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With no consensus document or guideline to help us compute the psychological make-up of rhinoplasty candidates and in the light of new perspectives of some key opinion leaders in the field of patient selection, the goals of this article are to offer a glimpse of the current literature together with the knowledge gaps, introduce some new tools for the preoperative consultation, help us identify who among our patients is at greatest risk for a poor outcome, and explain how childhood trauma can be linked to body shame and postoperative dissatisfaction.

Breast augmentation is one of the most performed cosmetic surgeries in the world. Personality traits predict the presence of psychological and social factors that may affect the patient satisfaction with a cosmetic surgical procedure and may be risk factors for body dysmorphic disorder. The aim of this study was to assess symptoms of body dysmorphic disorder in patients undergoing breast augmentation and identify their personality traits.Thirty-six women with hypoplasia of the breast (Sacchini index9 cm), a mean age of 28.1 years (SD = 6.2), body mass index ≤ 25 kg/mPersonality traits were associated with symptoms of body dysmorphic disorder. A significant decrease (p0.001) in IGFP-5 scores on the Conscientiousness dimension, symptoms of body dysmorphic disorder (BDSS scores), and the number of patients with body dysmorphic disorder (SCID-I) were observed among different time points. In the study population, breast augmentation decreased the symptoms of body dysmorphic disorder, psychosocial impairment, and mean scores on Conscientiousness.Personality traits varied in intensity and overlapped over time, and were associated with core symptoms of body dysmorphic disorder and the onset of body dissatisfaction.

Previous findings from cross-sectional studies suggest that social anxiety symptoms and negative peers’ experiences regarding appearance were predictors of body dysmorphic symptoms through appearance-based rejection sensitivity. However, little is known about longitudinal relations and parental appearance rejection on body dysmorphic symptoms. Therefore, this study aims to examine the longitudinal mediation of appearance-based rejection sensitivity with social anxiety symptoms, remembered peers’, maternal, and paternal appearance-based rejection as predictors, and body dysmorphic symptoms as an outcome. The study included 277 university students who completed questionnaires in two-measurements points 5 months apart. The results indicated that social anxiety symptoms predicted changes in body dysmorphic symptoms through appearance-based rejection sensitivity. In addition, remembered childhood peers’ appearance-based rejection predicted both directly and indirectly changes in body dysmorphic symptoms over time. Maternal and paternal appearance-based rejection were not predictors of appearance-based rejection sensitivity or body dysmorphic symptoms. Findings support rejection sensitivity theory and the long- lasting impact of negative peers’ experiences for impaired body dysmorphic symptoms. However, further research regarding remembered parental negative experiences is needed.

Purpose: Smartphones and the other internet supported gadgets have brought us very close to the glamour industry. The intentional representation entertainment industry does of only the 'beautiful, most attractive and the perfect faces and bodies' hides the enormous sum of money that is invested into this depiction. What is hidden from us is an army of professionals to help them look the way they look. There are people to design them clothes suiting their body type and clothe them, apply flawless makeup to conceal defects in every visible area of their bodies and on top of it another professional to capture and edit those perfect videos and photos that we see. These celebrities have the money to afford the best dietician, cook and the fitness trainer so that they fit into the bodily statistics given to them by the industry. This research on literature was done to understand the existing literature about body image issues, the extensive role of media & various other factors, its occurrence across females and males in all age groups. It also studies the psychological effect that the body image issues can cause and the corrective measures taken by those who suffer and the clinicians. The researcher eventually aims to instil a feeling of responsibility in celebrities about how they do not represent reality but depict a false sense of perfect body image and also to raise alertness among the general public about the need of focusing on internal health and better life rather than idealising celebrities and their slender bodies. Design/Methodology/Approach: The research is constructed on qualitative review of books, online articles, and research studies so as to better comprehend the effect of the celebrities on ordinary population including children. Findings/Result: The conclusions of this literature review show that celebrities and media are linked to body image disruption. As a result, this article delivers a complete review of the strength of the association between the use of social media and body image disturbance. Originality/Value: The study reviews the existing literature on the influence of media and media influencers on body image that may further lead to negative body image, behavioural and psychosocial disruption in human personality. Paper Type: Review of existing literature

Introduction: The prevalence of body dysmorphic disorder among candidates for plastic surgery may vary from 6% to 54%. Some studies report discrete benefits with the surgical results, while others show symptomatic exacerbation. Some authors even affirm that body dysmorphic disorder would be a surgical contraindication, against others who suggest satisfactory results. Objective: To describe the prevalence of body dysmorphic disorder in rhinoseptoplasty candidates and to compare outcomes among patients with and without body dysmorphic disorder symptoms. Methods: Cohort study. Individuals ≥ 16 years, candidates for aesthetic and/or functional rhinoseptoplasty were recruited at a university hospital in Brazil. The prevalence of body dysmorphic disorder was assessed through the Body Dysmorphic Disorder Examination (BDDE) and the patients divided into groups: no symptoms of body dysmorphic disorder, mild-moderate and severe symptoms. The specific quality of life outcomes, Nasal Obstruction Symptom Evaluation (NOSE) and Rhinoplasty Outcome Evaluation (ROE) were evaluated before and after 90 and 180 days of the procedure. Results: 131 individuals were included, 59.5% female. The prevalence of preoperative symptoms of body dysmorphic disorder was 38%. There was a reduction in the symptoms of body dysmorphic disorder in the preoperative body dysmorphic disorder examination versus 3 and 6 months in all groups (78.94 ± 2.46 vs. 33.63 ± 6.41 and 35.51 ± 5.92, respectively, p < 0.002). Among patients with severe body dysmorphic disorder symptoms, rhinoplasty outcome evaluation ranged from 21.24 ± 3.88 to 58.59 ± 5.83 at 3 months and 52.02 ± 5.41 at 6 months postoperatively (p < 0.001); while NOSE from 71 ± 8.47 to 36.11 ± 12.10 at 6 months postoperatively (p

Objectives: The objectives of the study were to examine the relationship between symptoms of body dysmorphic disorder (body image) and depression, anxiety, and stress as well as the mediating role of self-esteem in explaining this relationship in people undergoing cosmetic surgery. Methods: The following measurement instruments were used: (a) Sociodemographic variables; (b) The scale of depression, anxiety, and stress (DASS); (c) The Rosenberg Self-Esteem Scale (RSS); Appearance Anxiety Inventory; (AAI). Results: The results of the Pearson correlation coefficient showed that depression, anxiety, and stress were associated with the symptoms of Body dysmorphic disorder, and depression was the most significant. The results of hierarchical regression analysis, as well as mediation analysis, showed that self-esteem has a mediating role in the relationship between depression, anxiety, stress, and symptoms of Body dysmorphic disorder. Conclusions: This research opens new directions for research in the areas of depression, anxiety, stress, self-esteem, and body image in people who have undergone cosmetic surgery. It is also necessary to provide various psychoeducation programmes for the development of healthy ways of dealing with daily and life stressors, as well as support from psychotherapists whether it is anxiety, stress, depression, preoccupation with body image, or self-esteem., Ciljevi: Ciljevi rada bili su ispitati povezanost simptoma tjelesnog dismorfnog poremećaja (tjelesne slike) i depresije, anksioznosti i stresa kao i medijacijsku ulogu samopoštovanja u objašnjenju ove povezanosti kod osoba podvrgnutim estetskim kirurškim zahvatima. Metode: Korišteni su sljedeći mjerni instrumenti: (a) Upitnik općih podataka koji je sadržavao sociodemografska obilježja; (b) Skala depresivnosti, anksioznosti i stresa (DASS); (c) Rosenbergova skala samopoštovanja (RSS); Inventar izgledne anksioznosti (AAI). Rezultati: Rezultati Pearsonovog koeficijenta korelacije su pokazali da su depresija, anksioznost, stress povezani sa simptomima tjelesnog dismorfnog poremećaja, a najznačajnijom se pokazala depresivnost. Rezultati hijerarhijske regresijske analize kao i medijacijske analize su pokazale kako samopoštovanje ima medijacijsku ulogu na povezanost između depresije, anksioznosti, stresa i simptoma tjelesnog dismorfnog poremećaja. Zaključci: Ovo istraživanje otvara nove pravce za istraživanja u području depresije, anksioznosti, stresa, samopoštovanja i zaokupljenosti vlastitom tjelesnom slikom kod osoba koje su podvrgnute različitim estetskim kirurškim zahvatima. Također je potrebna psihoedukacija za zdravo nošenje sa svakodnevnim i životnim stresorima, podrška psihoterapeuta i značajnih drugih bilo da se radi o anksioznosti, stresu, depresiji, zaokupljenosti slikom tijela odnosno samopoštovanju.

In cognitive-behavioral models, body checking is understood as an important factor in the development and maintenance of body image disorders (e.g. bulimia nervosa and body dysmorphic disorder). We want to examine the relationship between body checking and the severity of psychopathology in more detail, examining the role of different psychological factors. In this context, we will investigate the extent to which different personality traits, i.e. insecurity intolerance, negative urgency and negative emotionality, contribute to the prediction of the relationship between body checking and disorder-specific psychopathology.

Muscle dysmorphia is an obsessive-compulsive disorder subcategorized as a body dysmorphic disorder. Studies in Latin America have assessed the prevalence of muscle dysmorphia in bodybuilders and gym users. Therefore, the purpose of this study was to evaluate the prevalence of muscle dysmorphia symptomatology (MDS) and associated factors in university male students in Lima, Peru. The participants (N = 618) had an average age of 21.0 years (DS = 2.3). We assessed MDS through the Muscular Appearance Satisfaction Scale (MASS) and obsessive-compulsive disorders through the Yale-Brown Scale Modified for Body Dysmorphic Disorders (BDD-YBOCS). We also tested participants on their food consumption and physical activity (PA) frequency. The prevalence of MDS was 1.3% (IC 95% = 0.4-2.2%) . associated with factors such as intense PA defined as more than five hours per week (PRa = 9.5; 95% CI = 1.1-84.4) and a hyperproteic diet (PRa = 1.3; 95% CI = 1.1-1.6). Thirty-two percent of participants consumed protein supplements. Muscle dysmorphia is a disorder present in the general population. However, more research must be done to understand how this is an emerging problem in Latin America. Therefore, to influence its prevention and early identification among the university population, it is necessary to deepen the understanding.ResumenLa dismorfia muscular es un trastorno obsesivo-compulsivo subcategorizado recientemente como un trastorno dismórfico corporal. En Latinoamérica se ha estimado la prevalencia de sintomatología de dismorfia muscular (SDM), pero principalmente en usuarios de gimnasio o fisicoculturistas. Por tanto, el propósito de este estudio fue evaluar la prevalencia de SDM y factores asociados entre estudiantes universitarios de Lima, Perú. Participaron 618 varones con edad promedio de 21.0 años (DE = 2.3), quienes completaron la Escala de Satisfacción con la Apariencia Muscular (MASS) y la Escala Obsesiva-Compulsiva de Yale-Brown Modificada para Trastorno Dismórfico Corporal (BDD-YBOCS), y además fueron evaluados en cuanto a su consumo de alimentos y realización de actividad física. La prevalencia de SDM fue 1.3% (IC 95% = 0.4-2.2%), asociada a la realización de actividad física intensa (PRa = 9.5; IC 95% = 1.1-84.4) y al seguimiento de una dieta hiperproteica (PRa = 1.3; IC 95% = 1.1-1.6). Adicionalmente, 32% de los participantes indicó consumir suplementos proteicos. La DM es un trastorno emergente en Latinoamérica, por lo que es aún incipiente el conocimiento que se tiene sobre él. Por tanto, para poder incidir en su prevención e identificación temprana entre población universitaria, es necesario profundizar en su comprensión.

Background Body dysmorphic disorder (BDD) and other psychological problems are more common in cosmetic surgery applicants. Objective The aim of this study was to investigate the frequency of the symptoms of BDD and narcissistic personality disorder in rhinoplasty candidates. Materials and methods This descriptive cross-sectional study was performed on rhinoplasty applicants. All subjects were evaluated by BDD and narcissistic personality questionnaires (NPI-16). Results A total of 380 patients were studied. Our findings showed that the prevalence of mild, moderate, and severe BDD symptoms was 31.6%, 43.4% and 25%, respectively. The mean BDD scores were not significantly different in variables such as gender, age, marital status, history of cosmetic surgery, education, place of residence, and income. 29.5% of the subjects had symptoms of narcissism. There was no significant relationship between the symptoms of narcissism and variables such as gender, age, marital status, history of cosmetic surgery, place of residence, and income. Higher education was associated with higher rates of narcissistic personality disorder (p-value = 0.021). Conclusions According to the results of the study, there was no statistically significant relationship between BDD score and demographic parameters. Also, association between narcissistic personality disorder and demographic characteristics was not significant except for education. Level of evidence iv This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BackgroundBody dysmorphic disorder (BDD) is a severe and undertreated condition. Although cognitive-behavioral therapy (CBT) is the first-line psychosocial treatment for this common disorder, how the intervention works is insufficiently understood. Specific pathways have been hypothesized, but only one small study has examined the precise nature of treatment effects of CBT, and no prior study has examined the effects of supportive psychotherapy (SPT).MethodsThis study re-examined a large trial (n = 120) comparing CBT to SPT for BDD. Network intervention analyses were used to explore symptom-level data across time. We computed mixed graphical models at multiple time points to examine relative differences in direct and indirect effects of the two interventions.ResultsIn the resulting networks, CBT and SPT appeared to differentially target certain symptoms. The largest differences included CBT increasing efforts to disengage from and restructure unhelpful thoughts and resist BDD rituals, while SPT was directly related to improvement in BDD-related insight. Additionally, the time course of differences aligned with the intended targets of CBT; cognitive effects emerged first and behavioral effects second, paralleling cognitive restructuring in earlier sessions and the emphasis on exposure and ritual prevention in later sessions. Differences in favor of CBT were most consistent for behavioral targets.ConclusionsCBT and SPT primarily affected different symptoms. To improve patient care, the field needs a better understanding of how and when BDD treatments and treatment components succeed. Considering patient experiences at the symptom level and over time can aid in refining or reorganizing treatments to better fit patient needs.

To analyze different variables that influence postrhinoplasty quality of life outcomes to ascertain the determinants of postoperative satisfaction.Prospective, observational study.This was a prospective, observational study where patients were divided into two groups based on the postoperative Rhinoplasty Outcome Evaluation (ROE) score: high satisfaction group, when postoperative ROE scores were50, and low satisfaction group, when postoperative ROE scores were ≤50. Patients' general characteristics, Portuguese version of the Nasal Obstruction Symptom Evaluation (NOSE-p) score, the Body Dysmorphic Disorder Examination, nasal angles, and measures from the esthetic facial analysis of postoperative photographs were compared between the groups.Seventy-eight patients were included: 19 in the low satisfaction group and 58 in the high satisfaction group. The median reduction in the NOSE-p score was -45 (interquartile range [IIQ] -20 to -60) (P .001) in the high satisfaction group and -10 (IIQ -10 to -30) in the low satisfaction group (P = .053). The high satisfaction group had a significantly higher reduction in NOSE-p scores. There was no significant difference between the groups in terms of the analyzed facial parameters, although a significant difference was found when comparing them with the ones established in the literature as a pattern. Previous rhinoplasty, preoperative crooked nose, and higher NOSE-p scores were significantly associated with lower ROE scores (P .05) in the robust Poisson regression model.Functional results play an important role in satisfaction after rhinoplasty. Neoclassical canons were not fulfilled even in a group of patients with a high postoperative satisfaction evaluation.3 Laryngoscope, 132:1569-1575, 2022.

Androgenetic alopecia (AGA) is highly prevalent in society, affecting both men and women. More than the sociological meaning of hair loss, it has become a very important part of self-identity or “body image.” A psychological concept of body image refers to one's thoughts, feelings, perceptions, and behavioral changes related to one's physical looks. In spite of alopecia's common occurrence, it often leads to psychological disturbance and distress. Hair thinning and perceived hair loss also has a very important negative impact on the psyche of the individual. The common emotional aspects associated are self-consciousness, embarrassment, frustration, and jealousy. Knowledge of these effects among the clinicians managing hair loss patients is beneficial. The clinician must make an active effort to identify the borderline group of patients with body dysmorphic syndrome so as to manage them with psychotherapeutic medication for their hair loss prior to hair transplantation. This article aims to provide important information and an understanding of how the psychology gets affected due to hair loss, particularly AGA and its management to the practicing hair transplant surgeons.

Background This study sought to examine whether mood, anxiety, and obsessive-compulsive spectrum disorders have unique (comorbidity-independent) associations with suicidal thoughts and behaviors in an acute psychiatric population. Methods Patients (N = 498) were evaluated during admission to a partial hospital. Semi-structured interviews were used to assess current psychiatric diagnoses and past-month suicidal ideation and suicidal behaviors (e.g., suicide attempts). Results After adjusting for age, gender and other psychiatric disorders, body dysmorphic disorder (BDD) had a significant association with suicidal ideation (odds ratio [OR] = 6.62; 95% CI, 1.92–22.79) and suicidal behaviors (OR = 2.45; 95% CI, 1.05–5.71). Similarly, major depressive episode was associated with suicidal ideation (OR = 3.00; 95% CI, 1.95–4.63) and suicidal behaviors (OR = 2.11; 95% CI, 1.12–3.98). When unipolar and bipolar depression were analyzed separately, unipolar depression was associated with suicidal ideation (OR = 1.82; 95% CI, 1.20–2.74), but not suicidal behaviors, whereas, bipolar depression was associated with suicidal ideation (OR = 2.71; 95% CI, 1.36–5.40) and marginally with suicidal behaviors (OR = 2.02; 95% CI, 0.99–4.13). Anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder were unrelated to suicidality in this sample after controlling for comorbid disorders. Limitations Cross-sectional design and a relatively small sample for analyses of low base-rate conditions. Conclusions Major depressive episode and BDD are unique markers of suicidality in an acute psychiatric setting. BDD is a common but often underdiagnosed condition, and clinicians should be aware of high rates of suicidality among these patients.

