Int. J. Oral Maxillofac. Surg. 2008; 37: 985–991doi:10.1016/j.ijom.2008.06.005, available online at http://www.sciencedirect.com Leading Clinical Paper Orthognathic SurgeryBody dysmorphic disorder N. C. C. Vulink1, A. Rosenberg2, J. M. Plooij3, R. Koole2, S. J. Berge3, D. Denys4 ´screening in maxillofacial 1 The Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, The Netherlands; 2Department of Oral - Maxillofacial Surgery, The Netherlands;outpatients presenting for 3 University Medical Center Utrecht, 3D Facial Imaging Research Group Nijmegen- Bruges, Department of Oral and Maxillofacial Surgery,orthognathic surgery Radboud University Nijmegen Medical Centre, The Netherlands; 4Department of Psychiatry, AMC Amsterdam, The Netherlands ´N. C. C. Vulink, A. Rosenberg, J. M. Plooij, R. Koole, S. J. Berge, D. Denys: Bodydysmorphic disorder screening in maxillofacial outpatients presenting fororthognathic surgery. Int. J. Oral Maxillofac. Surg. 2008; 37: 985–991. # 2008International Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.Abstract. Body dysmorphic disorder (BDD) is a severe psychiatric disease withdelusions about defects in appearance for which patients seek surgical help. This isthe ﬁrst European study to determine the half-year prevalence of BDD in amaxillofacial outpatient clinic. A total of 160 patients with maxillofacial problemscompleted a validated self-report questionnaire, while a staff member scoredmaxillofacial defects on a severity scale. Twenty-eight (17%) patients hadexcessive concerns about their appearance, which negatively inﬂuenced their Keywords: body dysmorphic disorder; somato-psychosocial functioning; 16 patients (10%; 95%CI 5–15%) screened positive for form disorders; maxillofacial.BDD. The high prevalence of problems related to psychosocial functioning and theoccurrence of BDD in maxillofacial patients means that maxillofacial surgeons Accepted for publication 6 June 2008should take psychological concerns about physical defects into account. Available online 21 July 2008Patients with body dysmorphic disorder tic surgeons to treat their imagined or which 3 patients (7.5%) were diagnosed(BDD) are obsessed with a particular part exaggerated defect. Because of the delu- with BDD8, the prevalence of BDD in aof their appearance or their whole appear- sional content of the disorder, patients with maxillofacial outpatient clinic is unknown.ance without having a defect or only a small BDD lack insight in the unreal nature of The aim of this study was to determine thedefect. BDD is a psychiatric disorder their bodily concerns. They are often not half-year prevalence of BDD in dysgnathicaccording to the Diagnostic and Statistical satisﬁed or only temporarily satisﬁed with patients in 2 maxillofacial outpatient clinicsManual of Mental Disorders (DSM IV), a the results of surgery. Most of them seek in 2 teaching hospitals.classiﬁcation system for mental disorders another doctor for treatment13,23 or becomeused worldwide2. Patients with BDD are litigious or violent. A quarter of OMF Methodsdistressed by their perceived defect, are patients meet criteria for a psychiatric dis-often socially isolated and have functional order12, but no studies have reported on This study was conducted from Septemberimpairments13,23. These patients ask oral precise psychiatric diagnoses. Except for 2005 to March 2007 at 2 maxillofacialand maxillofacial (OMF) surgeons or plas- one study in 40 adult orthodontic patients in outpatient clinics in 2 Dutch teaching0901-5027/110985 + 07 $30.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
986 Vulink et al.hospitals. All patients, who were referred Table 1. DSM-IV diagnostic criteria for body dysmorphic disorderby medical or dental practitioners, and A Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present,presenting for an orthognathic surgery the person’s concern is markedly excessiveconsultation received a self-report ques- B The preoccupation causes clinically signiﬁcant distress or impairment in social, occupational,tionnaire (see Appendix A: BDD Ques- or other important areas of functioning C The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfactiontionnaire) which they completed before with body shape and size in anorexia nervosa)the consultation. The questionnaire con-tains 20 questions of which 9 were drawnfrom the Body Dysmorphic Disorder DSM-IV criteria for BDD, by reporting tress, and dysfunction of patients with BDDQuestionnaire: Dermatology Version5, concerns and preoccupation with a per- and