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Figure 1.
Surgeon BDD Screening Form
Surgeon BDD Screening Form

BDD indicates body dysmorphic disorder.

Figure 2.
Pretest and Posttest Probabilities for Physician Diagnosis of Body Dysmorphic Disorder
Pretest and Posttest Probabilities for Physician Diagnosis of Body Dysmorphic Disorder

Shaded areas within bounds denote 95% CIs.

Table 1.  
Demographics of Participants by Study Site
Demographics of Participants by Study Site
Table 2.  
Participants Screening Positive for Body Dysmorphic Disorder as Determined by the Body Dysmorphic Disorder Questionnaire by Study Site
Participants Screening Positive for Body Dysmorphic Disorder as Determined by the Body Dysmorphic Disorder Questionnaire by Study Site
Table 3.  
Summary of Simple Logistic Regression Analysis for Baseline Factors Associated With Screening Positive on the Body Dysmorphic Disorder Questionnaire
Summary of Simple Logistic Regression Analysis for Baseline Factors Associated With Screening Positive on the Body Dysmorphic Disorder Questionnaire
1.
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
2.
Phillips  KA, Grant  J, Siniscalchi  J, Albertini  RS.  Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder.  Psychosomatics. 2001;42(6):504-510.PubMedGoogle ScholarCrossref
3.
Phillips  KA.  The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press; 2005.
4.
Cunningham  SJ, Bryant  CJ, Manisali  M, Hunt  NP, Feinmann  C.  Dysmorphophobia: recent developments of interest to the maxillofacial surgeon.  Br J Oral Maxillofac Surg. 1996;34(5):368-374.PubMedGoogle ScholarCrossref
5.
Wright  MR.  The male aesthetic patient.  Arch Otolaryngol Head Neck Surg. 1987;113(7):724-727.PubMedGoogle ScholarCrossref
6.
Sarwer  DB.  Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members.  Aesthet Surg J. 2002;22(6):531-535.PubMedGoogle ScholarCrossref
7.
Sarwer  DB, Spitzer  JC, Sobanko  JF, Beer  KR.  Identification and management of mental health issues by dermatologic surgeons: a survey of American Society for Dermatologic Surgery members.  Dermatol Surg. 2015;41(3):352-357.PubMedGoogle ScholarCrossref
8.
Phillips  KA, McElroy  SL, Lion  JR.  Plastic surgery and psychotherapy in the treatment of psychologically disturbed patients.  Plast Reconstr Surg. 1992;90(2):333-335.PubMedGoogle Scholar
9.
de Brito  MJ, Sabino Neto  M, de Oliveira  MF,  et al Yale-Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS): Brazilian Portuguese translation, cultural adaptation and validation.  Rev Bras Psiquiatr. 2015;37(4):310-316.Google ScholarCrossref
10.
Morselli  PG, Micai  A, Boriani  F.  Eumorphic plastic surgery: expectation vs satisfaction in body dysmorphic disorder.  Aesthetic Plast Surg. 2016;40(4):592-601.PubMedGoogle ScholarCrossref
11.
Aouizerate  B, Pujol  H, Grabot  D,  et al.  Body dysmorphic disorder in a sample of cosmetic surgery applicants.  Eur Psychiatry. 2003;18(7):365-368.PubMedGoogle ScholarCrossref
12.
Altamura  C, Paluello  MM, Mundo  E, Medda  S, Mannu  P.  Clinical and subclinical body dysmorphic disorder.  Eur Arch Psychiatry Clin Neurosci. 2001;251(3):105-108.PubMedGoogle ScholarCrossref
13.
Veale  D, De Haro  L, Lambrou  C.  Cosmetic rhinoplasty in body dysmorphic disorder.  Br J Plast Surg. 2003;56(6):546-551.PubMedGoogle ScholarCrossref
14.
Ishigooka  J, Iwao  M, Suzuki  M, Fukuyama  Y, Murasaki  M, Miura  S.  Demographic features of patients seeking cosmetic surgery.  Psychiatry Clin Neurosci. 1998;52(3):283-287.PubMedGoogle ScholarCrossref
15.
Vargel  S, Uluşahin  A.  Psychopathology and body image in cosmetic surgery patients.  Aesthetic Plast Surg. 2001;25(6):474-478.PubMedGoogle ScholarCrossref
16.
Vindigni  V, Pavan  C, Semenzin  M,  et al.  The importance of recognizing body dysmorphic disorder in cosmetic surgery patients: do our patients need a preoperative psychiatric evaluation?  Eur J Plast Surg. 2002;25(6):305-308.Google ScholarCrossref
17.
Sarwer  DB, Whitaker  LA, Pertschuk  MJ, Wadden  TA.  Body image concerns of reconstructive surgery patients: an underrecognized problem.  Ann Plast Surg. 1998;40(4):403-407.PubMedGoogle ScholarCrossref
18.
Crerand  CE, Sarwer  DB, Magee  L,  et al.  Rate of body dysmorphic disorder among patients seeking facial plastic surgery.  Psychiatr Ann. 2004;34(12):958-965.Google ScholarCrossref
19.
Woolley  AJ, Perry  JD.  Body dysmorphic disorder: prevalence and outcomes in an oculofacial plastic surgery practice.  Am J Ophthalmol. 2015;159(6):1058-1064.e1.PubMedGoogle ScholarCrossref
20.
Dey  JK, Ishii  M, Phillis  M, Byrne  PJ, Boahene  KD, Ishii  LE.  Body dysmorphic disorder in a facial plastic and reconstructive surgery clinic: measuring prevalence, assessing comorbidities, and validating a feasible screening instrument.  JAMA Facial Plast Surg. 2015;17(2):137-143.PubMedGoogle ScholarCrossref
21.
Alsarraf  R.  Outcomes research in facial plastic surgery: a review and new directions.  Aesthetic Plast Surg. 2000;24(3):192-197.PubMedGoogle ScholarCrossref
22.
Johns Hopkins University & Medicine. Development and Psychometric Evaluation of the FACE-Q Satisfaction with Appearance Scale—ClinicalKey. https://www-clinicalkey-com.proxy1.library.jhu.edu/#!/content/playContent/1-s2.0-S0094129812001940?returnurl=null&referrer=null. Accessed May 16, 2016.
23.
First  M, Williams  J, Karg  R, Spitzer  R.  Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV). Arlington, VA: American Psychiatric Association; 2015.
Original Investigation
Jul/Aug 2017