ObjectiveTo assess executive functions (EFs) in patients with body dysmorphic disorder (BDD) and obsessive–compulsive disorder (OCD) compared with healthy controls.MethodsAdults diagnosed with BDD (n = 26) or OCD (n = 29) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and healthy controls (n = 28) underwent validated and computerized neuropsychological tests, spatial working memory (SWM), intra–extra-dimensional set shifting (IED), and stop signal task (SST), from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Test performance was compared between groups, and correlated with standardized symptom severity of BDD and OCD. Significance level was set to P ResultsThere were no statistically significant between-group differences on key outcome measures in SWM, IED, or SST. There was a weak positive correlation between symptom severity and test errors on SWM and IED in both OCD and BDD groups; increased clinical severity was associated with more errors in these tests. Furthermore, there was a negative correlation between symptom severity and SST in the BDD group.ConclusionsPatients with BDD or OCD did not differ from healthy control subjects in terms of test performance; however, there were several statistically significant correlations between symptom severity and performance in those with BDD or OCD. More studies on EFs in BDD and OCD are required to elucidate if there are differences in EFs between these two disorders.

Purpose of review Cognitive behavioral therapy (CBT) with exposure and response prevention is the first-line treatment for obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD). We review here recent developments in CBT and related therapies in treating OCD and related disorders. Recent findings Superiority of CBT over medications in treating OCD is being questioned by some recent meta-analyses, nonetheless CBT continues to be the mainstay of treatment. Web-based therapies have been shown to be beneficial in treating at least mild-to-moderately ill patients. Mindfulness-based CBT, intensive residential treatment and Bergen 4-day concentrated exposure are also proving to be useful in treating OCD. Large well designed studies have demonstrated the efficacy CBT over supportive therapy in treating BDD. Research on the efficacy of CBT in treating hoarding disorder is accumulating. Summary Efficacy of web-based CBT has a potential public health importance in that CBT may now become accessible to all and benefit at least mild-to-moderately ill patients who form most of the clinically ill sample. Similarly, efficacy of Bergen 4-day concentrated exposure will have a huge public health implication if the findings can be replicated in other centers across the world.

Se observa que en la modernidad tardía la cirugía estética está experimentando un incremento constante cada año. A pesar de ser un área de estudio relativamente joven, ya existe una vasta y rica literatura que aborda la decisión de someterse a cirugía estética desde la perpectiva psicosocial. En relación con la cirugía estética, las motivaciones psicosociales más estudiadas son la imagen corporal, el trastorno dismórfico corporal, la identidad, el manejo del terror, la religión, etc. Para ello se consultaron autores como: Sarwer, et al. (1998), Behravan (2018), International Society of Aesthetic Plastic Surgery (2015, 2018, 2019), entre otros. En México existen muy pocas investigaciones sobre las motivaciones psicosociales de cirugía estética. El presente trabajo se propone como objetivo una revisión del estado del conocimiento sobre algunas de las motivaciones arriba mencionadas, con la intención de abrir el camino en la generación de conocimiento en este campo de estudio. La búsqueda de los materiales adecuados en el Internet se realizó a través de Google Académico excluyendo todas aquellas que no son de acceso abierto. Del análisis de los materiales encontrados se recuperan algunas de las aportaciones importantes, y se desprenden preguntas e hipótesis para investigaciones futuras. Finalmente, es importante decir que las motivaciones psicosociales de cirugía estética, por razones analíticas, se observan por separado, aunque en la realidad concreta suelen encontrarse interconectadas entre sí, lo que también amplia el panorama de investigación.

BACKGROUND Psychodermatology is an emerging field that relates cosmetic dermatology with several mental abnormalities associated with appearance and attraction. Being a latest field, psychodermatology lacks research in several fundamental aspects. The current study intended to analyze the prevalent role of cosmetic dermatologists and beauticians in handling the psychological issues of their clients, and to educate them on the relevant mental conditions associated with cosmetic dermatology, beauty, and attraction. METHOD The first aspect of the study involved interviewing cosmetic dermatologists (n = 30) and beauticians (n = 73) to analyze their psychodermatological role with their clients. The second aspect of the study intended to educate cosmetic dermatologists and beauticians on the relevant psychopathology which would possibly be present among their clients. RESULTS The findings revealed that the cosmetic dermatologists and beauticians were aware of several psychopathological issues of their clients. However, they were unable to identify and label the appropriate clinical diagnoses in this regard. Their clients did possess tendencies toward social anxiety disorder, body dysmorphic disorder, charismaphobia, generalized anxiety disorder, major depressive disorder, histrionic personality disorder, gerascophobia, and narcissistic personality disorder. The study also confirmed a significant rise in their clientele due to the psychopathological issues faced by their clients. The study also found cosmetic dermatologists and beauticians involved in providing psychological counseling to their clients while being untrained. CONCLUSION The current paper is a valuable contribution to the under-researched field of psychodermatology. It analyzed the existing psychodermatological role of cosmetic dermatologists and beauticians and facilitated them to practice in a more educated way.

Background The presentation of medical topics in the cinema can greatly influence the public’s understanding and perception of a medical field, with regard to the doctors and surgeons, medical diagnosis, and treatment and outcome expectations. This study aims to evaluate the representation of plastic surgery in commercial films that include a character with a link to plastic surgery, either as a patient or surgeon. Methods The international film databases Internet Movie Database (IMDb), The American Film Institute (AFI), and British Film Institute (BFI) were searched from 1919 to 2019 to identify feature-length films with a link to plastic surgery. Movies were visualized and analyzed to identify themes, and the portrayal of plastic surgery was rated negative or positive, and realistic or unrealistic. Results A total of 223 films were identified from 1919 to 2019, produced across 19 countries. Various genres were identified including drama (41), comedy (25), and crime (23). A total of 172 patient characters and 57 surgeon characters were identified as major roles, and a further 102 surgeons as minor roles. Disparities were noted in presentation of surgeons, both in terms of race and gender, with the vast majority of surgeons being white and male. In total only 11 female surgeons were portrayed and only one black surgeon. Thirteen themes emerged: face transplantation, crime, future society, surgeon mental status, body dysmorphic disorder, vanity, anti-aging, race, reconstructive surgery, deformity, scarring, burns, and gender transitioning. The majority of films (146/223) provide an unrealistic view of plastic surgery, painted under a negative light (80/146). Only 20 films provide a positive realistic image (24/77). Conclusions There exists a complicated relationship between plastic surgery and its representation on film. Surgical and aesthetic interventions are portrayed unrealistically, with surgeons and patients presented negatively, perpetuating stigma, particularly with regard to cosmetic surgery. Cinema is also characterized by lack of representation of female and non-white surgeons. Recruitment of surgeons as technical advisors would help present a more realistic, representative view, without necessarily sacrificing creativity. Level of evidence: Not ratable.