patients without BDD, a Mann–Whit-which was developed and tested in a der- ceived defect in appearance, and at least ney U-test was used for continuous vari-matological cosmetic surgery practice at moderate distress or impairment in (social, ables and a X2 test or Fisher’s exact test wasa university hospital, and 11 from the occupational or familial) functioning, and used for categorical variables.Body Dysmorphic Disorder Examination the facial defect was judged minimal or(BDDE)21, which is a validated and reli- nonexistent by the surgeon (Table 1). Resultsable interview to diagnose BDD and mea-sure symptoms of severely negative body A total of 160 patients completed the Statistical analysesimage. Both scales have good sensitivity questionnaire (n = 102 in UMCU, n = 58and speciﬁcity for the diagnosis of BDD. Results were analysed using SPSS version RUNMC). The mean age was 27.1 Æ 10The questionnaire contained questions 12.0 for Windows. The percentage of (range 12–56 years) and 106 patients weresuch as: ‘Are you very concerned about patients who met criteria for BDD was female (67%). Marital state, mean dura-the appearance of some part of your body, determined. Student’s t-tests were used to tion of diagnoses, previous surgical treat-which you consider especially unattrac- compare age in patients who screened posi- ment and psychiatric history are given intive?’, ‘Has your defect often caused you a tive or negative for BDD. To compare Table 2; diagnoses are reported in Table 3.lot of distress, torment or pain?’, ‘Has your gender, diagnoses, treatment, treatment Twenty-eight patients (17%) reporteddefect caused you impairment in social, history, psychiatric history, emotional dis- preoccupation with excessive concernoccupational or other important areas offunctioning?’, ‘How dissatisﬁed have you Table 2. Clinical data (pooled factors)been with your overall appearance?, ‘How Age at trial entryattractive physically do you feel other Mean 27.1 yearspeople thought you were?’ and ‘Does Range 12–56 yearsthe maxillofacial defect account for Gendermany problems in life?’. The study was Male 54approved by the Medical Ethical Review Female 106Committee of the University Medical Marital stateCenter Utrecht (UMCU) and the Medical Single 98Ethical Review Committee of the Rad- Married 32boud University Nijmegen Medical Cen- Divorced 6tre (RUNMC), the Netherlands. Living together 24 Duration of maxillofacial problemProcedure Mean 16.5 years Range 0.5–52 yearsAll new patients in the maxillofacial sur- Previous surgical treatmentgery outpatient clinics at UMCU and No previous surgical treatment 86%RUNMC who were referred by medical Previous surgical treatment 14%or dental practitioners, and presenting foran orthognathic surgery consultation Psychiatric history Yes 32/160received the questionnaire. A preface to No 128/160the questionnaire conﬁrms that complet-ing or failing to complete the question-naire would not have any effect on Table 3. Diagnoses in maxillofacial outpatientstreatment. Four OMF surgeons in UMCU BDD patients non BDD patientsand 1 OMF surgeon in RUNMC rated thedefect severity of all patients. The scale Diagnoses (n = 16) (n = 144) Class II skeletal relation with or without open bite 10 91ranges from 1 to 4, where 1 is no defect, 2 Class III skeletal relation with or without open bite 0 14is minimal/ slight defect, 3 is defect Class I skeletal relation 1 12clearly noticeable at conversational dis- Temporomandibular dysfunction 1 6tance, and 4 is severe defect. The rating Skeletal arch discrepancies 1 6accuracy of the 4 OMF surgeons at UMCU No facial deformity 1 4was assessed using 15 photographs of Orthognathic surgery in cleft lip and palate children 0 3patients with maxillofacial defects; they Complication of prior surgery 2 1showed an intraclass correlation coefﬁ- Neuromuscular disorder 0 1cient of 0.8178. Patients were screened Unknown 0 4positive for BDD if they fulﬁlled all Oligodontia 0 1