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Division of Oculoplastic Surgery, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor
  • 3Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 4Facial Plastic Surgicenter, Baltimore, Maryland
JAMA Facial Plast Surg. 2017;19(4):269-274. doi:10.1001/jamafacial.2016.1535
Key Points

Question  What is the prevalence of body dysmorphic disorder (BDD) and ability of facial plastic and oculoplastic surgeons to clinically diagnose this condition?

Findings  In this multicenter prospective study, 597 patients were screened for BDD. Approximately 10% of patients screened by a validated screening instrument were positive for BDD, but surgeons were only able to correctly identify approximately 5% of those patients screening positive.

Meaning  Body dysmorphic disorder is a common condition within facial plastic surgery practices, but surgeons have a low accuracy in identifying these patients when compared with validated screening instruments. Routine use of validated BDD screening tools may improve patient care.

Abstract

Importance  Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented.

Objective  To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD.

Design, Setting, and Participants  This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016.

Methods  All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE).

Results  Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE.

Conclusions and Relevance  Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care.

Level of Evidence  NA.

Introduction

Body dysmorphic disorder (BDD) is a psychiatric condition that is classified as an obsessive compulsive–related disorder.1Quiz Ref ID Patients with BDD have an obsessive preoccupation with perceived defects of their appearance that are minuscule or nonexistent and commonly involve the nose, eyes, skin, or hair.2,3 Patients with BDD often suffer from significant emotional distress and functional impairment.1 Mood, anxiety, and personality disorders are common psychiatric comorbidities in these patients.

