From Volume 47, Issue 4, April 2020 | Pages 303-313
Body Dysmorphic Disorder (BDD) is a relatively common psychiatric condition in which the individual is disproportionately concerned about an aspect of his/her appearance. People with BDD are highly likely to seek cosmetic dental treatment. However, the provision of such treatment is contra-indicated. This article will identify simple techniques for practitioners to screen for and manage patients with BDD.
Throughout the course of our lives, almost all of us have felt dissatisfied with our appearance and tried to improve it. After all, we are hounded by images and messages from all sides telling us that we are not pretty enough or we are not skinny enough. Who wouldn't like a flatter stomach, a more chiselled body, blemish-free skin? If we had the chance to use a magic wand to look better, most of us would. In fact, most of us try on a daily basis. From spending hours in changing rooms ensuring that clothes are as flattering as they can be, going on fad diets, (which just make us miserable) and spending fortunes on the latest moisturising cream promising to knock years off us, we have all tried to alter our image to some degree. However, for some people, these concerns are not just about disliking a body part; they're preoccupied with it. Every waking thought revolves around their perceived flaw and imperfection and their worries about their looks lead to distress and emotional pain, resulting in an interference in their quality of life. They no longer want to go to work for fear that people will notice the slight facial blemishes. They are terrified to go to their high school prom due to concerns that their thinning hair will be noticed. They can't engage in meaningful relationships due to the daily inner voice telling them that their breasts are ‘tiny’. In reality, these supposed flaws are usually not noticeable to those around them, or considered minimal. However, for the sufferer, the problem looks repulsive and abhorrent, magnified by the mind's eye.
Such people are considered to suffer from a mental illness known as Body Dysmorphic Disorder (BDD), which is classified under the Chapter of ‘Obsessive Compulsive and Related Disorders’ in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5®).1
The criteria used for diagnosis are outlined in Table 1. In previous DSM editions, BDD was classified both as a somatoform disorder and a delusional variant was also classified as a psychotic disorder. However, there was evidence to suggest that these two variants had more similarities than differences and that they were likely to be the same disorder, characterized by a spectrum of insight.2 As such, DSM V extended the original criteria and added a specifier, indicating the degree of insight regarding BDD beliefs. As a result, the delusional variant of BDD is no longer considered a delusional disorder but rather as a specific form, in which a patient with absent insight/delusional beliefs is ‘completely convinced that the body dysmorphic disorder beliefs are true’.1 These patients may be challenging to treat, so it is useful to ascertain whether this specifier is relevant at an early stage.
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Patients presenting to the dental clinician may well suffer from BDD, with varying levels of insight, and dentists may be the first to spot them. In this review, how to identify when a patient's aesthetic concern is considered ‘normal’ and when alarm bells should be ringing will be the focus. The best way to manage such patients and advise on the process of referral will also be addressed.
Body dysmorphic disorder appears to be a relatively common mental health condition, although exact prevalence is difficult to ascertain due to the shame commonly associated with the illness. A number of epidemiological studies have been conducted throughout the years and prevalence rates of between 0.7%-2.4% have been reported amongst different populations.3,4,5 It is, however, important to note that prevalence varies, depending on the setting that patients are in. Interestingly, it has been shown that the prevalence rates of BDD in those having cosmetic dental surgery or orthodontic treatment range from 4.2-7.5%,6 implying that dentists are more likely to encounter sufferers of BDD than the general population.
