A critical review of cosmetic treatment outcomes in body dysmorphic disorder

Caring for Patients With Body Dysmorphic Disorder Seeking to Undergo Plastic Surgery and/or Aesthetic Interventions

In the field of medical aesthetics and plastic surgery, it is not uncommon to interact with clients who never seem to be satisfied, regardless of the success of an intervention. Medical professionals may attribute this to the patient having an overly critical nature; however, this continual dissatisfaction could also be the result of a mental health disorder known as body dysmorphic disorder (BDD) that is significantly underdiagnosed and prevalent within the plastic surgery and aesthetic patient population. According to the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5; American Psychiatric Association, 2013), BDD is defined as, "a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others" (Substance Abuse and Mental Health Services Administration, 2016, Table 23). Having the ability to identify the signs of BDD, utilize appropriate communication skills with individuals who may have BDD, and understand the implications of providing additional aesthetic treatments for patients who present with BDD allows aesthetic practitioners to prioritize and promote patient safety, well-being, and satisfaction.

An Evidence-based Pathway for Body Dysmorphic Disorder in Facial Aesthetics

Aesthetic procedures should be avoided in patients with body dysmorphic disorder (BDD) since they can negatively impact mental health and lead to further aesthetic dissatisfaction. There are no evidence-based patient pathways for BDD in facial aesthetics which can result in the failure to identify patients with BDD, leading to unsuitable treatments and suboptimal patient care. We aim to construct the first evidence-based patient pathway for BDD in surgical and nonsurgical facial aesthetics. A systematic review was performed and articles that discussed screening or patient pathways for BDD in field of facial aesthetics were included. We extracted relevant information from each article on screening tools and pathways for BDD. Data were synthesized by summarizing the data under column headings into a structured narrative and into new tables. Based on this synthesis, a practical pathway for BDD was constructed. Forty articles fulfilled the criteria for inclusion. Twenty-eight BDD screening tools were discussed in the included articles, and we provide an overview of these tools. Thirty-one articles discussed patient pathways for BDD, and we synthesized this information into a structured narrative. Combining these findings, we present an evidence-based patient pathway for BDD for patients presenting for facial aesthetic treatments. This systematic review has resulted in the first, evidence-based, patient pathway for BDD in surgical and nonsurgical facial aesthetics. This practical pathway can be used by aesthetic clinicians to identify patients with potential BDD and provide clear guidance for managing cases where BDD is suspected. It will help reduce the number of facial aesthetic procedures performed on patients with BDD, safeguard patient mental well-being, and prevent further aesthetic dissatisfaction.

Body dysmorphic disorder among Lebanese females: A cross-sectional study

BACKGROUND

Body dysmorphic disorder (BDD) is a mental health disorder characterized by an excessive preoccupation with perceived flaws or defects in one's appearance. This study aimed to assess the prevalence of BDD, identify the predictors of BDD, explore the associations of BDD with social anxiety and social phobia, and examine the effect of social media on BDD.

METHODS

In this cross-sectional study that was conducted between January and March 2023, Lebanese adult females completed an online survey that included questions about sociodemographic characteristics, cosmetic interventions, BDD, social media use, and Social Interaction Anxiety Scale (SISA-6)/Social Phobia Scale (SPS-6). The collected information was analyzed using descriptive statistics and regression analysis. Statistical significance was set at p value <0.05.

RESULTS

A sample of 1048 were eligible for analysis and the mean age was 29.94 ± 10.01 years. It was shown that 141 (13.5%) participants were BDD positive. The results of the multivariable logistic regression showed that only females living in urban areas (aOR = 2.351 [95% CI 1.502-3.680], p < 0.001), unmarried (aOR = 1.672 [95% CI 1.041-2.684], p = 0.033), reporting higher social media use score (aOR = 1.526 (95% CI 1.401-1.661), p < 0.001), and higher SIAS/SPS score (aOR = 1.040 (95% CI 1.022-1.060), p < 0.001) were significantly positively associated with BDD.

CONCLUSION

This study found a high BDD prevalence (13.5%) among Lebanese adult females compared with other regions and was associated with anxiety and increased social media platforms use. This highlights the need for a comprehensive approach in the assessment of BDD, along with preventive measures to address the negative impacts of social media on well-being and promote healthy body image.

The heart of it all: Body dysmorphic disorder in cosmetic surgery

BACKGROUND

Body Dysmorphic Disorder (BDD) represents a prevalent mental health condition characterized by distress arising from self-perceived physical imperfections. BDD serves as a contraindication to aesthetic surgery. Recognizing BDD holds paramount importance for plastic surgeons, as it is instrumental in averting the exacerbation of this condition while ensuring appropriate referrals.

OBJECTIVE

This study aimed to investigate the prevalence of BDD in cosmetic surgery patients and to pinpoint key characteristics associated with BDD. This information provides plastic surgeons with specific factors to consider during preoperative evaluations.

METHODS

We employed TriNetX database to identify patients with BDD who underwent cosmetic surgery identified by Current Procedural Terminology codes. Demographics and patient characteristics were identified using the International Classification of Diseases 10 codes. We calculated odds ratios (OR) by using chi-squared tests to assess risk factors among patients with BDD.

RESULTS

Of 226,374 patients who underwent plastic surgery between August 2002 and August 2022, fewer than 0.1% were diagnosed with BDD. Of the BDD patients, 52.1% were diagnosed after cosmetic surgery. Compared with the control group, BDD patients were more likely to undergo rhinoplasty (OR=1.784, p = 0.004) and nonlocalized lipectomy (OR=1.448, p = 0.021) and less likely to undergo blepharoplasty (OR=0.451, p = 0.002). Findings indicated a strong association between BDD patients undergoing cosmetic procedures and comorbid psychiatric conditions such as depression (OR=4.279, p < 0.05), anxiety (OR=5.490, p < 0.05), and Attention-Deficit Hyperactivity Disorder (OR=3.993, p < 0.05).

CONCLUSIONS

These findings underscore the ongoing significance of BDD in the context of cosmetic surgery, potentially indicating a lower surgery rate among BDD patients compared with previous estimates. Nevertheless, avenues for further improvement persist. Our data affirm the noteworthy occurrence of postsurgery BDD development, thereby highlighting the ongoing necessity for psychiatric evaluation in surgical patients.

Body Dysmorphic Disorder

This article summarizes current knowledge of body dysmorphic disorder across the life span. An overview of the epidemiology and phenomenology of this condition is provided, as well as clinical perspectives on assessment and treatment. Barriers to accessing treatment are considered, along with recent developments to improve access. Future directions in research and clinical care for this population are summarized.

Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences.

AIMS

To identify validated BDD screening tools and critically appraise current literature regarding its implementation and efficacy in aesthetic medicine and surgery scenarios, with the purpose of transposing the findings to the broad clinical settings in the field.

METHODS

Data was collected using advanced search from PubMed (MEDLINE). Having satisfied the search parameters, 12 studies referring BDD definition according to Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria and including a BDD screening tool in clinical aesthetic settings were selected.

RESULTS

While BDD screening enables the recognition of at-risk individuals, further work is required to uncover the best screening tool for general aesthetic clinical practice. Level III evidence favored BDD Questionnaire (BDDQ)/BDDQ-Dermatology Version (DV), and The Dysmorphic Concern Questionnaire (DCQ) among the limited available validated screening instruments to be used outside the psychiatric environment. Based on level II self-classification, one study selected BDDQ-Aesthetic Surgery (AS) version for rhinoplasty patients. The validation process of both BDDQ-AS and Cosmetic Procedure Screening Questionnaire (COPS) had limitations. For BDD screening potential in avoiding postoperative complications, the limited studies found evaluating the outcomes following aesthetic treatments using validated BDD screening measures showed a trend toward less satisfaction with aesthetic treatment outcome among positive screening population against non-BDD counterparts.

