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Through a mirror darkly Suicide risk makes ID of BDD patients critical

Article-Through a mirror darkly Suicide risk makes ID of BDD patients critical

National report — While it is difficult to pin down precise data regarding body dysmorphic disorder (BDD), sources tell Cosmetic Surgery Times it's more common than many cosmetic surgeons think. Perhaps more importantly, the link between BDD and suicide attempts makes it crucial to accurately identify and refer such patients for appropriate treatment, experts say.

Seeking a predictive model

Dr. Fried
Experts define BDD as an unhealthy preoccupation with slight or imagined physical defects. The condition is "far more common than we ever realized," says Richard G. Fried, M.D., Ph.D., a board-certified dermatologist and clinical psychologist and clinical director of Yardley Dermatology and Yardley Skin Enhancement and Wellness Center, Yardley, Pa. Although many plastic surgeons and dermatologists are aware of BDD and interested in cooperating with psychiatrists to help these patients, "plastic surgeons and dermatologists are still afraid of diagnosing the real cases and finding out how big the problem is," partly because they are unfamiliar with psychiatry and psychology, adds Nienke C. Vulink, M.D. She is a Ph.D. student in psychiatry at the University Medical Center, Utrecht, Netherlands, who is working to develop and validate a predictive model for diagnosing BDD.

BDD prevalence

Domestically, Dr. Fried says BDD's prevalence in dermatology patients is 11.9 percent, and it is estimated at around 20 percent in patients presenting for cosmetic procedures (Fried RG. Dermatologic Non-Disease. In: Lebwohl MG, Ed. Treatment of Skin Disease 2nd Edition. St. Louis: Mosby; 2006: 159-161.).

Dr. Vulink
Internationally, a recent Dutch study involving more than 1,000 new patients presenting at outpatient plastic surgery (including hand surgery) and dermatology clinics reveals rates of 8.5 percent and 3.2 percent, respectively (Vulink NC et al. Ned Tijdschr Geneeskd. 2006 Jan 14;150(2):75-76.).

However, Dr. Vulink says that, compared to private facilities, academic settings, such as the one studied, usually see fewer BDD patients because such centers typically treat patients with difficult somatic problems.

Moreover, "We don't yet have any prospective studies that look at what happens to a patient who has been diagnosed with BDD after the procedure or surgery," adds David Veale, M.D., consultant psychiatrist, Institute of Psychiatry, University of London. "We're trying to do that research ourselves, but it's quite difficult," partly because studying psychosocial factors isn't part of the cosmetic surgery culture, he adds. Dr. Veale invites interested cosmetic surgeons to contact him via his web site:

Complex diagnosis

Dr. Glaser
Further complicating the BDD picture is the fact that its severity can vary greatly, Dr. Fried says. While some patients are only slightly preoccupied with their appearance problems, he says, "approximately one-quarter of people with BDD attempt suicide." Therefore, Dr. Fried says, "we have an obligation to identify these patients and try to get them into meaningful treatment."

In this regard, Dr. Vulink says, "it's very hard to get these patients to our offices. Patients are embarrassed" about seeing psychiatrists.

Conversely, Dr. Fried says plastic surgeons and dermatologists attract such patients like magnets. And almost by definition, he adds, "doing a procedure on one of these patients can be disastrous for the patient — and potentially the surgeon."

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