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PHYSICIANS-ESPECIALLY PSYCHIATRISTS, dermatologists, plastic surgeons, primary care physicians, and pediatricians-need to understand body dysmorphic disorder (BDD). Even though BDD is a mental disorder, a majority of patients with this illness seek surgery or nonpsychiatric medical treatment (e.g., dermatologic treatment) for their symptoms.1-3 Patients tend to be dissatisfied with these treatments.1-1 Some sue, or are even violent towards, the treating physician.4 As a noted dermatologist stated: "I know of no more difficult patients to treat than those with body dysmorphic disorder."4
Individuals with BDD are preoccupied with an imagined or slight defect in their physical appearance (for example, "scarred" skin or a "large" nose).3 They believe that they look abnormal, whereas the appearance defects they perceive are slight or nonexistent. The appearance preoccupations go beyond normal appearance concerns: they cause clinically significant distress or impairment in functioning. While such concerns may sound trivial, on the Medical Outcomes Short Form (SF-36), individuals with BDD have poorer quality of life than patients with depression, type II diabetes, or a recent myocardial infarction.5,6 From 78% to 81% have experienced suicidal thinking; 22%-28% have attempted suicide.7-9 A retrospective study of dermatology patients known to have committed suicide over 20 years found that most of the patients who suicided had acne or BDD.10 In the only prospective study of the course of BDD, the rate of completed suicide was higher than has been reported for any other mental illness.11
The Body Dysmorphic Disorder and Body Image Program at Butler Hospital (www.BodyImageProgram.com or www.butler.org/body.cfmFid= 123) is a leading research center for BDD.
A PATIENT WITH BODY DYSMORPHIC DISORDER
Ms. A, a 27-year-old single white female, presented with a chief complaint of "I see a lot of skin doctors." She had consulted with dozens of dermatologists, to no avail. Convinced that she had severe acne, scars, and "veins" on her face, she frequently checked mirrors, spent hours a day applying makeup, and picked at her skin. She stated that because she so incessantly sought reassurance from dermatologists, "most of the dermatologists in Boston are probably seeing therapists because of me."
Ms. A. had dropped out of college, was unemployed, and was housebound. She had attempted suicide and had been psychiatrically hospitalized. Treatment with numerous antibiotics and isotretinoin had not diminished her concerns....