Contrary to well-known psychiatric diseases,

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1 COSMETIC Body Dysmorphic Disorder: Diagnosis and Approach Michael Jakubietz, M.D. Rafael J. Jakubietz, M.D. Danni F. Kloss, M.D. Joerg J. Gruenert, M.D. St. Gallen, Switzerland Summary: Body dysmorphic disorder is a psychiatric disease that can be frequently encountered in an aesthetic practice. Body dysmorphic disorder is characterized by a preoccupation with a minimal or nonexistent appearance defect and causes significant distress and interferes with the social life of the patient. The perceived physical anomaly may involve the shape and size of the whole body or may be centered around single units. Body dysmorphic disorder patients are known to request multiple aesthetic procedures that leave them unsatisfied. Only a timely diagnosis will enable the surgeon and staff to adequately address the patient s needs. Body dysmorphic disorder patients cannot be cured with surgery. Diagnostic techniques such as patient interview and observation are presented in this article. With this, the plastic surgeon should be able to diagnose body dysmorphic disorder preoperatively. Using the presented algorithm to approach body dysmorphic disorder patients will avoid disappointment for patients and surgeons alike. (Plast. Reconstr. Surg. 119: 1924, 2007.) Contrary to well-known psychiatric diseases, body image disorders are very challenging to diagnose. In particular, body dysmorphic disorder is thought to occur frequently among patients requesting cosmetic surgery. As surgical cure is not attainable, most plastic surgeons are reluctant to perform appearancechanging procedures on these patients. Not only potential medicolegal issues but also hostility and violence toward surgeon and staff militate against surgical interventions. Unfortunately, reaching a diagnosis is not only challenging but may further be influenced by the competitive and progressive aesthetic surgery setting, where refusing surgical care is considered a disadvantage. Thus, body dysmorphic disorder warrants special attention from plastic surgeons. THE DISEASE Body dysmorphic disorder was first described as dysmorphophobia in 1886 by Morsellini. 1 These patients are also referred to as insatiable surgery patients, psychologically disturbed patients, and polysurgery addicts. 2 4 Only recently From the Department of Hand, Plastic, and Reconstructive Surgery, Kantonsspital St. Gallen. Received for publication November 24, 2005; accepted February 15, Copyright 2007 by the American Society of Plastic Surgeons DOI: /01.prs b was it included as a separate diagnosis in the Diagnostic andstatistical Manual of Mental Disorders, Fourth Edition. 5 Body dysmorphic disorder is characterized by a preoccupation with a minimal or nonexistent appearance defect and must cause significant distress and/or interfere with the social and work life of the patient. 5,6 The diagnostic criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition are as follows: (1) excessive concern with an imagined or minimal defect; (2) the preoccupation must cause major distress or impair occupational and social functioning; and (3) the concerns are not caused by other mental disorders. The perceived physical anomaly may involve the shape and size of the whole body or may be centered around single units such as the face, nose, skin, and hair. 7 Although male patients focus on genitals, height, muscularity, or excessive body hair, women are mainly concerned with their face, breasts, hips, and legs. 8 Body dysmorphic disorder is not confined to one region; often, patients have vague or specific complaints involving more than one body part, with the majority being bothered by three to four different areas that may shift to another over time. Insight that the concerns are excessive may vary interindividually and also change over the course of the disease, but is generally poor. Patients are deeply convinced of the severity of their defects and cannot be talked out of their belief

2 Volume 119, Number 6 Body Dysmorphic Disorder Body dysmorphic disorder is usually a disease of adolescence, but occurrences in childhood have been reported. 9,10 The onset is gradual, and patients may initially show adequate appearance concerns. Sudden onset may be evoked by major events such as moving away from home or the termination of a relationship. Although not a diagnostic criteria of body dysmorphic disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, most patients show an obsessive-compulsive component in their behavior. 10 This consists of repetitive, time-consuming acts such as checking mirrors and hiding perceived defects with makeup, hats, and so forth, or even performing self-surgery in extreme cases. The comorbidity of body dysmorphic disorder and obsessive-compulsive disorders is 12 to 15 percent Indeed, there are reports supporting the theory that body dysmorphic disorder belongs to the obsessivecompulsive spectrum, because psychopathologic symptoms such as avoidance or repetitive, recurrent, and intrusive thoughts are present in both. 15 Other comorbid psychopathologic symptoms seen with body dysmorphic disorder are depression, social phobia, and substance abuse. 