Amongst sufferers, the body part causing the most distress varies from person to person. However, there are certain areas that are more frequently cited as troublesome than others. These include nose, eyes, ears, balding, genitals and breasts, and it is not uncommon for a patient to have an issue with more than one of these body parts at any one time.7Table 2 lists examples of real life concerns from patients suffering with BDD, together with their associated behaviours and consequences.
| Appearance Concerns | Associated Behaviours and Consequences |
|---|---|
| Nose misshapen | Believes others take special notice |
| Thinning hair | Excessive hair combing |
| Spectacles | Wears tinted glasses to hide eyes |
| Hair too curly | Frequent hair perms and straightening |
| Penis too small | Stuffs shorts and wears shirt down to knees to cover crotch |
| Breasts too small | Wears padded bras |
| Ugly face | Checks mirrors, car bumpers and windows excessively |
| Fat waist | Checks mirrors and store and car windows |
Veale et al found that 86% of patients perceived themselves to have a facial defect, with 12% reporting specific teeth defects,8 whilst Phillips discovered that 20% of sufferers had concerns with their teeth.7 As such, it is highly likely that dentists, orthodontists, plastic surgeons and other specialists working in the facial region will become involved with such patients and, thus, need to be aware of their identification and management. Orthodontic examples might include concerns over the size and shape of a patient's teeth, as well as the perceived ‘straightness’ of teeth, whilst complaints that may present to the general dentist may include dissatisfaction with the whiteness of a patient's teeth.
The high levels of distress experienced by sufferers of BDD can sometimes lead to patients attempting to take their own life. In a study conducted by Phillips it was found that 79.5% of 185 subjects had experienced suicidal ideation and 27.6% had a history of a suicide attempt, which was found to be 45 times higher than levels experienced by the general population.9 These extremely high rates indicate the necessity for dental professionals to spot sufferers and to refer them for psychiatric help immediately rather than carrying out dental treatment.
If a clinician suspects that a patient may be suffering from BDD, it is important that a basic assessment is carried out to check if he/she is suitable for dental treatment or whether he/she would be better placed to receive psychological support. In numerous research papers, both dental-related and otherwise, it has been found that those suffering from BDD are rarely satisfied with the treatment they initially sought help for, as the issue is a mental one rather than a physical one.10 This can have far-reaching effects for dentists treating them, making early detection and appropriate management of paramount importance.11 Below is a useful guide on how best to assess patients.
Before raising any concerns dentists may have, it is crucial that they follow this step in order to maximize a patient's feeling of security in the dentist and to allow an open and honest dialogue. Dentists should make it clear that any information disclosed will remain confidential unless they feel they are at risk of harming themselves or others. It is also important that the dentist limits the number of people in the room to make the patient feel less intimated.
It is advisable to schedule a longer appointment time than usual as this will allow ample time for discussion, which will reduce the risk of the patient feeling rushed and pressurized.12 This will maximize the likelihood of making the correct diagnosis and signposting the patient to accessing the correct professional help.
If a new patient presents to the surgery with tell-tale signs of BDD, but there isn't sufficient time to have an in depth discussion with him/her, it is prudent to schedule in another appointment with a larger time allocation. Any treatment which the patient requests should be delayed until this discussion has been carried out rather than carrying out rushed, and potentially damaging, treatment during that first appointment.
Although many patients suffering from BDD will present to the practice unaware of their condition, some will have already been diagnosed but may be reluctant to divulge this information, especially if not directly questioned about it. Therefore, it is good practice to get into the habit of asking all patients if they have ever been diagnosed with a mental health condition. It is likely that many patients may still not share this information but, by asking the question, there is an increased probability that more will share than if the question wasn't asked. Another useful clue may be to ask patients if they are taking any medications. Many people diagnosed with BDD may be taking antidepressants, with the medication of choice being selective serotonin re-uptake inhibitors,13 and medication treatment is often essential for more severely ill and suicidal patients. Therefore, a declaration of regular medication may help a clinician build up a more comprehensive image of a patient's background and any underlying mental health issues he/she may have.
It is important to realize that BDD patients attending a dental clinic are likely to want some form of cosmetic dental treatment, such as braces or tooth whitening. As a result, patients might exaggerate or deviate from the truth in an attempt to encourage the dentist to agree to offer treatment.14 This could skew the assessment results, leading to misdiagnosis. Therefore, it is important that the clinician does not necessarily take the discussion at face value. However, it is also important to realize that patients often have beliefs about their appearance that they may truly feel and, as such, the clinician has to be careful to deny these statements and try to validate the extent of the distress from the stated disfigurement.
