

7 Volume 128, Number 2 Prevalence of Body Dysmorphic Disorder degree of emotional distress and behavioral impairment are more accurate indicators of body dysmorphic disorder in a plastic surgery population, regardless of the severity of the physical defect. 3,27,28 This study represents the first largescale study investigating the prevalence and severity of symptoms of the disorder among patients requesting rhinoplasty in a tertiary university setting. In addition, differences in demographic and clinical characteristics according to the severity of symptoms were investigated. The prevalence of moderate to severe body dysmorphic disorder symptoms in our overall rhinoplasty population was high (i.e., 33 percent of 226 patients). Moreover, patients seeking rhinoplasty for aesthetic reasons scored significantly higher on the Yale-Brown Obsessive Compulsive Scale modified for body dysmorphic disorder compared with patients requesting rhinoplasty for mainly or only functional raisons. In the aesthetic subgroup, 43 percent of patients showed at least moderate symptoms of body dysmorphic disorder, whereas the rate was only 12 percent in the functional subgroup. The prevalence of moderate to severe disorder symptoms in our control group was low (2 percent) and consistent with rates of body dysmorphic disorder reported in community samples Patients seeking revision rhinoplasty scored significantly higher on the modified Yale-Brown scale, indicating more severe body dysmorphic disorder symptoms. Moreover, the number of previous rhinoplasties correlated positively with the scale score. This finding may explain the inverse correlation between patient satisfaction after surgery and the number of revisions they underwent. 37 In our study, only 4 percent of patients reported a history of psychiatric disorder. This rate is lower compared with what has been reported in the literature (20 to 48 percent). 19,38 We believe that this is because patients are still reluctant to provide information about their mental health and the fact that no thorough mental history was obtained. We did find a positive correlation between the modified Yale-Brown scale score and psychiatric history, which might be explained by the high rate of psychiatric comorbidity in patients with body dysmorphic disorder. The most common co-occurring disorders are major depression, social phobia, substance abuse, obsessive-compulsive disorder, and personality disorders. 22,23,39 Depression has the highest rate of co-occurrence, with a lifetime rate of 80 percent and a current rate of 60 percent. 23 The onset of depression in patients with body dysmorphic disorder tends to be either concurrent with or subsequent to the onset of the disorder. 40 Thorough preoperative evaluation, including informing about psychiatric history, especially depression, should therefore be included in the preoperative assessment of cosmetic surgery patients, as it might be an indicator for latent body dysmorphic disorder. We found no significant correlation between age, sex, marital status, ethnicity, previous aesthetic surgery other than rhinoplasty, referral pattern, motivation for surgery, and severity of body dysmorphic disorder symptoms. Although the sex ratio has varied in some clinical samples, our results are consistent with findings from the largest clinical samples, in which the prevalence of the disorder in men and women was approximately equal 41 or the disorder was more common in women. 40 The first three items in the well-known acronym SIMON (single, immature, male, overly expecting, and narcissistic) are, according to our findings, not associated with an increased risk of body dysmorphic disorder symptoms. Information on ethnicity and body dysmorphic disorder symptoms is rare. Previous studies have shown that African Americans of both sexes are less dissatisfied with their bodies than Caucasians, Asians, and Hispanics, suggesting that ethnic background contributes to a person s vulnerability and risk for the disorder. 42 Because one of our inclusion criteria was a good knowledge of Dutch, ethnicity issues cannot be addressed. In accordance with previous studies, 36,37,43 we found no correlation between the patients and observers evaluation of the nasal shape. Interestingly, there was no correlation between the objective nasal score and the severity of body dysmorphic disorder symptoms. On the contrary, there was a significant inverse correlation between the severity of symptoms and the patients evaluation of his or her nose. This confirms that the degree of psychological distress is not related to the actual physical deformity but that it is related to and influences the patients perception of his or her nasal shape. Patients with body dysmorphic disorder often think about their (perceived) defect for many hours per day and are frequently occupied with time-consuming repetitive behaviors such as mirror checking and camouflaging. 22,24 Research in a psychiatric setting showed that this might lead to substantial avoidance of everyday activities, social isolation, reduction of quality of life, and even suicide. 30,44 46 This study was the first to investigate the influence of body dysmorphic disorder symptoms on the quality of life in patients requesting 515