14 The time-consuming nature of the disease affects the life of the patients. 16 Most patients experience significant social problems, such as broken relationships (with more than 70 percent having never been married), social isolation, and workrelated problems caused by avoidance of social interaction resulting from the imagined defect. 17 The so-called delusion of reference is the main reason patients are afraid of other people, because they are convinced that their surroundings take great notice of the defect. This may lead to unemployment, inadequate education, and being housebound. Patients may ultimately become suicidal, with suicidal ideation being found in up to 50 percent of body dysmorphic disorder patients. 11,13 The severity of body dysmorphic disorder may range from almost normal in the mild form, where patients lead a normal life despite a significant reduction of quality of life, to severely impaired in extreme cases, when patients leave their homes only at night to avoid public exposure. Patients report a very low mental quality of life, which is considered worse than in patients with myocardial infarction or depression. The course of body dysmorphic disorder is chronic in varying severity. Social changes and surgical interventions often exacerbate symptoms. True remissions are rare and are related not to surgery but to psychotherapy. 18,19 The prevalence of body dysmorphic disorder has been investigated in very few studies. Between 1 and 3 percent of the general population is estimated to suffer from body dysmorphic disorder. 16,20 22 In the plastic surgery setting, body dysmorphic disorder is grossly overrepresented, as it may be diagnosed in 7 to 15 percent of patients. 16,23 27 The gender ratio of body dysmorphic disorder is not clear; also, no cultural differences seem to be present. 28,29 The largest published study shows a male predominance, with 33 percent of men seeking cosmetic surgery meeting criteria of body dysmorphic disorder, in comparison with only 7 percent in the female population. 17 A more recent study by Pertschuk et al. shows that male cosmetic patients are no different from female cosmetic patients. 24 Nevertheless, cosmetic patients, regardless of their gender, show a body image different from that of the general population. 28 HOW TO DIAGNOSE BODY DYSMORPHIC DISORDER Diagnosing body dysmorphic disorder is very important for the plastic surgeon, not only for medicolegal reasons but also to initiate appropriate mental health care for these individuals If unrecognized, these patients may cause major personal and financial disturbances, even in well-established practices. Only a timely diagnosis will enable both surgeon and staff to adequately address the patient s needs. Surgeon and staff need to screen patients with a combination of patient interview, observation, and sometimes paper-andpencil measures. 27 When interviewing a patient, several issues should be evaluated. Motivation for surgery, personal expectations, and the patient s body image are important to consider. Medical and psychiatric history need to be obtained, and the overall impression of the patient should be noted. Unfortunately, there is no single question that will unmask body dysmorphic disorder. The surgeon will come up with the diagnosis by combining the answers of the patient. Determining the degree of impairment is considered most relevant for diagnosis. Consultation should start with an open question about what the patient dislikes about his or her appearance. Patients should be encouraged to use their own words and describe their defects accordingly. Their explanations convey several important messages to the surgeon. Patients who can articulate their problems realistically and describe their motivations and expectations are unlikely to suffer from body dysmorphic disorder. The surgeon must be particularly 1925

3 Plastic and Reconstructive Surgery May 2007 Table 1. Signs of Body Dysmorphic Disorder Unusual, demanding behavior Excessive requests for aesthetic procedures Dissatisfaction with previous surgical procedures Expectation that an aesthetic operation will solve all problems Excessive concern with nonexistent deformity Impaired functioning Referential thinking Reassurance seeking Camouflaging Poor insight alert to the presence of unrealistic views, marked exaggeration, and distress about nonexisting or almost imperceptible defects are present (Table 1). It is mandatory to ask the patient about the degree of dissatisfaction and its effects on the patient s life. 19 Knowing how much time a patient spends thinking about a defect is essential. Patients spending more than 1 hour per day thinking about or dealing otherwise with their anomaly may suffer from body dysmorphic disorder. In severe cases, the entire day may be centered around the perceived anomaly. If a patient blames the perceived defect for his or her lack of success in life, this must alert the surgeon. Impairment of social activities must also be evaluated. Patients reporting significant social impairment by minimal defects are very likely to suffer from body dysmorphic disorder. In particular, avoidance of daily activities in addition to job and relationship problems require closer evaluation. The surgeon must also evaluate how a patient copes with the defect. Camouflage techniques such as wearing makeup or avoiding certain clothing are often encountered even in normal patients. Contrary to this, body dysmorphic disorder patients often acquire meticulous, time-consuming techniques. Any patient who shows signs of self-surgery or reports personal body modification techniques should be considered to likely suffer from body dysmorphic disorder. 