Body dysmorphic disorder screening in maxillofacial outpatients 987about their appearance causing moderate to ance causing moderate to severe distress impairment in functioning and when thesevere distress and/ or impairment in func- and/ or impairment in functioning. Of person’s view of his or her appearancetioning. Of these patients, 16 (10%; CI 5– these patients, 16 (10%) suffer from BDD. defect is extreme, then BDD should be15%) met DSM-IV criteria for BDD Aesthetic appearance is one of the main considered. This study shows that patients(n = 13 in UMCU, n = 3 RUNMC). Of reasons why patients seek orthodontic or with BDD can be distinguished from non-the 28 patients, 12 were preoccupied but orthognathic surgical treatment11. In two BDD patients by their psychiatric history.failed the diagnosis of BDD because they separate studies in which orthognathic In agreement with the literature, BDDhad an obvious defect (dysgnathic defor- patients were interviewed preoperatively, patients frequently report psychiatric diag-mity), 5 had a clearly noticeable defect at over 60% of patients reported that their noses or psychological problems20. Theconversational distance and 7 had a severe facial appearance had negatively inﬂu- authors did not ﬁnd demographic variablesdefect. The remaining patients fulﬁlling the enced their personal life and over 40% that could identify BDD patients, in con-BDD diagnosis (n = 16) were referred to a reported impairments in social function- trast to some previous studies reporting thatpsychiatrist; 4 patients agreed to have a ing4,7; neither study reported the preva- BDD patients are younger than non-BDDpsychiatric consultation, but the other 12 lence of BDD. After maxillofacial patients16,25, although others report similardenied psychiatric symptoms and refused a surgery, most patients report improved ﬁndings22. Some studies show a higherpsychiatric consultation. Of the 16 patients, self-conﬁdence, body and facial image, prevalence in men than in women6,15,11 were female (69%), with a mean age of and social adjustment9,11, but some others a higher prevalence in women than32.6 Æ 8.7 (range 17–45 years). The most patients are only temporarily satisﬁed in men20 and others show equal gendercommon diagnosis in the BDD patients was and become litigious or violent. These rates5,14,18. As patients with BDD are con-Class II skeletal relation with or without patients may suffer from BDD. vinced they have a physical defect, theyopen bite (Table 3). According to DSM-IV In one comparable study of 40 ortho- seek help from dermatologists, plastic sur-criteria, all 16 patients with BDD reported dontic patients the prevalence of BDD was geons or OMF surgeons. No signiﬁcantat least moderate distress or impairment in 7%8. Comparable studies in dermatologi- difference could be found in the frequencysocial or occupational functioning and did cal and plastic surgery patients showed a of previous dermatological or surgicalnot have a defect or only a small defect. prevalence of BDD of 8–15% in derma- treatment between patients who screenedMore than half of the patients (n = 9) tology outpatient clinics5,16,22,25 and 3– negative or positive for BDD. The smallreported severe or very disturbing distress 53% in cosmetic surgery outpatient sample size of BDD patients may accountand one-third (n = 6) mentioned severe or clinics1,3,10,24,25. Different study popula- for the limited differences between BDDincapacitating impairment in functioning. tions, variations in inclusion criteria, and patients and non-BDD patients. Larger stu-More than 80% of the BDD patients use of self-report or psychiatric interview- dies are needed to compose a useful pre-(n = 13) avoided social situations, occupa- ing could account for the diversity in diction tool that can be used by a somatictional or study activities. prevalence rates. specialist to select BDD patients. No signiﬁcant differences were found in An easily applicable prediction model, A limitation of this study is that themean age, gender ratio, marital state diag- using clinical characteristics and/ or demo- authors did not use structured psychiatricnoses and treatment history between graphic variables, might support OMF sur- interviews to assess BDD and psychiatricpatients with BDD and patients without geons in their attempt to diagnose patients co-morbidity. This could explain the lowBDD. Signiﬁcant differences were found suffering from BDD. In this study, differ- number of psychiatric co-morbidity in allregarding psychiatric history (x2 = 10.420, ences were found between BDD patients patients. A selection bias and informationdf = 3, p = 0.015), time spent on appear- and non-BDD patients in clinical charac- bias could have distorted the results as onlyance (Mann–Whitney U-test = 734, p = teristics with regard to appearance-related patients seeking help for their proposed0.016), body camouﬂaging (U = 440.5, behavior and cognitions. Patients with face defect were included in this study.p = 0.000), hiding appearances (x2 = BDD spent more time on their appearance, In practice, OMF surgeons are advised