Portal de Periódicos da CAPES

The New Criteria for Body Dysmorphic Disorder

2013; Lippincott Williams & Wilkins; Volume: 132; Issue: 6 Linguagem: Inglês

10.1097/prs.0b013e3182a805ca

1529-4242

Mark B. Constantian,

Empathy and Medical Education

Approximately 20 years ago, Richard Bentall, a psychologist in Liverpool, England, wrote a cleverly provocative essay about happiness.1 He noted that happy people are relatively rare; exhibit cognitive distortions (such as optimism); try to force their moods on others; often behave in carefree, uninhibited manners, sometimes indulging in behaviors with life-threatening consequences (such as eating and drinking to excess); have impaired memory for negative events; and are prima facie irrational because happiness is not grounded in reality. Bentall proposed therefore that happiness be classified as a “major affective disorder, pleasant type.” Although Bentall meant to be amusing, he accurately described a diagnostic system that struggles with distinguishing the normal from the abnormal. Mental health diagnoses depend in part on who is examining the patient. On May 8, 2013, the American Psychiatric Association released the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. As anticipated from its subcommittee’s work,2 and of particular interest to me, body dysmorphic disorder has been redefined and reclassified for the first time since its inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised in 1987. Body dysmorphic disorder was previously grouped with the somatoform disorders (such as hysteria and hypochondriasis) and defined as follows: Preoccupation with an imagined or trivial defect in appearance that (B) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (C) The individual’s symptoms must not be better accounted for by another disorder.3 In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, body dysmorphic disorder has been promoted to a new chapter, “Obsessive Compulsive and Related Disorders,” which also includes obsessive compulsive disorder, hoarding disorder, and hair pulling and excoriation disorder. Here is its new definition: Preoccupation with a perceived defect(s) or flaw(s) in physical appearance that is not observable or appears slight to others. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. The preoccupation causes clinically significant distress (e.g., depressed mood, anxiety, shame) or impairment in social, occupational, or other important areas of functioning (e.g., school, relationships, household). The appearance preoccupations are not restricted to concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.4 These changes from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria describe the patient’s flaws as “perceived” instead of “imagined,” revised wording that is presumably less pejorative and captures the patient’s experience more accurately. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition also added a new criterion requiring that the patient have performed repetitive behaviors (i.e., mirror checking, grooming) or mental acts (i.e., comparing appearance to others) in response to his or her “perceived flaw,” which supports its reclassification with obsessive compulsive disorders. A specifier has been added to allow the examiner to determine the level of insight: “good” or “fair,” “poor,” or “delusional,” and specifically excludes eating disorders. Although I believe that body dysmorphic disorder could also be classified with the anxiety disorders because it shares so many traits with posttraumatic stress disorder, these are thoughtful, good changes. Nevertheless, the new criteria still beg the question—At what point does a shape become a deformity? Who decides what is “not observable” or “slight”? If the focus of a patient’s distress is not visible to the family, primary care physician, or mental health professional, does that make it only “perceived”? Is “subtle” the same as “not observable”? Who decides whether the patient is significantly distressed or impaired (i.e., whether the deformity merits the response)? These are not only theoretical questions. It is not hard to find articles on body dysmorphic disorder in which the deformity was evaluated by “panels of nonmedical people,”5,6 “friends and family,”7 or “objective observers.”8 Many, if not most, studies report body dysmorphic disorder diagnoses based on self-reporting by the patients themselves9–16 using Phillips’ Body Dysmorphic Disorder Questionnaire17 or Cash et al.’s Body Image Disturbance Questionnaire.18 As a result, even the best body dysmorphic disorder literature contains statements such as this: “With the exception of 6 patients, who had slight physical anomalies about which they were excessively concerned, all body parts of concern appeared normal to the investigators” [italics mine].19 There are many other validated psychometrics that assess “global” body image dissatisfaction; body dimensions; body appreciation; body shape; body shame; body checking; body image avoidance; body image compulsive actions; drive for leanness; muscle appearance satisfaction; body image avoidance; and questionnaires for men, women, and adolescents.20 However, their practical use in many studies relies on the assumption that any patient’s self-tested response to a facial or body feature, if deemed excessive by the psychometric, accurately establishes a mental health disorder. Can patients diagnose themselves? Does the diagnosis of body dysmorphic disorder depend on who is examining the patient? Admittedly, I am an