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procedures. A small German study (n 13) investigated “botulinophilia,” a potential subtype of body dysmorphic disorder characterized by persistent demands for Botox injections to treat hyperhidrosis despite the absence of symptoms, and suggested that 23 percent met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria.116 A recent study of 137 Australian patients presenting for nonsurgical cosmetic procedures (e.g., Botox injections, chemical peels) reported a rate of 2.9 percent.117 This rate is significantly lower than the rates reported among cosmetic surgery patients. The lower rate reported in this sample may be attributable to selection bias (e.g., no information about those who refused participation was collected). It is also possible that more people with body dysmorphic disorder present for surgery rather than less invasive procedures because they believe that their “defects” warrant more intensive intervention. Additional study of the rate of body dysmorphic disorder among persons seeking nonsurgical cosmetic interventions is needed. The rates of body dysmorphic disorder reported in dermatology settings, ranging from 9 to 15 percent, appear to be slightly higher than the rates found in cosmetic surgery populations.118 –120 In the largest study of body dysmorphic disorder in a dermatology setting (n 268), 12 percent met criteria for body dysmorphic disorder.118 These patients most frequently sought treatment for acne. In sum, 7 to 15 percent of patients who present for cosmetic surgical or dermatologic treatment may be suffering from body dysmorphic disorder. Among patients presenting for nonsurgical cosmetic procedures, the rate of body dysmorphic disorder appears to be lower, although this finding awaits replication. Nonetheless, these rates suggest that it is important for treatment providers to be aware of body dysmorphic disorder and its presentation in cosmetic populations.5–7 Body Dysmorphic Disorder in Other Medical Populations The rate of body dysmorphic disorder in other medical populations has received less empiric attention. However, there is evidence that the disorder occurs in other patient groups. Among persons seeking reconstructive surgical procedures, 7 to 16 percent reported appearance concerns and distress consistent with body dysmorphic disorder.110,121 Phillips reported that 4 percent of patients in a general medical clinic were found to have body dysmorphic disorder.70 Case descriptions of body dysmorphic disorder have been reported in dental practices122,123 and maxillofacial surgery clinics.124,125 A study of 30 patients presenting for orthognathic surgery assessed body dysmorphic disorder symptoms using a reliable and valid measure, but failed to report how many patients met criteria for body dysmorphic disorder preoperatively and postoperatively.126 Two studies have documented that persons with body dysmorphic disorder seek and receive treatments from orthodontists, ophthalmologists, and paraprofessionals.76,90 Additional empiric studies are needed to document the prevalence of body dysmorphic disorder among these and other medical specialties. TREATMENT As noted above, persons with body dysmorphic disorder typically believe that the cause of their distress is a “defective” appearance. Not surprisingly, these patients often turn to plastic surgeons, dermatologists, and other medical professionals for treatment. Patients also present for psychiatric and psychological treatment, often with greater success. Cosmetic Medical Treatments To date, no prospective studies of cosmetic medical treatment outcome among individuals with body dysmorphic disorder have been conducted. Thus, what is known about the outcome of such treatments has been gathered from retrospective studies73,76,90 and reports from the cosmetic surgery literature of poor outcomes among patients thought to have body dysmorphic disorder symptoms.127 These investigations suggest that cosmetic medical treatments typically produce no change or, even worse, an exacerbation of body dysmorphic disorder symptoms.76,90 In one of the largest studies, 91 percent of procedures resulted in no change in overall body dysmorphic disorder symptoms.90 After treatment, some recipients thought that their defect looked better, but they continued to worry about the treated body part (e.g., concerns that the part would become defective again).90 In other cases, new appearance concerns developed.90 Persons with body dysmorphic disorder who receive cosmetic treatments typically report dissatisfacPlastic and Reconstructive Surgery • December 2006 174e tion with their treatment results.73 Of greater concern, there are reports of patients with body dysmorphic disorder who have threatened or executed lawsuits against their treatment providers.91,128,129 In a survey of 265 aesthetic surgeons, 29 percent reported that they had been threatened legally by a patient with body dysmorphic disorder.91 The case of Lynn G v. Hugo also underscored the potential malpractice risks associated with providing treatment to persons with body dysmorphic disorder.128 In this case, Dr. Hugo was sued by his former patient, Lynn G, who claimed that she had body dysmorphic disorder and therefore could not consent for treatment. As there was no
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