Acne May Be Sign of Body Dysmorphic Disorder

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE