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however, may be especially prevalent. Body dysmorphic disorder, a disorder characterized by extreme appearance preoccupation, may be of particular relevance to plastic surgeons and other physicians who offer cosmetic procedures. Thus, this article provides an overview of body dysmorphic disorder and its relationship to cosmetic surgery. It includes a description of the history of the diagnosis, the current diagnostic criteria, etiologic theories, clinical and demographic features, and comorbidity associated with the disorder. The article then focuses on the prevalence of body dysmorphic disorder, particularly among persons who seek cosmetic treatment. A review of the medical, pharmacologic, and psychotherapeutic treatments for body dysmorphic disorder is also provided. The article concludes with suggestions for future research. HISTORY OF AND DIAGNOSTIC CRITERIA FOR BODY DYSMORPHIC DISORDER History of the Diagnosis Body dysmorphic disorder was initially called “dysmorphophobia” when it first appeared in the European medical literature in 1886.37 In other early descriptions, body dysmorphic disorder was termed “l’obsession de la honte du corps” (obsession with shame of the body)38 or “dysmorphophobic syndrome.”39 In the United States, case reports in the cosmetic surgery and dermatology literature describing symptoms consistent with body dysmorphic disorder appeared before the disorder’s inclusion in the Diagnostic and Statistical Manual of Mental Disorders. Descriptions of “minimal deformity” and “insatiable” patients were reported in the cosmetic surgery literature in the 1960s.2,40 Case reports of “dysmorphophobia” and “dermatological nondisease” were also described in the dermatology literature.41 Similar to persons with body dysmorphic disorder presenting for cosmetic treatments today, these patients requested multiple procedures to improve slight or imagined defects, and, typically, reported high levels of dissatisfaction with their postoperative results.2 Body dysmorphic disorder first appeared in Diagnostic and Statistical Manual of Mental Disorders, Third Edition in 1980, where it was described as an atypical somatoform disorder.42 Body dysmorphic disorder was included as a formal diagnosis and officially termed “body dysmorphic disorder” with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised in 1987.43 Two variations of body dysmorphic disorPlastic and Reconstructive Surgery • December 2006 168e der were included in the Diagnostic and Statistical Manual of Mental Disorders, Third Revision, Revised: nondelusional or delusional (or delusional disorder, somatic type). The differentiation between subtypes is less clear in both the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 44 and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 45 This likely reflects the growing consensus that the nondelusional and delusional subtypes are variations of the disorder.46 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Diagnostic Criteria Body dysmorphic disorder is currently categorized as a somatoform disorder.45 This classification has been criticized, with some researchers asserting that body dysmorphic disorder should be considered an obsessive-compulsive spectrum disorder47,48 or an affective spectrum disorder.48 Three diagnostic criteria are listed for body dysmorphic disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision: (1) a preoccupation with an imagined or slight defect in appearance (if a slight physical defect is present, the person’s degree of concern is extreme); (2) marked distress or impairment in social, occupational, or other areas of functioning resulting from the appearance preoccupation; and (3) the preoccupation is not attributable to the presence of another psychiatric disorder (e.g., anorexia nervosa).45 As in previous versions of the Diagnostic and Statistical Manual of Mental Disorders, if the appearance preoccupations are held with delusional intensity, a diagnosis of delusional disorder, somatic type can also be applied. The application of the body dysmorphic disorder diagnostic criteria to cosmetic surgery populations can be challenging.49 Applied independently, the first diagnostic criterion likely describes the majority of cosmetic surgery patients. Many individuals present for cosmetic surgery to correct slight imperfections or to enhance “normal” features, and cosmetic surgeons, by virtue of their training, are skilled at identifying and correcting these relatively modest appearance imperfections. Thus, the classification of a feature as “abnormal” or “correctable” is often quite subjective. Furthermore, in cosmetic surgery populations, some degree of distress about the appearance feature for which treatment is desired appears to be normative.30 –34 However, the degree of distress and impairment in functioning may be the most useful indicator of body dysmorphic disorder in these patients. 10,50 For example, a person who reports that his or her appearance concerns interfere with his or her ability to maintain a job likely meets criteria for body dysmorphic disorder. In contrast, the person who denies significant disruption in occupational or social functioning

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