CONCLUSION

Further research is necessary to establish more effective methods to identify BDD and evaluate the impact of positive findings on aesthetic intervention outcomes. Future studies may elucidate which BDD characteristics best predict a favorable outcome and provide high-quality evidence for standardized protocols in research and clinical practice.

To Inject or to Reject? The Body Image Perception among Aesthetic Dermatology Patients

Background: Nowadays, aesthetic dermatology treatment has become not only physical beautification but also it can have positive effects on patients’ mental health. Body dysmorphic disorder can be the reason for treatment dissatisfaction. In the general population, the prevalence of BDD is 1.9% and it is more common among cosmetic patients. The aim of this study was to conduct the most comprehensive evaluation of body image and BDD among aesthetic patients. Methods: We recruited a group of 412 individuals, who were asked to complete 6 different on-line questionnaires concerning self-image, i.e., COPS, AAI, FAS, BAS-2, BSQ-16, and RSES. Results: The prevalence of BDD ranged from 7.28% to 11.17%, depending on the screening tool that was used. Our research revealed that BDD susceptibility, body image, body appreciation, and self-esteem were strongly interrelated (p < 0.001). A higher BMI was a risk factor for BDD, body dissatisfaction, and depreciation. The financial status markedly influenced all of the features. A history of psychiatric treatment influenced the risk of BDD, body satisfaction, body appreciation, and self-esteem. A history of cosmetic procedures and treatment satisfaction had no impact on the obtained results. Conclusions: Improving recognition of body dissatisfaction among aesthetic patients is very important. The psychometric assessment of patients before cosmetic treatment could be of help in choosing the appropriate approach.

"We should educate the public that cosmetic procedures are as safe as normal medicine": Understanding corporate social responsibility from the perspective of the cosmetic procedures industry

The cosmetic procedures industry is profitable and expanding. Through its premise and promotion, the industry contributes to unrealistic societal appearance pressures considered harmful to body image. In the context of limited regulation, there is an uneasy reliance on businesses in the sector to act in a socially responsible way. Corporate social responsibility (CSR) refers to voluntary business practices designed to benefit society, and engagement in CSR is shaped by extrinsic and intrinsic drivers. This study aimed to explore how senior UK industry professionals view CSR as it applies to their sector and to body image. Findings from 14 semi-structured interviews show that participants' understanding of CSR was limited to a myopic focus on patients. Little reflexivity was demonstrated in relation to the industry's responsibilities concerning negative body image in society. More broadly, the drivers of socially responsible practice were overwhelmingly extrinsic - oftentimes explicitly linked to bolstering or protecting company and/ or industry reputation. Participants, acknowledging a lack of intrinsic motivation for CSR across the sector, were largely in support of greater regulation. This research contributes to understandings of how the adoption of a CSR agenda might combine with regulatory efforts to curb the industry's impact on negative body image.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

Does #beauty have a dark side? Testing mediating pathways between engagement with beauty content on social media and cosmetic surgery consideration

Beauty content on social media has grown exponentially, however research has yet to investigate its association with appearance concerns. This study drew on components of the tripartite influence model to test the associations between young women's engagement with beauty content on social media and cosmetic surgery consideration. A sample of 399 undergraduate women aged 17-25years (M_age = 19.36) completed measures of beauty social media engagement, upward appearance comparison, general attractiveness internalization, dysmorphic appearance concerns, and consideration of cosmetic surgery. Path analysis was used to test direct and indirect associations. In line with the tripartite influence model, results supported a serial mediation model that comprised significant paths from beauty social media engagement through in turn, upward appearance comparison, general attractiveness internalization, and dysmorphic appearance concerns, to cosmetic surgery consideration. However, neither general attractiveness internalization nor dysmorphic appearance concerns mediated the link between beauty social media engagement and consideration of cosmetic surgery. Findings provide new insights into the links between engagement with the growing beauty social media trend and cosmetic surgery consideration.

Prevalence of Body Dysmorphic Disorder in an Otolaryngology-Head and Neck Surgery Clinic

OBJECTIVE

To analyze the prevalence of body dysmorphic disorder (BDD) in a general otolaryngology population presenting to an outpatient clinic.

STUDY DESIGN

Prospective prevalence study.

SETTING

Single tertiary academic otolaryngology clinic.

SUBJECT AND METHODS

New patients over 18 years of age who presented to an academic otolaryngology clinic between August 2018 and May 2021 completed a questionnaire including demographic questions and the validated Body Dysmorphic Disorder Questionnaire (BDDQ). Data collected from the questionnaires were analyzed to assess demographics and prevalence of BDD in an otolaryngology clinic.

RESULTS

Of the 242 patients queried, 15 patients screened positive for BDD. The screened prevalence of BDD was determined to be 6.2%. None of the patients had previously been diagnosed with BDD. The prevalence of prior mental health diagnoses was 34.3%. These patients had initially presented for a variety of otolaryngologic concerns and had pre-existing diagnoses of anxiety, depression, obsessive-compulsive, bipolar and eating disorders.

CONCLUSION

The prevalence of BDD in our population of new patients presenting to an academic otolaryngology practice (6.2%) is higher than that of the general population (1.9%).

A review of the diagnosis and management of pediatric psychodermatologic conditions: Part II

Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self-induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient-perceived stigma and lack of educational opportunities for dermatology providers. This two-part series highlights the most up-to-date evidence-based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics.

Clinical characteristics of 172 children and adolescents with body dysmorphic disorder

Body dysmorphic disorder (BDD) often starts in childhood, with most cases developing symptoms before age 18. Yet, BDD research has primarily focused on adults. We report the clinical characteristics of the world's largest cohort of carefully diagnosed youths with BDD and focus on previously unexplored sex and age differences. We systematically collected clinical data from 172 young people with BDD consecutively referred to 2 specialist pediatric obsessive-compulsive and related disorders outpatient clinics in Stockholm, Sweden and in London, England. A series of clinician-, self-, and parent-reported measures were administered. The cohort consisted of 136 girls, 32 boys, and 4 transgender individuals (age range 10-19 years). The mean severity of BDD symptoms was in the moderate to severe range, with more than one third presenting with severe symptoms and more than half showing poor or absent insight/delusional beliefs. We observed high rates of current psychiatric comorbidity (71.5%), past or current self-harm (52.1%), suicide attempts (11.0%), current desire for cosmetic procedures (53.7%), and complete school dropout (32.4%). Compared to boys, girls had significantly more severe self-reported BDD symptoms, depression, suicidal thoughts, and self-harm. Compared to the younger participants (14 or younger), older participants had significantly more severe compulsions and were more likely to report a desire for conducting cosmetic procedures. Adolescent BDD can be a severe and disabling disorder associated with significant risks and substantial functional impairment. The clinical presentation of the disorder is largely similar across sexes and age groups, indicating the importance of early detection and treatment. More research is needed specifically focusing on boys and pre-pubertal individuals with BDD.

Validity and reliability of the diagnostic codes for hypochondriasis and dysmorphophobia in the Swedish National Patient Register: a retrospective chart review

OBJECTIVES

In the International Classification of Diseases, Tenth Edition (ICD-10), hypochondriasis (illness anxiety disorder) and dysmorphophobia (body dysmorphic disorder) share the same diagnostic code (F45.2). However, the Swedish ICD-10 allows for these disorders to be coded separately (F45.2 and F45.2A, respectively), potentially offering unique opportunities for register-based research on these conditions. We assessed the validity and reliability of their ICD-10 codes in the Swedish National Patient Register (NPR).

