Body dysmorphic disorder in adult orthodontic patients /certified fixed orthodontic courses by Indian dental academy

BODY DYSMORPHIC DISORDER IN
ADULT ORTHODONTIC PATIENTS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION
Body image plays an important role for patients
seeking orthodontic treatment. It affects how patients
feel about their physical appearance and, in extreme
cases, can lead to subjective fears of ugliness.
When there is a physical defect that, although within
normal limits, seems far more noticeable to the
patient, this may be diagnosed as body dysmorphic
disorder (BDD).

Dysmorphophobia
Dysmorphophobia was originally described as “the sudden
onset and subsequent persistence of an idea of deformity;
the individual fears he has become, or may become,
deformed and feels tremendous anxiety of such an
awareness.”


BODY DYSMORPHIC DISORDER
is defined by the fourth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV; American Psychiatric Association, 1994)
as-

“A preoccupation with some imagined defect in physical
appearance or a gross exaggeration of a slight physical
anomaly.”


DIAGNOSTIC CRITERIA
☻The person is preoccupied with a defect in appearance.
Either the defect is imagined or, if there is a defect, the
person’s concern is excessive.
☻The preoccupation causes significant distress in social,
occupational, and other important areas of functioning.
☻The preoccupation is not better accounted for by another
mental disorder – e.g., anorexia nervosa.

PREVALENCE OF BDD
The prevalence of BDD is unknown. Underdiagnosis and
underrepresentation are likely because patients are
secretive about their symptoms and do not always seek
professional treatment. However, it is estimated that up to
1% of the population in the United States suffers from BDD.
There is also uncertainly about sex differences. Biby found a
higher prevalence in women, but Hollander et al noted a
higher prevalence in men. Phillips et al discovered equal
rates among the sexes.

ONSET OF BDD
The onset of BDD is commonly during adolescence,
and early childhood experiences and psychological
vulnerabilities might have an impact on symptoms, In
addition, many suffers are unmarried, unemployed,
and socially isolated.


BDD IS ASSOCIATED WITH..
BDD is often present with
◙depressive disorders (a lifetime prevalence of 83 %),
◙social phobias (35% lifetime prevalence), and
◙obsessive-compulsive disorder (29 % lifetime
prevalence).
◙also in conjunction with substance abuse.

Methods of assessment
►Brown Assessment of Beliefs Scale (BABS)
►BDD modification of the Yale-Brown obsessive compulsive
scale (YBOCS)
►Body Dysmorphic Disorder Examination (BDDE).


TREATMENT MODALITIES
MEDICATION
ANTIDEPRESSANTS-SSRI E.G. CHLOMIPRAMINE AND
FLUOXETINE

PSYCHOTHERAPY
BEHAVIOURAL THERAPY
SURGERY


AIM OF THE PRESENT STUDY
To interview adults attending new patient clinics in the
Orthodontic Department of the Eastman Dental
Hospital in London for the first time to establish the
prevalence of BDD in this population. In addition these
findings were compared with those from a group of
adult nonpatients.


SUBJECTS AND METHODS
Two groups of adults were recruited for structured
interviews.
•The patient group comprised 40 consecutive adults (16
men, 24 women; > 18 years of age) attending new patient
clinics for the first time.
•The general public group comprised 40 men and 30
women, who were members of the general public. The
members of this group were recruited from a large company
with employees of all social groups and ages (range, 18-65
years).

ASSESSMENT
The BDD-YBOCS interview was used to access BDD. The
measure consists of initial questions to establish whether a
diagnosis of BDD is appropriate, according to the 3
diagnostic criteria. If no diagnosis was made initially, the
interview was terminated. If a positive diagnosis was made
with the initial component of the interview, the rest of the
semistructured interview (12 items) was undertaken to
establish the severity and types of symptoms during the
previous week.

RATING
Scores for the full BDD interview ranged from 3 to 9
•3 indicating no diagnosis of BDD,
•4-5 mild BDD,
•6-7 moderate BDD, and
•9 severe BDD.


RESULTS
From the 40 patients, 3 (2 women, 1 man; 7.5%) were
diagnosed with BDD. One was severely affected (BDDYBOCS score = 9), 1 was moderate (BDD-YBOCS score =
5). These 3 patients were concerned about dental or facial
features. The severely affected patient was referred to the
liaison psychiatrist, who confirmed the diagnosis, thus
validating the interview process


PATIENT GROUP
A diagnosis of BDD was made in 3 patients – 2 women
and 1 man. The 3 BDD patients were concerned about
facial profile, teeth, chin, smiling, talking, and laughing.
These factors had an impact on their abilities to work,
socialize, meet friends, and, therefore, reduced their
abilities to function normally in society.


General public group
In the general public group, 2 women diagnosed with
BDD, and both were excessively concerned about weight.
Neither had dental or facial concerns. Their concerns
regarding perceived weight problems had impacted their
day-to-day living.


Comparison of the groups
It appears that BDD is more common in the patient group,
and this certainly warrants further investigation in larger
epidemiological studies. Although there was no difference
in the age distribution of the groups, there were
differences in ethnicity, and this might have had some
influence on the findings . Because of the small numbers
involved, these data were not amendable to statistical
analysis but warrant further investigation about ethnic
differences.

BDD in Orthodontics
There has been little research on the impact of BDD in
orthodontic or orthognathic patients. It is known to significantly
affect quality of life and is associated with depression and
obsessive-compulsive disorder. It is therefore important to
determine the patients’ concerns and whether they have
previously received treatment. It is essential to elicit when the
concerns started and what impact they are having on their
lives.


IDENTIFYING THE POTENTIAL BADRISK PATIENT
A few carefully chosen questions during the initial consultation• Are you happy your appearance?
• Is there anything that you would like to change about your
appearance and, if so, what?
• Is there anything that you avoid because of the way that you
look?
• Have you sought help before?
• What do you expect to achieve from your treatment?

KEY TO TREATMENT PLANNING
The key is to take a full history and ensure that you are fully
aware of the patient’s expectations and whether they are
within the realms of reality. If there is any uncertainty,
referral should be made to a psychiatrist or clinical
psychologist for a thorough psychological analysis.


CONCLUSION
BDD occurs in adult orthodontic patients and in members of
the general public. This study suggests that BDD might be
more common in a referred than a nonreferred population;
this clearly requires further investigation. BDD occurs often
enough in adult orthodontic patients that all clinicians should
be aware of its features. This study should make clinicians
ask a few well-chosen questions at the start of each new
consultation to help identify the potential bad-risk patient.


REFERENCES
•Psychological assessment of patients requesting orthognathic surgery and the relevance
of BODY DYSMORPHIC DISORDER, S.J. Cunningham, C. Feinmann, BJO, VOL25,
NO.4,1998,293-298
•The Brown Assessment of Beliefs Scale:
Reliability and Validity,Jane L. Eisen, Katharine A. Phillips, Lee Baer,
Douglas A. Beer, Katherine D. Atala, and Steven A. Rasmussen, Am J Psychiatry 1998;
155:102–108.
•Surgical and Nonpsychiatric Medical Treatment of Patients
With Body Dysmorphic Disorder,KATHARINE A. PHILLIPS, JON GRANTJ.D.,JASON
SINISCALCHI, RALPH S. ALBERTINI,Psychosomatics 2001; 42:504–510


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You

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Body dysmorphic disorder in adult orthodontic patients /certified fixed orthodontic courses by Indian dental academy

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