Patients with BDD exhibit compulsive or repetitive behaviors that aim to improve or hide their perceived defects. Indeed, up to 76% of patients with BDD seek consultation for cosmetic procedures, and Quiz Ref IDup to 60% of patients with BDD actually undergo unnecessary surgical procedures for their perceived defects.2,4,5 A vast majority (84%) of cosmetic plastic surgeons report having operated on patients whom they believed had BDD, with 82% of these patients having a negative outcome.6,7 Numerous studies have shown that patients tend to have poor satisfaction following surgery and show a higher rate of aggression and litigation toward surgeons.4,5,8 Therefore, it is important to accurately identify patients with BDD in plastic surgery practices, because the proper treatment for these patients is psychiatric care and occasionally surgery with psychiatric care and/or intensive psychological support.9,10

The prevalence of BDD is approximately 2.4% in the general population.1 The reported prevalence of BDD in patients presenting for facial plastic and oculoplastic surgery varies significantly, likely owing to varying patient populations and inconsistent screening methods.11-18 Furthermore, because formal and routine screening for BDD is uncommon in these practices, there is often an underdetection of BDD.2,3,6,18Quiz Ref ID More recent studies suggest that the prevalence of BDD is up to 13% in the facial plastic surgery setting and 6.9% in the oculoplastic surgery practice.19,20

The Body Dysmorphic Disorder Questionnaire (BDDQ) was developed in the psychiatric setting for BDD screening. Recently, the BDDQ was validated in the facial plastic surgery patient population and was found to have a sensitivity of 100% and specificity of 90.3%.20Quiz Ref ID Despite the existence of this validated screening instrument for BDD, many surgeons continue to rely primarily on their intuition and intangible information gathered from the clinical encounter to determine if a patient has BDD. Whether surgeons’ suspicion of BDD based on clinical intuition correlates well with the validated BDDQ has not been investigated. In the study, we aim to establish the prevalence of BDD across multiple cosmetic and reconstructive facial plastic and oculoplastic surgery practices. Furthermore, we sought to prospectively determine surgeons’ accuracy in screening for BDD compared with the validated BDDQ.

Methods
Participants

This study was approved by the institutional review boards of the Johns Hopkins University School of Medicine and the University of Michigan Medical School. Informed consent or a waiver of informed consent for study participation was obtained for each study site. A total of 3 clinical sites participated in this study. Study site 1 represents an academic facial plastic and reconstructive surgery practice; site 2, a private facial plastic and reconstructive surgery practice; and site 3, an academic oculoplastic surgery practice. Across the 3 participating sites, a total of 597 patients that presented between March of 2015 and February of 2016 participated in this study.

Data Collection

All patients 18 years or older presenting to the participating sites for a new patient consultation were invited to complete the screening questionnaires during the registration process. Patients who agreed to participate were provided a portable electronic tablet which displayed the clinical instruments in an interactive manner. Regardless of the study site, the survey questions were presented in an identical order and had the same on-screen formatting. In addition to questions involving the primary screening instruments, patients were asked a series of background demographic questions including age, ethnicity, sex, marital status, education level, and primary category of consultation (reconstructive vs cosmetic).