DESIGN

Retrospective chart review.

METHODS

Six hundred individuals with a diagnosis of hypochondriasis or dysmorphophobia (300 each) were randomly selected from the NPR. Their medical files were requested from the corresponding clinics, located anywhere in Sweden. Two independent raters assessed each file according to ICD-10 definitions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and Fifth Edition criteria. Raters also completed the Clinical Global Impression-Severity (CGI-S) and the Global Assessment of Functioning (GAF).

PRIMARY OUTCOME MEASURE

Per cent between-rater agreement and positive predictive value (PPV). Intraclass correlation coefficients for the CGI-S and the GAF.

RESULTS

Eighty-four hypochondriasis and 122 dysmorphophobia files were received and analysed. The inter-rater agreement rate regarding the presence or absence of a diagnosis was 95.2% for hypochondriasis and 92.6% for dysmorphophobia. Sixty-seven hypochondriasis files (79.8%) and 111 dysmorphophobia files (91.0%) were considered 'true positive' cases (PPV=0.80 and PPV=0.91, respectively). CGI-S scores indicated that symptoms were moderately to markedly severe, while GAF scores suggested moderate impairment for hypochondriasis cases and moderate to serious impairment for dysmorphophobia cases. CGI-S and GAF inter-rater agreement were good for hypochondriasis and moderate for dysmorphophobia.

CONCLUSIONS

The Swedish ICD-10 codes for hypochondriasis and dysmorphophobia are sufficiently valid and reliable for register-based studies. The results of such studies should be interpreted in the context of a possible over-representation of severe and highly impaired cases in the register, particularly for dysmorphophobia.

Cosmetic Procedure Screening Questionnaire (COPS): creation and validation of the Polish language version

Introduction

Body dysmorphic disorder (BDD) is a disabling mental disorder characterized by excessive preoccupation with appearance. Trying to fix imagined defects many individuals with BDD search for aesthetic dermatology treatments. Due to omitting preliminary evaluation for BDD in subjects undergoing cosmetic procedures and lack of proper diagnostic tools among this group of individuals, the results of such interventions may face their disapproval and disappointment.

Aim

To translate and validate the Polish version of a Cosmetic Procedure Screening Questionnaire (COPS), which can be used in a cosmetic procedure setting to screen patients suspected to be suffering from BDD.

Material and methods

Both forward and backward translations of the original English version of the questionnaire to Polish were performed in accordance with international standards. The validation was conducted on 33 individuals undergoing aesthetic procedures, who completed the questionnaire twice with 3–6 days’ interval. Moreover, the subjects were also asked to fill the Polish versions of BIQLI (Body Image Quality of Life Inventory) and HADS (Hospital Anxiety and Depression Scale) for convergent validity procedure.

Results

The Polish version of COPS demonstrated good internal consistency (Cronbach α coefficient value of 0.76) and reproducibility (Intraclass Correlation Coefficient, ICC, of 0.79). COPS correlated strongly with BIQLI (r = –0.66, p < 0.01) as well as with HADS, in both depression and anxiety subscales (r = 0.68, p < 0.01 and r = 0.66, p < 0.01, respectively).

Conclusions

The Polish version of the COPS questionnaire showed sufficient internal consistency and reliability. It can be used for BDD screening among the Polish speaking subjects undergoing aesthetic dermatology procedures.

Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures

OBJECTIVES

Body dysmorphic disorder is commonly considered a contraindication for major cosmetic surgery, but whether body dysmorphic disorder relates to poorer outcomes from minor cosmetic treatment remains unknown. This study aimed to explore the prevalence of body dysmorphic disorder in clients seeking non-surgical cosmetic procedures and to examine whether body dysmorphic disorder clients are vulnerable in minor cosmetic settings. Vulnerability was explored in terms of psychological distress, unrealistic expectations and motivations for treatment outcome, and reduced satisfaction with past cosmetic procedures.

METHOD

A cross-sectional online survey was completed by 154 women seeking minor cosmetic procedures which included the Body Dysmorphic Disorder Questionnaire - Dermatology Version to screen for body dysmorphic disorder, and measures of cosmetic treatment motivation, expectations and satisfaction.

RESULTS

Roughly 25% of women in the current sample screened positive for a potential body dysmorphic disorder diagnosis. Participants with suspected body dysmorphic disorder demonstrated higher levels of psychological distress and more unrealistic expectations and motivations for cosmetic treatment, such as improving social or romantic relationships. However, body dysmorphic disorder participants reported similar levels of satisfaction with past minor cosmetic treatments to the non-body dysmorphic disorder group.

CONCLUSION

While the relationship between body dysmorphic disorder and treatment outcome warrants further investigation in prospective research tracking satisfaction and adverse reactions over time, this preliminary evidence suggests clients with suspected body dysmorphic disorder display several vulnerabilities in non-surgical cosmetic settings. Given the rapidly increasing accessibility of minor cosmetic procedures, further research is needed to determine their safety for clients with body dysmorphic disorder. Detection of body dysmorphic disorder in non-surgical cosmetic settings could facilitate earlier psychological intervention, promoting superior long-term outcomes.

The Zoom Effect: Exploring the Impact of Video Calling on Appearance Dissatisfaction and Interest in Aesthetic Treatment During the COVID-19 Pandemic

BACKGROUND

The popularity of videoconferencing platforms has skyrocketed during the COVID-19 pandemic; however, concerns have been expressed regarding the potential for video calls to promote appearance dissatisfaction because individuals are exposed to an image of themselves on camera for extended periods.

OBJECTIVES

The aim of the current study was to characterize current video usage behaviors and their relation to appearance dissatisfaction and interest in aesthetic procedures in the general population.

METHODS

An online survey was completed by 335 adults currently living in Australia. Multiple aspects of video usage were assessed, including engagement in video-manipulation techniques to enhance appearance and the focus of visual attention (ie, on self or others) while on video calls. The Dysmorphic Concern Questionnaire was administered to determine if video-use behaviors were associated with greater body image disturbance.

RESULTS

Over one-third of participants had identified new appearance concerns while on video. Dysmorphic concern was associated with self-focused attention, greater engagement in video-manipulation behaviors, and increasing appearance concerns due to their time on video calls. Individuals who identified new video-based appearance concerns reported greater interest in obtaining future beauty treatments (eg, waxing) and aesthetic procedures (eg, nonsurgical procedures such as antiwrinkle injections).

CONCLUSIONS

This is one of first empirical studies to report the potential consequences of video-call usage for increasing appearance dissatisfaction and dysmorphic concern, and to demonstrate a link between the use of video calls and interest in cosmetic procedures.

Eating disorders: A neglected group of mental disorders in patients requesting aesthetic surgery

BACKGROUND

There is a lack of data concerning the prevalence of eating disorders in patients requesting aesthetic surgery in spite of a large body of literature on the psychopathology of these patients. This may mostly be due to insufficient diagnostic assessment instruments. Therefore, the aim of this study was to determine the prevalence of eating disorders and their comorbidities in patients undergoing aesthetic surgery.

METHODS

The assessment of prevalence of the eating disorders as anorexia nervosa, bulimia nervosa and binge eating disorder as well as other mental disorders was performed with the Structured Clinical Interview for DSM-IV mental disorders (SCID), axis 1.

