Body Dysmorphic Disorder
Spotting the inappropriate cosmetic surgery patient
By: Lisette Hilton
February 01, 2003
Source: Dermatology
Times
San Francisco –– Dermatologists might
find it strange when patients come into their offices complaining of
nearly invisible "scars" or other imperfections. Yet the patients
focus on the flaws to the point that one would think they were dominant
features.
Be aware of these patients, says Lucinda Buescher,
M.D., associate professor of dermatology, Southern Illinois University
School of Medicine, Springfield, Ill. They might be suffering from
body dysmorphic disorder (BDD).
It is worth getting acquainted with the disorder
and how you will handle it because chances are people with BDD will
end up in every dermatologist's office.
According to Dr. Buescher, research has shown
that 49 percent of the patients being treated by psychiatrists and
psychologists for their BDD reported they had been to a dermatologist.
Every dermatologist tends to get his or her share. A paper by Phillips
KA et al in the March 2000 Journal of the American Academy of Dermatology
reported that 11.9 percent of patients seeking dermatological treatment
screened positive for BDD.
Dr. Buescher said BDD is defined in the DSM-IV
to have three components: 1) patients have to be preoccupied with
a defect in their appearance and it is usually imagined or minimal;
2) the defect causes significant distress; 3) it cannot be accounted
for by another medical or psychiatric condition.
"The distress is the most important thing,"
Dr. Buescher said. "We consider it normal to dislike parts of
ourselves, but we are not impaired by it. We can still function, work,
and interact normally. But people who have BDD, by definition, are
hindered by their perceived deformity in some way, and it can be very
severe."
A BDD patient, for example, might perceive
that a normal looking nose is too big, and avoid a situation where
he has to talk closely with someone for fear that the other person
will notice his nose. Dr. Buescher said that BDD, which has an average
onset in adolescence, might cause a teen with mild acne to drop out
of school because she just cannot bare the anxiety.
The first consultation often reveals BDD. But
a more definitive diagnosis can make it easier for a dermatologist
to confront the patient with the disorder. Dr. Buescher recommends
instituting a brief four-question self-assessment (The BDD Questionnaire
developed by Katharine Phillips, M.D.) for all cosmetic patients.
Patients can answer the questions in the waiting room, so the dermatologist
can review the answers during the consultation.
A "no" answer to either of the first
two questions weeds out those who do not have a disorder. The questions
are:
Some BDD patients are easier than others to
reach, she said. "If patients have good insight, that's a wonderful
thing because we can usually talk with them very early on about the
fact that it is somewhat of a misperception. But if their insight
is poor and they are somewhat defensive or in denial, or bordering
on delusional, oftentimes getting them to agree to take the medication
is impossible," according to Dr. Buescher.
In general, Dr. Buescher brings up BDD with
patients she suspects have it. Patients who have good insight might
bring it up themselves, saying that they know no one else notices
their imperfections but the flaws bother them, anyway. "Then,
the physician can say, 'You are right, it is a problem that does not
need to be medially or surgically corrected but we can probably help
you about how you feel about it and perceive it. One way to do that
would be to try the medications,'" Dr. Buescher said.
For the patient who is delusional or has poor
insight, Dr. Buescher said that it is best to simply prescribe the
medications and hope the patient sees the light. Having the results
of the questionnaire also can help. At least, the test gives the physician
some objective evidence, such as results of a blood test, to discuss
with the patient, saying, "Looking at these results, you probably
have BDD or some degree of it."
Of course, the advice does not apply to a patient
with obvious lid redundancy or a large nose - even if they might seem
obsessive, she said.
Dr. Buescher's message to dermatologists is
that they need to recognize that BDD exists and be willing to deny
treatment that is not medically indicated. It is also important that
dermatologists have a plan in place, in which they can begin to help
these patients by offering medications and suggesting professional
help.
In her practice of 12 years, Dr. Buescher concurs
with research that about 12 percent of her patients are affected by
the disorder. And in her experience the dermatologist cannot make
these patients happy in the conventional way. "It is not up to
us, necessarily, to definitely treat these patients and make them
better but we may be the front door [to their getting help],"
she said. "These patients repeatedly implore physicians to perform
cosmetic procedures and it is often difficult to deny their wishes.
But I would like to think that we would be happier as practitioners
if we did address it head on and tried to get these people in the
right avenue of treatment."
