Beneath the surface: A psychodermatological approach for body dysmorphic disorder in cosmetic and esthetic interventions

INTRODUCTION

Our physical appearance is our outward projection to the world. This includes our looks, facial features, skin, hair, genitalia, and body shape and size. Hence, body dysmorphic disorder (BDD) is particularly prevalent among dermatology patients. Excessive checking of minor moles, freckles, and pores, seeking reassurance from peers, excessive grooming, picking at skin or white hair, anorexia nervosa, and seeking cosmetic treatments with no satisfaction are common behaviors that dermatologists encounter. These individuals switch from one dermatologist to another or anyone who is happily ready to cater to their demands for “perfection.” It is common for these individuals to spend large amounts of money on these cosmetic procedures, and often limit their social interactions and professional or personal responsibilities. Dermatologists need to develop a keen eye to screen for BDD in such patients to provide an adequate cosmetic and psychological intervention.

DEFINITION OF BDD

BDD is a distressing preoccupation with a perceived physical defect in appearance that is minimal or unobservable to others, often resulting in significant functional impairment in social and occupational domains.^[1] BDD was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III as an atypical somatoform disorder called “dysmorphophobia.” DSM-4 had a BDD diagnosis based on “preoccupation with appearance, distress, and impairment, and appearance concerns that are not better accounted for by any other mental disorder.” In DSM-5, BDD was classified in a new category as an obsessive-compulsive and related disorder (OCRD), along with obsessive-compulsive disorders, trichotillomania, hoarding disorder, and excoriation disorder^[2] [Figure 1]. The new criteria also included repetitive behaviors (mirror checking, excessive grooming, or skin picking) or thoughts (comparison of appearance with other individuals).^[2]

Close

Figure 1:

Definition of body dysmorphic disorder as given by the Diagnostic and Statistical Manual of Mental Disorders and the 11^th revision of the World Health Organization’s International Classification of Diseases.

Export to PPT

The 11^th revision of the World Health Organization’s International Classification of Diseases (ICD-11), 2019, included a culmination of Clinical Descriptions and Diagnostic Requirements (CDDR) specifically for ICD-11 mental, behavioral, and neurodevelopmental disorders (CDDR).^[3] BDD is defined under code 6B21 as a “persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others” [Figure 1]. BDD and OCD co-occur frequently and have common risk factors. Therefore, in DSM-5 and ICD-11, BDD and OCD are classified together as OCRDs. The only somatoform condition excluded from BDD in ICD-10 was hypochondriasis (i.e., health anxiety). ICD-11 keeps hypochondriasis within OCRDs because it responds to treatments used for OCRDs and has similar repetitive behaviors and neural activation patterns on brain imaging.^[4,5]

Individuals experience excessive self-consciousness, often with ideas of reference, i.e., they have a conviction that people are taking notice of, judging, or talking about the perceived defect or flaw. In response to this preoccupation, individuals engage in repetitive and excessive behaviors that include repeated examination of their appearance or perceived defect or flaw, excessive attempts to camouflage or alter the perceived defect, or marked avoidance of social situations or triggers that increase their distress. The symptoms are sufficiently severe to result in significant distress or impairment in personal, family, social, educational, occupational, or other important aspects of functioning.^[3] BDD is often associated with other mental disorders such as depressive disorder, substance use disorders, social anxiety disorder, and low quality of life.^[6] These individuals are also at a high risk of suicidal ideation or attempts.

PREVALENCE

Two-thirds of individuals with BDD experience the onset of symptoms before 18 years of age. The most common age of onset is around 12 years of age, but it is diagnosed after a delay of several years because adolescents seek help from non-medical health professionals or social media. Adolescents with chronic conditions such as acne, atopic dermatitis, psoriasis, and hidradenitis suppurativa should be screened for BDD.^[7,8] Moreover, physical unattractiveness can be considered a greater social liability in females than in males.^[9] With the growing awareness of grooming and self-care, esthetic and cosmetic interventions are increasingly sought by men, if not more so, than women these days. Hence, all adult dermatology patients who have an esthetic chief complaint should be screened for BDD.

SCREENING SCALES FOR BDD IN DERMATOLOGY

All adult dermatology patients with an esthetic chief complaint should be screened for BDD.^[14,15] The self-report BDD questionnaire (BDDQ)-dermatology version is a valid screening tool that can be used to screen for BDD in a dermatology setting [Figure 2].

Close

Figure 2:

The self-report body dysmorphic disorder questionnaire-dermatology version.

Export to PPT

It is less clear which adolescents with dermatological complaints should be screened for BDD.^[14] Whenever a dermatologist suspects that an adolescent patient may have BDD, it is essential and helpful to use a self-screening method like the BDDQ for adolescents [Figure 3]. Screening is prudent in cases of acne and acne excoriee (habitual picking and scratching of acne), psoriasis, atopic dermatitis, hidradenitis suppurativa, and prurigo nodularis due to the increased incidence of BDD for these patients.^[13]

Close

Figure 3:

Self-screening body dysmorphic disorder questionnaire for adolescents.

