Rate of body dysmorphic disorder in dermatology patients

BACKGROUND: Dermatologists appear to be the physicians most often seen by patients with the psychiatric condition body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. The frequency of BDD among patients seeking dermatologic treatment is unknown, however. OBJECTIVE: This study determined the percentage of patients seeking dermatologic treatment who screened positive for BDD. METHODS: A validated self-report questionnaire and a reliable defect severity scale were used to determine the rate of BDD in 268 patients seeking dermatologic treatment. RESULTS: A total of 11.9% (95% confidence interval [CI], 8.0%-15.8%) of patients screened positive for BDD. Rates were similar in a community general dermatology setting (14.4% [95% CI, 8.5%-20.3%]) and a university cosmetic surgery setting (10. 0% [95% CI, 6.1%-13.9%]). CONCLUSION: BDD appears relatively common among patients seeking dermatologic treatment. Further research is needed to confirm these findings and to assist dermatologists in identifying these potentially high-risk patients.     

Pathologic grooming behavior: facial dermatillomania

Dermatillomania is a pathologic grooming disorder characterized by repetitive, ritualistic, impulsive skin picking without an underlying dermatologic condition. It can lead to skin damage and distress and can affect patient function. This disorder has not received much attention in the literature, with few studies reporting treatment efficacy. Patients with dermatillomania typically present to primary care physicians and frequently are referred to dermatologists; only rarely do patients receive additional psychiatric consultation that may improve treatment efficacy and decrease morbidity. We provide a case report of long-standing facial dermatillomania and our multimodal treatment approach.     

Psychosocial issues and body dysmorphic disorder in aesthetics: Review and debate

Body dysmorphic disorder (BDD) is a serious and debilitating psychiatric condition that disproportionately presents in dermatologic and cosmetic surgery patients. BDD is currently underrecognized in cosmetic medical settings and is thought to be underdiagnosed by behavioral health professionals. The significant comorbidities associated with this disorder, as well as potential harm done to both patient and physician, raise ethical and medicolegal concerns regarding its treatment. Although cosmetic interventions have historically been discouraged in BDD, recent studies have provided controversial evidence of benefit in certain cohorts. The rise of “snapchat dysmorphia” and the proposed explanatory phenomenon of perception drift have generated further debate around the de novo development or unmasking of BDD. We critically review and summarize existing debates around the treatment of BDD in cosmetic medicine. We provide guidance for screening, clinical interviewing, and the provision of psychoeducation in cases of suspected BDD.     

Body-focused repetitive behaviors and the dermatology patient

Body-focused repetitive behaviors (BFRBs) are psychiatric disorders that involve recurrent pulling and picking one’s own body resulting in skin lesions with varying degrees of severity. For that reason, the interface with dermatology is important. Currently, the classified BFRBs are trichotillomania and excoriation disorder. Both trichotillomania and excoriation disorder appear to be more common than previously thought. Besides that, most patients are unlikely to seek mental health treatment for their condition. Thus, many patients will instead seek dermatologic help due to the cosmetic damage incurred.In trichotillomania, the main characteristic is the pulling out of one’s hair, most commonly from the scalp. It is associated with many negative consequences. Patients may present with different patterns of alopecia. Often, more than one body part will be affected.In excoriation disorder, the pathologic behavior frequently starts with picking at an underlying dermatologic condition such as acne but can continue after dermatologic treatment. The body area most frequently picked is the face, but other sites may also be involved. The dermatologic findings and distribution are atypical and will help the clinician differentiate from other dermatologic conditions.A complete therapeutic plan for BFRBs should include a dermatologic assessment of the affected areas, psychotherapy, and possibly pharmacotherapy.     

Body dysmorphic disorder and dermatologists

The aim  of this study was to determine the frequency of body dysmorphic disorder (BDD) identified by Polish dermatologists and to evaluate the treatment modalities applied by them.
Methods  A specially designed questionnaire was distributed to 172 dermatologists. A total of 118 doctors responded (68.6%). The dermatologists were asked regarding demographic data, frequency of BDD in their everyday practice and methods of treatment they used in managing BDD patients.
Results  During the whole working period, over the half of dermatologists (64%) had observed at least one BDD patient in their practice. One fifth (20%) of the respondents observed 1 or 2 BDD cases during the past 5 years, 14% observed 3 to 5 such patients, 7% observed 5 to 10 BDD cases, and 5% of the doctors reported seeing more than 10 BDD patients within this period. Almost 18% of dermatologists were currently treating a BDD patient. Our data show that 40.7% of the respondents always ask and 28.8% often ask for a psychiatric opinion. More experienced dermatologists statistically more frequently ( P < 0.05) obtained a psychiatric opinion about their patients. Only a small group of dermatologists (15.3%) use their own pharmacological treatment. If they do so, they first use anxiety-relieving drugs and placebo.
Conclusion  BDD is a quite common disorder; however, not all dermatologists are sufficiently prepared to treat it. There is an urgent need for training of dermatologists on the effective approach to psychodermatoses.     

