Dr Raj Arora outlines the current tools available for carrying out a suitable screening for Body Dysmorphic Disorder prior to a proposed aesthetic procedure
Body dysmorphic disorder (BDD) is a condition whereby patients suffer from a disabling preoccupation with perceived flaws or defects in their appearance.1 These perceived flaws/ defects are often unnoticeable to others but are a huge focus to the patient. Individuals with BDD frequently seek cosmetic treatments to correct perceived defects and reduce the extreme dissatisfaction with their physical appearance. I also think it’s important to note here that the prevalence of BDD in a cosmetic surgery setting is significantly higher (5-15%) than in the general population (1-3%).2 This was also highlighted in recent news that high-street retailer Superdrug, which now offers injectable treatments, would need to introduce BDD questionnaires as a priority due to the volume of the general population having access to them.3 One survey carried out in the US found that 84% of plastic surgeons had unknowingly carried out a cosmetic procedure on a patient with BDD.4 As an aesthetic practitioner and GP, I take a keen interest in mental health; especially that surrounding body image. Guidelines provided by the National Institute for Health and Care Excellence (NICE) state the importance of screening to diagnose BDD and it is crucial to be able to identify those individuals who are struggling with, or are at risk, of BDD5 to ensure we are not overlooking a mental health condition requiring treatment. This also allows us, as responsible practitioners, to offer the help that patients may need. It is also important to ensure that we protect ourselves (by screening for BDD) from those patients that may have unrealistic expectations from a planned procedure. If we are treating patients with an ethical stance then we should show interest in their mental wellbeing and consider if we will achieve a desired outcome or whether the issue deeper. During my day-to-day practice, I have found that there are many different screening tools available to assess for this disorder and it is not always clear which tool is ‘best’ to use. In this article, I will analyse some, but not all, of the tools available to assess and screen for BDD and share, in my opinion, which I believe to be most effective.
BDD is an under-diagnosed and often underreported condition. Research published in Plastic Surgery Nursing found that it often occurs during the adolescent years.6 According to the NICE guidelines, it is estimated that approximately 0.5-0.7% of the UK population has BDD.5 NICE reported a tendency of equal proportions of men and women across all age groups.
The causes of BDD are often embedded in psychological and physiological factors.6 They can include, but are not limited to:
• Abuse or bullying
• Low self-esteem
We can also look at the symptoms of BDD to understand what is required in an assessment tool to ensure we are correctly screening individuals. If we broadly group symptoms then there are two categories: common obsessive concerns about appearance and common compulsive behaviours.7 Obsessive concerns can include intrusive negative thoughts about body image; a particular feature or multiple features. Common compulsive behaviours may include repetitively checking mirrors, seeking constant reassurance from others, constantly comparing appearance to others, or even seeking cosmetic enhancements.8 BDD criteria looks at the categories of preoccupation (constant thoughts regarding the ‘perceived flaw’), impairment of global functioning (not being able to carry out normal daily activities, social avoidance, impact on work life/school life), and subjective distress (intensity of emotions experienced by an individual in response to their ‘perceived flaw’ in those with possible BDD).9,10 From a litigation perspective; detection of BDD is vital to ensure optimal patient outcomes and to reduce patient dissatisfaction post procedure. Having a pre-procedure checklist, which includes an assessment for BDD, can provide practitioners with some legal protection but can also ensure that we are practising ethically and in the best interests of our patients. Should we feel that a patient exhibits symptoms of a mental health disorder then referral and further management is needed.11 There has been a transition in the way that BDD is viewed with regards to its relationship with aesthetic procedures. Previously, BDD was viewed as an absolute contraindication to aesthetic procedures. However, more recent research shows that decision-making based on BDD severity and individual global functioning (as mentioned above) of a patient may be more appropriate.9
There are a number of tools in place, created by a number of associations and researchers, that are designed to screen for BDD. Each has its advantages and disadvantages in my opinion, however whichever tool you use in your clinical environment it is important to understand exactly how the patient’s flaw is affecting their day to day life. The tools which provide a detailed insight allow us to assess the patient better by looking at different facets of their life and heeding the impact that the flaw may have. Also, some questionnaires look at the patient’s own insight into their possible BDD symptoms. This is helpful to understand whether the patient has any awareness of a possible mental health condition related to their perception of their own appearance. There are a number of tools available, however, for the purpose of this article, I have chosen both quick answer questionnaires and others that are more detailed. This way we can see how they differ and whether they could potentially be used together.
