Sunday, 6 August 2017

Body Dismorphic Disorder in Dentistry with Professor Tim Newton

A couple of weeks ago I attended an evening lecutre held by the BDA metropolitan branch with Professor Tim Newton who taught us about managing Body Dismorphic Disorder (BDD) in dentistry. 



I think this topic is only going to become more prominent within the field of medicine and dentistry, with social media like Snapchat and Instragram being the benchmark for attractiveness in many young person's lives. During the talk I kept thinking of cases I had experienced already in my short practising career so far and how I may have managed them better. Below is a summary of what I learnt from the lecture. 

What is BDD?


BDD is a somatoform disorder; this means it is a recognised mental disorder categorised in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It includes:
  1. Preoccupation with a perceived defect in appearance
  2. This preoccupation causes clinically significant distress or impairment of socialising, occupation or other areas of function
  3. This preoccupation is not better attributed for by another mental disease e.g. anorexia nervosa

Who is affected?

  • Late adolescents
  • People in their early 30s
  • Equal ratio of men to women
  • 38% of cases are preceded by a social phobia
  • Obsessive Compulsive Disorder (OCD) is commonly related, as is alcohol dependence 
  • Prevalence is reported at 0.7-3% in the general population and 7-15% in the cosmetic surgery world

How is the person affected?

  • The person often has obsessive thoughts regarding a particular trait
  • Their obsession can move from one body part to another 
  • They often have compulsive behaviours e.g. checking mirrors, not leaving the house without make-up on, comparing their appearance to others
  • This can interfere with their daily life as it can be time-consuming e.g. their working life can be affected
  • Individuals suffer from higher levels of depression, anxiety and anger
  • 27% are housebound
  • 78% have suicidal ideations
  • 17-33% have attempted suicide

How has the medical world encountered these patients?

Whilst research in the field of dentistry in this area is sparse, there have been studies mostly in the field of cosmetic surgery. According to these studies:

71-76% of BDD sufferers have sought cosmetic treatment

64-66% of BDD sufferers received some sort of cosmetic treatment

Only 35% of BDD sufferers were refused treatment

There is one study which focuses on orthodontic patients, which had around 7.5% of patients who sought orthodontic treatment suffered from BDD.


How can we assess and manage these patients in dentistry?

1. Setting

Establish a rapport with the patient and ensure you are in a private setting. Try to minimise the number of people present

2. Questions

Ask your usual questions but you may find it useful to ask:
  • Why are they seeking a solution to their problem now?
  • When did they become aware of the problem?
  • What do they hope can be achieved from treatment?
  • How much do their concerns interfere with their life?
  • Do they have support from family/friends?
  • Have they seen any other health professionals before seeing you?
  • Do they have any diagnosed psychiatric disorder or have in the past e.g. OCD, depression, eating disorder?

3. Formal Assessment

I.e. refer onto a psychologist for a formal BDD assessment when you have a strong suspicion or if they disclose any suicidal ideations.

Management

  1. Cosmetic treatment to address their concerns. This does not address their underlying BDD
  2. Cognitive Behavioural Therapy (CBT)
  3. Pharmacology e.g. Selective Serotonin Reuptake Inhibitors (SSRIs) although there is no evidence for these

Managing these patients and identifying them early can be really tricky! Prof Newton gave us a few example cases he had seen in the past and honestly with a few of them, on initial presentation it wasn't that obvious they were suffering from BDD. I think what I learnt was to ask in depth questions early on e.g. have they seen anyone else for their problem before, is there any pressure from family/friends/partners to improve their appearance? Breaking the news to them can also be a very awkward situation and the right wording can be hard to find. A good phrase Prof gave us was:

 'The solution to your problems is not further treatment.' 

To read more about BDD, a good resource is the Mind website.



Have you seen any patient who you suspect suffered from BDD? How did you manage them? Let me know in the comments below. 





References:

Phillip, Grant et al 2001
Crerand et al 2005
De Jongh and Adain 2000
Max Cunningham et al 2004
Hepburn and Cunningham 2006

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