RESULTS

212 patients (198 females, 14 males), requesting different types of aesthetic surgery, were included in this study. Eating disorders had a current prevalence of 8.0% (17/212) and a lifetime prevalence of 11.3% (24/212). Anorexia nervosa was predominantly found in patients with breast augmentation [current: 7.4% (2/27); lifetime: 11.1% (3/27)] and rhinoplasty [6.3 (1/16); 12.6% (2/16)]. Bulimia nervosa dominated in patients with liposuction [10% (3/30); 13.3% (4/30)] and binge eating disorder in patients with abdominoplasty [current/lifetime: 10.8% (4/37)]. Levels of significance (p ≤ 0.002) were reached for prevalence of the eating disorders in above mentioned types of surgery, when compared to prevalence data of the general population (two proportion Z test for SPSS).

CONCLUSION

Eating disorders are distributed according to a certain pattern in the different types of aesthetic surgery. Interestingly, the current prevalence of eating disorders (17/212) was comparable to that of body dysmorphic disorder (26/212).

Body dysmorphic disorder and personality in breast augmentation: The big-five personality traits and BDD symptoms

BACKGROUND

Breast augmentation is one of the most performed cosmetic surgeries in the world. Personality traits predict the presence of psychological and social factors that may affect the patient satisfaction with a cosmetic surgical procedure and may be risk factors for body dysmorphic disorder. The aim of this study was to assess symptoms of body dysmorphic disorder in patients undergoing breast augmentation and identify their personality traits.

METHODS

Thirty-six women with hypoplasia of the breast (Sacchini index < 9 cm), a mean age of 28.1 years (SD = 6.2), body mass index ≤ 25 kg/m², and no history of breast surgery or breast-associated conditions were included in this prospective study.The Brazilian versions of the Structured Clinical Interview (SCID-I), Big Five Inventory (IGFP-5), and Body Dysmorphic Symptoms Scale (BDSS) were applied preoperatively and at 2 and 4 months after breast augmentation.

RESULTS

Personality traits were associated with symptoms of body dysmorphic disorder. A significant decrease (p< 0.001) in IGFP-5 scores on the Conscientiousness dimension, symptoms of body dysmorphic disorder (BDSS scores), and the number of patients with body dysmorphic disorder (SCID-I) were observed among different time points. In the study population, breast augmentation decreased the symptoms of body dysmorphic disorder, psychosocial impairment, and mean scores on Conscientiousness.

CONCLUSION

Personality traits varied in intensity and overlapped over time, and were associated with core symptoms of body dysmorphic disorder and the onset of body dissatisfaction.

The relationship between body dysmorphic disorder symptoms and 'not just right' experiences in a sample of individuals seeking cosmetic surgery and aesthetic medicine procedures

BACKGROUND

Body dysmorphic disorder (BDD) is characterized by concerns for perceived defects in physical appearance that appear to others as mild or unobservable. Individuals with BDD frequently refer concerns with their physical appearance being 'not right' (not just right experiences; NJREs), and BDD-related behaviours may be performed until their appearance is perceived as 'right'. The aim of the study was to explore the relationship between BDD and NJREs in cosmetic surgery and aesthetic medicine settings.

METHODS

Individuals requesting cosmetic procedures with BDD symptoms (BDD-symptoms group; n = 24), without BDD symptoms (cosmetic intervention [CI] group; n = 45), and individuals that have never required these procedures (no cosmetic intervention [NCI] group; n = 53) entered the study.

RESULTS

Results showed a greater number of past-month NJREs, higher NJREs severity, higher drive for thinness, and greater general distress in the BDD-symptoms group. Pertaining to features associated with NJREs (perfectionism and obsessive-compulsive disorder symptoms) and ED core features, the BDD-symptoms group scored higher only with respect to NCI. Regression analyses showed that BDD symptoms were predicted by age, NJREs severity, and drive for thinness above and beyond general distress, perfectionism, obsessive-compulsive disorder symptoms, bulimia, and body dissatisfaction related to weight and shape in the BDD-Symptoms group (in comparison with the CI and NCI groups).

CONCLUSIONS

NJREs may represent a potential vulnerability factor for BDD symptoms in cosmetic settings.

Validation of the Cosmetic Procedure Screening (COPS) Questionnaire in the Greek language

Practitioners in cosmetic and aesthetic treatment practices are likely to unknowingly work with patients with Body Dysmorphic Disorder (BDD). Screening questionnaires to identify the disorder in Greece are lacking. The purpose of this study was to validate a Greek version of the Cosmetic Procedure Screening (COPS) questionnaire, a self-report measure of how the respondents feel about their appearance, before an aesthetic intervention. The COPS was translated into Greek and was completed by 216 adult females from several areas of Attica (four private beauty centers, three dermatology clinics, five plastic surgery clinics, and Thriasio General Hospital of Elefsina) who pursued a cosmetic procedure. Participants also completed the Perceived Stress Scale (PSS-14). The Greek version of the COPS questionnaire demonstrated high internal consistency (Cronbach's α of 0.856) with corrected item's total range 0.468 to 0.687. Two of the factors explained 58.98% of total variance. Twenty (9.26%) women had a possible diagnosis of BDD (80% were unmarried, 95% had no children, 80% had university education). An increase in perceived stress levels was associated with an increase in the likelihood of being diagnosed with BDD (Pearson's r=0.726). The Greek version of the COPS questionnaire is a valid instrument that can be used by professionals to screen adult women for BDD.

Body dysmorphic disorder of female genitalia: a qualitative study of Swiss obstetrician-gynecologists' experiences and practices

Purpose

This work focuses on the experiences and practices of obstetrician–gynecologists (ob–gyns) with patients suffering from body dysmorphic disorder (BDD) and issues with their aesthetics, specifically focusing on female genitalia. Ob–gyns are likely to play an important role in the recognition and treatment of women facing such issues.

Methods

This study took a qualitative, explorative approach. Semi-structured interviews were conducted with 11 ob–gyns about their experiences with patients who presented symptoms of BDD of female genitalia, their treatments, and interest in further education and supportive material. Interviews were analyzed through qualitative content analysis.

Results

A categorization system was created. The results showed that the participating ob–gyns are often confronted with genital dissatisfaction of patients. The study sample demonstrated a lack of mental health literacy concerning BDD. The treatments that the ob–gyns of this sample suggested for BDD of female genitalia were not in line with what evidence suggests. Finally, interest in further education and supportive material for consultation was evidenced in this sample.

Conclusions

The findings encourage further studies to identify the recognition of BDD concerning genitalia or etiological factors. Furthermore, practical implications (e.g., need of supportive material) can be derived from the results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06270-w.

Science mapping research on body image: A bibliometric review of publications in Body Image, 2004-2020

Science mapping is a methodology that combines quantitative analysis, classification, and visualisation to identify the composition and inter-relationships between bibliographic objects. Here, we used bibliometric science mapping to identify the overarching structure, evolution of research themes and research fronts, and geographic spread of body image research. We examined 2,783 keywords in 1,107 articles published in Body Image between 2004 and 2020, selected as being representative of body image research during this period. Co-occurrence analysis of the keywords enabled us to identify five general themes in the literature: "clinical and weight-related issues", "body image and disordered eating", "positive body image and objectification", "media effects", and "ethnicity/race". Burst analysis allowed us to identify research fronts in this research, with work on social media and positive body image in particular being identified as emergent. Finally, co-author analysis indicated that body image research networks are heavily focused on a small handful of nations, although there is evidence of a recent shift toward greater geographic spread. Our results, and the provision of interactive maps and extensive tables, should allow readers to examine connections between research clusters and areas, generate novel research ideas, and more fully understand the evolution and future trajectories of body image research.

Using Nasal Self-Esteem to Predict Revision in Cosmetic Rhinoplasty

BACKGROUND

It would be useful if existing tools or outcomes measures could predict which patients are at greater risk of revision surgery following rhinoplasty.