There are many screening tools available to help establish whether a patient might suffer from BDD. Some are lengthier than others and may not be appropriate for use in a dental surgery. It is recommended that dentists familiarize themselves with all the screening tools available and then decide which one they feel most comfortable with and which they think will be most amenable to their day-to-day practice. It is important to note that these are just screening tools and not diagnostic tools. Dentists are not qualified to make a formal diagnosis of BDD using these tools but they can help determine whether a referral should be made. A screening tool also means that the decision is based on a relatively objective measure in addition to clinical opinion. Ideally, a formal diagnosis will be made following a face-to-face interview with a trained clinician. Examples of commonly used screening tools with information on their scoring system and uses can be found in Table 3, with samples of some of the questionnaires included displayed in Figures 1-3.
| Name of Screening Tool | Number of Items | Comments |
|---|---|---|
| Body Dysmorphic Disorder Questionnaire6 (Figure 1) | 4 items | |
| Yale-Brown Obsessive Compulsive Scale Modified for body dysmorphic disorder17 | 12 items |
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| Cosmetic Procedure Screening Scale19 | 9 items |
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| Dysmorphic Concern Questionnaire20,21,22 (Figure 2) | 7 items |
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| Marks and Matthew Suicidal Ideation Scale23 | 3 items |
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Table 4 provides two examples of possible cases of BDD, identifying the key features as they may present in dental practice.
| Miss A, aged 30 years, presented at an orthodontic clinic requesting treatment for her ‘crooked’ upper anterior teeth. She also felt her teeth were too yellow and was keen to discuss tooth whitening. She was generally anxious in the dental surgery. She had a Class I occlusion with moderate crowding and an average overbite. A number of teeth showed signs of erosion. The orthodontist advised her that fixed braces would be required for a period of 2 years to correct her crowding and bite with extractions required to alleviate the crowding. Miss A described how she could not abide a gap during any of the treatment and asked again about tooth whitening. |
Mr B, aged 28, was referred to the orthodontic department by his dentist for an assessment of his Class II division 2 malocclusion with increased overbite. He had recently registered with the GDP and at his first appointment discussed the issues concerning him, prompting the referral. On examination Mr B had a significant skeletal II background with increased overbite, complete to the palate and retroclined upper labial segment. His teeth were in good condition and his oral hygiene excellent. Further discussion during the examination revealed that Mr B was also concerned about the appearance of his chin and deep groove under his bottom lip. |
| Additional Medical History | |
|---|---|
| Miss A was on no current medication and had been hospitalized as a child for tonsillectomy. She had previously been diagnosed with an eating disorder, for which she had received psychiatric treatment. She attended a GDP in the area for some time and had little more than check-ups in that time. She had not had any treatment for her erosion but was aware that it was linked to her previous eating disorder. | Mr B was allergic to Penicillin and was taking fluoxetine. He had undergone surgery twice in the previous four years, having been administered a General Anaesthetic on both occasions. He registered with this dentist recently although had been living in the area some time, and on closer questioning revealed that he had seen a number of dentists in the area, including another orthodontist, about the possibility of an osteotomy. |
| Overall Assessment | |
| Miss A clearly has a history of psychiatric illness, which is often a co-morbidity in BDD, though note that a diagnosis of an eating disorder would normally exclude a co-existing diagnosis of body dysmorphophic disorder. |
Mr B, though attending for a seemingly appropriate treatment, shows many features of body dysmorphic disorder. His concerns that the appearance of his teeth and chin is preventing him getting a job are disproportionate to the actual problem. Accessing information on the internet is an accepted background in many instances, but may be an indication of preoccupation with a condition or treatment. Discovering that he has seen someone else about the possibility of an osteotomy is also an indication of his preoccupation with appearance. |
The short answer is no. Instead, the patient should be referred for specialist psychological support. Once this has been undertaken, it will become clear what dental treatment, if any, is appropriate. The reasons for this are discussed in more detail below.