Background/objective Unwanted intrusive thoughts (UITs) are considered normal variants of the obsessions found in obsessive-compulsive disorder (OCD). Similarly, intrusive and persistent preoccupations about appearance defects in body dysmorphic disorder (BDD) and images and thoughts about illness in illness anxiety disorder (IAD) are abnormal variants of the thoughts and concerns about appearance and health found in non-clinical individuals. This study examines whether patients with OCD have frequent and distressing UITs with contents related to BDD and IAD, in addition to OCD-related UITs. Method Thirty-nine participants with OCD (Mage = 32.45, standard deviation [SD] = 11.57; 63% men) completed the Questionnaire of Unpleasant Intrusive Thoughts (QUIT), designed to assess obsessional, dysmorphic and illness anxiety UITs and their associated functional consequences (emotions, appraisals, and neutralizing or control strategies). Results Up to 71% of the individuals with OCD experienced the three UIT modalities. As expected, OCD-related UITs were the most frequent, although were no differences among the three UIT contents in terms of the disturbance they caused. The OCD intrusions were the most interfering, egodystonic and dysfunctionally appraised, and they instigated more neutralizing behaviours. Nonetheless, all UITs instigate the need to do something to alleviate the discomfort caused by their intrusion and attempts to suppress them. Conclusion UITs with different contents not always related to typical obsessive themes are a common experience in patients with OCD. These UITs could have detrimental consequences for the course of the disorder itself, and they should be adequately addressed in both the assessment and treatment of these patients.

The associations between the distinct types of obsessive-compulsive and related disorders and experiential avoidance have received mixed evidence. We, thus, undertook this meta-analysis to i) re-examine the association between obsessive-compulsive disorder and experiential avoidance, ii) extend this association to hoarding disorder, trichotillomania, and body dysmorphic disorder, and iii) identify potential variables affecting these associations. Five databases, including Medline, Embase, PsychINFO, Web of Science and CINAHL, were searched until March 15th, 2021. Meta-analyses based on random-effect models were performed. Heterogeneity and publication bias tests were applied using the I2 statistic and the Egger's test. Meta-regression analyses were performed to identify potential moderators affecting the strength of these associations. Thirty-six unique studies based on n = 11,859 participants were identified. The association between obsessive-compulsive disorder and experiential avoidance was moderate (SMD = 0.75, 95% CI = 0.57–0.92), whereas the associations between individual obsessive-compulsive symptoms, including obsessions, responsibility for harm, ordering, checking, washing and neutralizing, and experiential avoidance ranged from low to strong (SMD ranged between 0.41 and 1.06, 95% CI = 0.25 to 1.40). The associations between hoarding disorder (SMD = 0.93, 95% CI = 0.46–1.40), trichotillomania (SMD = 0.56, 95% CI = 0.48–0.63), body dysmorphic disorder (SMD = 1.55, 95% CI = 0.72–2.37) and experiential avoidance were moderate to strong. Meta-regression analyses demonstrated that studies using the AAQ/AAQ-II scales for measuring experiential avoidance, and/or self-report scales for assessing OCRDs contributed smaller effect sizes. These findings suggest that reducing experiential avoidance may be a viable way of complementing exposure strategies in alleviating obsessive-compulsive and related symptoms.

Body dysmorphic disorder (BDD) is a controversial topic in the field of plastic surgery. Our aim was to determine whether BDD knowledge, attitude and practice (KAP) are affected by the experience of the surgeon in the field, sex of the surgeon, country of practice, and the number of patients the surgeon sees annually. We were particularly interested in uncovering any significant relations in KAP of BDD between plastic surgeons practicing in developed versus developing countries. We created a two-page survey of 24 questions about the KAP of BDD. The survey was sent to aesthetic plastic surgeons worldwide via ISAPS global email list. The data were collected over a period of 20 days at the end of 2020. A total of 464 plastic surgeons completed the survey. The only factor that determines the awareness of BDD is the experience of the surgeon. The more experienced the surgeon is, the more likely he/she is to be familiar with the clinical picture of BDD. Although aware, the more experienced surgeons tend to dismiss the importance of referring BDD patients to psychiatrists/psychologists. Male surgeons tend to diagnose more patients with BDD than female surgeons. Surgeons who estimated the correct prevalence of BDD among patients seeking surgery acquired knowledge of BDD from scientific journals. The KAP is relatively similar between surgeons practicing in developed and developing countries, and the main statistically significant difference was in the questions used during the course of the interviews to diagnose BDD. We can deduce from the results that most aesthetic surgeons worldwide have got knowledge of the presentation of BDD and are keen to diagnose the disorder in their practice. It is worth noting that surgeons usually have their unique approach in the management of BDD. Our study highlights the importance of not only raising awareness of the best management of BDD, but also of establishing a consensus that BDD is a contraindication to aesthetic treatment. The best methods to raise awareness are through journals and plastic surgery residency. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Body dysmorphic disorder is a chronic disorder involving imagined or partial appearance defects that lead to significant impairment in everyday life. It is quite prevalent but remains a clinically underdiagnosed psychiatric condition especially in the inpatient psychiatric setting. Onset of body dysmorphic disorder typically begins in adolescence with subclinical symptoms. Over time, symptoms progress to patients meeting the full Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Severe cases of the body dysmorphic disorder are often camouflaged by concurrent diseases like major depressive disorder, obsessive-compulsive disorder, substance use disorder, and social anxiety disorder. Further, compounding the complexity of body dysmorphic disorder is a treatment of patients who present with coinciding suicidal ideations. Here, we present a unique case of a 40-year-old female admitted to an inpatient psychiatric unit for treatment of ongoing depression and suicidal symptoms. Early on in her inpatient course, she had symptoms of obsessive-compulsive disorder, social anxiety disorder, and alcohol use disorder. The constellation of symptoms prompted evaluation for body dysmorphic disorder and subsequent targeted treatment. This case report highlights the complexities associated with diagnosing body dysmorphic disorder, the importance of considering it a branch point for other psychiatric conditions, and the treatment for patients who present with coinciding suicidal behavior.