OBJECTIVES

The authors sought to determine if a single question assessing nasal self-esteem could be utilized to predict which patients are at greatest risk of revision surgery following rhinoplasty.

METHODS

The authors conducted a retrospective chart review of 148 patients who underwent cosmetic rhinoplasty. Results of pre- and postoperative Standardized Cosmesis and Health Nasal Outcomes Survey questionnaires and rates of revision or patient-initiated revision discussions (RD) were collected. Patients were stratified based on answers to Standardized Cosmesis and Health Nasal Outcomes Survey question 5 (SQ5), "Decreased mood and self-esteem due to my nose."

RESULTS

Of the 148 patients included in the analysis, 72.9% were women, and the mean age was 30.9 (15-59, standard deviation = 10.3) years. Those patients who selected 4 or 5 on SQ5 had an overall revision rate of 16.7% and 18.8%, respectively, and a RD rate of 27.8% and 31.25%, respectively. Those patients who selected 0 through 3 on SQ5 had an overall revision rate of 0% and an overall RD rate of 10.4%. Only SQ5 was predictive of revision and RD on logistic regression analysis (P = 0.0484 and P = 0.0257) after Bonferroni correction.

CONCLUSIONS

SQ5 appears to offer a useful adjunct to guide surgical management of the cosmetic rhinoplasty patient. Those patients who reported worse nasal self-esteem and associated mood preoperatively were more likely to request and undergo revision.

LEVEL OF EVIDENCE: 4

An update on gender differences in major symptom phenomenology among adults with body dysmorphic disorder

There has not been a comprehensive comparison of differences between men and women with body dysmorphic disorder (BDD) for approximately two decades. Major social and technological changes over this time may have changed patterns of bodily concerns and symptom profile among men and women with BDD, thus warranting an updated assessment of gender differences. BDD symptomatology, insight, and associated clinical and sociodemographic characteristics were compared between 49 women and 27 men with BDD. Skin was the most common concern for both men and women. Women showed more concerns than men about the appearance of their legs. Men were more concerned about muscularity/body build. Women demonstrated significantly more severe distress associated with BDD behaviours, and poorer illness insight than men. Age at BDD onset, illness duration, as well as mean severity of depression, anxiety, stress, and social anxiety were similar across the genders. These data suggest that the most common body areas of concern in people with BDD have not dramatically changed over the past two decades. However, the finding of worse insight among women is novel, and suggests a need for further investigation.

Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology

Background

The incidence of body dysmorphic disorder in cosmetic dermatology is high. Even though treating patients with this disorder may worsen symptoms and is fraught with potential complications, screening is low, due in part to lack of knowledge of the disorder, as well as inadequate screening tools.

Objectives

To verify the probability of body dysmorphic disorder in a nonsurgical esthetic setting and determine the effect of a multiphasic screening protocol on mitigating poor outcomes in high‐risk patients.

Methods

A multiphasic screening protocol for body dysmorphic disorder was distributed to a total of eight esthetic clinics in the United States. Practitioners administered an anonymous, cryptic prescreening form to all new, incoming patients aged ≥ 18 to ≤ 65 years from June 1, 2019, through September 1, 2019, followed by a second, more extensive screening questionnaire. Patients with suspected or subclinical body dysmorphic disorder could be refused treatment.

Results

A total of 734 initial screenings were recorded over 16 weeks. Of these, 4.2% (31/734) proceeded to the secondary screening phase; 29% (9/31) subsequently screened positive for body dysmorphic disorder. Practitioners refused to treat 77.8% (7/9) of positive screenings. Two patients out of seven who tested positive underwent a third screening and were subsequently treated with positive outcomes.

Conclusions

Use of a cryptic screening protocol enables identification of individuals at risk for BDD and encourages open and continuous communication between patient and provider.

The COVID-19 pandemic: Psychological and behavioral responses to the shutdown of the beauty industry

OBJECTIVE

During the COVID-19 pandemic, Australia implemented widespread closure of beauty and cosmetic services to control the virus spread. The effect of these restrictions is unknown, given that beauty services are widely used for stress relief or to enhance confidence. The current study explored the relationship between engagement in appearance-focused behaviors and distress regarding beauty service closure. Participants with high and low levels of dysmorphic concern were compared to determine whether COVID-19 restrictions may affect these groups differently.

METHOD

An online survey was completed by 216 participants living in Australia. Questions addressed engagement in appearance-focused behaviors during the COVID-19 pandemic and attitudes toward beauty service closure. The Dysmorphic Concern Questionnaire (DCQ) was used to group participants by low and high dysmorphic concern.

RESULTS

Appearance-focused behaviors decreased in the low DCQ group (n = 163) during the COVID-19 pandemic, while such behaviors in the high DCQ group (n = 53) remained unchanged. Individuals who were living alone, younger, reported higher dysmorphic concern and greater distress over beauty service closure engaged in more frequent appearance-focused behaviors (R² = .57, p < .001). The high DCQ group reported greater distress over beauty service closure and increased desire to obtain future beauty treatments.

DISCUSSION

While COVID-19 restrictions may have provided a break from societal appearance pressure for those with low dysmorphic concern, appearance-focused behaviors persisted in individuals with high dysmorphic concern. A greater understanding of the long-term impacts on appearance-related distress is needed to determine mental health priorities emerging from the COVID-19 pandemic.

Psychiatric Disorders in Facial Plastic Surgery

Body dysmorphic disorder and borderline personality disorder are common in esthetic practices and occur in up to 15% of patients. Operating on these patients may not only lead to dissatisfaction but may also worsen their premorbid condition and can induce negative behavior toward the practice. Preventing surgery and referring patients for cognitive therapy is essential. An adequate understanding of these conditions and the available screening tools is indispensable for all esthetic practitioners. Unrealistic emotional attribution to a facial shape, multiple procedures, a near-normal nose at the outset, childhood trauma, multiple comorbid mental conditions, and social dysfunction are red-flags to consider.

Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria

AIM

To promote a discussion on the ethics and justifications of stature lengthening in patients without skeletal deformity.

BACKGROUND

Stature lengthening for height gain in patients without skeletal deformity has stirred controversy within the orthopedic community. However, current literature does not delineate the ethical issues surrounding this procedure. Improvements in the techniques, technology, and safety profile of stature lengthening warrant an ethical discussion to challenge, justify, and guide the use of this surgical procedure.

REVIEW RESULTS

Examination of ethical issues leads to the distinction between the dual roles of stature lengthening as a treatment vs an enhancement. The primary focus on stature lengthening as treatment allows for exploration of "height dysphoria"-a psychological burden caused by a dissatisfaction with one's height-as the primary pathology that may justify surgical intervention.

CONCLUSION

In our opinion, additional work is required to establish "height dysphoria" as a true pathology in order to ethically justify stature lengthening as a legitimate form of treatment. Further discussion is needed to address the ethics of stature lengthening as an enhancement.

CLINICAL SIGNIFICANCE

This paper addresses salient ethical issues of stature lengthening in patients without skeletal deformity by exploring historical, contemporary, and comparative contexts.

HOW TO CITE THIS ARTICLE

Lee RC, Aulisio M, Liu RW. Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria. Strategies Trauma Limb Reconstr 2020;15(3):163-168.

More than just filler: an empirically informed ethical analysis of non-surgical cosmetic procedures in body dysmorphic disorder

OBJECTIVES

To identify and analyse ethical considerations raised when individuals with body dysmorphic disorder (BDD) consult for non-surgical cosmetic procedures.

METHODS

Ethical analysis was conducted addressing the issues of best interests and capacity to consent for non-surgical cosmetic procedures in individuals with BDD. Analysis was informed by the findings of semistructured interviews with non-surgical cosmetic practitioners and mental health professionals.

