I P d c M F F R A d h 0 B Anais Brasileiros de Dermatologia 96 (2021) 40---46 Anais Brasileiros de Dermatologia www.anaisdedermatologia.org.br NVESTIGATION revalence and factors associated with body ysmorphic disorder in women under dermatological are at a Brazilian public institution�,�� ariana Mathias Morita , Maira Renata Merlotto , Cássia Lopes Dantas , ernando Henrique Olivetti , Hélio Amante Miot ∗ aculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil eceived 21 November 2019; accepted 23 June 2020 vailable online 18 November 2020 KEYWORDS Alcoholism; Body image; Child abuse, sexual; Depression; Health surveys Abstract Background: Body dysmorphic disorder consists of excessive concern with minimal appearance defects, which causes functional impairment. Its prevalence is estimated to range from 5% to 35% of dermatological patients, especially adult women with esthetic complaints. Objectives: To investigate the prevalence and factors associated with dysmorphic disorder in female dermatological patients, in a public institution in Brazil. Methods: This was a cross-sectional study involving adult women attended at a public der- matological service in Brazil. Participants underwent a demographic survey, in addition to a screening form for body dysmorphic disorder (Body Dysmorphic Disorder Examination [BDDE]). The presence of dysmorphic disorder (BDDE > 66 points) was assessed among the participants according to demographic covariates and psychological problems, through logistic regression. Results: A total of 223 women were evaluated. The BDDE showed high internal consistency (Cronbach’s � = 0.90). It is noteworthy the high prevalence of psychological problems and the fact that over one-third (38%) of the sample presented a high degree of dissatisfaction with their image. The prevalence of dysmorphic disorder was 48% among women with esthetic complaints and 30% among the others (p < 0.01). Lower family income (OR = 2.97), history of domestic violence (OR = 3.23), search for dermatological care due to an esthetic complaint (OR = 2.05), and suicidal ideation (OR = 4.22) were independently associated with the occurrence of body dysmorphic disorder. Study limitations: This was a single-center study of a non-randomized sample from public service. � How to cite this article: Morita MM, Merlotto MR, Dantas CL, Olivetti FH, Miot HA. Prevalence and factors associated with body dysmorphic isorder in women under dermatological care at a Brazilian public institution. An Bras Dermatol. 2021;96:40---46. �� Study conducted at the Department of Dermatology, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil. ∗ Corresponding author. E-mail: heliomiot@gmail.com (H.A. Miot). ttps://doi.org/10.1016/j.abd.2020.06.003 365-0596/© 2021 Sociedade Brasileira de Dermatologia. Published by Elsevier España, S.L.U. This is an open access article under the CC Y license (http://creativecommons.org/licenses/by/4.0/). https://doi.org/10.1016/j.abd.2020.06.003 http://www.abd.org http://crossmark.crossref.org/dialog/?doi=10.1016/j.abd.2020.06.003&domain=pdf https://orcid.org/0000-0002-6396-7388 https://orcid.org/0000-0002-8918-5640 https://orcid.org/0000-0003-2311-9365 https://orcid.org/0000-0002-4880-5786 https://orcid.org/0000-0002-2596-9294 mailto:heliomiot@gmail.com https://doi.org/10.1016/j.abd.2020.06.003 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ Anais Brasileiros de Dermatologia 96 (2021) 40---46 Conclusions: Body dysmorphic disorder is prevalent among female dermatological patients; it is associated with traumatic psychological experiences, lower income, affective disorders, and demand for esthetic care. It is essential to recognize the diagnosis in order to treat such patients and refer them for appropriate psychiatric treatment instead of trying to satisfy their esthetic demands. © 2021 Sociedade Brasileira de Dermatologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). I B d m n i l l c c a t 3 c a w o r l t a a t t c d t e s a a s o b a a w b e p a B M T a ( e a a e c c c g s s d t o h i h c I c n a i c fi s t t t t 1 ( 80 cases of BDD was needed to conduct the analysis, thus requiring up to 220 participants.20 Data were analyzed using the IBM SPSS v. 25 