Body dysmorphic disorder in a facial plastic and reconstructive surgery clinic: measuring prevalence, assessing comorbidities, and validating a feasible screening instrument.

IMPORTANCE: Body dysmorphic disorder (BDD) is underrecognized and underdetected among patients undergoing facial plastic and reconstructive surgery. Patients with BDD require psychiatric care, not cosmetic surgery.

OBJECTIVES: To measure the prevalence of BDD in a facial plastic and reconstructive surgery clinic, to validate the Body Dysmorphic Disorder Questionnaire (BDDQ) in that setting, to assess the feasibility of implementing a standardized process for identifying patients with BDD accurately in a busy clinical practice, and to assess the comorbidity of BDD, depression, and anxiety in our patient population.

DESIGN, SETTING, AND PARTICIPANTS: We performed a prospective prevalence and instrument validation study in an academic facial plastic and reconstructive surgery clinic. We included 234 consecutive patients 18 years or older presenting to the clinic from March 3 to June 30, 2014.

MAIN OUTCOMES AND MEASURES: Prevalence of BDD as determined by the BDDQ and the criterion-standard BDD Structured Clinical Interview for DSM-IV (BDD SCID). The BDD SCID and a defect severity scale were used to confirm the BDD diagnosis and to validate the BDDQ finding. We also assessed demographic characteristics, depression, and anxiety in all patients.

RESULTS: As confirmed by the BDD SCID, 13.1% of patients undergoing cosmetic surgery and 1.8% of those undergoing reconstructive surgery had BDD. We found the BDDQ to be an accurate (91.7%), sensitive (100%), and specific (90.3%) screening instrument for BDD. Patients with a positive BDD finding were most commonly concerned with their nose (10 of 18 [56%]), skin (5 of 18 [28%]), hair (1 of 18 [6%]), chin (1 of 18 [6%]), and ears (1 of 18 [6%]), that is, areas commonly addressed by facial plastic surgeons. Furthermore, compared with patients who did not have BDD, patients with BDD had elevated depression scores (mean [SD], 12.6 [10.8] vs 3.2 [4.2]). In the non-BDD population, mean (SD) state and trait anxiety scores resembled the norm (30.0 [7.7] and 30.3 [7.7], respectively, for men; 31.7 [10.0] and 32.1 [8.7], respectively, for women); in the BDD population, these scores were elevated (53.8 [23.4] and 50.4 [19.5], respectively, for men; 47.8 [12.7] and 49.0 [11.6], respectively, for women). Depression and anxiety scores were highly correlated in patients with BDD (r = 0.84 for patients with a BDDQ-positive screen result; r = 0.94 for patients with a positive BDD SCID finding) compared with those who did not have BDD (r = 0.51).

CONCLUSIONS AND RELEVANCE: Patients with BDD often seek cosmetic treatment. Given the documented risks and harms of surgery for patients with BDD, a systematic process for identifying such patients who seek cosmetic surgery is imperative. We found a BDD screening instrument (BDDQ) followed by the BDD SCID for patients with a BDDQ-positive screen result to be a feasible and effective way to identify patients with BDD.

LEVEL OF EVIDENCE: NA.