Body dysmorphic disorder screening in maxillofacial outpatients presenting for orthognathic surgery

Transcription

1 Int. J. Oral Maxillofac. Surg. 2008; 37: doi: /j.ijom , available online at Leading Clinical Paper Orthognathic Surgery Body dysmorphic disorder screening in maxillofacial outpatients presenting for orthognathic surgery N. C. C. Vulink 1, A. Rosenberg 2, J. M. Plooij 3, R. Koole 2, S. J. Bergé 3, D. Denys 4 1 The Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, The Netherlands; 2 Department of Oral - Maxillofacial Surgery, The Netherlands; 3 University Medical Center Utrecht, 3D Facial Imaging Research Group Nijmegen- Bruges, Department of Oral and Maxillofacial Surgery, Radboud University Nijmegen Medical Centre, The Netherlands; 4 Department of Psychiatry, AMC Amsterdam, The Netherlands N. C. C. Vulink, A. Rosenberg, J. M. Plooij, R. Koole, S. J. Bergé, D. Denys: Body dysmorphic disorder screening in maxillofacial outpatients presenting for orthognathic surgery. Int. J. Oral Maxillofac. Surg. 2008; 37: # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Body dysmorphic disorder (BDD) is a severe psychiatric disease with delusions about defects in appearance for which patients seek surgical help. This is the first European study to determine the half-year prevalence of BDD in a maxillofacial outpatient clinic. A total of 160 patients with maxillofacial problems completed a validated self-report questionnaire, while a staff member scored maxillofacial defects on a severity scale. Twenty-eight (17%) patients had excessive concerns about their appearance, which negatively influenced their psychosocial functioning; 16 patients (10%; 95%CI 5 15%) screened positive for BDD. The high prevalence of problems related to psychosocial functioning and the occurrence of BDD in maxillofacial patients means that maxillofacial surgeons should take psychological concerns about physical defects into account. Keywords: body dysmorphic disorder; somatoform disorders; maxillofacial. Accepted for publication 6 June 2008 Available online 21 July 2008 Patients with body dysmorphic disorder (BDD) are obsessed with a particular part of their appearance or their whole appearance without having a defect or only a small defect. BDD is a psychiatric disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), a classification system for mental disorders used worldwide 2. Patients with BDD are distressed by their perceived defect, are often socially isolated and have functional impairments 13,23. These patients ask oral and maxillofacial (OMF) surgeons or plastic surgeons to treat their imagined or exaggerated defect. Because of the delusional content of the disorder, patients with BDD lack insight in the unreal nature of their bodily concerns. They are often not satisfied or only temporarily satisfied with the results of surgery. Most of them seek another doctor for treatment 13,23 or become litigious or violent. A quarter of OMF patients meet criteria for a psychiatric disorder 12, but no studies have reported on precise psychiatric diagnoses. Except for one study in 40 adult orthodontic patients in which 3 patients (7.5%) were diagnosed with BDD 8, the prevalence of BDD in a maxillofacial outpatient clinic is unknown. The aim of this study was to determine the half-year prevalence of BDD in dysgnathic patients in 2 maxillofacial outpatient clinics in 2 teaching hospitals. Methods This study was conducted from September 2005 to March 2007 at 2 maxillofacial outpatient clinics in 2 Dutch teaching / $30.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

