Body dysmorphic disorder, skin diseases and psychological morbidity: common and complex
Authors: Parker Magin, Katie Fisher
Journal: British Journal of Dermatology (2022)

Linked Article: Schut et al. Br J Dermatol 2022; https://doi.org/10.1111/bjd.21021. Body dysmorphic disorder (BDD) is characterized by perceived defects or flaws in appearance which may not be apparent to others.1 Skin diseases are singularly visible conditions2 and BDD is common,3, 4 but considered to be under-recognized in dermatological practice.1, 4 In dermatology patients it is associated with psychiatric symptoms, decreased quality of life and suicide.4, 5 Recognition is important given these associations and the perception of patients that physicians (including dermatologists) may often underestimate the psychological implications of skin diseases, and may be insensitive to the emotional suffering of their patients.6 In this issue of the BJD, Schut et al.7 report on a cross-sectional multicentre study of dermatology outpatient clinics in 17 European countries. Their findings of high prevalence of BDD in dermatology outpatients (10·5%) and of positive associations of BDD with demographic (younger age and female sex) and psychological factors (stress and stigmatization) are of considerable practical interest. The study has many strengths – a large sample size, use of a well-validated instrument (the Dysmorphic Concern Questionnaire) as the outcome measure, dermatologist diagnosis of participants' skin diseases and assessment of disease severity, and measurement of a range of demographic and psychological factors potentially related to BDD. The breadth of the study – across 17 European countries – is a strength; it is plausible that BDD could be influenced by cultural factors and by skin type.8 There are also some limitations that should be considered when interpreting the findings. The choice of healthy skin controls (a nonprobability, convenience sample) is a considerable limitation, although the large effect sizes of the dermatology patient/healthy skin control comparisons should be noted. In the analyses within the dermatology patient study population, there are also some limitations. It is unclear to what extent the populations of the participating clinics (within the 17 countries, and across Europe) are representative of dermatology outpatients. An apparent over-representation of participants with psoriasis (as noted by the authors) is an indication of the need for caution in interpreting the findings. Of note, however, is the marked difference in BDD prevalence between different categories of skin disease (with especially high prevalence in hyperhidrosis, alopecia areata and vitiligo). This is certainly an important finding. One caveat, though, is uncertainty regarding generalizability to the majority of people with skin disease managed outside specialist dermatology practice (or not presenting to medical care at all). Individuals with BDD may be more likely to present for care, especially dermatologist care.4 Perhaps the most interesting findings of this study relate to the psychological associations of BDD. The study demonstrates significant associations of BDD with psychological stress and feelings of stigmatization. Associations of BDD with suicidal ideation, depression and anxiety are no longer significant when stigmatization is included in the model. Similarly, severity of the skin disease is no longer significantly associated with BDD when stigmatization is included in the model. These analyses shed further light on the complex interrelationships of skin diseases, BDD and various psychological morbidities.5 The findings of Schut et al. suggest the need for further examination of the central role of stigmatization in these relationships. Parker Magin: Conceptualization (lead); writing – original draft (lead); writing – review and editing (equal). Katie Fisher: Conceptualization (supporting); writing – original draft (supporting); writing – review and editing (equal).