software. A p-value ≤ 0.05 was considered significant. ntroduction ody dysmorphic disorder (BDD), or dysmorphophobia, is efined as an excessive and pathological concern with mini- al or nonexistent defects in appearance. BDD differs from ormal concerns because it causes important functional mpairment to the individuals, decreasing their quality of ife, distancing them from daily activities, and taking up a ot of their time. Examples of BDD include anorexia, con- ern with muscle definition, and aspects related to esthetic omplaints, such as open pores, facial asymmetry, wrinkles, nd discreet spots.1---3 BDD is quite prevalent among plastic surgery and derma- ology patients. It is estimated to affect between 4.5% to 5.2% of dermatological patients, vs. 0.7% to 2.3% of the ontrol population. A higher prevalence is observed among dult women (76% of cases) (25 − 40 years) and patients ho report esthetic complaints.4---8 These seek care in search f successive treatments, always dissatisfied with previous esults. They adopt compulsive ritualistic behaviors such as ooking in mirrors and using makeup or clothes that cover he body. They also overuse the prescribed treatments, such s exfoliating soaps and excessive use of acids.7 Severely ffected individual avoid social life. It is estimated that up o 80% of individuals with BDD have suicidal ideation during heir lifetime, and 24%−28% have attempted suicide.1,9---12 BDD is underdiagnosed in dermatology, and its psychoso- ial aspects have been receiving greater focus in recent ecades.13,14 However, the multifactorial aspects that lead o the onset of the disease are not yet fully understood, specially in Brazil. The Body Dysmorphic Disorder Examination (BDDE) is a pecific instrument for assessing BDD, developed in 1996 nd translated into Brazilian Portuguese in 2008.15---17 It is questionnaire with 34 items that assess the intensity of ymptoms linked to concern with and negative assessment f appearance; self-awareness, discomfort, and feeling of eing observed in public; excessive care for appearance; voidance of social situations or activities in public, or even voidance of physical contact; camouflage of appearance ith clothing, makeup, or body posture; self-observation ehavior, in the form of self-inspection, dressing up repeat- dly, seeking reassurance, and comparing oneself to other eople. This study aimed to explore the prevalence and variables ssociated with BDD in female dermatological patients in a razilian public institution. 41 ethods his was a cross-sectional study involving adult women ttended at the public dermatological service of UNESP Botucatu, SP, Brazil). The research was approved by the thics committee (No. 969.426) and all participants signed n informed consent form. Women in care at the psychi- tric clinic or those with evident cognitive impairment were xcluded. There was no randomization of the inclusion of the parti- ipants, who were approached consecutively after medical are at dermatological outpatient clinics with esthetic omplaints, in order to adequately represent this cate- ory and allow comparisons between the strata of the ample. The participants underwent a standardized demographic urvey regarding age, phototype, medical or psychiatric iagnosis, educational status, and family income, in addi- ion to the BBDE questionnaire. The sum of the scores f the BDDE items varies from 0 to 168 points, with igher scores indicating greater dissatisfaction with body mage. There is no accepted scale for categorizing patients; owever, scores equal to or greater than 66 points indi- ate a high degree of dissatisfaction with appearance. ts internal consistency was assessed by Cronbach’s alpha oefficient. Dermatological complaints were classified as esthetic or on-esthetic by a qualified dermatologist (H.A.M). BDD was defined as BDDE scores > 66, and assessed ccording to the behavior of demographic and psycholog- cal covariates using a logistic regression model. Only the ovariables that maintained significance (p < 0.05) in the nal model were maintained in the multivariate model. The ize of the effect was estimated by the odds ratio (OR) of he regression and its 95% CI. For the multivariate analysis, he missing