Body Dysmorphic Disorder (BDD) is reportedly under diagnosed due to the significant shame that individuals experience in revealing the distress they feel regarding their perceived flaws. Despite th...

Background The extent to which obsessive–compulsive and related disorders (OCRDs) are impulsive, compulsive, or both requires further investigation. We investigated the existence of different clusters in an online nonclinical sample and in which groups DSM-5 OCRDs and other related psychopathological symptoms are best placed. Methods Seven hundred and seventy-four adult participants completed online questionnaires including the Cambridge–Chicago Compulsivity Trait Scale (CHI-T), the Barratt Impulsiveness Scale (BIS-15), and a series of DSM-5 OCRDs symptom severity and other psychopathological measures. We used K-means cluster analysis using CHI-T and BIS responses to test three and four factor solutions. Next, we investigated whether different OCRDs symptoms predicted cluster membership using a multinomial regression model. Results The best solution identified one “healthy” and three “clinical” clusters (ie, one predominantly “compulsive” group, one predominantly “impulsive” group, and one “mixed”—“compulsive and impulsive group”). A multinomial regression model found obsessive–compulsive, body dysmorphic, and schizotypal symptoms to be associated with the “mixed” and the “compulsive” clusters, and hoarding and emotional symptoms to be related, on a trend level, to the “impulsive” cluster. Additional analysis showed cognitive-perceptual schizotypal symptoms to be associated with the “mixed” but not the “compulsive” group. Conclusions Our findings suggest that obsessive–compulsive disorder; body dysmorphic disorder and schizotypal symptoms can be mapped across the “compulsive” and “mixed” clusters of the compulsive–impulsive spectrum. Although there was a trend toward hoarding being associated with the “impulsive” group, trichotillomania, and skin picking disorder symptoms did not clearly fit to the demarcated clusters.

Background: Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are severe body image disorders that severely interfere with the daily functioning of the individual. They are separate but overlapping nosologically entities. There is a study on the tendency of wrong eating behaviour in adolescents with specifications for anorexia nervosa in Jakarta 11.6% and there is also a study at High School in Jakarta 88.5% of adolescents experience wrong eating behaviour with the specifications of anorexia nervosa. And the two largest epidemiological surveys regarding BDD, there were 2.5% women and 2.2% men. With a fairly high number of these two events, this has the potential to have a negative impact on someone’s health. This study aims to discuss the impact of anorexia nervosa. Methods: The researcher used several literature and scientific journals, which was based on 15 journals and literature, discussing a tendency to anorexia nervosa with the incidence of Body Dysmorphic Disorder and its medical emergencies. Conclusion: There is a correlation of anorexia nervosa among teenager especially girl teenage.

Body dysmorphic disorder (BDD) is characterised by a distressing preoccupation with perceived defects or flaws in one’s appearance. BDD most typically emerges in adolescence and is estimated to aff...

Background Little data exist on remission rates following psychotherapy for body dysmorphic disorder (BDD). Methods Using data from a large study of therapist-delivered cognitive behavior therapy (CBT) versus supportive psychotherapy (SPT) for BDD (N = 120), we estimated remission rates at treatment endpoint, and rates of delayed remission, sustained remission, and recurrence at 6-month follow-up. We also examined improvement in broader mental health outcomes among remitters. Results Full or partial remission rates at end-of-treatment were significantly higher following CBT (68%) than SPT (42%). At 6-month follow-up, an additional 10% (CBT) and 14% (SPT) experienced delayed remission, 52% (CBT) and 27% (SPT) experienced sustained remission, and 20% (CBT) and 14% (SPT) experienced recurrence. Remission was never achieved by 18% (CBT) and 45% (SPT). Participants in remission at end-of-treatment experienced significant improvements in functional impairment, depression severity, BDD-related insight, and quality of life compared to nonremitters. Conclusions Full or partial remission rates are high following CBT for BDD and higher than after SPT.

Objetivo: Elencar características do transtorno dismórfico corporal (TDC) e alertar quanto a importância de inteirar com esse distúrbio tão prevalente entre pacientes que buscam procedimentos estéticos. Contexto: Realizou-se a presente revisão bibliográfica num contexto que se avoluma tanto o número de procedimentos quanto os diferentes profissionais que o realizam. Revisão da literatura: Transtorno Dismórfico Corporal designa a diferença entre aquilo que o indivíduo acredita ser em relação a sua autoimagem e aquilo que ele realmente é. Enrico Morselli¹⁵ (1891) descreve que quem tem a dismorfobia é um indivíduo infeliz e que pode ter ataques de dor e angústia que levam ao desespero. Casos extremos do transtorno podem elevar a chance de suicídios de 6 a 45 vezes. Trauma na infância, bullying, maus-tratos, abuso emocional, físico e/ou sexual e níveis baixos de atenção parental podem fazer parte da história de vida desses pacientes. Vinte por cento (20%) dos jovens com TDC podem abandonar a escola. O psiquiatra é procurado tardiamente e após o paciente ter feito visitas indevidas a cirurgiões plásticos, dentistas e dermatologistas e ter submetido a procedimentos desnecessários. A influência da mídia social e do tempo de tela parece ser um fator na diminuição de percepção da imagem corporal. O risco de suicídio é alto, especialmente quando a cirurgia corretiva falha. A medicina estética que trabalha com técnicas de reabilitação pós-cirúrgicas que proporcionam a construção da imagem corporal, reabilitação e a promoção à saúde física, mental e social dos indivíduos. Conclusão: Conduzir o paciente com TDC ao psiquiatra aumenta a eficácia do tratamento estético além de evitar a insatisfação do paciente, diminuindo ideação suicida, suicídio consumado e evitar processos judiciais. Os sintomas de TDC em jovens são comuns e os riscos de comorbidades psicopatológicas coexistentes elevam em jovens com triagem positiva para TDC.