Clinical Instruments

Several instruments were used in this study. The BDDQ was the primary instrument used to determine whether a patient exhibited symptoms consistent with BDD. This instrument was originally developed and validated in the psychiatric setting but has since been validated in a number of patient populations including the facial plastic and reconstructive surgery patient population.3,20 Within the facial plastic and reconstructive surgery population, it was found to have a very high sensitivity (100%) and high specificity (90.3%).20 Instruments that were used to assess patient satisfaction with their appearance include the FACE-Q (Overall Facial Appearance Scale), Rhinoplasty Outcomes Evaluation (ROE), Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), and the Skin Rejuvenation Outcomes Evaluation (SROE).21,22 All patients completed the FACE-Q instrument. Depending on the patients’ reasons for presentation, they also completed any relevant outcomes evaluation surveys. After completing the screening instruments, patients proceeded to their surgical consultation. At the end of the encounter, surgeons completed a short series of questions to determine whether they believed each patient met diagnostic criteria for BDD and their certainty in the diagnosis (Figure 1). Surgeons were blinded to the results of the BDDQ instrument throughout the study.

Statistical Analysis

Descriptive statistics were used to assess baseline demographic variables. For categorical variables, the Fischer exact test or χ2 test was used to test for differences across study sites. Analysis of variance (ANOVA) methods were used to compare continuous demographic variables (age) across study sites. Simple logistic regression was used to assess for differences in baseline patient-rated satisfaction scores based on BDDQ status. Surgeon diagnostic accuracy was compared with the validated BDDQ screening instrument. Sensitivity, specificity, positive predictive value, negative predictive value, prevalence, receiver operating curve (ROC) area, and positive and negative likelihood ratios were calculated from frequency tables. Our primary performance metric—our surgeon’s ability to classify BDD—were the positive and negative likelihood ratios. We generated the pretest vs posttest probability curves using Mathematica 10.0 (Wolfram). These curves illustrate how much a surgeon’s diagnostic ability changes the likelihood that a patient is diagnosed or not diagnosed as a BDD case. Missing data were assumed to be missing at random and a sensitivity analysis of our results to missing data was performed using multiple imputation; 200 imputations were used for this analysis. All tests were 2-sided and P values less than .05 were considered statistically significant. Besides what was otherwise noted, all remaining statistical analyses were performed using Stata Data Analysis and Statistical Software, version 14.0 (StataCorp LP).

Results
Study Population

A total of 597 patients completed the surveys and were included in the study population. Baseline demographic variables are shown in Table 1. Patients presenting to each study site had similar age. Across study sites, there was a difference in the distribution of gender (χ2 [2, N = 595] = 17.36; P < .001), education (χ2 [10, N = 595] = 21.13; P = .049), self-reported race (χ2 [10, N = 595] = 25.81; P = .004), and marital status (χ2 [4, N = 594] = 34.08; P < .001). Furthermore, the proportion of patients presenting primarily for cosmetic concerns differed across sites (χ2 [2, N = 597] = 58.21; P < .001).

BDDQ Screening

A total of 58 patients (9.7%) across study sites screened positive for BDD based on the BDDQ instrument. The proportion of patients screening positive at each study site is shown in Table 2. There was no significant difference in the proportion of patients screening positive across the 3 study sites (χ2 [2, N = 597] = 1.11; P = .57). Patients presenting primarily for cosmetic purposes (37 of 283 patients [13.1%]) were more likely than those presenting for reconstructive reasons (21 of 314 patients [6.7%]) to screen positive on the BDDQ (odds ratio [OR], 2.10; 95% CI, 1.20-3.68; P = .01).