data (< 5% per variable) were estimated using he multiple imputation technique, with ten iterations.18 The sensitivity analysis of the results was performed from he perceptual map by multiple correspondence analysis.19 Sample design calculation was based on a pre-test with 00 participants. The prevalence of BDD, up to 15 covariates including dummy variables) indicated that a minimum of http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ M.M. Morita, M.R. Merlotto, C.L. Dantas et al. Table 1 Clinical and demographic data of adult women treated at a public dermatology service (n = 223). Variables Values Age (years)a 41.7 (11.9) ≤ 30b 56 (25) 31 − 50b 106 (48) > 50b 57 (26) Educational statusb Elementary school 60 (27) High school 81 (36) College or university degree 81 (36) Phenotypeb White 188 (84) Mixed-race 23 (10) Black 10 (5) Family income (R$)b < 1,000 51 (23) 1,000 − 3,000 116 (52) > 3,000 55 (25) Lives with partnerb 125 (56) Salaried workb 123 (55) Esthetic complaintb 102 (46) Domestic violenceb 21 (9) Sexual abuseb 16 (7) Bullyingb 52 (23) Parental alcoholismb 47 (21) Suicidal ideationb 65 (29) Suicide attemptb 22 (10) Psychotropic useb 49 (22) BDDE scorea 59 (32) BDDE > 66b 85 (38) a Mean (standard deviation). R A t o t p b t w w ( o n ( a a s n p d Table 2 Groups of dermatological diseases sampled in this study (n = 223). Diagnosis n % Photoaging 58 26.0% Melasma/dyschromias 35 15.7% Acne/folliculitis 30 13.5% Eczema 21 9.4% Psoriasis 18 8.0% Others 12 5.4% Alopecia 9 4.0% Cutaneous lupus 8 3.6% Milium 3 1.3% Rosacea 3 1.3% Vitiligo 3 1.3% Skin cancer 2 0.9% Epidermal cyst 2 0.9% Pustular dermatosis of skin folds 2 0.9% Leprosy 2 0.9% Ringworm 2 0.9% Itching 2 0.9% Keloid 2 0.9% Viral wart 2 0.9% Vibex 2 0.9% Pseudoacanthosis nigricans 1 0.4% ( g s c m B p T s a a D T a b g a a s r c h b b and can be influenced by cultural, economic, social, reli- 23,24 b n (%). esults total of 223 women were evaluated. Table 1 presents he main clinical and demographic data; approximately half f the sample was of productive age (30−50 years), and he majority identified themselves as white (84%). The high revalence of psychological problems (domestic violence, ullying, sexual abuse) is noteworthy, and over one-third of he sample (38%) showed a high degree of dissatisfaction ith their image. The prevalence of BDD was 48% among omen with esthetic complaints and 30% among the others p < 0.01). There was no refusal to participate or difficulty in filling ut the questionnaire, and the BDDE showed adequate inter- al consistency, with Cronbach’s alpha coefficient = 0.90 95% CI: 0.88 − 0.92). The dermatological diseases sampled are listed in Table 2 nd some of the reports referring to the disgust with appear- nce were transcribed, verbatim, in Table 3. Table 4 presents the bivariate and multivariate analy- es according to the prevalence of BDD. It is important to ote that seeking care due to esthetic complaints (OR = 2.05; = 0.02), lower income (OR = 2.97; p = 0.01), history of omestic violence (OR = 3.23; p = 0.04), and suicidal ideation g s 42 Melanocytic nevus 1 0.4% Urticaria 1 0.4% OR = 4.22; p < 0.01) were independently associated with a reater risk of presenting BDD. The perceptual map (multiple correspondence analy- is) of the variables explained 33% of the variance of the omplete model and is shown in Fig. 1, confirming the ultidimensional proximity of the highest tertile of the DDE scores with low education, african descent phenotype, arental alcoholism, lower income, and suicidal ideation. he multidimensional proximity of lowest tertile of BDDE cores with higher income, higher educational level, lower ge group, and the denial of suicidal ideation and parental lcoholism was observed. iscussion he skin is the main organ of social contact, and body ppearance can represent concepts such as health, well- eing, youth, fertility, and success. In a range of cultures, ood-looking individuals are more likely to get better grades t school, to be hired for a job, to receive higher salaries, nd to be seen as better, smarter, and healthier.21,22 The earch for improving appearance, maintaining youthfulness, aising self-esteem, and combating aging are demands of the ollective, and