This study assessed the occurrence of probable eating disorders (EDs), ED symptoms, probable body dysmorphic disorder (BDD), BDD symptoms, drive for muscularity, and appearance and performance enhancement drug (APED) misuse, in an ethnically/racially diverse sample of 962 cisgender sexual minority (SM) individuals in the United States, aged 18-30 years old. The overall occurrence of probable ED, probable BDD, and APED misuse in the current sample was 32.7 %, 50.9 %, and 30.6 %, respectively. With respect to ethnicity/race, Hispanic SMs reported the highest rates of EDs, BDD, APED misuse, and drive for muscularity, and may therefore be particularly at risk for developing body image disorders (BIDs). With respect to gender, SM men reported significantly greater drive for muscularity and APED misuse compared to SM women, while SM women reported significantly higher occurrence of probable ED and ED symptoms. The occurrence of EDs, BDD, and APED misuse were higher among SMs in this sample compared to previous rates found among heterosexual samples, suggesting that SMs, regardless of gender and ethnicity/race, are vulnerable to experiencing BIDs and APED misuse. Future research is needed to identify the mechanisms that place SMs at (increased) risk for BIDs, which will aid prevention/intervention development.

DergiPark: 889274 tmsj Body dysmorphic disorder is psychiatric morbidity that comes under the spectrum of obsessive-compulsive disorders. Individuals suffering from body dys- morphic disorder are incredibly concerned about their minor or so-called defects to such an extent that their lives may be affected drastically. As a result of continuously thinking about the asserted defect, the individuals end up suffering from major depression, anxiety, and self-harm. Diagnosis of body dysmorphic disorder is based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria. The management of body dysmorphic disorder consists of psychotherapeutic and pharmacological interventions. Body dysmorphic disorder is a hidden disorder and is often under-reported. It has been linked to muscle dysmorphia, substance abuse, and major depressive disorder. The lack of studies in different countries and populations has made this a topic that requires sub- stantial input from researchers.

Objectives: Body dysmorphic disorder is commonly considered a contraindication for major cosmetic surgery, but whether body dysmorphic disorder relates to poorer outcomes from minor cosmetic treatment remains unknown. This study aimed to explore the prevalence of body dysmorphic disorder in clients seeking non-surgical cosmetic procedures and to examine whether body dysmorphic disorder clients are vulnerable in minor cosmetic settings. Vulnerability was explored in terms of psychological distress, unrealistic expectations and motivations for treatment outcome, and reduced satisfaction with past cosmetic procedures. Method: A cross-sectional online survey was completed by 154 women seeking minor cosmetic procedures which included the Body Dysmorphic Disorder Questionnaire – Dermatology Version to screen for body dysmorphic disorder, and measures of cosmetic treatment motivation, expectations and satisfaction. Results: Roughly 25% of women in the current sample screened positive for a potential body dysmorphic disorder diagnosis. Participants with suspected body dysmorphic disorder demonstrated higher levels of psychological distress and more unrealistic expectations and motivations for cosmetic treatment, such as improving social or romantic relationships. However, body dysmorphic disorder participants reported similar levels of satisfaction with past minor cosmetic treatments to the non–body dysmorphic disorder group. Conclusion: While the relationship between body dysmorphic disorder and treatment outcome warrants further investigation in prospective research tracking satisfaction and adverse reactions over time, this preliminary evidence suggests clients with suspected body dysmorphic disorder display several vulnerabilities in non-surgical cosmetic settings. Given the rapidly increasing accessibility of minor cosmetic procedures, further research is needed to determine their safety for clients with body dysmorphic disorder. Detection of body dysmorphic disorder in non-surgical cosmetic settings could facilitate earlier psychological intervention, promoting superior long-term outcomes.

Interpretation biases are suggested to be transdiagnostic phenomena, but have rarely been compared across different disorders and current concerns. We investigated explicit, decision-based, and more implicit, reaction time-based interpretation bias in individuals with body dysmorphic disorder (BDD; N = 29), social anxiety disorder (SAD; N = 36), generalized anxiety disorder (GAD; N = 22), and non-clinical controls (NC; N = 32), using an adapted Word Sentence Association Paradigm (WSAP). Results indicated that interpretation bias occurred transdiagnostically, while content-specific bias patterns varied meaningfully across groups. BDD and SAD shared explicit and, more inconsistently, implicit interpretation biases for appearance-related and social situations. The GAD group exhibited an explicit and implicit negative interpretation bias for general situations, and an additional implicit lack of positive bias. Mechanistic Wiener diffusion model analyses revealed that interpretation bias patterns were mainly driven by speeded information uptake, potentially mirroring disorder-specific associative memory organization. These findings have important implications for understanding interpretation biases as both etiological and treatment factors., Projekt DEAL

To evaluate the usefulness of the DSM-5 maladaptive personality domains in explaining the similarities and differences among four disorders included in the obsessive–compulsive spectrum, 428 Italian community-dwelling women (mean age=31.96years, SD=12.30years) were administered the Obsessive–Compulsive Spectrum Disorder Scales and the Personality Inventory for DSM-5-Short Form as part of an ongoing online survey on women's health. Multiple Indicators Multiple Causes (MIMIC) confirmatory bifactor analysis results showed that the OCSD general factor (i.e., obsessive–compulsive spectrum factor) was positively associated with Negative Affectivity, whereas Body Dysmorphic Disorder (BDD), Hoarding Disorder (HD), and Skin-Picking Disorder (SPD) specific factors showed significant and substantial differential relationships with dysfunctional personality domains. Specifically, BDD was positively associated with Negative Affectivity, Detachment and Psychoticism domains; HD was associated with high Negative Affectivity and Psychoticism; and SPD was associated with Detachment. © 2020 John Wiley & Sons, Ltd.

Social media use links with 2 major concerns of adolescents, namely, appearance and comparing favorably with others. Founded on theory, our purpose was to develop a reliable and valid measure of appearance preoccupation online, the Social Media Appearance Preoccupation Scale (SMAPS). In Study 1 (N = 283 Grade 9–12 students), Australian adolescents completed surveys containing 21 SMAPS items. After psychometric analyses, 18 retained items loaded highly on factors tapping (a) online self-presentation, (b) appearance-related activity online, or (c) appearance comparison. The items loading on each factor had high interitem correlations, and girls had higher SMAPS scores than boys. In Study 2 (N = 327 Australian university students

It is well established that 1 in 50 individuals receives a diagnosis of body dysmorphic disorder (BDD). Within body image disorders, there is genital retraction syndrome also known as Koro. A unique syndrome in which there is a heightened belief that one’s genitals will diminish in size, retract into the abdomen and ultimately lead to death. However, we have recently discovered a separate form of BDD that is directly opposite of Koro, in which the patient presents a strong belief that his penis will enlarge and extend out of their body. We present a unique case report of a counter-Koro syndrome. This syndrome is characterized by the delusion that one’s penis is growing larger and that it will result in its extreme protrusion from the abdomen and a consequent fear of recurring and visible erections. Given its mirror-like presentation and uniqueness to occurring only in males, we refer to it as Roko Syndrome. To our knowledge, this syndrome has not yet been reported in the literature and requires further study to understand whether it fits as a separate syndrome or falls along the spectrum of body dysmorphia. Thus, assessments used to identify body image disorders can be broadened to include items representing the behavior and presentation of Roko that we delineate in comparison of Koro. The new syndrome is also easily distinguishable from a priapism which is a urological emergency.