2 986 Vulink et al. hospitals. All patients, who were referred by medical or dental practitioners, and presenting for an orthognathic surgery consultation received a self-report questionnaire (see Appendix A: BDD Questionnaire) which they completed before the consultation. The questionnaire contains 20 questions of which 9 were drawn from the Body Dysmorphic Disorder Questionnaire: Dermatology Version 5, which was developed and tested in a dermatological cosmetic surgery practice at a university hospital, and 11 from the Body Dysmorphic Disorder Examination (BDDE) 21, which is a validated and reliable interview to diagnose BDD and measure symptoms of severely negative body image. Both scales have good sensitivity and specificity for the diagnosis of BDD. The questionnaire contained questions such as: Are you very concerned about the appearance of some part of your body, which you consider especially unattractive?, Has your defect often caused you a lot of distress, torment or pain?, Has your defect caused you impairment in social, occupational or other important areas of functioning?, How dissatisfied have you been with your overall appearance?, How attractive physically do you feel other people thought you were? and Does the maxillofacial defect account for many problems in life?. The study was approved by the Medical Ethical Review Committee of the University Medical Center Utrecht (UMCU) and the Medical Ethical Review Committee of the Radboud University Nijmegen Medical Centre (RUNMC), the Netherlands. Procedure All new patients in the maxillofacial surgery outpatient clinics at UMCU and RUNMC who were referred by medical or dental practitioners, and presenting for an orthognathic surgery consultation received the questionnaire. A preface to the questionnaire confirms that completing or failing to complete the questionnaire would not have any effect on treatment. Four OMF surgeons in UMCU and 1 OMF surgeon in RUNMC rated the defect severity of all patients. The scale ranges from 1 to 4, where 1 is no defect, 2 is minimal/ slight defect, 3 is defect clearly noticeable at conversational distance, and 4 is severe defect. The rating accuracy of the 4 OMF surgeons at UMCU was assessed using 15 photographs of patients with maxillofacial defects; they showed an intraclass correlation coefficient of Patients were screened positive for BDD if they fulfilled all Table 1. DSM-IV diagnostic criteria for body dysmorphic disorder A Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person s concern is markedly excessive B The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning C The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa) DSM-IV criteria for BDD, by reporting concerns and preoccupation with a perceived defect in appearance, and at least moderate distress or impairment in (social, occupational or familial) functioning, and the facial defect was judged minimal or nonexistent by the surgeon (Table 1). Statistical analyses Results were analysed using SPSS version 12.0 for Windows. The percentage of patients who met criteria for BDD was determined. Student s t-tests were used to compare age in patients who screened positive or negative for BDD. To compare gender, diagnoses, treatment, treatment history, psychiatric history, emotional distress, and dysfunction of patients with BDD and patients without BDD, a Mann Whitney U-test was used for continuous variables and a X 2 test or Fisher s exact test was used for categorical variables. Results A total of 160 patients completed the questionnaire (n = 102 in UMCU, n = 58 RUNMC). The mean age was (range years) and 106 patients were female (67%). Marital state, mean duration of diagnoses, previous surgical treatment and psychiatric history are given in Table 2; diagnoses are reported in Table 3. Twenty-eight patients (17%) reported preoccupation with excessive concern Table 2. Clinical data (pooled factors) Age at trial entry Mean 27.1 years Range years Gender Male 54 Female 106 Marital state Single 98 Married 32 Divorced 6 Living together 24 Duration of maxillofacial problem Mean 16.5 years Range years Previous surgical treatment No previous surgical treatment 86% Previous surgical treatment 14% Psychiatric history Yes 32/160 No 128/160 Table 3. Diagnoses in maxillofacial outpatients BDD patients non BDD patients Diagnoses (n = 16) (n = 144) Class II skeletal relation with or without open bite Class III skeletal relation with or without open bite 0 14 Class I skeletal relation 1 12 Temporomandibular dysfunction 1 6 Skeletal arch discrepancies 1 6 No facial deformity 1 4 Orthognathic surgery in cleft lip and palate children 0 3 Complication of prior surgery 2 1 Neuromuscular disorder 0 1 Unknown 0 4 Oligodontia 0 1