represent a search for inclusion. Medical care (plastic or esthetic) is part of the concept of ealth and disease, due to the damage to well-being that can e inflicted by the appearance. However, the perception of ody image is deeply dependent on individual subjectivity, ious, and psychological experiences of each individual. Self-image disorders greatly influence the search for kin and body care, which should alert medical profession- Anais Brasileiros de Dermatologia 96 (2021) 40---46 Table 3 Transcript of the main reports regarding dissatisfaction with appearance in the last month. Acne bothers me a lot; in general, I feel ugly. My expression lines bother me a lot, I try to change my hair to disguise them. These spots make me ugly and I have low self-esteem; I don’t want to go out. My hand bothers me, people look at it with disgust and they think it is contagious. Before there was no spot, and now there is this horrible one on my face. The lesions appear on the face, they are ugly and everyone stares. The spots make me look older, I put on makeup and it doesn’t look good. The discoloration bothers me a lot, it gives the impression of being dirty, people keep asking what it is. The spots on my legs won’t allow me to wear different kinds of clothes. The spots on my face bother me a lot, I’ve already lost jobs because of them. The spots on my face bother me, when I take a photo it looks even uglier. The drooping eyelids make me look like an older woman. People notice my melasma. Wrinkles and blemishes really bother me, I can’t look in the mirror. They keep looking at the spots on my face I have many wrinkles, my skin is ugly. Striae are the worst possible thing, a blow to self-esteem. I think this mole is horrible, when you go somewhere everyone looks. I don’t like what I see on my face. The spots are very uncomfortable. I don’t want people to see my hands. I have expression lines around my mouth, I feel terrible I have to wear clothes to cover lupus lesions, I suffer a lot. I’m ashamed of my varicose veins, I can’t wear the clothes I want. I avoid leaving the house as much as possible. Whenever I look at myself in the mirror, I only see the spots and keloids. I used to be beautiful, but now I’m old and I feel ridiculous. I worry about the fat deposits under my eyes, the spots. I’ve had plastic surgery, but it’s no use. I feel strange with the blemishes. I feel ugly, I have a lot of dark circles and white hair. I feel uncomfortable and ugly with acne. I feel very uncomfortable when I don’t wear makeup, the skin on my face is horrible. My face is very spotted, the skin looks very aged and lifeless. My skin is aged, I want everything to come off and a new one to grow. My hands are very old and ugly. I fight against it, but it doesn’t get better. I’m spotted. Nothing in my appearance pleases me, if I could I would change everything. I received a bad job evaluation because of my appearance. I don’t like the skin on my forehead and eyes, there’s a hole in my forehead. I don’t like the blemishes and scars. I don’t think I’m beautiful, I have low self-esteem. I don’t like the wrinkles on my neck and the spot on my skin. People say I’m crazy, but I want to fix it. I don’t like the wrinkles around my eyes, especially when I smile. I don’t like anything about my appearance. I don’t like anything about my appearance. Others have a way of fixing it, I don’t. There is redness on my face, spots, and flaws in my hair. I never leave home without makeup to cover up my blemishes. My face gets very ugly, very spotted, it upsets me, I get nervous. My face bothers me, it has blemishes and holes, people stare. I want to be without that spot. I’ve suffered since I was a child, because they think it’s dirty. If I could avoid it, I would never look in the mirror. If I had money, I would do all of the possible procedures. Aging is difficult: I got a divorce because of that, I can’t get another partner because of that. Men don’t like old women. I know people think, "Why doesn’t she try to improve her appearance?" Whenever I’m talking, I feel like they’re looking at my blemishes and not at me. I feel like I have a hard time getting a job because of the blemishes. I hate to look in the