Patients with common psychocutaneous diseases, including body dysmorphic disorder (BDD), often refuse a psychiatric referral and instead, present to dermatologists and cosmetic surgeons.
Body Dysmorphic Disorder (BDD) is a psychiatric diagnosis, however, the prevalence of patients that suffer from BDD is higher among dermatology patients, than in the background population.1 In his session at the 2023 American Academy of Dermatology (AAD) Annual Meeting in New Orleans, Louisiana, Geoge Kroumpouzos, MD, PhD, FAAD, explored the relationship between psychocutaneous disease patients and the role their dermatologist or cosmetic surgeon may play in diagnosing and treating the disease.
Krompouzos is director of GK Dermatology, clinical associate professor of dermatology at Brown University, and Board Member of the International Academy of Cosmetic Dermatology. In his session, "Psychocutaneous Disease: Treating the Difficult Patient", Kroumpouzos focused on managing such conditions in the complex patient and how to approach a patient with BDD in the dermatology space.
George Kroumpouzos, MD: I'm George Kroumpouzos, I am a dermatologist in Massachusetts. I'm in solo practice and I'm also teaching at Brown University as a clinical associate professor, and I have combined both clinical and cosmetic dermatology. Psychodermatology is one of the fields on which a focus in my practice.
Dermatology Times®: How common is BDD in dermatology patients?
Kroumpouzos: Psychiatric comorbidity is very common in my practice, but it's common also in dermatology. In general, the prevalence of body dysmorphic disorder (BDD )in dermatology is 8.5 to 15%, but likely higher in cosmetic surgery patients. In that group, the prevalence ranges between 6 and 20% in various statuses. So very status encounter a psychiatric condition in 1 out of 3 dermatology patients. We see patients with psychiatric comorbidity all the time.
Dermatology Times: What signs should dermatologists look for when suspecting BDD?
Kroumpouzos: Well, distress and functional impairment are common denominators among BDD patients and patients with other psychiatric issues. Emotional distress is often quite apparent during a brief interview. Dermatologists should try to evaluate psychosocial issues and the patient's quality of life. It's important to know how much the problem affects the quality of life of the patient. Lack of insight correlates with the severity of the pyscho dermatologic conditions. So patients who have a lack of insight or complete lack of insight are always difficult to manage. And I would always encourage other dermatologists to look into the patient's quality of life and try to elucidate other psychosocial issues.
Dermatology Times: Explain your diagnostic procedure when diagnosing a patient.
Kroumpouzos: There are 3 elements in the diagnosis process. Warning signs, which we also call red flags, from the history and in-office observation; a structured interview that doesn't need to be long, and a BDD questionnaire. Not every practice uses a disability questionnaire, but there are BDD questionnaires that are only 7 questions long, and they're easy to fill out in 5 minutes so the patient would not mind taking that questionnaire. Now the red flags from the history interview include a belief of the patient that surgery will solve all problems based on its design and dissatisfaction with the outcomes of previous procedures; they're never happy. And there is often a history of comorbidity or psych comorbidity or pysch treatment. And if we look carefully at the patient's records, we'll find that previous psych treatment. Now red flags from the novice observation include repeated consultations for the perceived defect. So the patient goes from physician to physician, from aesthetic provider to aesthetic provider, to ask their opinion about the same defect. These patients bring photographs [social media images of celebrities], they ask the nurses to compare them with a celebrity, and they often reveal their preoccupation to the staff. So this patient often refused to undergo standard preoperative evaluations, which is another red flag. So if we see a patient with all these warning signs, we should suspect BDD and again, the best way to confirm it is to provide final a questionnaire to the patient. Some of these questionnaires do not take more than 5 minutes to complete.
This transcript has been edited for clarity and length.
1. Herbst, I., Jemec, G.B.E. Body Dysmorphic Disorder in Dermatology: a Systematic Review. Psychiatr Q 91, 1003–1010 (2020). https://doi.org/10.1007/s11126-020-09757-y