to22.880, df = 4, p = 0.000) and avoiding body camouﬂaging, and blamed their life explore the distress and dysfunction ofsocial or occupational activities (x2 = problems on perceived defects in their patients with maxillofacial defects (e.g.8.418, df = 1, p = 0.004). Patients with appearance more often. They also reported with the BDD questionnaire), and to con-BDD blamed all their problems on per- higher frequencies of others noticing their sult a psychiatrist when patients have sig-ceived defects in their appearance (Fisher’s defect or criticizing their excessive con- niﬁcant distress and moderate to severeexact test p = 0.001). They also reported cern. These typical BDD symptoms are behavioral impairment. Patients with minorhigher frequencies of others noticing their items of the BDDE, which is a validated maxillofacial defects, clear emotional dis-defect (Mann–Whitney U-test = 695.0, and reliable interview to diagnose BDD and tress and problems in functioning couldp = 0.017) or criticizing their excessive measure symptoms of severely negative suffer from BDD. Psychiatrists could playconcern (Fisher’s exact test: p = 0.026). body Image21. No differences were found an important role in educating OMF sur-No differences were found on (dis)satisfac- on (dis)satisfaction with general appear- geons in how to recognize patients withtion with general appearance, embarrass- ance, embarrassment, appeal to others, BDD. Referral of these patients to psychia-ment, appeal to others and checking and checking appearance, which are also trists is necessary for appropriate treatmentappearance. known BDD symptoms. This might be due with for example SSRIs17,19, thus minimiz- to a lack of power or may be a result of the ing the patient seeking several referrals, difﬁculty in distinguishing between normal litigation and unnecessary orthognathicDiscussion body dissatisfaction and BDD. HEPBURN surgery in these patients.This is the ﬁrst European study assessing et al.8 suggested conceptualizing concernsprevalence of BDD in a maxillofacial about body image on a continuum withsurgery outpatient clinic. Twenty-eight levels of disturbance ranging from none Acknowledgement. The authors thank Dr.patients (17%) reported preoccupation to extreme. Higher levels of body image E. Geuze for his assistance with this manu-with excessive concern about their appear- disturbance are associated with signiﬁcant script.
Body dysmorphic disorder screening in maxillofacial outpatients 989Appendix A (Continued )
990 Vulink et al.Appendix A (Continued )References MA. Psychological evaluation of patients 9. Hunt OT, Johnston CD, Hepper PG, scheduled for orthognathic surgery. J Burden DJ. The psychosocial impact of 1. Altamura C, Paluello MM, Mundo Nihon Univ Sch Dent 1993: 35: 1–9. orthognathic surgery: a systematic E, Medda S, Mannu P. Clinical and 5. Dufresne RG, Phillips KA, Vittorio review. Am J Orthod Dentofacial Orthop subclinical body dysmorphic disorder. CC, Wilkel CS. A screening question- 2001: 120: 490–497. Eur Arch Psychiatry Clin Neurosci naire for body dysmorphic disorder in a 10. Ishigooka J, Iwao M, Suzuki M, 2001: 251: 105–108. cosmetic dermatologic surgery practice. Fukuyama Y, Murasaki M, Miura S. 2. American Psychiatric Association. Dermatol Surg 2001: 27: 457–462. Demographic features of patients seeking Diagnostic and Statistical Manual of 6. Fukuda O. Statistical analysis of dys- cosmetic surgery. Psychiatry Clin Neu- Mental Disorders. 4th ed Washington, morphophobia in an outpatient clinic. rosci 1998: 52: 283–287. DC: American Psychiatric Association Jpn J Plastic Reconstr Surg 1977: 20: 11. Lazaridou-Terzoudi T, Kiyak HA, 1994. 569–577. Moore R, Athanasiou AE, Melsen 3. Aouizerate B, Pujol H, Grabot D, 7. Garvill J, Garvill H, Kahnberg KE, B. Long-term assessment of psychologic Faytout M, Suire K, Braud C, Aur- Lundberg S. Psychological factors in outcomes of orthognathic surgery. J Oral iacombe M, Martin D, Baudet J, orthognathic surgery. J Craniomaxillofac Maxillofac Surg 2003: 61: 545–552. Tignol J. Body dysmorphic disorder in Surg 1992: 20: 28–33. 12. Phillips C, Bennett ME, Broder HL. a sample of cosmetic surgery applicants. 8. Hepburn S, Cunningham S. Body dys- Dentofacial disharmony: psychological Eur Psychiatry 2003: 18: 365–368. morphic disorder in adult orthodontic status of patients seeking treatment 4. Barbosa AL, Marcantonio E, Bar- patients. Am J Orthod Dentofacial Orthop consultation. Angle Orthod 1998: 68: bosa CE, Gabrielli MF, Gabrielli 2006: 130: 569–574. 547–556.