FINDINGS

Non-surgical cosmetic interventions were viewed not to be in the best interests of individuals with BDD, as they fail to address core psychological issues, result in dissatisfaction post-procedure, and risk harm. Referral to mental health services was advocated, however numerous obstacles to this were perceived. The issue of capacity to consent to non-surgical cosmetic procedures raised questions regarding whether standard capacity assessment is sensitive to the manner in which BDD may influence decision-making processes. In addition, concerns were voiced that decisions made by individuals with BDD in this context may be judged foolish, and thus wrongly equated with lack of capacity.

DISCUSSION/CONCLUSIONS

Ethical analysis, informed by the available evidence base, suggests that it is generally not in the best interests of individuals with BDD to undergo non-surgical cosmetic intervention, and referral to mental health services is indicated. Analysis of capacity draws parallels between BDD and anorexia nervosa, as decision-making capacity in both conditions can be impaired by pathological values derived from the disorder. Means of differentiating clinical assessment of pathological values from inappropriate value judgements are advocated, in order to safeguard against the latter encroaching into capacity assessment.

Awareness and experiences of cosmetic treatment providers with body dysmorphic disorder in Saudi Arabia

Body Dysmorphic Disorder (BDD) is defined as a constant obsession with one’s external appearance and flaws, and it falls under the criteria of neuropsychiatric disorders. Individuals suffering from this disorder may seek unnecessary cosmetic procedures from cosmetic treatment providers such as dermatologists or plastic surgeons. Cosmetic treatments have become readily available, which has led to an influx of undiagnosed BDD patients electing to undergo such treatments. Therefore, physicians should have the clinical knowledge about BDD to diagnose and manage these cases to avoid psychological and physical harm to these patients. However, there were no studies conducted in our region to assess the awareness of BDD among physicians who provide cosmetic treatments with regards to their attitude toward such cases and how they would manage it. This study aims to assess the awareness of Body Dysmorphic Disorder among Saudi physicians who provide cosmetic treatments. We conducted an observational cross-sectional study among physicians practicing in hospitals and cosmetic clinics in Riyadh and Jeddah city (Saudi Arabia), who perform cosmetic procedures, namely dermatologists, plastic surgeons, and otorhinolaryngologists. A paper-based questionnaire consisting of multiple-choice questions was distributed among them. The total number of participants was 155 physicians: 113 (72.9%) males and 42 (27.1%) females. Eighty-two (52.9%) participants reported that they have been familiar with the diagnostic criteria of BDD for a long time and ninety-nine (63.8%) reported being familiar with the clinical picture of BDD. Sixty-three (40.6%) participants estimated the prevalence of BDD cases seen in cosmetic practice to range from 1%-5%, and most agreed on an equal prevalence of BDD among female and male patients. Half of the participants (n = 76) (49%) reported that they sometimes share knowledge about BDD with patients whom they suspect to suffer from this condition. In conclusion, cosmetic treatment providers in Saudi Arabia are aware of BDD, but we have identified a discrepancy between the self-reported participant knowledge of diagnostic criteria and their ability to accurately estimate the prevalence of BDD cases seen in clinical practice.

Störungseinsicht bei körperdysmorpher Störung, Zwangsstörung und sozialer Angststörung

Hintergrund

Die körperdysmorphe Störung (KDS) geht mit einer geringen Störungseinsicht bis zu wahnhaft anmutenden Überzeugungen bezüglich wahrgenommener körperlicher Makel einher, die für andere nur leicht oder nicht sichtbar sind. Während die Einsicht bei der KDS bereits vielfach untersucht wurde und obwohl sie ein transdiagnostisch relevantes Merkmal ist, gibt es kaum vergleichende Studien.

Ziel der Arbeit

Es wird untersucht, inwiefern sich Personen mit einer KDS von Personen mit einer Zwangsstörung (ZS) und einer sozialen Angststörung (SAS) dimensional und kategorial hinsichtlich der Einsicht unterscheiden.

Material und Methode

Personen mit KDS (n = 36), ZS (n = 38) und SAS (n = 36) beantworteten diagnostische Interviews und Fragebogen. Die Einsicht wurde mithilfe eines teilstrukturierten Interviews, das verschiedene Facetten und Grade von Einsicht erfasst, beurteilt (Brown Assessment of Beliefs Scale).

Ergebnisse

In allen Gruppen lagen unterschiedliche Einsichtsgrade im gesamten Spektrum von exzellent bis fehlend vor. Bei den Betroffenen mit einer KDS entsprach der Gesamtmittelwert einer schlechten (M = 13,25, SD ± 6,32), bei Betroffenen mit einer SAS einer ausreichenden (M = 10,39, SD ± 5,70) und bei Betroffenen mit einer ZS einer guten Einsicht (M = 4,74, SD ± 5,49). Abgesehen von einer stärkeren Fixiertheit der Überzeugung bei KDS war die Einsicht bei KDS und SAS dimensional und kategorial nicht signifikant voneinander verschieden, jedoch bei beiden Störungen schlechter als bei ZS.

Diskussion

Die Ergebnisse bestätigen, dass die KDS mit geringer Einsicht einhergeht, dies jedoch fast gleichermaßen auf die SAS zutrifft. Die Störungseinsicht erscheint bei allen untersuchten Störungen relevant und sollte in der Psychotherapie von Beginn an diagnostisch und psychotherapeutisch berücksichtigt werden.

Ethics and aesthetics in injection treatments with Botox and Filler

The medical nature of esthetic treatments is confusing, as the boundaries between medicine and beauty are unclear. A person's autonomous decision is an indicator for esthetic treatments that will improve their self-image, self-esteem and appearance to others. Robust ethical consideration is therefore necessary for the medical esthetician in each meeting with the client. This study aimed to describe medical estheticians' perceptions of ethics and esthetics in injection treatments with Botox and Filler. The results are described in Understanding what different clients desire, Reaching a mutual understanding of expectations and possibilities and Taking responsibility for beauty.

Treatment utilization and treatment barriers in individuals with body dysmorphic disorder

BACKGROUND

Although effective treatments are available, most individuals with body dysmorphic disorder (BDD) do not receive an appropriate diagnosis or treatment. We aimed to examine treatment utilization and barriers to treatment, and to identify associated socio-demographic and clinical characteristics.

METHODS

German individuals completed an online self-report survey of appearance concerns. A sample of N = 429 individuals met criteria for BDD. We examined the frequency of treatment utilization and barriers, analyzed comparisons between treated and untreated individuals and assessed the relationships of socio-demographic and clinical features with mental health treatment utilization and treatment barriers, respectively.

RESULTS

Only 15.2% of the individuals with BDD had been diagnosed with BDD, and lifetime rates of mental health treatment were low (39.9%). Individuals endorsed multiple barriers to mental health treatment, especially shame, low perceived need and a preference for cosmetic and medical treatments. Associated features were identified, including age, a BDD diagnosis, body dysmorphic symptom severity, a likely major depressive disorder, prior cosmetic surgery, and insight.

CONCLUSIONS

The results of this largest study to date highlight that BDD is still underrecognized and undertreated even in a country with extensive mental health care and few financial barriers. We discuss modifiable factors and strategies to foster awareness of BDD in sufferers and professionals to improve treatment dissemination and to reduce treatment barriers.

