Introduction

Body dysmorphic disorder (BDD), also known as dysmorphophobia, is fairly common and is characterized by a distorted perception of one’s own body image. Patients have exaggerated concern with an imagined appearance defect or a minute existing body defect [1]. Most individuals with BDD present with some degree of social and occupational impairment, with obsessive complaints about appearance leading to the development of compulsive behaviors and, in more severe cases, suicidal thoughts [2–4].

In the current list of psychiatric disorders (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders—DSM-5), the only diagnostic category that directly considers the concern with body image is BDD, defined as a concern with one or more defects or flaws in one’s physical appearance which are not observable or only subtly perceptible by others [5].

Due to their exaggerated dissatisfaction with body aesthetics, individuals with BDD frequently seek cosmetic treatments, when, in actuality, they should be treated for a psychological disorder [1]. However, due to the limited amount of literature on BDD in the past [6], many health professionals are unable to recognize and/or diagnose potential patients, and perform aesthetic treatments without realizing that such therapy will not result in patient satisfaction.

Thus, considering the need for more information on BDD and its occurrence in patients of specialties other than psychiatry, the present study aimed to verify, by means of a systematic review of the literature and performance of a meta-analysis, the prevalence of BDD in plastic surgery and dermatology patients.

Methodology

To achieve the proposed objective, the most relevant studies published originally in any language before October 2016 (when the search was performed) were analyzed; the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scientific Electronic Library Online (SciELO) databases were used to perform this research.

With the aim of selecting studies with scientific evidence of quality, publications referring to meta-analyses and randomized controlled clinical trials (RCTs) in humans were selected. The searches were performed separately, according to the specialty.

In searches related to plastic surgery, the following combinations of keywords were used: “body dysmorphic disorder,” “dysmorphophobia,” “body dysmorphia,” “plastic surgery,” “aesthetic surgery,” “cosmetic surgery,” and “prevalence.” In searches related to dermatology, the following combinations of keywords were used: “body dysmorphic disorder,” “dysmorphophobia,” “body dysmorphia,” “dermatology,” “dermatological clinic,” “dermatological treatment,” and “prevalence.”

To identify the study protocols, the terms “randomized controlled trial,” “humans,” and “meta-analysis” were used in the searches for both specialties. No filters were used regarding the dates of publication, with the aim of obtaining the most complete literature results possible.

Inclusion and exclusion criteria were applied as demonstrated in Table 1.

Table 1 Inclusion and exclusion criteria and the main results
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Among the studies that examined the prevalence of BDD in plastic surgery, dermatology, or other specialties, only the data related to the present study specialties were collected. In addition, the data from two studies [7, 8] comparing the prevalence of BDD in plastic surgery and dermatology were included in the meta-analyses of both specialties.

To verify the prevalence of BDD, data referring to the number of patients within the samples and the number of patients diagnosed with BDD were collected. Furthermore, to develop a profile of patients with BDD in each specialty studied, data referring to patient gender and age group were also investigated.

Results

In total, 33 publications were found within the scope of analysis of this study. Of these, 23 were related to the prevalence of BDD in the specialty of plastic surgery (Table 2) and 10 were related to BDD in dermatology (Table 3).

Table 2 Publications that comprised the sample for the meta-analysis of the specialty of plastic surgery
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Table 3 Publications that comprised the sample for the meta-analysis regarding the specialty of dermatology
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The data obtained from the publications in this meta-analysis are shown in Tables 4 and 5.

Table 4 Data obtained from the publications in this meta-analysis regarding the specialty of plastic surgery
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Table 5 Data obtained from the publications included in this meta-analysis regarding the specialty of dermatology
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There was a 15.04% prevalence of patients with BDD (range 2.21–56.67%) in the specialty of plastic surgery, with mean age of 34.54 ± 12.41 years, and most were women (74.38%).

In dermatology, 12.65% of patients had BDD (range 4.52–35.16%), with mean age of 27.79 ± 9.03 years, and most were women (76.09%).

Discussion

Despite the importance of adequately managing patients with BDD in the specialties of plastic surgery and dermatology [8], there are few studies in the literature that addressed the identification of patients with this disorder in either specialty, even though 23 studies were related to plastic surgery and 10 to dermatology.

A study was found [7] in which the prevalence of BDD was examined in adult and teenaged patients, students, adult and adolescent psychiatric patients, patients seeking general cosmetic surgery, rhinoplasty, orthognathic surgery, and orthodontic or cosmetic dentistry, and patients in general dermatology, aesthetic dermatology, and acne-specific dermatology. Generally, plastic surgery and dermatology patients showed the highest rates of BDD, with the highest incidence found in plastic surgery.

A study by Vulink et al. [8] specifically examined the prevalence of BDD in plastic surgery and dermatology patients, and found higher prevalence among dermatology patients (8.5%) than in plastic surgery patients (3.16%). Such findings are in contrast to the present study, which showed an increased prevalence of BDD among plastic surgery patients (15.04%) than among dermatology patients (12.65%).

Nonetheless, patients from both specialties showed considerably higher rates of BDD compared with patients in the general population, with prevalence of 0.7–2.4% [36–39]. In individual analysis of the 33 studies that comprised the sample, only one [21], which evaluated the prevalence of BDD in plastic surgery, reported a percentage within this range (2.21%).

It is important to highlight that women showed high prevalence of BDD, both in plastic surgery (74.38%) and in dermatology (76.09%), and that out of the total of 33 studies included in this sample, only three had a higher prevalence of BDD in males (two studies were on plastic surgery [9, 23] and one on dermatology [30]).

Thus, in view of the high prevalence of BDD found in this study, it is essential for plastic surgeons and dermatologists to be alert to the possibility that their patients may have BDD; the correct diagnosis and treatment of this disorder may improve self-esteem and quality of life in these patients, who may need a multidisciplinary approach.

In addition, further research is needed to assess whether submitting patients to aesthetic procedures/treatments reduces or aggravates BDD symptoms.

Conclusion

Based on the meta-analysis performed on 33 publications that met the inclusion and exclusion criteria established in this study, it was possible to conclude that a higher percentage of patients with BDD were observed in the specialty of plastic surgery (15.04%) than in dermatology (12.65%). However, professionals from both specialties must become aware of these data and of the likelihood of BDD in their patients, especially women aged 25-40 years, who showed a higher prevalence of BDD in the majority of studies.

Both plastic surgeons and dermatologists must adequately assess their patients to identify those with an increased potential for BDD and should arrange multidisciplinary care for such individuals.