A role for addiction psychiatry in aesthetic treatment-seeking behavior has been evidenced for ultraviolet light tanning.We aim to demonstrate an initial proof of concept for the presence of addictive behaviors in cosmetic procedure use.Adults visiting a cosmetic dermatology practice with history of at least 1 cosmetic procedure and consideration of at least 1 cosmetic procedure in the past 12 months were included. Two previously validated instruments in the detection of alcohol use disorder, the Cut Down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria were modified to evaluate participants for a substance-related disorder (SRD) in cosmetic procedures.Of 153 adults, 34 (22.2%) met modified CAGE criteria, and 40 (26.1%) met modified DSM-V criteria. Results from both instruments were significantly associated (P .0002). Significant differences in consideration and use of cosmetic treatments were found in SRD positive versus negative groups (P .0001 and P = .009, respectively).Preliminary criteria for SRD in cosmetic procedure use in this study has not yet been validated.A type of SRD involving cosmetic procedures may exist, and qualifying individuals may have increased cosmetic treatment use. Future efforts to rigorously validate an instrument for SRD detection in cosmetic procedures use are warranted for future research and clinical application.

Although body dysmorphic disorder is a psychiatric disorder. Sometimes, it can be a variant of a variety of psychiatric syndromes like schizophrenia, mood disorders, OCD etc. Here is an atypical case report of a 28 years old male patient who presented with body dysmorphic disorder later on diagnosed as having schizophrenia. The difficult part in this diagnosis is to make the difference between the psychotic and the non-psychotic form of the disorder. Finally, its successful treatment with antipsychotic drugs, thus contributing to what has been documented on the subject. Bang J Psychiatry 2018;32(2): 40-43

Objective Despite the high rates of suicidality in body dysmorphic disorder and eating disorders (EDs), research on suicidality in a related disorder, muscle dysmorphia (MD), is essentially nonexistent. Thus, this study tested relations between suicidal thoughts and behaviors and MD and ED symptoms in an online male community sample. Method A total of 464 males (Mage = 40.3; 85% Caucasian) recruited from Amazon's Mechanical Turk completed measures that evaluated ED symptoms, MD symptoms, current suicidal ideation, and past suicide attempts. Results Most MD and ED symptoms were correlated with current suicidal ideation and previous suicide attempts. In multivariate regression models, vomiting and appearance intolerance remained significantly related to suicidal ideation, while hard exercise and lower functional impairment were significantly related to prior suicide attempts. Conclusion Results indicate that appearance dissatisfaction, a core MD criterion, and hard exercise, a common behavioral symptom of MD, are associated with suicidality.

El Trastorno Dismórfico Corporal (TDC) es un trastorno caracterizado por la preocupación por defectos físicos corporales no existentes, o apenas perceptibles, que generan un gran malestar psicológico o un deterioro en el funcionamiento de la persona que lo padece. La prevalencia de este trastorno oscila entre el 1,7 y 2,5% en la población general, siendo las dos terceras partes de los casos de inicio en la adolescencia. Existen diferencias significativas a la hora de clasificar este trastorno. Mientras que la CIE-10 lo hace dentro de los trastornos somatomorfos, el DSM-5 y la futura CIE-11 lo clasifican dentro del Trastorno obsesivo compulsivo (TOC) y Trastornos relacionados. Así mismo, a nivel clínico, pueden surgir dudas diagnósticas con los trastornos psicóticos o con los trastornos de la conducta alimentaria. Presentamos el caso de una paciente de 16 años, cuya sintomatología planteaba los interrogantes previamente descritos, decantándonos finalmente por el diagnóstico de TDC en la forma en que lo hacen el DSM-5 y la futura CIE-11 (TOC y trastorno relacionados), siendo tratada como tal y evolucionando de forma favorable. Este artículo tiene dos objetivos principales. En primer lugar, actualizar al lector en el novedoso cambio nosológico del TDC en la CIE-11, que se aproxima cada vez más a la orientación americana, siendo ésta la que hemos usado como referente para nuestro trabajo. En segundo lugar, profundizar en el diagnóstico diferencial de esta entidad, ya que no resulta una tarea sencilla y prueba de ello es el cambio clasificatorio anteriormente mencionado.

Background The incidence of body dysmorphic disorder in cosmetic dermatology is high. Even though treating patients with this disorder may worsen symptoms and is fraught with potential complications, screening is low, due in part to lack of knowledge of the disorder, as well as inadequate screening tools. Objectives To verify the probability of body dysmorphic disorder in a nonsurgical esthetic setting and determine the effect of a multiphasic screening protocol on mitigating poor outcomes in high‐risk patients. Methods A multiphasic screening protocol for body dysmorphic disorder was distributed to a total of eight esthetic clinics in the United States. Practitioners administered an anonymous, cryptic prescreening form to all new, incoming patients aged ≥ 18 to ≤ 65 years from June 1, 2019, through September 1, 2019, followed by a second, more extensive screening questionnaire. Patients with suspected or subclinical body dysmorphic disorder could be refused treatment. Results A total of 734 initial screenings were recorded over 16 weeks. Of these, 4.2% (31/734) proceeded to the secondary screening phase; 29% (9/31) subsequently screened positive for body dysmorphic disorder. Practitioners refused to treat 77.8% (7/9) of positive screenings. Two patients out of seven who tested positive underwent a third screening and were subsequently treated with positive outcomes. Conclusions Use of a cryptic screening protocol enables identification of individuals at risk for BDD and encourages open and continuous communication between patient and provider.