Export to PPT

The BDDQ-esthetic surgery is a brief screening tool that can be used before administering a cosmetic surgery [Figure 4].^[15]

Close

Figure 4:

The body dysmorphic disorder questionnaire – esthetic surgery before administering a cosmetic surgery.

Export to PPT

The Body Image Disturbance Questionnaire was developed to provide a means for a thorough assessment of body image disturbance on a continuum within both non-clinical and clinical populations.^[16] It is a modified BDDQ, made as a 5-point rating system with open-ended clarification of responses, rather than a yes or no format of BDDQ [Figure 5].

Close

Figure 5:

The body image disturbance questionnaire (BDDQ). It is a modified BDDQ, made as a 5-point rating system with open-ended clarification of responses, rather than a yes or no format of BDDQ.

Export to PPT

THE IMPACT OF SOCIAL MEDIA

Social media has introduced the concept of skin care across all ages, genders, and social statuses. The pitfall of social media is the portrayal of a distorted perception of youthfulness, which has pushed people toward unrealistic expectations from their dermatologists. Social media has taught us how to dress, how to look a certain way, how to be socially presentable, what to use, and what not to use. In short, it molds us according to the ever-changing trends to fit into a certain socially acceptable cast. Nobody needs that many clothes, that many skin care products, or that many procedures. However, we consume all this information daily, and at some point, it is bound to hurt our body image. Adolescents and individuals with BDD are a soft target to be influenced by all this information. The “mere-repeated exposure effect” is a psychological phenomenon where individuals tend to form a liking for certain objects or concepts that have become familiar to them through repeated exposure.^[17] The influence of social media on young people’s appearance-related expectations has given rise to the term “Snapchat dysmorphia” or “selfie dysmorphia.” This phenomenon reflects a growing trend in which individuals aspire to look like their filtered images and increasingly seek cosmetic treatments from dermatologists, plastic surgeons, and estheticians to achieve such ideals.^[18] While this term lacks nosological validity, it is certainly a cause for major concern. According to a 2022 survey, between 2014 and 2015, a 22% rise was reported in the use of smartphones by adolescents between 13 and 17 years of age.^[19] Although social media may offer adolescents a platform to seek emotional support, share experiences, and obtain information, 95% dermatologists in this survey reported that social media posed a problem for their young patients.^[19] The repeated, brief encounters with images may cause individuals to perceive these unnatural, polished, and photoshopped traits as more attractive.^[17] This can significantly contribute to enhancing the already perceived self-skewed body image in patients with BDD and further decline the quality of life.

IMPLICATIONS OF BDD ON A DERMATOLOGICAL TREATMENT

Patients with BDD have a higher symptom awareness, i.e., they recognize minimal differences in appearance more accurately. BDD is common in dermatological patients with pigmentation, acne, scars, excess body hair, alopecia, psoriasis, and signs of aging. This awareness may be more aggravated in patients with dermatological conditions like alopecia or psoriasis.^[20] This can also stem from personal experiences of stigmatization and discrimination, therefore causing a noticeable burden of negative emotions like anxiety and depression. A new development in psycho-dermatology is a condition called “Charismaphobia,” i.e., persistent and excessive fear of being or becoming unattractive.^[21] Hence, patients with BDD who visit a dermatologist with a clinical or cosmetic complaint need a holistic approach to prevent negative implications on treatment outcomes.

As patients with BDD suffer from negative body image, no amount of dermatological intervention is enough. They always tend to seek more, visiting one dermatologist or plastic surgeon after another, undergoing multiple treatments and consultations. Even after a successful treatment, these patients may shift their focus to a new perceived defect, leading to additional procedures. These patients have unrealistic expectations for any cosmetic intervention and thus remain unsatisfied with the treatment outcome. This is frustrating not only for the patient but also for the dermatologist. Underlying BDD may also make assessment of the primary dermatological condition difficult, and there is always a possibility that BDD is the etiological cause of a dermatological condition. For example, individuals with a habit of skin picking tend to damage the skin further, thus hampering the progress of the treatment. Addressing only the dermatological or cosmetic complaint will not effectively treat these individuals. Many times, these patients have poor insight into their psychological illness and do not recognize the need for a psychiatric intervention.^[8] Skin picking disorder (SPD) and BDD have a clinical overlap, but neurocognitive research has failed to provide any differences or similarities between the two. SPD and BDD may co-occur, and it is hypothesized that this co-occurrence may result in more severe skin picking, greater psychological dysfunction, and worse quality of life.^[22]

Patients with BDD are ten times more likely to meet the criteria for depression, and four times more likely to meet the criteria for an anxiety disorder.^[10] The social anxiety, financial burden due to repeated cosmetic procedures, and impact on social, professional, and personal responsibilities impact the quality of life of an individual. The rates of suicidal ideation and behaviors are also higher in these individuals^[23] [Figure 6].

