by Elizabeth Cook*
Keywords: Body dysmorphic disorder, cosmetic dermatology, cosmetic surgery, screening, surgery
We all know someone who sees a different reality in the mirror. We try to convince her that she is beautiful. “No one is staring,” you say. “Your nose looks just fine.” She may point to her cheek and demand confirmation of invisible flaws. I say she because body dysmorphic disorder (BDD) favors women. Like eating disorders, it usually begins in adolescences, but unlike eating disorders the focus is on minimally noticed or imagined defects, not on fat. By the time these women reach adulthood, they end up in the dermatology clinic, seeking an instant cure for what they believe to be a physical problem. BDD affects the general population at a rate of 0.7%-2.2%, but cosmetic and general dermatologists see an influx nearing 15%.  One study from an elective plastic surgery clinic reported 53% of surgical candidates with BDD. 
It’s important for dermatologists to recognize BDD before performing procedures. After reviewing the literature, I’m providing what I believe to be the five most important takeaway points about BDD in the dermatology setting.
Top 5 Reasons Why You Should Care That Your Patient Has BDD
- BDD is real. You can find it in the DSM-V as an obsessive compulsive and related disorder. Surgery is neither effective nor the standard of care. [1, 3, 4]
- Patients are often dissatisfied with surgical outcomes, leading to repeated surgeries and increased risk of complications. [2, 3]
- Substitution, the exchange of a previously flawed feature for a newly flawed feature in the mind of the patient, is a possible outcome of surgery and could lead to unnecessary surgeries on multiple body parts. 
- There have been reports of lawsuits, personal threats, and acts of violence against physicians as a result of not meeting the patient’s expectations for surgical outcomes. [1, 5]
- Dermatologists have the opportunity to provide real help to patients with BDD in the form of redirecting them toward mental health professionals and away from procedures that continue the cycle of self-dissatisfaction.
When a patient suspicious for BDD walks through the clinic doors, dermatologists can take action. Stocking the clinic with a screening tool, such as the body dysmorphic disorder questionnaire- dermatology version (BDDQ-DV) is a good first step. It was developed by Dufresne et al. as an adaptation to the BDDQ used by psychiatrists. It’s a self-administered screening tool that takes 1-2 minutes to complete and score, and it has a sensitivity of 100% and specificity of 92.3%.  If your patient screens positive, here’s what you can do to begin addressing their mental health needs:
- Educated them about BDD
- Explain that surgery is not likely to help BDD
- Provide a referral to a psychiatrist or other qualified mental health professional
Dermatologists are one of the most common medical professionals seen by patients with BDD.  It is imperative to recognize the greater influx of BDD in this patient population and avoid offering procedures that could cause more harm than good. Providers can best serve these patients by taking the time to educate them on this condition and refer them to a mental health specialist for further evaluation.
- Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice.Dermatol Surg. 2001 May;27(5):457-62. PubMed PMID: 11359494. [If you cannot access this questionnaire, here is a link to the Body Dysmorphic Disorder Foundation’s screening tool.
- Vindigni, V., Pavan, C., Semenzin, M. et al. The Importance of Recognizing Body Dysmorphic Disorder in Cosmetic Surgery Patients: Do Our Patients Need a Peroperative Psychiatric Evaluation? Eur J Plast Surg (2002) 25: 305. https://doi.org/10.1007/s00238-002-0408-2
- Lai CS, Lee SS, Yeh YC, Chen CS. Body dysmorphic disorder in patients with cosmetic surgery.Kaohsiung J Med Sci. 2010 Sep;26(9):478-82. doi: 10.1016/S1607-551X(10)70075-9. PubMed PMID: 20837344.
- Griffiths S, Murray SB, Krug I, McLean SA. The Contribution of Social Media to Body Dissatisfaction, Eating Disorder Symptoms, and Anabolic Steroid Use Among Sexual Minority Men.Cyberpsychol Behav Soc Netw. 2018 Mar;21(3):149-156. doi: 10.1089/cyber.2017.0375. Epub 2018 Jan 24. PubMed PMID: 29363993; PubMed Central PMCID: PMC5865626.
- Danesh, Melissa, et al. “Body Dysmorphic Disorder Screening Tools for the Dermatologist: A Systematic Review.” Practical Dermatology, Feb. 2015, pp. 44–49., doi:http://practicaldermatology.com/2015/02/body-dysmorphic-disorder-screening-tools-for-the-dermatologist-a-systematic-review-s/.
*Author Bio: Elizabeth Cook is a 3rd year medical student in the Class of 2020 at Texas Tech University Health Sciences Center (TTUHSC) in Lubbock, Texas. She is pursuing a career in dermatology. She is active in her medical school government, volunteers at the student-run free clinic, and painted 2 murals at a children’s clinic in Lubbock. Before attending medical school, she was a public school teacher in the Dallas, Texas area for 5 years.