Through a mirror darkly

Perhaps more importantly, the link between BDD and suicide attempts makes it crucial to accurately identify and refer such patients for appropriate treatment, experts say.

Seeking a predictive model

The condition is "far more common than we ever realized," says Richard G. Fried, M.D., Ph.D., a board-certified dermatologist, clinical psychologist and clinical director of Yardley Dermatology and Yardley Skin Enhancement and Wellness Center, Yardley, Pa.

BDD prevalence

Domestically, Dr. Fried says BDD's prevalence in dermatology patients is 11.9 percent, and it is estimated at around 20 percent in patients presenting for cosmetic procedures (Treatment of Skin Disease 2nd Edition. St. Louis: Mosby; 2006: 159-161).

Internationally, a recent Dutch study involving more than 1,000 new patients presenting at outpatient plastic surgery (including hand surgery) and dermatology clinics reveals rates of 8.5 percent and 3.2 percent, respectively (Ned Tijdschr Geneeskd. 2006 Jan 14;150(2):75-76).

However, Dr. Vulink says that, compared to private facilities, academic settings, such as the one studied, usually see fewer BDD patients because such centers typically treat patients with difficult somatic problems.

Moreover, "We don't yet have any prospective studies that look at what happens to a patient who has been diagnosed with BDD after the procedure or surgery," adds David Veale, M.D., consultant psychiatrist, Institute of Psychiatry, University of London. "We're trying to do that research ourselves, but it's quite difficult," partly because studying psychosocial factors isn't part of the cosmetic surgery culture, he adds.

Complex diagnosis

Further complicating the BDD picture is the fact that its severity can vary greatly, Dr. Fried says.

Therefore, Dr. Fried says, "we have an obligation to identify these patients and try to get them into meaningful treatment."

In this regard, Dr. Vulink says, "It's very hard to get these patients to our offices. Patients are embarrassed" about seeing psychiatrists.

Conversely, Dr. Fried says plastic surgeons and dermatologists attract such patients like magnets.

And almost by definition, he adds, "Doing a procedure on one of these patients can be disastrous for the patient - and potentially the surgeon."