Close

Figure 6:

Implications of body dysmorphic disorder.

Export to PPT

INTEGRATING PSYCHOLOGICAL INTERVENTIONS WITH DERMATOLOGY

The motivation to seek dermatological and cosmetic treatments is more or less close to the core definition of BDD. In a dermatological practice, BDD can often be missed because the dermatologist may not suspect it or may not be asking the right questions to screen for BDD. Hence, even though a dermatologist is not equipped to provide psychiatric or psychological intervention, it becomes pertinent for dermatologists to have an eye to screen for BDD and provide apt hand-holding and referral to the patient [Figure 7].

Close

Figure 7:

Algorithm to rule out body dysmorphic disorder in patients seeking cosmetic and esthetic interventions.

Export to PPT

Combining psychological and dermatological treatments can help healthcare providers to effectively alleviate distress and improve treatment outcomes.

Warning signs of BDD to be considered by a dermatologist: (i) “Feeling” that surgical intervention will solve all problems. (ii) Refusal to go through a standard pre-operative evaluation. (iii) History of psychological interventions and treatments. (iv) History of visiting several doctors for treatment, without satisfaction. (v) Comparison with pictures on social media or celebrities and asking for constant assurance to look like them.^[24]

The task of steering a patient with BDD toward psychiatric assessment and treatment may not be easily accomplished. Although some patients may feel relief at the prospect of identifying the reason behind their distress and may be open to addressing it, many are unlikely to take this suggestion kindly. Hence, it is of utmost importance to validate their concerns and distress. It would be pointless to talk them out of their beliefs; in fact, empathy may prove to be a more useful tool.^[25] Literature suggests that the patient should be educated about BDD in detail.^[26] However, our experience suggests that this may not always be the best approach. In many cases, while advising a patient about the psychological nature of their complaints, it is better to avoid the usage of terms such as “body dysmorphic disorder,” “body dysmorphia,” or “dysmorphophobia” initially. Such terms may make the patients feel “labelled” as having a psychiatric condition and not taken seriously, particularly when insight into their symptoms is limited. It may also lead to an internet-search spiral, reinforcing feelings of shame and embarrassment. Instead, one can try to focus on the symptoms and their resultant distress and dysfunction. Explain that cosmetic interventions alone may be ineffective and may even lead to worsening of symptoms, body image dissatisfaction, and distress. Suggest the involvement of a psychiatrist to alleviate this distress and improve socio-occupational functioning. Active liaison between the dermatologist and psychiatrist is an invaluable tool in providing holistic care and easing the patient’s transition into psychiatric care [Figure 8].

Close

Figure 8:

Some common case scenarios dermatologists may come across in their practice.

Export to PPT

PSYCHIATRIC CARE FOR A PATIENT WITH BDD

Cognitive behavioral therapy (CBT) is the first line of therapy for BDD, and it has emerged as a cornerstone in addressing BDD symptoms in the context of dermatology.^[10] Patients with BDD do not and cannot benefit from cosmetic procedures alone.^[27] CBT in patients with BDD includes psycho-education, during which the therapist explains the BDD treatment. This includes cognitive restructuring, ritual prevention, and prevention of relapse.^[28]

Psychotropic medications, like selective serotonin reuptake inhibitors, are efficacious in reducing obsessive thoughts and compulsive behaviors associated with BDD.^[10] These medications improve functioning and treatment response by alleviating the symptoms of anxiety and depression.

Merely advising individuals with BDD to discontinue social media use or to consciously reduce repetitive behaviors is not sufficient. Dermatologists often collaborate with physicians or pediatricians in patient care. Similarly, collaborating with mental health professionals is essential for the comprehensive assessment and management of BDD. Cosmetic or dermatological interventions alone are inadequate without addressing the underlying psychological components.

CONCLUSION

BDD is a psychiatric disorder prevalent among adult and adolescent dermatology patients seeking cosmetic resolution to their visible or perceived complaints. These individuals often face social stigmatization and discrimination, impaired social and professional functioning, strain in personal associations, and psychological burden of anxiety, depression, and suicidal ideation. When such an individual approaches a dermatologist, it is unlikely that she/he is going to be satisfied with a cosmetic intervention alone. Hence, dermatologists must be equipped with effective screening tools to identify BDD and provide guidance for a psychiatric intervention. The recognition and management of BDD in a dermatological practice demands a holistic approach in collaboration with mental healthcare professionals. Doing so not only enhances cosmetic treatment outcomes but also helps break the cycle of repeated cosmetic procedures and persistent psychological distress.