3 Body dysmorphic disorder screening in maxillofacial outpatients 987 about their appearance causing moderate to severe distress and/ or impairment in functioning. Of these patients, 16 (10%; CI 5 15%) met DSM-IV criteria for BDD (n = 13 in UMCU, n = 3 RUNMC). Of the 28 patients, 12 were preoccupied but failed the diagnosis of BDD because they had an obvious defect (dysgnathic deformity), 5 had a clearly noticeable defect at conversational distance and 7 had a severe defect. The remaining patients fulfilling the BDD diagnosis (n = 16) were referred to a psychiatrist; 4 patients agreed to have a psychiatric consultation, but the other 12 denied psychiatric symptoms and refused a psychiatric consultation. Of the 16 patients, 11 were female (69%), with a mean age of (range years). The most common diagnosis in the BDD patients was Class II skeletal relation with or without open bite (Table 3). According to DSM-IV criteria, all 16 patients with BDD reported at least moderate distress or impairment in social or occupational functioning and did not have a defect or only a small defect. More than half of the patients (n = 9) reported severe or very disturbing distress and one-third (n = 6) mentioned severe or incapacitating impairment in functioning. More than 80% of the BDD patients (n = 13) avoided social situations, occupational or study activities. No significant differences were found in mean age, gender ratio, marital state diagnoses and treatment history between patients with BDD and patients without BDD. Significant differences were found regarding psychiatric history (x 2 = , df = 3, p = 0.015), time spent on appearance (Mann Whitney U-test = 734, p = 0.016), body camouflaging (U = 440.5, p = 0.000), hiding appearances (x 2 = , df = 4, p = 0.000) and avoiding social or occupational activities (x 2 = 8.418, df = 1, p = 0.004). Patients with BDD blamed all their problems on perceived defects in their appearance (Fisher s exact test p = 0.001). They also reported higher frequencies of others noticing their defect (Mann Whitney U-test = 695.0, p = 0.017) or criticizing their excessive concern (Fisher s exact test: p = 0.026). No differences were found on (dis)satisfaction with general appearance, embarrassment, appeal to others and checking appearance. Discussion This is the first European study assessing prevalence of BDD in a maxillofacial surgery outpatient clinic. Twenty-eight patients (17%) reported preoccupation with excessive concern about their appearance causing moderate to severe distress and/ or impairment in functioning. Of these patients, 16 (10%) suffer from BDD. Aesthetic appearance is one of the main reasons why patients seek orthodontic or orthognathic surgical treatment 11. In two separate studies in which orthognathic patients were interviewed preoperatively, over 60% of patients reported that their facial appearance had negatively influenced their personal life and over 40% reported impairments in social functioning 4,7 ; neither study reported the prevalence of BDD. After maxillofacial surgery, most patients report improved self-confidence, body and facial image, and social adjustment 9,11, but some patients are only temporarily satisfied and become litigious or violent. These patients may suffer from BDD. In one comparable study of 40 orthodontic patients the prevalence of BDD was 7% 8. Comparable studies in dermatological and plastic surgery patients showed a prevalence of BDD of 8 15% in dermatology outpatient clinics 5,16,22,25 and 3 53% in cosmetic surgery outpatient clinics 1,3,10,24,25. Different study populations, variations in inclusion criteria, and use of self-report or psychiatric interviewing could account for the diversity in prevalence rates. An easily applicable prediction model, using clinical characteristics and/ or demographic variables, might support OMF surgeons in their attempt to diagnose patients suffering from BDD. In this study, differences were found between BDD patients and non-bdd patients in clinical characteristics with regard to appearance-related behavior and cognitions. Patients with BDD spent more time on their appearance, body camouflaging, and blamed their life problems on perceived defects in their appearance more often. They also reported higher frequencies of others noticing their defect or criticizing their excessive concern. These typical BDD symptoms are items of the BDDE, which is a validated and reliable interview to diagnose BDD and measure symptoms of severely negative body Image 21. No differences were found on (dis)satisfaction with general appearance, embarrassment, appeal to others, and checking appearance, which are also known BDD symptoms. This might be due to a lack of power or may be a result of the difficulty in distinguishing between normal body dissatisfaction and BDD. HEPBURN et al. 8 suggested conceptualizing concerns about body image on a continuum with levels of disturbance ranging from none to extreme. Higher levels of body image disturbance are associated with significant impairment in functioning and when the person s view of his or her appearance defect is extreme, then BDD should be considered. This study shows that patients with BDD can be distinguished from non- BDD patients by their psychiatric history. In agreement with the literature, BDD patients frequently report psychiatric diagnoses or psychological problems 20. The authors did not find demographic variables that could identify BDD patients, in contrast to some previous studies reporting that BDD patients are younger than non-bdd patients 16,25, although others report similar findings 22. Some studies show a higher prevalence in men than in women 6,15, others a higher prevalence in women than in men 20 and others show equal gender rates 5,14,18. As patients with BDD are convinced they have a physical defect, they seek help from dermatologists, plastic surgeons or OMF surgeons. No significant difference could be found in the frequency of previous dermatological or surgical treatment between patients who screened negative or positive for BDD. The small sample size of BDD patients may account for the limited differences between BDD patients and non-bdd patients. Larger studies are needed to compose a useful prediction tool that can be used by a somatic specialist to select BDD patients. A limitation of this study is that the authors did not use structured psychiatric interviews to assess BDD and psychiatric co-morbidity. This could explain the low number of psychiatric co-morbidity in all patients. A selection bias and information bias could have distorted the results as only patients seeking help for their proposed face defect were included in this study. In practice, OMF surgeons are advised to explore the distress and dysfunction of patients with maxillofacial defects (e.g. with the BDD questionnaire), and to consult a psychiatrist when patients have significant distress and moderate to severe behavioral impairment. Patients with minor maxillofacial defects, clear emotional distress and problems in functioning could suffer from BDD. Psychiatrists could play an important role in educating OMF surgeons in how to recognize patients with BDD. Referral of these patients to psychiatrists is necessary for appropriate treatment with for example SSRIs 17,19, thus minimizing the patient seeking several referrals, litigation and unnecessary orthognathic surgery in these patients. Acknowledgement. The authors thank Dr. E. Geuze for his assistance with this manuscript.