Body dysmorphic disorder screening in maxillofacial outpatients 99113. Phillips KA. Body dysmorphic disorder: body dysmorphic disorder. Psychoso- survey of ﬁfty cases. Br J Psychiatry the distress of imagined ugliness. Am J matics 2001: 42: 504–510. 1996: 169: 196–201. Psychiatry 1991: 148: 1138–1149. 19. Phillips KA, Albertini RS, Rasmus- 24. Vindigni V. The importance of recogniz-14. Phillips KA, Diaz SF. Gender differ- sen SA. A randomized placebo-con- ing body dysmorphic disorder in cosmetic ences in body dysmorphic disorder. J trolled trial of ﬂuoxetine in body surgery patients: do our patients need a Nerv Ment Dis 1997: 185: 570–577. dysmorphic disorder. Arch Gen Psychia- preoperative psychiatric evaluation? Eur15. Phillips KA, McElroy SL, Keck Jr try 2002: 59: 381–388. J Plast Surg 2002: 25: 305–308. PE, Pope Jr HG, Hudson JI. Body dys- 20. Phillips KA, Menard W, Fay C, Weis- 25. Vulink NC, Sigurdsson V, Kon M, morphic disorder: 30 cases of imagined berg R. Demographic characteristics, Bruijnzeel CA, Westenberg HG, ugliness. Am J Psychiatry 1993: 150: phenomenology, comorbidity, and family Denys D. Body dysmorphic disorder in 302–308. history in 200 individuals with body dys- 3-8% of patients in outpatient dermatol-16. Phillips KA, Dufresne Jr RG, Wilkel morphic disorder. Psychosomatics 2005: ogy and plastic surgery clinics. Ned CS, Vittorio CC. Rate of body dys- 46: 317–325. Tijdschr Geneeskd 2006: 150: 97–100. morphic disorder in dermatology patients. 21. Rosen JC, Reiter J. Development of the J Am Acad Dermatol 2000: 42: 436–441. body dysmorphic disorder examination. Address: Nienke Vulink17. Phillips KA, Albertini RS, Siniscal- Behav Res Ther 1996: 34: 755–766. UMC Utrecht chi JM, Khan A, Robinson M. Effec- 22. Uzun O, Basoglu C, Akar A, Cans- B.01.206 tiveness of pharmacotherapy for body ever A, Ozsahin A, Cetin M, Ebrinc S. P.O.Box 85500 dysmorphic disorder: a chart-review Body dysmorphic disorder in patients 3508 GA Utrecht study. J Clin Psychiatry 2001: 62: 721– with acne. Compr Psychiatry 2003: 44: The Netherlands 727. 415–419. Tel.: +31 30 250637018. Phillips KA, Grant J, Siniscalchi J, 23. Veale D, Boocock A, Gournay K, Fax: +31 30 2505443 Albertini RS. Surgical and nonpsychia- Dryden W, Shah F, Willson R, Wal- E-mail: N.C.C.email@example.com tric medical treatment of patients with burn J. Body dysmorphic disorder. A