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emotional suffering related to body dysmorphic disorder may lead some persons to contemplate or attempt suicide. Up to 78 percent of persons with body dysmorphic disorder report suicidal ideation and 17 to 33 percent report suicide attempts over the course of the disorder.72,73,78,79,88 Case reports of attempted and completed suicides have been described in the dermatology literature.41,89 Use of Cosmetic Treatments Persons with body dysmorphic disorder frequently seek cosmetic surgery and other related treatments to improve their “flawed” appearance. Veale et al.73 reported that nearly half of their sample (n 50) had sought cosmetic or dermatologic treatment, with 26 percent having undergone more than one surgical procedure. In a larger sample (n 188), 70 percent had sought and 58 percent had obtained cosmetic treatments.72 Two recent studies suggest that 71 to 76 percent sought and 64 to 66 percent received cosmetic treatments.76,90 Rhinoplasty, liposuction, and breast augmentation were among the most frequently sought surgical procedures. Receipt of minimally invasive (e.g., collagen injections) and dental (e.g., tooth whitening) procedures was also common.90 Somewhat encouragingly, providers often refuse to perform procedures on persons with Volume 118, Number 7 • Body Dysmorphic Disorder 171e body dysmorphic disorder. In Phillips et al.’s76 sample of 250 patients, 35 percent of all requested treatments (n 785) were not provided, most commonly because the physician deemed the treatment unnecessary. Similarly, in a sample of 200 patients, 21 percent of all sought procedures (n 528) were not received, primarily because the provider refused to perform the procedure.90 A survey of 265 cosmetic surgeons found that 84 percent had refused to operate on a patient they suspected of having body dysmorphic disorder.91 Nonetheless, patients may engage in “doctor shopping” until they find a provider who will perform the desired treatment.70 Comorbid Psychopathology Body dysmorphic disorder frequently occurs with other psychiatric disorders. In the largest study of comorbidity among persons with body dysmorphic disorder (n 293), on average, participants met criteria for at least two lifetime comorbid Axis I diagnoses.92 Mood and anxiety disorders, obsessive-compulsive spectrum disorder, substance use disorders, eating disorders, and personality disorders were the most typical comorbid diagnoses. Mood and Anxiety Disorders Major depression appears to be the most common comorbid condition. More than 75 percent of patients with body dysmorphic disorder had a lifetime history of major depression, and over half met criteria for current major depression.92 Anxiety disorders also frequently co-occur. Gunstad and Phillips92 reported that over 60 percent of patients had a lifetime history of an anxiety disorder. The lifetime co-occurrence rate for social phobia is roughly 38 percent.72,92 Social phobia tends to predate the onset of body dysmorphic disorder.92,93 Obsessive-Compulsive Spectrum Disorders Body dysmorphic disorder also frequently cooccurs with obsessive-compulsive disorder. Lifetime rates of obsessive-compulsive disorder among persons with body dysmorphic disorder range from 3092 to 78 percent,47 and current rates range from 673 to 30 percent.72,78,92 Body dysmorphic disorder shares overlapping features with several other obsessive-compulsive spectrum disorders as well. Data on their co-occurrence are mixed, making it difficult to establish strong connections between the disorders. For example, body dysmorphic disorder and hypochondriasis both involve obsessional thinking and checking behaviors, but the focus of concern in body dysmorphic disorder is on appearance, whereas in hypochondriasis the concerns relate to health status. Phillips et al.52 found that only 2 percent of their body dysmorphic disorder sample had comorbid hypochondriasis. Trichotillomania is defined as repetitive pulling out of one’s hair, resulting in observable hair loss.45 The disorder is typically maintained by positive reinforcement rather than by negative reinforcement,94 which contrasts with body dysmorphic disorder, where negative reinforcement plays a much more prominent role in symptom maintenance. Although the prevalence of trichotillomania has not been examined in a body dysmorphic disorder sample, Soriano et al.95 found that 26 percent of their small sample of trichotillomania patients had body dysmorphic disorder. The comorbidity of body dysmorphic disorder with other obsessive-compulsive spectrum disorders such as pathologic gambling, tic disorders, and compulsive shopping has yet to be examined systematically. Substance Use Disorders Substance abuse and dependence frequently co-occur with body dysmorphic disorder. Gunstad and Phillips92 reported that lifetime rates of substance abuse disorders ranged from 25 to 30 percent, with rates as high as 47 percent being previously reported.78 Current rates of substance abuse disorders range from 273 to 35 percent.72,92 In a study of substance use disorders among persons with body dysmorphic disorder, 49 percent had a lifetime history and 17 percent met current criteria for a disorder.96 Alcohol dependence was the most common lifetime substance use
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