Reply: The Continuous Nature of Body Dysmorphic Symptoms and Plastic Surgery.

Abstract

Sir: We would like to thank Dr. van der Lei and Dr. Bouman for their interest in our study. With regard to our article on the prevalence of body dysmorphic disorder symptoms in patients seeking abdominoplasty, rhinoplasty, and rhytidectomy,1 we would like to point out that most patients with body dysmorphic disorder first seek treatment from plastic surgeons instead of psychiatrists or psychologists because they are distressed by their perceived physical defect and do not believe that they have a mental disorder. Unfortunately, few psychiatrists or experts who make first contact with these undiagnosed patients recognize the condition, and therefore the prevalence of body dysmorphic disorder is probably underestimated.1,2 Body dysmorphic disorder is not equivalent to dysmorphic concern, which refers to a broader construct. Body dysmorphic disorder involves symptoms that reflect an excessive concern with slight defects or flaws in appearance or perceived defects not observable by others.3 The distinction among body dissatisfaction, subclinical body dysmorphic disorder symptoms, and body dysmorphic disorder requires the evaluation of various factors, including level of subjective distress and impairment of global functioning.1,3,4 For this reason, the clinical assessment of body dysmorphic disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a classification of the degree of severity of the defect from the point of view of both plastic and non–plastic surgeons, and the Body Dysmorphic Disorder Examination were used to classify the participants into those with and without body dysmorphic disorder symptoms.1 Thus, the terms body dysmorphic disorder, body dysmorphic disorder symptoms, and body dissatisfaction were not used interchangeably, but placed contextually in a continuum, because body image–related psychopathology has no obvious discontinuity between normal and pathologic, thus revealing the dimensionality of symptoms. In this study, complaints about the shape of the abdomen were associated with body weight and shape. Body mass index was one of the variables related to the severity of body dysmorphic disorder symptoms; the more severe the symptoms of body dysmorphic disorder, the higher the level of concern with body weight and shape. Note that patients seeking abdominoplasty were preoperatively included in the study, not only those who in fact underwent surgery. In addition, candidates with severe physical deformities as a result of obesity and bariatric surgery were excluded from the sample. Approximately 28 percent of patients with body dysmorphic disorder symptoms who had excessive concerns about nonobservable or slight defects associated with severely negative body image and extreme distress and were dissatisfied with their body weight actually had a normal weight. Body dysmorphic disorder symptoms were identified in candidates for different plastic surgery procedures of different ages.1 To state that “patients with a diagnosis of body dysmorphic disorder are hardly present among the group of, for example, abdominoplasty patients”5 is to ignore the reality of cosmetic surgery patients and that the expression of body dissatisfaction in the contemporary world has changed and therefore may affect the expression of dissatisfaction with specific body areas in patients with body dysmorphic disorder. Clinical observations of patients with this profile and the dimensional identification and classification of body dysmorphic disorder symptoms have opened new perspectives and possibilities for research and treatment on body dysmorphic disorder in cosmetic surgery. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Maria José Azevedo de Brito, Ph.D.Graduate Program in Translational SurgeryFederal University of São PauloSão Paulo, BrazilCollege of Health ScienceSapucaí Valley UniversityPouso Alegre, Brazil Fábio Xerfan Nahas, M.D., Ph.D.Division of Plastic SurgeryFederal University of São Paulo Táki Athanássios Cordás, M.D., Ph.D.Hermano Tavares, M.D., Ph.D.Department of PsychiatryUniversity of São Paulo Lydia Masako Ferreira, M.D., Ph.D.Division of Plastic SurgeryFederal University of São PauloSão Paulo, Brazil