Body dysmorphic disease (dermatologic nondisease): Synonyms: body dysmorphic disorder, dysmorphophobia (not good as the condition is not a ‘phobia’), dermatological nondisease (not good as it is not particularly accurate)



Body dysmorphic disease (dermatologic nondisease)


Synonyms: body dysmorphic disorder, dysmorphophobia (not good as the condition is not a ‘phobia’), dermatological nondisease (not good as it is not particularly accurate)


Anthony Bewley


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


Body dysmorphic disorder (BDD) is characterized by a preoccupation with an imagined defect in physical appearance, or if there is a slight physical anomaly, concern is out of proportion to the anomaly. There is a spectrum from patients with overvalued ideas to those whose beliefs are held with delusional conviction. The prevalence of BDD is surprisingly common, occurring 1–2% in of the general population; the average age at onset is late adolescence. There is a high degree of comorbidity with mood disorders, obsessive compulsive disorder, and social phobia. These are a very difficult group of patients to treat, one of the main obstacles being that most patients lack insight and will not accept psychiatric treatment or referral. They are therefore best seen in a joint psychodermatology clinic where they can be supported, and gradually encouraged to accept psychological interventions. Their help-seeking behavior should also be contained as they may repeatedly try to consult other dermatologists or plastic surgeons.


Preoccupations commonly involve the face and head, the skin and hair being the most frequent areas of concern, but any area of the body can be affected. Dermatologic preoccupations are distressing, time-consuming, and difficult or impossible for patients to resist. Insight is typically poor, and alterations in perception often reach delusional proportions. Most patients have ideas of reference, thinking that others take special notice or mock them for their perceived defect. Repetitive behaviors are present in almost all patients: excessive checking or grooming, constant need for reassurance, and skin picking are common. The risk of suicide is high, with approximately one-quarter of patients attempting suicide.



Management strategy


BDD is common in dermatologic settings, especially in dermatological surgery where the prevalence is estimated at 11.9%. In aesthetic surgery and laser suites the prevalence may be as high as 25–30% of patients, and so identification of these patients is extremely important, as they typically have a poor response to cosmetic dermatological treatments. Dissatisfaction, anger, and even aggression toward the treating dermatologist are known. Patients with BDD may have underlying psychiatric disorders, including depression, alcohol and other recreational substance abuse and obsessive–compulsive disorder.


Body areas on which patients with BDD may focus:



Patients presenting with extreme concern that appears out of proportion to their chief complaint, accompanied by a paucity of objective physical findings, should raise suspicion that dermatologic nondisease may be present. Obsession, rumination, and extreme psychological distress are striking features. These patients usually report dissatisfaction with previous physicians and describe poor outcomes from past medical and surgical interventions. Skin picking and related behaviors such as excessive grooming, and relentless need for reassurance are characteristic. Attempts at reassurance are inevitably futile, as their perceptions are at least fixed, and in some cases, delusional, which by definition suggests that the distorted perceptions are unresponsive to logic and persuasion. The frequent presence of referential thinking further substantiates the delusional nature of the perceptions. Patients often wear heavy makeup and hats to hide their imperfections and perceived ugliness. Patients with BDD make unusual and excessive requests for cosmetic procedures in the belief that they will transform or fix their lives. Clinical interactions and consultations with these patients are typically long, difficult, and emotionally draining.


In the management of patients with BDD, appropriate treatment of any actual skin disease should not be overlooked. Selective serotonin reuptake inhibitors are first-line therapies, and can be administered in conjunction with cognitive behavioral therapy. If patients fail to respond and the disorder is severe, or where there is delusional BDD, antipsychotics may be a second line alternative (though the evidence for the successful usage in these circumstances is anecdotal).



Specific investigations




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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Body dysmorphic disease (dermatologic nondisease): Synonyms: body dysmorphic disorder, dysmorphophobia (not good as the condition is not a ‘phobia’), dermatological nondisease (not good as it is not particularly accurate)

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