8 Plastic and Reconstructive Surgery August 2011 rhinoplasty. Patients with more severe symptoms had a significantly lower generic quality of life and showed significantly more appearance-related disruption of everyday living, more difficulties with personal relations, lowering of self-esteem, and emotional distress. The most crucial question, of course, is whether cosmetic surgery tackles these issues in this particular subgroup of patients requesting rhinoplasty. As patient satisfaction and quality of life are the major objectives in aesthetic surgery, further prospective research in this field is obligatory. CONCLUSIONS This study shows that the prevalence of body dysmorphic disorder symptoms in a cosmetic rhinoplasty population is high and that the severity of symptoms has a clearly negative effect on daily functioning. Patients undergoing revision rhinoplasty and patients with a psychiatric history are particularly at risk for body dysmorphic disorder symptoms. Large-scale and long-term prospective outcome studies investigating the influence of these symptoms on outcomes are imperative, as they will help us in the establishment of guidelines concerning patient selection in aesthetic surgery. Peter W. Hellings, M.D. Ear, Nose, and Throat Department University Hospitals Leuven Campus Sint-Rafaël Kapucijnenvoer 33 B-3000 Leuven, Belgium peter.helling@med.kuleuven.be REFERENCES 1. Andretto Amodeo C. The central role of the nose in the face and the psyche: Review of the nose and the psyche. Aesthetic Plast Surg. 2007;31: Babuccu O, Latifoğlu O, Atabay K, Oral N, Coşan B. Sociological aspects of rhinoplasty. Aesthetic Plast Surg. 2003;27: Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101: Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. The psychology of cosmetic surgery: A review and reconceptualization. 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Female college students and cosmetic surgery: An investigation of experiences, attitudes, and body image. Plast Reconstr Surg. 2005;115: Andreasen NC, Bardach J. Dysmorphophobia: Symptom or disease? Am J Psychiatry 1977;134: Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci. 1998;52: Aouizerate B, Pujol H, Grabot D, et al. Body dysmorphic disorder in a sample of cosmetic surgery applicants. Eur Psychiatry 2003;18: Vindigni V. The importance of recognizing body dysmorphic disorder in cosmetic surgery patients: Do our patients need a preoperative psychiatric evaluation? Eur J Plast Surg. 2002; 25: Phillips KA, McElroy SL, Keck PE Jr, Pope HG Jr, Hudson JI. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993;150: Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. 1997;185: Phillips KA. 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9 Volume 128, Number 2 Prevalence of Body Dysmorphic Disorder 30. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder: A survey of fifty cases. Br J Psychiatry 1996;169: Cororve MB, Gleaves DH. Body dysmorphic disorder: A review of conceptualizations, assessment, and treatment strategies. Clin Psychol Rev. 2001;21: Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR, De- Caria C, Goodman WK. A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull. 1997;33: Harris D, Carr T, Moss T. Manual for the Derriford Appearance Scale 59 (DAS59). Bradford on Avon: Musketeer Press; Ching S, Thoma A, McCabe RE, Antony MM. Measuring outcomes in aesthetic surgery: A comprehensive review of the literature. Plast Reconstr Surg. 2003;111: ; discussion Harris DL, Carr AT. The Derriford Appearance Scale (DAS59): A new psychometric scale for the evaluation of patients with disfigurements and aesthetic problems of appearance. Br J Plast Surg. 2001;54: Hens G, Picavet V, Vander Poorten V, Schoenaers J, Jorissen M, Hellings PW. High patient satisfaction after secondary rhinoplasty in cleft lip patients. Allergy Rhinol. 2011;1: Hellings PW, Nolst Trenité GJ. Long-term patient satisfaction after revision rhinoplasty. Laryngoscope 2007;117: Sarwer DB, Zanville HA, LaRossa D, et al Mental health histories and psychiatric medication usage among persons who sought cosmetic surgery. Plast Reconstr Surg. 2004;114: ; discussion Sarwer DB, Crerand CE, Didie ER. Body dysmorphic disorder in cosmetic surgery patients. Facial Plast Surg. 2003;19: 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: Phillips KA, Grant J, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics 2001;42: Mayville S, Katz RC, Gipson MT, Cabral K. Assessing the prevalence of body dysmorphic disorder in an ethnically diverse group of adolescents. J Child Family Studies 1999;8: Shaw WC, Brattström V, Mølsted K, Prahl-Andersen B, Roberts CT, Semb G. The Eurocleft study: Intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 5: Discussion and conclusions. Cleft Palate Craniofac J. 2005;42: Didie ER, Walters MM, Pinto A, et al. A comparison of quality of life and psychosocial functioning in obsessive-compulsive disorder and body dysmorphic disorder. Ann Clin Psychiatry 2007;19: Phillips KA, Menard W, Fay C, Pagano ME. Psychosocial functioning and quality of life in body dysmorphic disorder. Compr Psychiatry 2005;46: Phillips KA, Menard W. Suicidality and body dysmorphic disorder: A prospective study. Am J Psychiatry 2006;163: Advertising in Plastic and Reconstructive Surgery Please direct all inquiries regarding advertising in Plastic and Reconstructive Surgery to: Christopher J. Ploppert Advertising Representative Lippincott Williams & Wilkins Two Commerce Square 2001 Market Street Philadelphia, PA Tel: Fax: christopher.ploppert@wolterskluwer.com 517