Surgeon Diagnostic Accuracy

The diagnostic accuracy of surgeons in performing clinical screening for BDD was compared with that of the validated BDDQ screening instrument. A total of 402 patients completed the baseline screening surveys and were also screened by a surgeon. Independent of BDDQ status, a total of 16 patients (4.0%) were suspected by surgeons as having BDD. While 43 out of the 402 patients (10.7%; 95% CI, 7.8%-14.1%) screened positive on the BDDQ instrument, only 2 of these patients (4.7%) were correctly identified by surgeons as having BDD. The sensitivity of surgeon diagnosis of BDD when compared with the BDDQ was 4.7% (95% CI, 0.6%-15.8%) with a specificity of 96.1% (95% CI, 93.5%-97.9%). The positive predictive value was found to be 12.5% (95% CI, 1.6%-38.3%) and negative predictive value was 89.4% (95% CI, 85.9%-92.3%). The positive and negative likelihood ratios for surgeon diagnosis were 1.19 (95% CI, 0.3-5.1) and 1.0 (95% CI, 0.9-1.1), respectively, and both 95% CIs contain one suggesting that little additional information is gained for discriminating BDD status of a patient based on clinical diagnosis of a surgeon. The ROC area was 0.50 (95% CI, 0.47-0.54). Plots of pretest and posttest probability for surgeon diagnosis are shown in Figure 2. Despite poor ability to predict BDD status, surgeons had a mean (SD) certainty of 89.0% (15.3%) (median, 90%) of the accuracy of their ability to screen for BDD. The multiple imputation results are all within the presented 95% CIs presented suggesting these results are robust to missing data.

Factors Associated With BDDQ Status

Logistic regression analysis revealed that age and category of consultation (cosmetic consultation vs reconstructive or functional) were associated with BDDQ status (Table 3). Quiz Ref IDSpecifically, patients who were younger (OR, 0.98; 95% CI, 0.96-0.99; P = .04) or who presented for primarily cosmetic concerns (OR, 2.10; 95% CI, 1.20-3.68; P = .01) were more likely to screen positive on the BDDQ. Sex was not significantly associated with BDDQ status (OR, 1.8; 95% CI, 0.95-3.43; P = .07). Patients screening positive for BDD on the BDDQ also had lower baseline (preoperative) satisfaction with their appearance as measured by the FACE-Q (OR, 0.93; 95% CI, 0.91-0.95; P < .001), ROE (OR, 0.95; 95% CI, 0.92-0.98; P = .002), BOE (OR, 0.94; 95% CI, 0.90-0.97; P < .001), FOE (OR, 0.89; 95% CI, 0.85-0.94; P < .001), and SROE (OR, 0.92; 95% CI, 0.87-0.97; P = .003).

Discussion

Patients with BDD frequently seek plastic surgery to address their perceived defects in appearance. Yet, data suggest that these patients most commonly have poor satisfaction and may not benefit from surgery.2 Therefore, it is of critical importance that surgeons accurately identify patients with BDD who present seeking surgery and manage them appropriately. Many plastic surgeons do not formally screen for BDD. This may be owing to surgeons’ underestimation of the prevalence of BDD in their practice setting or a lack of familiarity with validated screening tools. Indeed, when members of the American Society of Aesthetic Plastic Surgery were surveyed, a majority of respondents believed that the prevalence of BDD was only 2% in their practice.6 In this prospective multicenter study, we aimed to determine the prevalence of patients screening positive for BDD across multiple facial plastic and oculoplastic surgery settings in a standardized fashion. This is also the first study to determine the accuracy of surgeons at identifying patients with BDD.

The overall prevalence of patients screening positive for BDD by BDDQ in our study population was 9.7%. The prevalence was higher in patients with primarily cosmetic concerns (13.1%) than those presenting for noncosmetic reconstruction (6.7%). The gold standard for diagnosing patients with BDD is the structured clinical interview for diagnosis (SCID), which is time-consuming and challenging to implement in a busy cosmetic surgery practice.23 However, the BDDQ is a validated screening instrument in the facial plastic surgery setting with a very high sensitivity and specificity.20 Of patients who screen positive on the BDDQ, approximately two-thirds of cosmetic patients and one half of reconstructive patients are expected to have BDD by SCID.20 Thus, the BDD prevalence in our study population can be estimated to be 9.9% in the cosmetic population and 3.4% in the reconstructive population. These findings are consistent with those that were recently reported elsewhere.17,18,20 There was no significant difference in the proportion of patients screening positive on BDDQ across the various practice settings (academic vs private practice, facial plastic vs oculoplastic surgery). The BDDQ-positive patients were also shown to have significantly lower baseline satisfaction on all outcome measures tested (FACE-Q, ROE, BOE, FOE, SROE).