4 988 Vulink et al. Appendix A. BDD Questionnaire

5 Appendix A (Continued ) Body dysmorphic disorder screening in maxillofacial outpatients 989

6 990 Vulink et al. Appendix A (Continued ) References 1. Altamura C, Paluello MM, Mundo E, Medda S, Mannu P. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci 2001: 251: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed Washington, DC: American Psychiatric Association Aouizerate B, Pujol H, Grabot D, Faytout M, Suire K, Braud C, Auriacombe M, Martin D, Baudet J, Tignol J. Body dysmorphic disorder in a sample of cosmetic surgery applicants. Eur Psychiatry 2003: 18: Barbosa AL, Marcantonio E, Barbosa CE, Gabrielli MF, Gabrielli MA. Psychological evaluation of patients scheduled for orthognathic surgery. J Nihon Univ Sch Dent 1993: 35: 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: Fukuda O. Statistical analysis of dysmorphophobia in an outpatient clinic. Jpn J Plastic Reconstr Surg 1977: 20: Garvill J, Garvill H, Kahnberg KE, Lundberg S. Psychological factors in orthognathic surgery. J Craniomaxillofac Surg 1992: 20: Hepburn S, Cunningham S. Body dysmorphic disorder in adult orthodontic patients. Am J Orthod Dentofacial Orthop 2006: 130: Hunt OT, Johnston CD, Hepper PG, Burden DJ. The psychosocial impact of orthognathic surgery: a systematic review. Am J Orthod Dentofacial Orthop 2001: 120: Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998: 52: Lazaridou-Terzoudi T, Kiyak HA, Moore R, Athanasiou AE, Melsen B. Long-term assessment of psychologic outcomes of orthognathic surgery. J Oral Maxillofac Surg 2003: 61: Phillips C, Bennett ME, Broder HL. Dentofacial disharmony: psychological status of patients seeking treatment consultation. Angle Orthod 1998: 68:

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