A case of body dysmorphic disorder in an adolescent with hypohidrotic ectodermal dysplasia

We report the case of an adolescent with hypohidrotic ectodermal dysplasia, who had obsessive-compulsive disorder and was later diagnosed with body dysmorphic disorder (BDD). BDD is a highly distressing, adolescent-onset disorder that may lead to social isolation, the development of comorbid mental health disorders and suicidality. Patients typically lack insight into their BDD and frequently present to dermatologists for medical treatment. In this paper, we address the challenges faced when working with patients with BDD.     

Body dysmorphic disorder: A critical appraisal of diagnostic,screening, and assessment tools

Body dysmorphic disorder (BDD) is a psychiatric condition characterized by profound concern about a minor or imagined defect in the appearance of individuals and increased preoccupation with the imagined/perceived defect. Individuals with BDD often undergo cosmetic intervention for the perceived imperfection but rarely experience improvement in their signs and symptoms after such treatment. It is recommended that aesthetic providers evaluate individuals face-to-face and screen for BDD with approved scales preoperatively to determine the candidate's suitability for the procedure. This contribution focuses on diagnostic and screening tools and measures of disease severity and insight that providers working in nonpsychiatric settings can use. Several screening tools were explicitly developed for BDD; others were designed to evaluate body image/dysmorphic concern. The BDD Questionnaire (BDDQ)–Dermatology Version (BDDQ-DV), BDDQ–Aesthetic Surgery (BDDQ-AS), Cosmetic Procedure Screening Questionnaire (COPS), and Body Dysmorphic Symptom Scale (BDSS) have been developed explicitly for BDD and validated in cosmetic settings. The limitations of screening tools are discussed. Given the increasing use of social media, future revisions of BDD instruments should consider incorporating questions relevant to patients’ behaviors on social media. Current screening tools can adequately test for BDD despite their limitations and a need for updates.     

Use of psychotropic drugs in the dermatology patient: When to start and stop?

Dermatologists often find themselves treating patients with psychiatric disorders, most commonly anxiety and depression, in the context of skin disease. The psychiatric condition may either be present before the skin condition developed and exacerbate it or, in some cases, even create it (eg, delusions of parasitosis). Alternatively, the psychiatric condition may occur subsequent to the development of the dermatologic condition. The treatment of psychodermatogic disorders requires collaboration between psychiatrists and dermatologists. Dermatologists should be able to recognize primary psychiatric disorders and refer patients to psychiatrists for appropriate treatment; however, the patient may encounter delays in accessing psychiatric care, and dermatologists should be familiar with the basic use of psychotropic drugs. This review describes common psychiatric disorders encountered in a dermatology practice and their treatment with psychotropic drugs. For each commonly used drug, dose range, side effects, and how to initiate and terminate treatment are described. Although psychotherapy is an important part of the treatment of most psychiatric disorders, we have limited our focus to psychotropic drugs in this review.     

Evaluation of cutaneous body image dissatisfaction in the dermatology patient

Cutaneous body image (CBI), defined as the individual's mental representation of his or her skin, hair, and nails, is an important clinical factor in dermatologic disorders and often the primary consideration in deciding whether to proceed with cosmetic procedures or institute treatment in some skin disorders such as acne. CBI is a highly subjective construct that can be significantly confounded by cultural, psychosocial, and psychiatric factors. Assessment of CBI in the dermatology patient is best accomplished using a biopsychosocial model that involves (1) evaluation of concerns about the appearance of the skin, hair, and nails, (2) assessment of comorbid body image pathologies, especially body dysmorphic disorder, and (3) assessment of other psychiatric comorbidities such as major depressive disorder that can confound the presentation of the CBI complaint. Depending on the psychiatric comobidities, an assessment of suicide risk may have to be done, and if necessary, a referral made to a mental health professional. The clinician should consider the patient's developmental stage (eg, body image concerns are likely to be much greater in the adolescent patient independent of his or her dermatologic disorder) and sociocultural background (eg, a desire for lighter skin in some ethnic groups), factors that can also have a major effect on CBI.     