mirror and see these spots. I have psoriasis on my nails. It hurts a lot, it affects my self-esteem, and people are afraid to eat the food I make because ished a d o o they are afraid that the disease is contagious. Everything bothers me. My hair doesn’t grow, my face is blem ls (especially plastic surgeons and dermatologists) to this emand, which has no correlation with the physical status f the condition.13,25,26 This study showed a high prevalence f excessive preoccupation with appearance among female d i i B 43 , I look horrible in the photos. ermatological patients, especially those with lower family ncome, personal history of domestic violence, and suicidal deation, highlighting a psychological construction basis for DD. M.M. Morita, M.R. Merlotto, C.L. Dantas et al. Table 4 Assessment of the prevalence of body dysmorphic disorder in terms of demographic covariates and psychological damage (n = 223). Variables BDDE score Bivariate analysis Multivariate analysisa Mean (standard deviation) Odds ratio 95% CI p-value Odds ratio 95% CI p-valueb Age (years) 1.02 0.99 − 1.04 0.09 ≤ 30 51 (29) 31 − 50 65 (32) > 50 56 (34) Phenotype 2.57 0.70 − 9.43 0.15 White 58 (32) Mixed-race 63 (29) Black 73 (33) Educational status 0.87 0.81 − 0.94 < 0.01 Elementary school 65 (32) High school 63 (32) College or university degree 51 (31) Esthetic complaint Yes 64 (33) 2.18 1.26 − 3.78 < 0.01 2.05 1.10 − 3.82 0.02 No 55 (31) Income (R$) < 1.000 67 (34) 3.82 1.71 − 8.52 < 0.01 2.97 1.27 − 6.99 0.01 1,000 − 3,000 63 (32) > 3,000 45 (26) Salaried work yes 59 (32) 0.88 0.51 − 1.52 0.65 No 59 (33) Lives with partner Yes 61 (33) 1.00 0.58 − 1.72 0.99 No 56 (31) Domestic violence Yes 84 (33) 6.17 2.17 − 17.55 < 0.01 3.23 1.02 − 10.23 0.04 No 57 (31) Sexual abuse Yes 78 (28) 3.95 1.32 − 11.82 0.01 No 58 (32) Bullying Yes 70 (34) 1.71 0.91 − 3.21 0.09 No 56 (31) Parental alcoholism Yes 68 (36) 2.20 1.14 − 4.22 0.02 No 57 (31) Suicidal ideation Yes 77 (34) 5.40 2.89 − 10.07 < 0.01 4.22 2.15 − 8.29 < 0.01 No 52 (28) Use of psychotropics Yes 65 (36) 2.09 1.11 − 3.96 0.02 No 57 (31) BDDE, body dysmorphic disorder examination. R (Nagerlkerke = 0.29); Hosmer-Lemeshow test (p = 0.96). s b a a B p a p (model) < 0.01; p (constant) < 0.01. b adjusted p-value. The evaluation of the participants’ statements demon- trates the diversity of meanings that patients associate with ody appearance: beauty, self-esteem, disgust, appear- nce of being older than their actual age, shame, calling ttention, strangeness, rejection, failure. In the case of e i o 44 DD, considering the behavioral strategies used, there is a redilection for escape or avoidance behaviors in relation to vents in which their appearance can trigger aversive feel- ngs, which promotes social isolation and favors the onset f affective disorders. Furthermore, patients with BDD have Anais Brasileiros de Dermatologia 96 (2021) 40---46 espon a s w e w a a s o m d e t s I o c a l h s d L a o w T t p a s r d t o t ( T f c p w C B a i I s o d F F A M m t t t lection, analysis, and interpretation of data, intellectual Figure 1 Perceptual map of the multiple corr frequent history of coercive educational practices, low ocial skills, great appreciation of appearance by people ith whom they lived during childhood, and unpleasant vents related to the part of the body with which they ere concerned.27 Traumatic psychological episodes such s domestic violence, sexual abuse, bullying and parental lcoholism have repercussions on the construction of per- onality, including changes in self-esteem.28 The skin, as an rgan of social contact, can induce stigmas linked to der- atological disease or esthetic complaints, which may be isproportionate to common sense.29 A controlled study with magnetic resonance imaging in ight women with BDD revealed morphometric changes in he caudate nucleus and a higher volume of white matter, imilarly to what happens in obsessive compulsive disorder.30 n fact, in the psychiatric sphere, BDD is associated with bsessive-compulsive symptoms, although it is also asso- iated with affective complaints (e.g., depression) and nxiety.4,9,28,31 The study has limitations related to sampling in a pub- ic institution and the lack of randomization of the sample; owever, the high frequency of esthetic complaints by the ampled patients may allow a certain inference for private ermatological activity, where this practice is more usual. ikewise, there was no obstacle to the internal comparative nalysis of the subgroups. Dermatologists should be aware of the high prevalence f BDD, especially in adult women with esthetic complaints, ho present affective disorders or use of psychotropic drugs. he implemented procedures and treatments are unlikely o achieve satisfaction. This is primarily because skin com- laints can result from the somatization of internal conflicts, nd reveal a desire for change or permanent personal dis- atisfaction, which can indicate psychological problems and esult in suicidal ideation.32 It is essential to recognize the iagnosis in order to treat such patients and refer them to he appropriate psychologic or psychiatric treatment instead f trying to satisfy their esthetic demands.33 p o r 45 dence analysis of the study variables (n = 223). In dermatology, BDD is not only linked to dissatisfac- ion with treatments, but also to the urgency of its results treatment overdose) and intolerance to adverse effects. he increase in longevity and the availability of technologies or skin and body care result in greater demand for esthetic are by the population. Careful selection of patients and rocedures should lead to better levels of satisfaction and ell-being. onclusions DD is prevalent among female dermatological patients; it is ssociated with traumatic psychological experiences, lower ncome, affective disorders, and demand for esthetic care. t is essential to recognize the diagnosis in order to treat uch patients and refer them to the appropriate psychologic r psychiatric treatment instead of trying to satisfy their emands. inancial support APESP (no 2015/04592-5). uthors’ contributions ariana Mathias Morita: Approval of the final version of the anuscript; drafting and editing of the manuscript; collec- ion, analysis, and interpretation of data; critical review of he literature; critical review of the manuscript. Maira Renata Merlotto: Approval of the final version of he manuscript; drafting and editing of the manuscript; col- articipation in propaedeutic and/or therapeutic conduct f studied cases; critical review of the literature; critical eview of the manuscript. rlott m a t c m c fi o o p t c m C N R 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 M.M. Morita, M.R. Me Cássia Lopes Dantas: Approval of the final version of the anuscript; design and planning of the study; collection, nalysis, and interpretation of data; intellectual participa- ion in propaedeutic and/or therapeutic conduct of studied ases; critical review of the manuscript. Fernando Henrique Olivetti: Drafting and editing of the anuscript; collection, analysis, and interpretation of data; ritical review of the manuscript. Hélio Amante Miot: Statistical analysis; approval of the nal version of the manuscript; conception and planning f the study; elaboration and writing of the manuscript; btaining, analyzing, and interpreting the data; effective articipation in research orientation; intellectual participa- ion in propaedeutic and/or therapeutic conduct of studied ases; critical review of the literature; critical review of the anuscript. onflicts of interest one declared. eferences 1. Conrado LA. Body dysmorphic disorder in dermatology: diag- nosis, epidemiology and clinical aspects. An Bras Dermatol. 2009;84:569---81. 2. Veale D, Bewley A. Body dysmorphic disorder. BMJ. 2015;350:h2278. 3. Anson M, Veale D, Miles S. Appearance comparison in individ- uals with body dysmorphic disorder and controls. Body Image. 2015;15:132---40. 4. Ribeiro RVE. Prevalence of body dysmorphic disorder in plas- tic surgery and dermatology patients: a systematic review with meta-analysis. 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http://refhub.elsevier.com/S0365-0596(20)30292-0/sbref0165 Prevalence and factors associated with body dysmorphic disorder in women under dermatological care at a Brazilian public i... Introduction Methods Results Discussion Conclusions Financial support Authors’ contributions Conflicts of interest References