Appearance Anxiety Inventory
The Appearance Anxiety Inventory (AAI) is a 10 question self-report scale that measures the cognitive and behavioural aspects of body image anxiety and BDD. It can be used for both diagnosis and assessing severity.12 The AAI was developed by Veale et al.12 to assess cognitive processes and behaviour characteristics of BDD. It was originally used to assess the progress of patients throughout therapy for BDD. The AAI uses a five-point Likert scale to answer the 10 questions. The range of scores is from 0-40. The recommended cut-off score is 19, at and above this level is thought to be indicative of BDD.
The 10 questions are as follows:
1. I compare aspects of my appearance to others
2. I check my appearance (e.g. in mirrors, by touching with my fingers, or by taking photos of myself)
3. I avoid situations or people because of my appearance
4. I brood about past events or reasons to explain why I look the way I do
5. I think about how to camouflage or alter my appearance
6. I am focused on how I feel I look, rather than on my surroundings
7. I avoid reflective surfaces, photos or videos of myself5
8. I discuss my appearance with others or question them about it
9. I try to camouflage or alter aspects of my appearance
10. I try to prevent people from seeing aspects of my appearance within particular situations (e.g. by changing my posture, avoiding bright lights)
I feel that the above tool is helpful in that it does cover a broad range of questions with relation to symptoms of BDD. It looks at both obsessive concerns and compulsive behaviours. In terms of severity, it is difficult to assess from this scale as it does not quantify frequency of behaviours. As an overall screening tool this could be useful; however, I believe that other tools could be better at capturing detail.
Working closely with mental health professionals is, in my opinion, very important
Cosmetic Procedures Screening-Questionnaire
The Cosmetic Procedures Screening-Questionnaire (COPS) looks at perceived defects or flaws. The scale describes these perceived flaws as ‘features’.13 The questionnaire was also developed by Veale et al.13 and the idea was to create a questionnaire that would be brief, easy to access and would be able to pick up potential dissatisfaction post procedure or a deterioration in BDD symptoms. During the assessment the patient fills out a self-report where they outline up to five top features which cause concern. The initial part of the questionnaire is qualitative; therefore patients get an opportunity to document their feelings in their own words. There is then opportunity for a pie chart to be filled out with percentage attribution of concern with regards to the aforementioned ‘features’. The pie chart is useful as it allows us to understand from the patient’s perspective exactly how much this ‘feature’ is affecting them and the importance that they are placing on that particular feature, compared with a second or third feature. The next step screening questionnaire then uses nine questions to explore these features further. Each question has a scale of 1-8. A score of 40 or more is highly suggestive of BDD.13 The COPS questionnaire provides a lot of detail and insight into the symptoms of the patient. The questions are structured in a way that they look at both frequencies of obsessive behaviours, as well as the effect of their symptoms on their relationships and social interactions. I feel that this tool gives good amount of detail and can be useful for the patient to visualise the concerns in the pie chart, but it can be lengthy compared to others to follow through in a busy clinic. It may be helpful to get the questionnaire filled in prior to the first appointment with a patient.
Body Dysmorphic Disorder Questionnaire
The Body Dysmorphic Disorder Questionnaire (BDDQ) asks four questions based on concerns for appearance, frequency of concern and how this concern with appearance may have affected different domains of the patient’s life such as social, school/work and any avoidance of activities.14 The likelihood of BDD is then based on the answers to these particular questions and a note is made by the practitioners of which answers of ‘yes’ indicate a likely BDD diagnosis.
The first two questions are:
• “Are you worried about how you look?”
• “Do you think about your appearance problems a lot? And do you wish you could think about them less?”
The patient must answer positively to at least one of these to continue with the questionnaire. Following this, a positive answer to at least one part of the third question (below), assessing distress and global impairment caused by the preoccupation, is further required for a likely BDD diagnosis.
