Psychiatric Manifestations of Body Dysmorphic Disorder Clinical Presentation

Due to the nature of the symptoms and the perceived solution, patients with body dysmorphic disorder (BDD) typically present to their plastic or cosmetic surgeon. Given the significant rates of prevalence of BDD in this population it is critical that plastic and cosmetic surgeons elicit an appropriate history and consider referral to a psychiatrist.

Most patients with BDD presenting to their surgeon will not consider the possibility that the cause is perception-based and are thus more amenable to treatment from a psychiatrist versus surgical treatment; therefore, the referring surgeon or internist is advised to exercise sensitivity and empathy when making the referral. Framing the referral in the context of standard procedures, similar to the psychological workup required as part of many elective bariatric procedures may increase the likelihood that that patient will follow through with the referral, decrease the likelihood that the patient will be disappointed with the referring physician, and possibly decrease the likelihood that the patient will engage in surgeon-shopping.

Screening, identifying and referring patients with BDD is particularly critical when physicians consider that patients with BDD who undergo corrective surgical procedures are typically unsatisfied with the results and often present with new complaints related to perceived defects ensuing surgery and are reported to become both litigious and violent.

Eliciting a thorough history focused on symptoms pertinent for BDD is the most reliable tool clinicians have to make an accurate diagnosis. A few surveys/scales are available that clinicians can use to assist them in making such a diagnosis. First published in 1997, Phillips and colleagues developed a version of the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). This survey is a 12-item semistructured clinician-administered tool that has consistently been shown to be a reliable and valid measure of BDD severity.^[20]

In the course of interviewing a patient with BDD, a clinical picture will emerge that illustrates many of the following behaviors.

• Patients with body dysmorphic disorder feel compelled to engage in ritualistic behaviors to confirm the perceived defect or avoid its recognition by others. These behaviors include compulsive mirror checking, compulsive mirror avoidance, compulsive grooming (eg, hair combing, hair plucking, picking skin, applying makeup), and repetitively comparing the perceived defect with the bodies of others.
• Sometimes patients require constant reassurance from others that their defect is "normal" or "not that bad."
• Thoughts and behaviors relating to the perceived defect generally take up to 1 hour or more per day, and in some cases can take up to 8 hours per day. In a series of adolescent patients, the average amount of time spent in activities related to their perceived defect was as much as 3 hours. These patients had particularly poor insight into their problem.
• Patients with poorer insight are likely to spend more time dealing with the imagined defect. Patients often seek repeated dermatologic or cosmetic referral for correction of the perceived defect.

Social situations are difficult for these patients, because they fear people may point out their imagined defect or avoid them. They usually have difficulty maintaining relationships with peers, family, and spouses. Some patients skip school or work repeatedly. Many become housebound. About 30% of those with BDD have been housebound at some point for at least 1 week because of their preoccupation.^[17]

Asking the following questions can quickly help clinicians screen for the presence of these symptoms.

1. Are you worried about how you look? Yes/No
2. If yes: Do you think about your appearance problems a lot and wish you could think about them less? Yes/No
How much time per day on average do you spend thinking about how you look? Add up all the time you spend on this.
1. Less than 1 hour a day
2. 1-3 hours a day
3. More than 3 hours a day
3. Is your main concern with how you look that you aren’t thin enough or that you might become too fat? Yes/No
How has this problem with how you look affected your life?
1. Has it often upset you a lot? Yes/No
2. Has it often gotten in the way of doing things with friends, your family, or dating? Yes/No
3. Has it caused you any problems with school or work? Yes/No
4. Are there things you avoid because of how you look? Yes/No

As described on the Butler Hospital’s public website, the authors explain the results.^[21]

You're likely to have BDD if you gave the following answers:

Question 1: Yes to both parts

Question 2: Answer b or c

Question 3: While a "yes" answer may indicate that BDD is present, it is possible that an eating disorder is a more accurate diagnosis.

Question 4: Yes to any of the questions

All patients should undergo a thorough mental status examination. Key findings that may be associated with a patient experiencing symptoms consistent with a diagnosis of BDD include the following:

• Mood: Patients may characteristically describe mood disturbances consisting of feelings of depressed mood as well as irritability and anxiousness.
• Thought process: Patients may demonstrate perseveration on their physical appearance, particularly associated with their perceived defect.
• Thought content: Patients’ thoughts associated with the perceived defect in their physical appearance may actually represent such a distortion of reality that their belief is delusional. As with any patient, assessing the presence of suicidal and homicidal ideation is crucial. Patients with BDD may be at particularly high risk for the presence of both following an “unsuccessful” surgery.

With regard to a physical examination, it is the lack of physical findings compared to the patient’s complaint regarding the perceived physical defect that is notable in BDD. Similar to other psychiatric illnesses that have a substantive somatic component, the presence of occult medical conditions like a brain tumor or endocrine perturbations must be ruled out. Thus, all patients should have a thorough physical examination.^[22]

See Pathophysiology.