Obsessive‐compulsive disorder in dermatology

Patients with obsessive‐compulsive (OCD) and related disorders – primarily trichotillomania, body dysmorphic disorder, and skin picking disorder – frequently present to dermatologists due to associated hair and skin symptoms. It is therefore crucial that dermatologists be familiar with these disorders. In this review article, we provide an update on clinical features, neurobiology factors, and treatment options for OCD spectrum disorders. Employing PubMed and Cochrane Library databases, a selective literature search was conducted using keywords related to dermatological disorders within the OCD spectrum. OCD and its related disorders share several phenomenological as well as pathophysiological similarities, thus warranting their classification within a separate nosological category of psychiatric disorders. Another similarity of OCD spectrum disorders is the frequent concurrence of hair and skin diseases. Besides symptomatic dermatological treatment, the combination of psychotherapy (behavioral therapy) and psychopharmacotherapy (SSRIs) may be helpful. Although recent insights into OCD have contributed to a better understanding and treatment thereof, more research is required, especially with respect to OCD spectrum disorders, for which large controlled treatment studies are still lacking.     

Understanding the psychology of the cosmetic patients

ABSTRACT:  Patients seeking cosmetic surgery commonly present with psychiatric disorders including body dysmorphic disorder, narcissistic personality disorder, and histrionic personality disorder. A basic understanding of the characteristic features of these conditions and the importance of specialized screening questionnaires and preoperative interview questions are valuable to dermatologic surgeons as the information extracted can help provide clinicians with the most appropriate management including referral for psychiatric intervention.     

Delusional disorders in dermatology: a brief review

There are several unique psychiatric disorders that are likely to present to a dermatologist because of their accompanying skin complaints. Delusions of parasitosis (DP) is a fixed, false belief of parasitic infestation that may lead patients to compulsively self-mutilate while attempting to remove the non-existent parasites. Morgellons disease is a controversial condition characterized by a fixed belief that fibers that are imbedded or extruding from the skin; this condition is likely in the spectrum of DP. Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance that causes significant distress and is associated with time consuming rituals, isolation, depression, and increased risk of suicide. Olfactory reference syndrome (ORS) is a preoccupation with body odor leading to the stigmata of shame, embarrassment, and social isolation. This brief review examines each of these conditions and their management because any one of them may present to a dermatologist.     

Body dysmorphic disorder

Body dysmorphic disorder is a relatively common psychiatric disorder among the dermatology patient population. These individuals may present to dermatologists for treatment of normal or minimally abnormal skin findings. Recognizing that these patients have body dysmorphic disorder can avert unnecessary and potentially unsuccessful treatments. Understanding and directing patients toward appropriate treatment options can minimize the distress and morbidities associated with the disorder.     

Dermatology manpower needs

The future need for dermatologists is difficult to predict, as it depends on the structure of our health care delivery system, which is still rapidly evolving, and whose future shape is unknown. The best strategy to deal with this unpredictable situation is to de-emphasize trying to predict the future and focus on responding as rapidly as possible to whatever changes in dermatologic manpower needs the future may bring. From that perspective, it is best to train fewer rather than more dermatologists, as it is much quicker to rectify a shortage than an excess in medical manpower. Other issues that impact on dermatologist manpower include a very rapid increase in nonphysicians taking care of skin diseases, the maldistribution of dermatologists, the decreasing proportion of common skin diseases treated by dermatologists, and the need to upgrade the residency training to master the explosion in medical knowledge which has occurred, and to gain a greater expertise in the medical and cosmetic aspects of the specialty.     

Psychodermatology of vitiligo: Psychological impact and consequences

Vitiligo is an autoimmune dermatologic disorder that causes chronic skin depigmentation, which affects an estimated 1% of the world's population. This disfiguring condition can have devastating psychological consequences on its sufferers. The field of psychodermatology examines psychiatric manifestations of dermatologic conditions. Although previous research in this area has been done on other skin disorders, no large‐scale review exists on the dermatologic‐psychiatric connection in vitiligo specifically. The current article will discuss the psychodermatology of vitiligo with an emphasis on depression, stress, and low self‐esteem. The social and cultural considerations will also be explored. Finally, the implications of these psychiatric manifestations on treatment will be discussed, with the goal of implementing early psychiatric intervention for those with vitiligo.     

Psychiatric evaluation of the dermatology patient

Over one third of dermatologic disorders have significant psychiatric comorbidity. The impact of the skin disorder on quality of life, the role of psychosocial stressors, and use of substances should be assessed. Major depressive disorder is the most frequently encountered psychiatric disorder in dermatology and is often associated with suicide risk. Other psychiatric syndromes comorbid with dermatologic disorders include obsessive-compulsive disorder, social phobia, posttraumatic stress disorder associated with dissociation and conversion symptoms, body image pathologies, delusional disorder, and a wide range of personality disorders. This article reviews psychiatric guidelines that may be used to assess psychopathology in the dermatology patient.     