• “How much time do you spend thinking about your defect(s) per day on average?” has the response alternatives a) less than 1 hour per day, b) 1-3 hours per day and c) >3 hours per day
Thinking about the appearance flaw ‘at least an hour per day’ is a) time-criterion when diagnosing BDD according to the Structured Clinical Interview for DSM-IV.8 The DSM-IV are the codes used in the diagnostic and statistical manual of mental disorders.15 It is published by the American psychiatric association and covers mental health disorders for both children and adults. BDD criteria is fulfilled with positive answers to the first three questions of the BDDQ in combination with answer b) or c) on the fourth question. The fourth question, “Is your main concern with your appearance that you are not thin enough or that you might become fat?” is used to exclude people primarily concerned about their weight and body image appearance. This helps to not over diagnose BDD when an eating disorder might be a potentially more accurate diagnosis. I believe that this is a fair tool for the diagnosis of BDD as it does enquire about compulsive behaviour as well as obsessive concerns with regards to one’s appearance. However, the fourth question directly addresses body concerns over a specific perceived flaw. Perceived flaws can be seen to be an issue if they are causing pre-occupational thoughts, social avoidance or mental health concerns in line with BDD. Compared with some of the other BDD questionnaires and screening tools I feel that this particular scale may be slightly vague. However, the BDDQ does work as a self-reporting questionnaire and a study carried out by Phillip et al. has shown it has high sensitivity (100%) and specificity (89%) for BDD diagnosing in psychiatry and cosmetic medicine.16
Body Dysmorphic Disorder Modification of the Y-BOCS (BDD-YBOCS)
This is a modified version of the Yale-Brown obsessive disorder scale.10 It looks specifically at BDD and covers both insight and avoidance. This is an 11-item questionnaire with an individualised four-point answering scale for each question. Scale scores range from 0-48 and the cut off is 20 for a BDD diagnosis.10 The questions are aimed at 12 specific areas, these include the following:
• Time occupied by thoughts of defect
• Interference in daily life due to thoughts related to defect
• Distress with regards to thoughts about defect
• Resistance against thoughts of body defect
• Degree of control over thoughts of body defect
• Time spent in activities related to body defect
• Interference due to activities related to body defect
• Distress associated with activities related to body defect
• Resistance against compulsions
• Degree of control over compulsive behaviour
The BDD-YBOCS questionnaire is only practitioner administered, as there has been no reliability or validity demonstrated in using it as a self-reporting measure as of yet. The first 10 items on the questionnaire assess excessive preoccupation, obsessions and compulsive behaviours associated with dissatisfaction with physical appearance. The first three items (time, interference and distress) are based on the BDD diagnostic criteria as mentioned earlier. These are, in turn, related to both excessive preoccupation and compulsive behaviours. As seen above, the last two questions assess insight and avoidance. I believe that this tool works well as it looks at different aspects of a patient’s life that could be affected by the flaw that they are concerned about. BDD is a condition which affects social, professional and day-to-day activities, so it is helpful to have a questionnaire which focuses on the frequency of these compulsive behaviours. It also looks at severity of dissatisfaction which is also an important factor in assessing BDD.10 The BDD-YBOCS goes into great detail looking at both obsessive concerns and compulsive behaviours. The rating scale also allows us to rate severity and this can be very helpful when considering possible treatments for BDD.
It is, of course, important to consider exactly how we may use the above BDD tools. The first two mentioned, the AAI and the COPS questionnaire, can be filled out by the patient. The last two are practitioner led and therefore must be filled out in clinic with the presence of the practitioner and of course this will be more time consuming, especially as both the BDDQ and BDD-YBOCS scale are quite detailed. I believe that it may be an idea to combine use of these BDD questionnaires. The AAI and COPS could be used as a screening tool whereby the patient fills them out prior to clinic appointment. Based on the score from these questionnaires the clinician can then decide whether a more in-depth BDD assessment tool is required and can fill out the BDDQ or BDD-YBOCS. The COPS questionnaire is longer than the AAI and does provide more information on insight and possibly severity of symptoms so, in my opinion, this would be a good initial screening tool. This could then be combined with BDDYBOCS to get a more detailed idea of the patient’s symptoms and
level of dissatisfaction with their appearance. We must also appreciate that there could be limitations to solely letting patients fill out their questionnaires as if they have limited insight into their possible BDD symptoms they may underscore on the initial screening tool. Therefore, I think to some extent there should always be at least a brief psychological assessment as part of the aesthetic consultation. Practitioners could, in theory, adapt or create their own BDD tools, but these must be validated and trialled/tested in further research by practitioners themselves to check both sensitivity and specificity to be used as a valued tool in assessing BDD. Working closely with mental health professionals is, in my opinion, very important. This could mean that you are able to refer a patient back to their GP or refer onto a colleague who specialises in BDD or Obsessive Compulsive Disorder (OCD). Building such relationships can be beneficial not just for referral purposes, but also for gaining and sharing knowledge with mental health colleagues. Not all of the mentioned tools cover all aspects, however those that do, such as BDD-YPOCS and COPS, can be fairly time consuming as they require a higher number of detailed questions to be answered.
Validated assessment tools like those mentioned in this article are valuable for the pre-procedure assessment process. The important aspects of BDD that need to be evaluated via such assessment tools include compulsive behaviours, impairment of global functioning, avoidance of social situations and also insight into their condition. Although there are many tools available to assess BDD, there is still room for further research to be carried out in perhaps finding a more succinct assessment tool.
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