Surgeons commonly determine whether or not a patient has BDD based on interaction with the patient and clinical intuition. Interestingly, our results show that surgeons are poor at screening for BDD when compared with the standardized BDDQ, with the former having sensitivity of only 4.7% and a positive likelihood ratio (1.2; 95% CI, 0.3-5.1) that indicates that little additional useful information is gained by surgeon screening—that is, out of 100 patients with BDD, surgeons could identify less than 5 of them. This point is most clearly illustrated by the positive and negative posttest vs pretest probability curves that show that the chance a patient would screen positive or negative does not change appreciably based on the surgeon’s opinion. Nevertheless, surgeons were extremely confident of their ability to identify patients with BDD, with an average 89% certainty of the accuracy of their judgement. Not surprisingly, in the same American Society of Aesthetic Plastic Surgery survey discussed above, 84% of plastic surgeons said they had unknowingly performed surgeries on patients with BDD.6 Taken together, these findings point to the need for a validated, standardized, objective method to screen for BDD in the plastic surgery practice.

While the performance metrics are specific to the study, this study had a broad geographic pool and sampled both academic and private practices. In addition, the likelihood ratios and the corresponding posttest vs pretest probability curves can be used to estimate surgeon’s performance based on local prevalence, which should be globally poor.

The BDDQ is a self-administered, brief (1-2 minutes), validated screening instrument that patients can easily complete as they wait for the surgeon. It was successfully used in high volume facial plastic and oculoplastic surgery practices in our study, without impeding clinic flow. Patients screening positive on the BDDQ should alert surgeons to the possibility that a patient may have BDD, and prompt surgeons to ask additional questions as part of the clinical interview. Surgeons should pay special attention to BDDQ-positive patients to determine if there is a true indication for surgery since most patients with BDD have been shown to not benefit from cosmetic surgery and have poor satisfaction after surgery.8

To our knowledge this is the largest prospective study undertaken to estimate the prevalence of patients screening positive for BDD in the facial plastic and oculoplastic surgery setting. Our inclusion of a variety of practice settings (private and academic; cosmetic and reconstructive), and geographic locations, lends to the generalizability of our findings.

Limitations

One limitation of our study is that not every patient that was screened by the BDDQ was also screened for BDD by their surgeon (402 of 597 patients [67.3%] were screened by their surgeon and with the BDDQ). It is possible that this may have introduced bias to the analysis of surgeons’ accuracy in identification of patients with BDD. Nonetheless, the extremely poor ability of surgeons to clinically identify patients with BDDQ underscores the value of routine screening for BDD with validated screening instruments in facial plastic and oculoplastic surgery practices.

Conclusions

Body dysmorphic disorder is a common condition in patients who present for facial plastic and oculoplastic surgery. The BDDQ is a validated, 100% sensitive, and efficient method to screen for patients with BDD. Patients who screen positive by the BDDQ appear to have lower baseline satisfaction with their facial appearance. Surgeons have a poor ability to screen for BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated screening instruments into the clinical workflow of facial plastic and oculoplastic surgery practices may result in improved patient care.

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Article Information

Corresponding Author: Lisa Ishii, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 N Caroline St, 6th Floor, Baltimore, MD 21287 (learnes2@jhmi.edu).

Accepted for Publication: August 29, 2016.

Published Online: December 8, 2016. doi:10.1001/jamafacial.2016.1535

Author Contributions: All authors had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: A. Joseph, L. Ishii, S. Joseph, Byrne, Boahene, Douglas, M. Ishii.

Acquisition, analysis, or interpretation of data: A. Joseph, L. Ishii, S. Joseph, Smith, Su, Bater, Boahene, Papel, Kontis, Douglas, Nelson, M. Ishii.

Drafting of the manuscript: A. Joseph, L. Ishii, S. Joseph, M. Ishii.