outsider reading the mental health literature, and there may be points or assumptions that evade me. However, in the absence of independent physical examination by a surgeon who treats the deformity in question, these self-administered assessments may reflect not body dysmorphic disorder but rather anxiety, depression, obsessive compulsive disorder, eating disorders, generalized worry disorder, poor insight, social anxiety disorder, or cognitive distortions instead, each of which may exist alone or coexist with body dysmorphic disorder.10,13–15,21–25 The primary dangers here are twofold: the tendency to produce false-positives, and the dilution of study conclusions by including patients who do not really have body dysmorphic disorder. So what does this mean? It means that unless the patients being studied have been evaluated by a surgeon who treats the deformity in question, the diagnosis of body dysmorphic disorder must be considered to be incomplete or speculative. Even those patients evaluated by a structured clinical interview would benefit from this added information. Imagine, for example, a rhinoplasty patient with postoperative valvular obstruction who has already had septal and turbinate surgery but cannot sleep or exercise, has intercurrent sinus infections, and who has become depressed and obsessed about having corrective surgery. The physical findings may be subtle, but they are real. This is not body dysmorphic disorder, and there are many such patients. Or imagine a patient who has a perfectly acceptable rhinoplasty result but is distraught because a personal, ethnic, or familial trait was inadvertently destroyed by the operation; this perceived loss motivates a sizeable percentage of patients seeking secondary rhinoplasty,26 many of whom have been diagnosed with body dysmorphic disorder, and it is not body dysmorphic disorder. Cosmetic diagnoses are always in context. In cancer or trauma, the diagnosis is unquestioned and the patient’s response can be presumed to be “normal” within his or her culture. It is not so with body image issues, best seen in the interface between mastectomy and breast reconstruction, where the cancer diagnosis and the patient’s body image come face to face. Deformities have different meanings to different patients, influenced by the patient’s personality, culture, and past. The same intensity of emotion that would be considered appropriate for a patient with a large facial cancer may be diagnosed as body dysmorphic disorder if the deformity is cosmetic. How can body dysmorphic disorder be associated with so many seemingly disparate disorders? Can there be a common thread that links them all? I believe that there is. In preparation is a manuscript that will describe an association between the degree of preoperative nasal deformity, satisfaction with the postoperative result, and a history of abuse or neglect.27 I believe that a significant component of postoperative patient satisfaction, perhaps one missing piece to the body dysmorphic disorder story, and what may link anxiety, obsessive compulsive disorder, eating disorders, posttraumatic stress disorder, and depression with body dysmorphic disorder may be the common thread of developmental trauma (which has been independently associated with each of those other disorders). The potential connection among body image, body shame, and trauma has not received much attention in the mental health literature until recently with, to my knowledge, only three nonsurgical patient series28–30 and tangential mention in two other articles.31,32 I have previously described several individual patients with body dysmorphic disorder and coexistent trauma and hypothesized such an association.33 Specialty differences in diagnosis and perspective are inevitable because plastic surgeons and mental health professionals see different patient populations: the former see patients in whom a diagnosis has been made and who come for therapy, and the latter see patients who want surgery. This specialty difference is highlighted by the ironic omission of “plastic surgery” in the repetitive behaviors listed in criterion B---the very route by which most of us meet body dysmorphic patients, and a regrettable omission that will limit the usefulness of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to surgeons. We need criteria that match the characteristics of patients seeking plastic surgery. There is potentially enormous additive value in these discrete perspectives of our different specialties. So which discipline should make the diagnosis of body dysmorphic disorder? The answer is both: body dysmorphic disorder should be a two-specialty diagnosis. An accurate assessment of the physical deformity by the surgeons who treat them is the missing piece in much of the body dysmorphic disorder literature, and a consensus decision would strengthen the research conducted by both specialties and decrease the prevalence of false-positive diagnoses. I hope that the authors of the next revision of the Diagnostic and Statistical Manual of Mental Disorders will consider this change. Patients have a history. We spend our careers trying to find out what makes patients happy. The answer turns out to be an even simpler question: What makes people happy? The past is never dead. It’s not even past. —William Faulkner, Requiem for a Nun, 1951, Act 1, Scene 3 ACKNOWLEDGMENT The author gratefully acknowledges the expert research assistance of Marcy Brackett, R.N., M.B.A., Southern New Hampshire Medical Center, Nashua, New Hampshire.