Body dysmorphic disorder may be ‘under-diagnosed’ by cosmetic professionals, study suggests

Plastic surgeons and other cosmetic professionals are familiar with the challenges posed by patients with body dysmorphic disorder (BDD) seeking cosmetic procedures, reports a survey study in the February issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

But BDD may be "under-diagnosed" by cosmetic professionals, compared with the two to ten percent prevalence rates reported in previous studies, suggests the study by Theo Bouman, PhD, of University of Groningen, the Netherlands, and colleagues. "Body image problems should become a standard topic during cosmetic consultations," the researchers write.

Most Doctors Consider BDD in Evaluating Patients for Cosmetic Procedures
The researchers surveyed three groups of Dutch cosmetic professionals—plastic surgeons, dermatologists, and others—regarding their knowledge of and experience with BDD. Responses were received from 173 professionals who perform cosmetic procedures—not only surgery but also minimally invasive procedures, such as botulinum toxin or filler injections.

Body dysmorphic disorder refers to perceived flaws in appearance that lead to personal, social, or occupational impairment. Patients with such extreme dissatisfaction with body image have high rates of mental health problems, including depression and suicide risk.

Most of the cosmetic professionals surveyed said they were familiar with BDD and the criteria used to diagnose it. About two-thirds of said they had encountered one to five patients with BDD in their practice over the past years. By comparison, studies have reported that BDD is present in about two percent of the general population, and in up to ten percent of patients seeking cosmetic procedures.

Most respondents said they sometimes or often addressed body image problems while consulting with patients—but only seven percent routinely did so. Just under half said they collaborated with psychologists or psychiatrists.

Most patients with BDD seek plastic surgery or other cosmetic procedures. However, they are generally dissatisfied with the results, often causing them to desire further procedures. As a result, BDD is considered a "contra-indication" for cosmetic procedures. About 70 percent of survey respondents said they would refuse to perform cosmetic procedures in a patient they suspected of having BDD.

Plastic surgeons were more likely to refer patients to a psychiatrist or psychologist and to refuse treatment in a patient with BDD, compared to the other groups of cosmetic professionals. About 16 percent of cosmetic professionals reported verbal altercations, while six percent received legal threats.

"Most of the cosmetic professionals in our sample reported to have a considerable degree of awareness of BDD and to use this knowledge in their decision whether or not to perform a cosmetic procedure," Dr. Bouman and coauthors write. While generally consistent with previous studies, the results indicate an "apparent under-diagnosis" of BDD.

This suggests that cosmetic professionals should receive education about recognition and management psychological contra-indications to cosmetic procedures. Dr. Bouman and colleagues conclude, "This would make the exploration of body image problems (such as BDD) a standard topic in every patient encounter in a cosmetic clinic."