A patient presenting to a dentist in obvious distress about a perceived defect and a convincing argument as to why he/she needs treatment can be difficult to refuse. However, numerous studies have been conducted over the years which have demonstrated that surrendering to the patient's requests have not benefited the patient at all. One such study, conducted by Phillips et al, found that more than two-thirds of patients who received physical treatment with no accompanying psychiatric support experienced no alleviation or worsening in their BDD symptoms, usually because the patient's concerns had simply been transferred to another body part or he/she was worried that the improvement would get worse again.24 In this particular study, only 7.3% of all treatments resulted in both a decrease in concern with the treated body part as well as an alleviation in BDD symptoms. Similar findings were reported by Crerand et al, in which 91% of patients experienced no change in overall BDD symptoms after treatment25 and Veale et al, in which 81% of patients who had sought a consultation or operation were dissatisfied or very dissatisfied.8 These findings are clear indications that provision of the requested treatment is clearly not in the patient's best interest when he/she is suffering from BDD.
Unfortunately, not only can treating BDD patients be detrimental to the patient themselves, but it can also prove detrimental to the treating clinician as a result of the patient's unattainably high standard, of which the dentist will almost always fall short. As a consequence of the perceived failure to improve a patient's image, it is not uncommon for him/her to attempt litigation against his/her clinician. In 2001, all members of the American Society for Aesthetic Plastic Surgery (ASAPS) were emailed the ‘2001 Body Image Survey’, of which 265 members responded. The survey revealed that 40% of respondents had been threatened by a patient suffering from BDD; 29% had been threatened legally, 2% physically and 10% both legally and physically.26 It is important to be aware that legal action may be taken against a clinician, even when consent has been taken, as demonstrated in the Lynn vs Hugo case of 2001.27 Although the patient didn't succeed in her claim, it raised the interesting, and potentially concerning point that patients suffering from BDD may well be declared unfit to consent due to their impaired mental ability. This may well result in a clinician being found liable in a court of law, emphasizing how critical it is not to proceed with treatment when BDD is suspected, but rather to signpost a patient towards psychiatric or psychological services for further treatment.
It is natural that a dentist will feel uncomfortable talking with a patient about what is potentially a serious psychiatric diagnosis. However, it is important to bear in mind the following:
Guidance from the National Institute for Health Care Excellence recommends that, in the majority of cases, the most appropriate care can be provided in primary care settings, so referral to the individual's General Medical Practitioner should be considered as the first step. Alternatively, the dental team may consider a direct referral to clinical psychology services. Furthermore, there are some considerations which might suggest that it is appropriate to seek urgent support from psychiatric and psychological services. This is particularly the case if the patient has expressed suicidal thoughts. Where such thoughts are current, emergency referral to psychiatry via Accident and Emergency services should be made.
When writing a referral letter, there are certain key points a dentist should make sure to include:
It is important that the patient is aware that the referral letter is being made and that permission has been granted. If a patient refuses to allow the clinician to send the letter, the dentist can still make a referral if he/she feels that the situation is sufficiently concerning to warrant such a step, for example if there is danger to the patient (such as suicidal ideation) or to others.
As with all treatment, it is crucial to keep very careful contemporaneous notes with a detailed record of any referrals that may have been made. This will be particularly important if referral is made without consent. The reasons for taking these steps should be clearly documented.
Body dysmorphic disorder is a distressing psychiatric illness where the individual is disproportionately concerned about his/her appearance. People with BDD are likely to present for cosmetic dental treatments. Dental practitioners should be equipped with techniques for screening individuals for BDD, discussing their concerns with patients and making appropriate referrals.