35 Patients who pick at their skin are also very likely to suffer from body dysmorphic disorder. 16 The patient should be observed during the entire interview. The patient s behavior is best studied while he or she is talking. Aggression, demands, threats, or fear can easily be detected. Not only the patient s expression but also the gestures, movements, ticks, fumbling around, restlessness, or also motionless and depressed behavior warrant closer observation. Any behavior that is not within a normal range may suggest underlying psychiatric conditions. 27 The office staff should be asked about their observations as well. Body dysmorphic disorder patients may exhibit normal behavior in front of the surgeon, who only spends a limited amount of time with the patient. Very often, the patient is more talkative with office staff and may display alarming behavior only there. Frequent canceling and rescheduling of appointments, demanding appointments outside of office hours, or refusal to talk to anyone but the physician should alert the surgeon. 27 If any suspicious observations are made by the surgeon or the staff, the patient should be seen at least for a second preoperative consultation. 16,27,36 Another way to diagnose body dysmorphic disorder is the use of questionnaires. All questionnaires require patient motivation before a consultation. Body dysmorphic disorder patients are often secretive and therefore may not be willing to fill out such questionnaires. 37 There are several available questionnaires, for example, the body dysmorphic disorder questionnaire is a self-report measure that is based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and detects appearance concerns and their impact on activities of daily living. 38 A second version, the body dysmorphic disorder questionnaire dermatology version, is used mainly in dermatology settings. It is described as a screening tool only and is not diagnostic. It is also reported to be useful in clinical settings. The questionnaire has a high sensitivity and specificity, which may result in overdiagnosis. Questionnaires are useful tools but not very practical in a busy practice. To date, no uniformly accepted questionnaires, eliminating the impressionistic process of diagnosing body dysmorphic disorder, exist. 36 THE DECISION TO OPERATE Because body dysmorphic disorder is a psychiatric disorder, surgery cannot cure the patient. Only the symptom and not the cause of the disease can be approached by the surgeon. Although no prospective outcome studies with surgical treatment exist, the almost unanimous recommendation is not to operate on patients with body dysmorphic disorder. 18,19,39 41 The outcome is generally poor. 42 Dissatisfaction with the result or ultimately violence toward the surgeon have been reported. 2,43 46 A retrospective study has shown that surgery in such patients not only results in dissatisfaction in 70 percent, but patients may escalate complaints and bear grudges against the physician. 4 In over 80 percent of cases, the patient s psychological situation will destabilize or the patient will find new defects Only very few authors have suggested correction of minor de- 1926

4 Volume 119, Number 6 Body Dysmorphic Disorder formities after patients have been screened. In these reports, it remains unclear whether the diagnosis of body dysmorphic disorder had been made. 47,51 After consideration of these results, it seems justified to avoid operating on patients with body dysmorphic disorder. 18,19,40,41 A similar recommendation was made by Fukuda: Once we had a difficult time with dysmorphophobics we tended to avoid surgery. 4 ALGORITHMIC APPROACH Despite the vast body of literature on body dysmorphic disorder and the high awareness of aesthetic surgeons of the disease, diagnosing body dysmorphic disorder during a preoperative consultation remains challenging. 34 To date, no proven and practical method exists. Therefore, we have developed an algorithm, combining established methods, that will help to filter out body dysmorphic disorder patients preoperatively (Fig. 1). This algorithm is based on two main parameters. The first is the severity of the deformity from the surgeon s point of view. The second is the general behavior of the patient, an impression gained from the patient interview, surgeon and staff observation, and sometimes questionnaires. There are three groups of patients. The first group includes patients with no deformity and unreasonable behavior. Such patients are recognized easily, and the diagnosis of body dysmorphic disorder may be considered and patients should be referred to a psychiatrist. The opposite group consists of patients with a correctable deformity and reasonable expectations and may also easily be defined. A surgical correction may be offered. The middle group, consisting of patients with a minimal but correctable deformity and inadequate behavior poses the greatest risk of missing the diagnosis of body dysmorphic disorder. These patients not only are a challenge from the surgical point of view but also display inadequate behavior. The surgeon must be extremely critical when offering an operation. Such patients should at least be evaluated at a second preoperative consultation. 