Psychodermatology of skin picking (excoriation disorder): A comprehensive review

Excoriation disorder (ED) is a primary psychiatric disorder characterized by recurrent skin picking, which may lead to self‐induced cutaneous lesions and significant distress or functional impairment. The affected patient is aware of his/her self‐destructive behavior but feels unable to give up this habit, despite having made repeated attempts to decrease or stop it. ED is a relatively frequent disorder, of notable heterogeneity and phenomenological complexity, accompanied by significant emotional and physical consequences. Therefore, further research is necessary to enhance the knowledge on its clinical manifestations, epidemiology, and comorbidities. This article presents an update regarding the etiopathogenesis, clinical aspects, and treatment options of ED to provide an up‐to‐date review for psychiatrists, dermatologists, and general practitioners.     

Psychiatric and Psychological Co-Morbidity in Patients with Dermatologic Disorders

Psychiatric and psychological factors play an important role in at least 30% of dermatologic disorders. In many cases the impact of the skin disorder upon the quality of life is a stronger predictor of psychiatric morbidity than the clinical severity of the disorder as per physician ratings. Furthermore, in certain disorders such as acne and psoriasis, the psychiatric co-morbidity, which can be associated with psychiatric emergencies such as suicide, is an important measure of the overall disability experienced by the patient. The severity of depression and increased suicide risk are not always directly correlated with the clinical severity of the dermatologic disorder. Consideration of psychiatric and psychosocial factors is important both for the management, and for some aspects of secondary and tertiary prevention of a wide range of dermatologic disorders. It is useful to use a biopsychosocial model which takes into account the psychological (e.g. psychiatric comorbidity such as major depression and the impact of the skin disorder on the psychological aspects of quality of life) and social (e.g. impact upon social and occupational functioning) factors, in addition to the primary dermatologic factors, in the management of the patient. Some dermatology patients are likely to benefit from psychotherapeutic interventions and psychotropic agents for the management of the psychosocial comorbidity, in addition to the standard dermatologic therapies for their skin disorder.     

Body dysmorphic disorder and cosmetic dermatology: more than skin deep

Body dysmorphic disorder (BDD) is relatively common in cosmetic practise, yet it remains under-recognized. BDD patients are unnaturally concerned with minimal or non-existent flaws, most commonly in the skin (e.g. facial acne or scarring) and hair (e.g. hair loss). Many patients develop social avoidance and suffer occupational or academic impairment. More severely ill patients may become housebound or even attempt suicide. Despite the minimal or non-existent nature of the perceived appearance flaws, patients with BDD may request dermatological treatments such as isotretinoin or dermabrasion. Although treatment outcome has received little investigation, it appears that most patients are dissatisfied with dermatological treatment and, even if the outcome is objectively acceptable, they do not worry any the less about their appearance afterwards. In contrast, a majority of patients respond to serotonin reuptake inhibitors or cognitive behavioural therapy. Treatment of these patients is best given by an experienced health professional. This may be a mental health professional or a dermatologist with an interest in psychological medicine.     

Identifying and managing naevus dysmorphia in clinical practice

Naevus dysmorphia is a form of appearance concern/body image dissatisfaction, which describes a preoccupation withthe appearance of a clinically small melanocytic naevus. The naevus is perceived by the patient to be disfiguring. Such perception leads to maladaptive behaviours and is often associated with low mood, as well as high levels of anxiety and social avoidance. Affected individuals form a diverse group. However, what they have in common is that the distress experienced is disproportionate to the objective visual appearance of the mole. There is a range of severity of the impact on the individual's well being. Naevus dysmorphia may or may not be a cutaneous manifestation of body dysmorphic disorder(BDD). It is essential that patients with naevus dysmorphia are identified and distinguished from patients requesting removal of a mole for other uncomplicated cosmetic reason. Patients with naevus dysmorphia can be challenging to treat and communicate with. Surgical excision of the naevus will not address the underlying psychopathology and so it may not result in long-term positive outcome. Ideally, a detailed psychological assessment and formulation can be made potential y followed by psychological therapy tailored to the needs of the individual. A therapeutic trial of appropriate psychopharmacological course may be indicated in certain cases, e.g., when symptoms of a depressive disorder, anxiety disorder or BDD are present. A case series of 10 patients with naevus dysmorphia is presented, in order to highlight the above issues.