Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology

Abstract

Background The incidence of body dysmorphic disorder in cosmetic dermatology is high. Even though treating patients with this disorder may worsen symptoms and is fraught with potential complications, screening is low, due in part to lack of knowledge of the disorder, as well as inadequate screening tools. Objectives To verify the probability of body dysmorphic disorder in a nonsurgical esthetic setting and determine the effect of a multiphasic screening protocol on mitigating poor outcomes in high‐risk patients. Methods A multiphasic screening protocol for body dysmorphic disorder was distributed to a total of eight esthetic clinics in the United States. Practitioners administered an anonymous, cryptic prescreening form to all new, incoming patients aged ≥ 18 to ≤ 65 years from June 1, 2019, through September 1, 2019, followed by a second, more extensive screening questionnaire. Patients with suspected or subclinical body dysmorphic disorder could be refused treatment. Results A total of 734 initial screenings were recorded over 16 weeks. Of these, 4.2% (31/734) proceeded to the secondary screening phase; 29% (9/31) subsequently screened positive for body dysmorphic disorder. Practitioners refused to treat 77.8% (7/9) of positive screenings. Two patients out of seven who tested positive underwent a third screening and were subsequently treated with positive outcomes. Conclusions Use of a cryptic screening protocol enables identification of individuals at risk for BDD and encourages open and continuous communication between patient and provider.

Evidence‐based review: Screening body dysmorphic disorder in aesthetic clinical settings

“…Hence, a face‐to‐face consultation sustained on good communication and observation skills, alongside some common‐sense perspective, remains critical. This is particularly true considering that BDD patients tend to hide any practical signs that may preclude elective procedures 13 …”

“…Body dysmorphic disorder has become a popular topic among aesthetic practitioners, and some studies have attempted to develop more practical strategies for the identification of individuals at risk for BDD and encourage the appropriate medical, surgical, psychological, and global management of this disorder in aesthetic population. The level V pilot study by Fletcher recommended a multiphasic cryptic screening protocol for BDD in aesthetic dermatology practice 13 . This approach intended to avoid patients recognizing the initial psychological assessment, which was thought to decrease the sensitivity and specificity of the psychometric screening.…”

“…It seems therefore that the more recent studies using validated BDD screening tools were supportive of a relationship between BDD‐positive screenings and poor subjective outcomes following rhinoplasty and oculofacial plastic aesthetic surgery. Interestingly, only the two prospective studies using other non‐validated measures to screen BDD have investigated the subjective outcomes following non‐surgical minimally invasive treatments 13,84 . The positive screenings for the multiphasic approach by Fletcher using the modified version of COPS have been reportedly successfully treated 13 .…”

“…Interestingly, only the two prospective studies using other non‐validated measures to screen BDD have investigated the subjective outcomes following non‐surgical minimally invasive treatments 13,84 . The positive screenings for the multiphasic approach by Fletcher using the modified version of COPS have been reportedly successfully treated 13 . Pikoos et al, using a modified version of BDDQ‐DV to screen for BDD, reported that all participants had high mean levels of satisfaction with treatment‐decision, without differences between positive and negative screenings on any satisfaction variables following minor aesthetic treatments 84 .…”

“…Interestingly, one study in Saudi Arabia suggested that cultural differences rendered lack of management of confirmed BDD involving psychiatrists, considering that in the country a patient diagnosed with BDD may be stigmatized 16 . Moreover, studies have emphasized the challenge of establishing BDD diagnosis or recognizing high‐risk patients during a preoperative consultation, leading to an increased risk of unnecessary elective procedures with ethical and medicolegal consequences 13,17 . It may be particularly difficult for aesthetic practitioners without training or experience in mental health to determine if the appearance‐preoccupation is disproportionate when the defect is only mild, fueling the debate on whether BDD incidence in aesthetic population may be underrated 3,5 .…”