52 A second consultation has been suggested, especially for patients requesting secondary rhinoplasties, a field where many body dysmorphic disorder patients are found. Only when the patient displays adequate behavior at the second visit may surgical correction be considered. 52 All other patients should be turned down and a referral to a psychiatrist should be offered. Fig. 1. Algorithm for detecting body dysmorphic disorder (BDD) preoperatively. 1927

5 Plastic and Reconstructive Surgery May 2007 HOW TO TELL THE PATIENT Once a surgeon has diagnosed body dysmorphic disorder, telling the patient without offending him or her will prove quite demanding. Ultimately, a patient with body dysmorphic disorder needs to receive mental health care. Because body dysmorphic disorder patients have poor insight, defensive reactions and refusal of psychiatric referrals should be anticipated. Nevertheless, a surgeon needs to communicate this to the patient and a referral to a psychiatrist should be no different from sending a patient to a gastroenterologist. 39 The information should be given in a straightforward manner to avoid embarrassing or ridiculing the patient. Not mentioning the term psychiatrist will be interpreted as contempt by the patient. The surgeon should suggest a consultation in a nonthreatening way, underscoring the importance. It could sound like the following: Operations that change the shape of the body may have all sorts of psychological effects. You and I need some help in figuring out how an operation may affect you. Undergoing an elective surgical operation is not a decision that should be made lightly. Therefore, I would like to refer you to a psychiatrist who is an expert in helping people understand their feelings about their bodies and how they may react to operations that change the body. 39 By using the term psychiatrist, the surgeon demonstrates that he or she accepts this as a routine aspect of health care. Nevertheless, there will be patients who will not accept such referrals and will deny any illness. TREATMENT OPTIONS Patients suffering from body dysmorphic disorder should be treated by psychiatrists. Psychotherapy and pharmacotherapy either alone or as in combination are useful. 53 Psychotherapy has been reported to have positive effects on body dysmorphic disorder In particular, cognitive-behavioral therapy is successful Cognitive-behavioral therapy typically consists of exposure, where the patient has to expose the imagined defect in a social setting, and response prevention techniques, which prevent the patient from using established patterns such as mirror checking, reassurance seeking, and camouflaging behaviors. 16 Cognitive techniques that identify and challenge the patient s thinking also are used. They are meant to change the erroneous belief of the patient. Cognitive-behavioral therapy may reduce body dysmorphic disorder and depressive symptoms in the long term. 55,57 Other approaches such as supportive or insight-oriented psychotherapy or counseling seem to be ineffective for body dysmorphic disorder. 50,58 Pharmacotherapy has also proven to be effective for body dysmorphic disorder. Selective serotonin reuptake inhibitors are currently the best choice. 50,59,60 Selective serotonin reuptake inhibitors are antidepressants that, in addition, reduce obsessive and compulsive behaviors. In particular, fluvoxamine and clomipramine have been studied and have a response rate of above 60 percent Clinical experience suggests that all selective serotonin reuptake inhibitors may be effective for body dysmorphic disorder. 59 Selective serotonin reuptake inhibitors seem to work regardless of the fact that the patient is delusional. 50 Non selective serotonin reuptake inhibitor psychotic medications have not been found to help in body dysmorphic disorder. 61 CONCLUSIONS Body dysmorphic disorder is a disease that can be found in approximately 10 percent of patients seeking cosmetic procedures. It is characterized by an excessive preoccupation with a perceived aesthetic deformity and significantly impairs the functioning of the patient. Such patients request cosmetic procedures to relieve themselves from their distress. Patients do not benefit from surgery, which leaves them dissatisfied and often even exacerbates their symptoms or leads to a shift to other imagined defects. For the surgeon, it is important to diagnose body dysmorphic disorder before an operation. A careful patient interview and observation in combination with observations of the staff will establish the diagnosis. Given the responsibility of a surgeon for himself or herself, the staff, and colleagues, it is mandatory to tell the