Critical revision of the manuscript for important intellectual content: All Authors.

Statistical analysis: A. Joseph, L. Ishii, M. Ishii.

Obtained funding: Douglas, L. Ishii, M. Ishii.

Administrative, technical, or material support: L. Ishii, S. Joseph, Smith, Su, Bater, Byrne, Papel, Nelson, M. Ishii.

Study supervision: L. Ishii, S. Joseph, Byrne, Boahene, Douglas, M. Ishii.

Conflict of Interest Disclosures: None reported.

Additional Contributions: The authors wish to thank Sadeepa Munasinghe, BS, and Joseph Joshua, MD, for their assistance with data acquisition throughout this project; they were not compensated for their contributions.

References
1.
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
2.
Phillips  KA, Grant  J, Siniscalchi  J, Albertini  RS.  Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder.  Psychosomatics. 2001;42(6):504-510.PubMedGoogle ScholarCrossref
3.
Phillips  KA.  The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press; 2005.
4.
Cunningham  SJ, Bryant  CJ, Manisali  M, Hunt  NP, Feinmann  C.  Dysmorphophobia: recent developments of interest to the maxillofacial surgeon.  Br J Oral Maxillofac Surg. 1996;34(5):368-374.PubMedGoogle ScholarCrossref
5.
Wright  MR.  The male aesthetic patient.  Arch Otolaryngol Head Neck Surg. 1987;113(7):724-727.PubMedGoogle ScholarCrossref
6.
Sarwer  DB.  Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members.  Aesthet Surg J. 2002;22(6):531-535.PubMedGoogle ScholarCrossref
7.
Sarwer  DB, Spitzer  JC, Sobanko  JF, Beer  KR.  Identification and management of mental health issues by dermatologic surgeons: a survey of American Society for Dermatologic Surgery members.  Dermatol Surg. 2015;41(3):352-357.PubMedGoogle ScholarCrossref
8.
Phillips  KA, McElroy  SL, Lion  JR.  Plastic surgery and psychotherapy in the treatment of psychologically disturbed patients.  Plast Reconstr Surg. 1992;90(2):333-335.PubMedGoogle Scholar
9.
de Brito  MJ, Sabino Neto  M, de Oliveira  MF,  et al Yale-Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS): Brazilian Portuguese translation, cultural adaptation and validation.  Rev Bras Psiquiatr. 2015;37(4):310-316.Google ScholarCrossref
10.
Morselli  PG, Micai  A, Boriani  F.  Eumorphic plastic surgery: expectation vs satisfaction in body dysmorphic disorder.  Aesthetic Plast Surg. 2016;40(4):592-601.PubMedGoogle ScholarCrossref
11.
Aouizerate  B, Pujol  H, Grabot  D,  et al.  Body dysmorphic disorder in a sample of cosmetic surgery applicants.  Eur Psychiatry. 2003;18(7):365-368.PubMedGoogle ScholarCrossref
12.
Altamura  C, Paluello  MM, Mundo  E, Medda  S, Mannu  P.  Clinical and subclinical body dysmorphic disorder.  Eur Arch Psychiatry Clin Neurosci. 2001;251(3):105-108.PubMedGoogle ScholarCrossref
13.
Veale  D, De Haro  L, Lambrou  C.  Cosmetic rhinoplasty in body dysmorphic disorder.  Br J Plast Surg. 2003;56(6):546-551.PubMedGoogle ScholarCrossref
14.
Ishigooka  J, Iwao  M, Suzuki  M, Fukuyama  Y, Murasaki  M, Miura  S.  Demographic features of patients seeking cosmetic surgery.  Psychiatry Clin Neurosci. 1998;52(3):283-287.PubMedGoogle ScholarCrossref
15.
Vargel  S, Uluşahin  A.  Psychopathology and body image in cosmetic surgery patients.  Aesthetic Plast Surg. 2001;25(6):474-478.PubMedGoogle ScholarCrossref
16.
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