[Body Dysmorphic Disorder: Diagnosis, Treatment and Challenges in the General Practice]

Body Dysmorphic Disorder: Diagnosis, Treatment and Challenges in the General Practice Abstract. Body dysmorphic disorder (point prevalence: 1.7-2.4 %) is characterized by excessive preoccupation with one or more subjectively perceived blemishes of the appearance, as a result of which those affected show a high burden of disease due to avoidance behavior and time-consuming rituals, and often secondary problems (including depression, suicidal tendencies). The disorder is often accompanied by pronounced shame and is therefore associated with challenges in diagnostics, which is why the indication and specialist treatment (first-line treatment: cognitive-behavioural therapy) are usually only carried out with great latency. Family doctors can play a key role in diagnosis and treatment because of the often long-standing relationship of trust with their patients. Targeted screening, active and at the same time prudent discussion, as well as knowledge of treatment options and special features of the disease pattern (e.g. fluctuating understanding of the disease, desire for plastic surgery measures) are necessary. Against this background, the article provides an overview of the clinic, diagnostics and therapy and concludes with specific challenges and practical recommendations for family practice.

Body dysmorphic disorder and facial aesthetic treatments in dental practice

There is a relatively high prevalence of body dysmorphic disorder (BDD) and it is known that this patient group regularly and frequently visit dental practitioners, especially those who advertise themselves as cosmetic or aesthetic practices. The market for facial aesthetics is hugely increasing both generally and within dental practices making it ever more likely that dentists will encounter this patient group frequently. Moreover, due to the nature of their concerns individuals within this group are likely to have contact with dentists (or other medical professionals in the physical health field) prior to any contact with mental health professionals. The aim of this paper is to give an overview of the presentation of BDD, to discuss the changing climate of facial aesthetic treatments and to highlight a care pathway for general dentists. Identification of patients with potential BDD is far more predictable with the use of a validated questionnaire, and the BDD Questionnaire and Dysmorphic Concern Questionnaire are described. A flowchart approach for the management of patients requesting aesthetic improvements is presented as the ideal method for identifying, referring and managing the aesthetic treatment desires of potential BDD patients.

Invited Response on: Body Dysmorphic Disorder: There is an "Ideal" Strategy?

Body dysmorphic disorder (BDD) has been considered the most relevant neuropsychiatric condition to cosmetic treatments. Patients' ideal expectations often exceed what is expected to be achieved in reality by plastic surgery, signaling the presence of BDD. It is fundamental to detect BDD symptoms during screening for cosmetic surgery. A secondary concern with physical appearance may be one of the most important parameters to be detected during patient assessment, as it may interfere with overall patient satisfaction following treatment. A good doctor-patient relationship is essential for detecting this psychopathology. Mild-to-moderate BDD is not an exclusion criterion for cosmetic surgery, but specific treatment planning and a multidisciplinary approach are required. Recent studies have presented preliminary evidence for the effectiveness of cosmetic procedures in reducing BDD symptoms and providing patient satisfaction with treatment results. The use of validated instruments at pre- and postoperative assessments to systematically evaluate the patient's level of distress with the physical appearance and patient satisfaction with treatment results will provide important information for the development of more sensitive validated tools for detection of severe levels of BDD symptoms to help plastic surgeons in the selection of patients in a more effective and practical manner.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Body Dysmorphic Disorder in Adolescents

Background and Objectives:

Body Dysmorphic Disorder (BDD) is characterized by an abnormal preoccupation with alleged misshapen body parts. There is often poor insight and effort is made to hide the imagined defects, and consultation may be sought seeking unnecessary cosmetic surgery or procedures. It is underdiagnosed and established treatment protocols are lacking. The disease has a chronic and undulating course and is seriously compromises quality of life. Despite the fact that the prime age of onset of BDD is during adolescence relatively little has been written about it during this phase of life. This review aims to comprehensively cover the present understanding of BDD, including clinical features, epidemiology, psychopathology, nomenclature, comorbidity and management.

Methods:

A literature search was undertaken using suitable key words on Google Scholar, MEDLINE & PsychoINFO up to June 2018 limited to articles in English.

Results:

he prevalence of BDD is variable in the general and psychiatric population with equal gender distribution. Both sexes are equally affected. It is associated with poor functioning and a chronic course. There is considerable comorbidity and diagnostic overlap between BDD and obsessive-compulsive disorder, major depressive disorder, social anxiety disorder, anorexia nervosa, schizophrenia spectrum disorders and personality disorders. Psychiatric consultation is often late. Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavior Therapy (CBT) are currently the first line modalities for treatment. Internet based CBT, Acceptance and commitment therapy, and repetitive Transcranial Magnetic Stimulation (rTMS) are emerging treatment options.

Conclusions:

BDD is a complex disorder with still lot of uncertainty about its diagnostic placement, treatment approaches, especially for refractory patients, and prognosis. Further study is needed to clarify its prevalence, especially in adolescents; to fully understand its neurobiological aspects, to determine its exact relation to obsessive compulsive related disorders, and to develop better treatment approaches.

Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size

INTRODUCTION

Evidence on penile enhancement interventions is lacking. Nonetheless, many non-evidence-based solutions are readily available.

AIM

To investigate enhancement and nonenhancement interventions in men without penile abnormalities seeking to increase penis size.

METHODS

We performed a systematic review with no time restrictions adhering to the PRISMA guidelines. Studies with fewer than 10 cases or including men with organic penile pathologies or previous penile surgeries were excluded.

MAIN OUTCOME MEASURES

When available, treatment efficacy was evaluated based on patient satisfaction, penile size increase, and complications.

RESULTS

We included 17 studies, assessing a total of 21 interventions in 1,192 men screened, with 773 followed up after nonsurgical (n = 248) or surgical (n = 525) treatment. The quality of the studies was poor in terms of methodology for patient selection and outcomes assessment. The vast majority of series reported normal penile size. Among nonsurgical treatments, extenders increased flaccid length (but by <2 cm), injectables increased girth but were associated with a high complication rate, and vacuum devices did not increase size. Surgical interventions included suspensory ligament incision (the most used method; n = 12), tissue grafting (autologous, n = 2; dermal fat, n = 3, ex vivo, n = 2), flaps (n = 2), and penile disassembly (n = 1). Some men reported a significant size increase; however, complications were not infrequent, and none of the techniques was externally validated. When provided, counseling was effective, with the majority of men coming to understand that their penis was normal and unwilling to undergo any further treatment.

CONCLUSION

Treatment of small penis in normal men is supported by scant, low-quality evidence. Structured counseling should be always performed, with extenders eventually used by those still seeking enhancement. Injectables and surgery should remain a last option, considered unethical outside of clinical trials. Marra G, Drury A, Tran L, et al. Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size. Sex Med Rev 2020;8:158-180.

Nonsurgical Medical Penile Girth Augmentation: A Retrospective Study of Psychological and Psychosexual Outcomes

BACKGROUND

Although interest in penile augmentation procedures is increasing, there is a significant lack of research into the psychological and psychosexual outcomes of these procedures.

OBJECTIVES

To investigate the psychological and psychosexual outcomes of nonsurgical medical penile girth augmentation.

METHODS

This retrospective study involved a mixed method approach. Twenty-five men who had undergone a nonsurgical medical penile girth augmentation between 1 and 12 months prior (mean, 6.6 months) completed an online questionnaire containing measures of procedure motivation, procedure satisfaction, genital self-image, penile-focused body dysmorphic disorder symptoms, self-esteem, and sexual relationship satisfaction. Six of these men elected to complete in-depth one-to-one semi-structured phone interviews to further explore the psychological impacts of the procedure.