patient that there is concern about the patient and not just send the patient off to the next surgeon. Patients in which body dysmorphic disorder is diagnosed or suspected should not be operated on but should be referred to a psychiatrist to receive appropriate treatment, including cognitive-behavioral therapy and selective serotonin reuptake inhibitor medication. The challenge is a timely diagnosis. Despite the extensive research on body dysmorphic disorder, no standardized approach for a correct diagnosis in a busy practice setting exists so far. The presented algorithm will help to identify patients who are likely to suffer from body dysmorphic disorder preoperatively and to avoid disappointment for the surgeon and patient alike. Future research will have to focus on 1928

6 Volume 119, Number 6 Body Dysmorphic Disorder further refining such algorithms for a preoperative diagnosis. Michael Jakubietz, M.D. Department of Hand, Plastic, and Reconstructive Surgery Kantonsspital St. Gallen Rorschacherstr. 85 CH-9007 St. Gallen, Switzerland michael.jakubietz@kssg.ch DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. REFERENCES 1. Morsellini, E. Sulla dismorfofobia e sulla tafefobia. Bull. Acad. Med. Genova 6: 110, Groenman, N. H., and Sauer, H. C. Personality characteristics of the cosmetic surgical insatiable patient. Psychother. Psychosom. 40: 241, Edgerton, M. T., Langman, M. W., and Pruzinsky, T. Plastic surgery and psychotherapy in the treatment of 100 psychologically disturbed patients. Plast. Reconstr. Surg. 88: 594, Fukuda, O. Statistical analysis of dysmorphophobia in outpatient clinic. Jpn. J. Plast. Reconstr. Surg. 20: 569, American Psychiatric Association. 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7 Plastic and Reconstructive Surgery May Goin, M. K., and Rees, T. D. A prospective study of patients psychological reactions to rhinoplasty. Ann. Plast. Surg. 27: 210, Phillips, K. A., Atala, K. D., and Pope, H. G. Diagnostic instruments for body dysmorphic disorder. In New Research Program and Abstracts of the American Psychiatric Association 148th Annual Meeting in Miami, Fla., May 20 25, Washington, D.C.: American Psychiatric Association, P Goin, J. M., and Goin, M. K. Changing the Body: Psychological Effects of Plastic Surgery. Baltimore: Williams & Wilkins, Crerand, C. E., Phillips, K. A., Menard, W., and Fay, C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics 46: 549, Phillips, K. A., Pagano, M. E., Menard, W., et al. Predictors of remission from body dysmorphic disorder: A prospective study. J. Nerv. Ment. Dis. 193: 564, Phillips, K. A. Body dysmorphic disorder: The distress of imagined ugliness. Am. J. Psychiatry 148: 1138, Phillips, K. A., McElroy, S. L., and Lion, J. R. Body dysmorphic disorder in cosmetic surgery patients. Plast. Reconstr. Surg. 90: 333, Ladee, G. A. Hypochondrial Syndromes. Amsterdam: Elsevier, Wright, M. R. The male aesthetic patient. Arch. Otolaryngol. Head Neck Surg. 113: 724, Thomson, J. A., Knorr, N. J., and Edgerton, M. T. Cosmetic surgery: The psychiatric perspective. Psychosomatics 19: 7, Edgerton, T., Jacobson, W. E., and Meyer, E. Surgical-psychiatric study of patient seeking plastic surgery: Ninety-eight consecutive patients with minimal deformity. Br. J. Plast. Surg. 13: 136, Andreasen, N. C., and Bardach, J. Dysmorphophobia: Symptom or disease? Am. J. Psychiatry 134: 673, Veale, D., Boocock, A., Gournay, K., et al. Body dysmorphic disorder: A survey of fifty cases. Br. J. Psychiatry 169: 196, Phillips, K. A., McElroy, S. L., Keck, P. E., et al. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharm. Bull. 30: 179, Crisp, A. H. Dysmorphophobia and the search for cosmetic surgery. Br. Med. Surg. 282: 1099, Daniel, R. K. Rhinoplasty: An Atlas of Surgical Techniques. New York: Springer, Pp Sarwer, D. B., Gibbons, L., and Crerand, C. Treating body dysmorphic disorder with cognitive-behavior therapy. Psychiatr. Ann. 34: 934, Wilhelm, S., Otto, M. W., and Lohr, B. Cognitive behavior group therapy for body dysmorphic disorder: A case series. Behav. Res. Ther. 37: 71, Veale, D., Gournay, K., Dryden, W., et al. Body dysmorphic disorder: A cognitive behavioral model and pilot randomized controlled trial. Behav. Res. Ther. 34: 717, Castle, D. J., and Morkell, D. Imagined ugliness: A symptom which can become a disorder. Med. J. Aust. 173: 205, McKay, D. Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behav. Mod. 23: 620, Phillips, K. A., McElroy, S. L., Keck, P. E., et al. Body dysmorphic disorder: 30 cases of imagined ugliness. Am. J. Psychiatry 150: 302, Phillips, K. A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, Phillips, K. A., and Rocco, C. Body dysmorphic disorder. Curr. Opin. Psychiatry 14: 113, Phillips, K. A., Dwight, M. M., and McElroy, S. L. Efficacy and safety of fluvoxamine in body dysmorphic disorder. J. Clin. Psychiatry 59: 165, Perugi, G., Giannotti, D., Di Vaio, S., et al. Fluvoxamine in the treatment of body dysmorphic disorder (dysmorphophobia). Int. Clin. Psychopharmacol. 11: 247, Hollander, E., Allen, A., Kwon, J., et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: Selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch. Gen. Psychiatry 56: 1033,