Recognizing Body Dysmorphic Disorder in Ophthalmology Patients

Body dysmorphic disorder (BDD) is a psychiatric disturbance characterized by an excessive preoccupation with a perceived or minor defect in one’s appearance. According to the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria, BDD is classified as an obsessive-compulsive disorder (1), and it is one of a number of psycho-ophthalmologic disease entities – in conjunction with neurotic excoriations, trichotillomania, delusional parasitosis, trichotillomania, etc. – that an ophthalmologist may encounter in their practice.

A common characteristic of the BDD patient is that they become obsessed with an imagined flaw in their physical appearance. This creates intrusive thoughts, leading to internal distress, and over time patients may develop rituals to help alleviate their anxiety. Almost all BDD patients will perform certain compulsive behaviors, including repeatedly touching the area of concern, checking perceived defects in mirrors or windows, excessive grooming, seeking frequent assurance, as well as camouflaging these perceived defects (2).

BDD can be challenging for ophthalmologists to detect. Patients may present initially with only a few “dysmorphic concerns,” but with no other clinical manifestations of BDD. Furthermore, they can often be secretive about their symptoms and may attempt to hide their perceived defect in a preoperative exam (2).

The main challenge for ophthalmologists is identifying BDD features in this preoperative setting. Around 33-76 percent of BDD patients undergo surgery or minimally invasive cosmetic procedures, which means that, currently, they are managing to successfully evade our screening processes (3). But BDD patients have higher-than-usual post-op complaint rates (2). Increased levels of depression and suicide have been recorded in these patients (4), and there are also higher-than-average rates of medico legal consequences and threats of violence. In some extreme cases, the surgeon has even been murdered by the patient (5).

Clinical clues for BDD can include flaws described by the patient being either grossly exaggerated or completely absent; the patient focusing much time and energy on the perceived flaw to the extent it is affecting their entire life; the patient already having had several prior procedures with different surgeons; the patient having unrealistic expectations for their surgical outcomes; and the patient expressing dissatisfaction with previous doctors (2, 3, 4).

Recognizing these clinical clues can be useful, but I believe we need a robust screening test for BDD in preoperative assessments. There have been several validated screening tests published over the years (e.g., BDDQ, COPS), but they are generally quite complex and require a trained individual to interpret the results. However, I have found that the Dysmorphic Concern Questionnaire (DCQ) can act as a simple and efficient clinical test for detecting potential BDD patients. The seven-item questionnaire takes only a few minutes to complete; Questions are designed to measure patient concerns about their physical appearance, with each question marked from one to three. Final scores run from 0-21, with higher numbers representing greater “dysmorphic concerns” (6, 7).

The grading system of the DCQ has helped me in determining whether to proceed with any surgical plans for patients exhibiting potential BDD signs. The literature seems to agree with me on this point. In 2001, Jorgenson et al. gave the test to 65 psychiatric patients, finding it to be a reliable and valid tool (6). While the DCQ does not imply a definitive diagnosis of BDD, it acts as a quick, simple and efficient means of identifying dysmorphic concern, raising a red flag for any patients that might require further scrutiny.

In 2010 Mancuso et al. gave the DCQ to 57 BDD outpatients, along with 244 controls, finding that the BDD patients obtained significantly higher scores than their control counterparts (7). In line with Jorgenson et al., the authors concluded that the DCQ was a sensitive and specific screening tool for BDD. Wooley and Perry (2015) gave the DCQ to 728 new oculoplastic surgery patients and found that a score of nine can alert clinicians to potential problems (8). They added that a score of nine or more can occur in patients with some degree of BDD, as well as in patients with real functional problems, such as ptosis. Patients with scores of nine or above generally had higher post-op pain levels, greater complication rates, and greater reoperation rates.

I use the DCQ questionnaire on all cosmetic patients and have them fill it out during their initial registration. Knowing the DCQ score beforehand prepares you for the patient consultation – you go into the room with your antennae up!

That said, when a patient scores 0 on the DCQ, this does not mean I immediately disregard them as a potential BDD candidate. Such a low score can sometimes be a sign that they are hiding something. Patients in their sixties or seventies may not be really interested in the cosmetic aspect of surgery, but if I see a patient in their forties or fifties with a score of zero, I watch and listen carefully during the interview in case I detect any hints that they are attempting to “camouflage” dysmorphic characteristics.

Generally speaking, patients in the 1-8 DCQ range are good candidates to operate on. This is not universal, as some 5-8’s can exhibit other features suggesting dysmorphic concerns, and I will add a “be careful” sticky note at the bottom of their score sheet. Those in the 9-12 range usually have something clinically you pick up on during the consultation that warns you about possible dysmorphic concerns. If the interview seems to be going too well in this group, I suggest you slow down and pay closer attention. It’s true that there are patients who score in the 9-12 range who will be okay to operate on, but always bear in mind that their high score still suggests a higher risk of postoperative issues.

I would say that scores of 13 and 14 should be viewed as potential high-risk patients; if you don’t pick something up during the first visit, it may very well show up later on. With these individuals, I routinely bring up the Wooley and Perry results, explaining to them that people with high DCQ scores have a higher post-op pain level, higher complication rate, and higher re-op rate. I also make sure this is well documented in the chart if I decide to proceed. If you do operate on a patient with a DCQ score of 9-14, I would suggest that you remain vigilant every time you see them post-op – ask your staff to pay a little more attention to them and to let you know when they’re coming in.

I never operate on those with a DCQ score of 15 or higher. If you don’t initially pick something up in the interview, my experience is that it will show up at a later date and you won’t want to be there when it does. If you do have a high DCQ (e.g., 15) and want to dissuade the patient from surgery, I recommend telling them that they should wait until things progress further, or maybe tell them that they are asking for more than you can deliver. Not uncommonly, I will find something in their medical history that I can also use to dissuade them from surgery.

BDD comes in a spectrum, from mild dysmorphic concerns to classic, full-blown BDD. Maintaining good clinical judgment, as well as using a valid and reliable screening test such as the DCQ, has been beneficial in my practice to avoid operating on potential BDD patients. The condition is difficult to treat, and unknowingly operating on a BDD patient can be damaging for both the patient and the physician. Routinely implementing the DCQ can improve patient care and outcomes, and avoid a lot of unnecessary stress for the surgeon.