RESULTS

In the online questionnaire, most men were satisfied with their penile size, appearance, and function after penile girth augmentation. The men also reported statistically significant improvements in their genital self-image (P < 0.001) and self-esteem (P = 0.008), and a reduction in penile-focused body dysmorphic disorder symptoms (P = 0.002) at the time of completing the questionnaire compared to recalled pre-procedural levels. The in-depth interviews yielded 3 themes surrounding penile augmentation outcomes: (1) high satisfaction with increased penis girth; (2) increased self-confidence, particularly in situations in which the penis would be seen, such as a locker room; and (3) increased sexual confidence, but some mixed impacts on sexual relationships.

CONCLUSIONS

Most men appear to be satisfied with their nonsurgical medical penile girth augmentation results, and they also seem to experience improvements in their overall self-esteem.

LEVEL OF EVIDENCE: 4

Cosmetic Surgery and Body Dysmorphic Disorder - An Update

With the increasing volume and popularity of cosmetic procedures and surgeries, physicians in related specialties are increasingly likely to encounter patients with body dysmorphic disorder. Given the ethical, safety, and legal considerations involved in aesthetic procedures in these patients, accurate identification and appropriate selection for procedures is crucial.

['Barbie Doll Syndrome'. A case report of body dysmorphic disorder]

BACKGROUND

This case report aims to present a 37-year-old women striving to shape her body like a Barbie doll of which she has been fascinated since childhood. She could hardly tolerate any deviation from this beauty ideal. She has been admitted to the psychosomatic ward due to an eating disorder.

METHODS

The ICD-10 and DSM-5 criteria were established for axis I disorders and the German version of the SCID II interview (for DSM-4) was applied for axis II disorders. Additionally, the "modified Yale-Brown Obsessive Compulsive Scale for body dysmorphic disorder" was carried out.

RESULTS

The diagnosis of dysmorphophobia (ICD-10: F45.21) or body dysmorphic disorder (DSM-5: 300.7) and bulimia nervosa (ICD-10: F50.2; DSM-5: 307.51) was confirmed. The patient fulfilled criteria of an avoidant, depressive and histrionic personality disorder. Psychopharmacological treatment with Fluoxetine was started and the patient participated in an intensive inpatient psychosomatic program. The body image, self-concept and the sense of shame were therapeutic key topics.

CONCLUSION

The present case report focuses on body dysmorphic disorder as a distinctive entity with high prevalence. Diagnostic criteria of different classification systems were contrasted and comorbidity with eating disorders was discussed. In clinical praxis, body dysmorphic disorder remains underdiagnosed, especially when cooccurring with an eating disorder. However, the correct diagnosis could be relevant for therapy planning.

Recent advances in understanding and managing body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common and disabling psychiatric disorder characterised by excessive and persistent preoccupation with perceived defects or flaws in one's appearance, which are unnoticeable to others, and associated repetitive behaviours (eg, mirror checking). The disorder generally starts in adolescence, but often goes unnoticed and is severely underdiagnosed. Left untreated, BDD typically persists and causes marked functional impairment in multiple domains. This clinical review considers recent advances in the epidemiology and classification of BDD, including its reclassification in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders under the new 'Obsessive-Compulsive and Related Disorders' chapter. Key issues in assessment are outlined including the use of validated screening instruments to minimise misdiagnosis and the importance of risk assessment in this population given the high rates of suicidality and inappropriate use of cosmetic treatments. In addition, current knowledge regarding the causes and mechanisms underlying BDD are summarised. The recommended treatments for BDD are outlined, namely cognitive behavioural therapy (CBT) and antidepressants, such as selective serotonin reuptake inhibitors. Both CBT and pharmacotherapy have been shown to be efficacious treatments for BDD in adult populations, and evidence is emerging to support their use in young people. Although the majority of patients improve with existing evidence-based treatment, a large proportion are left with clinically significant residual symptoms. Priorities for future research are therefore discussed including the need to further refine and evaluate existing interventions with the goal of improving treatment outcomes and to increase their availability.

Long-Term Outcomes of Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

Emerging evidence suggests that cognitive-behavioral therapy (CBT) is an efficacious treatment for adolescent body dysmorphic disorder (BDD) in the short term, but longer-term outcomes remain unknown. The current study aimed to follow up a group of adolescents who had originally participated in a randomized controlled trial of CBT for BDD to determine whether treatment gains were maintained. Twenty-six adolescents (mean age = 16.2, SD = 1.6) with a primary diagnosis of BDD received a course of developmentally tailored CBT and were followed up over 12 months. Participants were assessed at baseline, midtreatment, posttreatment, 2-, 6-, and 12-month follow-up. The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD. Secondary outcomes included measures of insight, depression, quality of life, and global functioning. BDD symptoms decreased significantly from pre- to posttreatment and remained stable over the 12-month follow-up. At this time point, 50% of participants were classified as responders and 23% as remitters. Participants remained significantly improved on all secondary outcomes at 12-month follow-up. Neither baseline insight nor baseline depression predicted long-term outcomes. The positive effects of CBT appear to be durable up to 12-month follow-up. However, the majority of patients remained symptomatic and vulnerable to a range of risks at 12-month follow-up, indicating that longer-term monitoring is advisable in this population. Future research should focus on enhancing the efficacy of CBT in order to improve long-term outcomes.

Body dysmorphic disorder in the dermatology patient

Body dysmorphic disorder is primarily a psychiatric disorder, in which the patient believes that some normal or very near normal aspect of his or her physical appearance is distorted or ugly. Should there be a minor abnormality, it is grossly exaggerated in the mind of the patient, causing feelings of shame and embarrassment and leading daily to spending hours at the mirror, or any reflecting surface, as the patient tries to conceal or remove the perceived abnormality through the development of ritualistic behavior. Although other organs can be involved-for example, the shape of the nose or a portion of an ear- the skin, hair, and nails are most commonly involved, while the patient constantly seeks reassurance about appearance from friends and family. There is a broad spectrum of severity in body dysmorphic disorder, ranging from obsessional worry to frank delusion, and the psychiatric comorbidities-anxiety, depression, and personality disorder-are prominent parts of the picture. Unfortunately, the psychiatric comorbidities and the negative impact on every aspect of the patient's life may not be recognized by dermatologists and other non-psychiatric physicians, so that effective treatment is often not instituted or appropriate referrals made. This paper describes the incidence, possible etiologies, and clinical picture of body dysmorphic disorder in dermatology patients and discusses interpersonal approaches that may permit appropriate treatment or referral to take place. Specific treatments and prognosis are also discussed.

A qualitative study of life events and psychological needs underlying the decision to have cosmetic surgery

Objective A thorough psychological assessment of patients requesting cosmetic surgery can help to protect them from the risk of postoperative dissatisfaction and the onset and/or aggravation of psychiatric disorders. This study seeks to shed more light on why people desire cosmetic surgery and thus help surgeons, psychiatrists, and psychologists to conduct assessments before surgery. Methods In-depth interviews were conducted with 35 subjects who requested cosmetic surgery. The interviews were recorded and transcribed and then analyzed qualitatively with Grounded Theory. Themes and categories were identified and compared in logical order, to build a consistent theoretical model. Results In each interview, we identified one or more recent events that the subjects considered to be contributing factors in their decisions to have cosmetic surgery. We observed that 33 of 35 patients said they sought cosmetic surgery at a time when they were experiencing, or had just experienced, one or more major changes in their bodies or their relationships. Recent life events triggered or strengthened specific psychological needs in the subjects: to cope with the past and with change, attain a consistent identity, find or regain a positive self-image, alter others' perceptions, define themselves in relation to others, or please themselves or others. Patients said that they chose plastic surgery to fulfill one or more of these needs. Conclusions This study identifies the role of recent events in inciting individuals to resort to cosmetic surgery. This factor provides new perspectives for surgeons to understand those patients and opens new avenues for research.