Massimo Marini

Psychopathologic Aspects of Body Dysmorphic Disorder: A Literature Review

Body dysmorphic disorder (BDD) is a somatoform disorder characterized by the patient’s excessive concern with an imagined or minor defect in physical appearance. Patients with BDD often have been observed in aesthetic surgery settings seeking surgical enhancement at a reported prevalence of 6% to 15%. Published studies in the general population tend to aggregate a prevalence of 0.7% to 2.3%. This review aimed to search the literature for data on the prevalence, psychopathologic aspects, and comorbidity of BDD, and to provide an update on current BDD research. Relevant literature was identified by searching the Medline, PubMed, PsycINFO, and EMBASE databases. The following search words were used alone or in combination when appropriate: “body dysmorphic disorder,” “somatoform disorder,” “obsessive compulsive spectrum disorder,” “personality disorders,” “presurgical counseling,” “aesthetic surgery,” “cosmetic surgery,” and “plastic surgery.” Further articles were sourced from the reference lists of the articles ascertained through the search. Recent findings include the relationship between BDD and the obsessive-compulsive spectrum, treatment of BDD based on pharmacologic and psychological approaches, and the hypothesis that the often distinguished delusional and nondelusional variants of BDD very likely are the expression of a single disorder with varying degrees of severity. Retrospective outcome studies suggest that patients affected by BDD typically do not benefit from surgical treatment. In contrast, serotonin reuptake inhibitors and cognitive-behavior therapy appear to be good practice in addressing the disorder. Further research is needed to identify effective interventions for patients who do not respond to these treatment methods.

Psychosocial profiles of painful TMD patients

The aim of the present investigation is to test the null hypothesis that the presence of psychopathology in patients with temporomandibular disorders (TMD) is related to the presence of pain, independent of its location [(i.e. myofascial and/or temporomandibular joint (TMJ) pain]. Ninety-six (n = 96) patients affected by painful TMD underwent a clinical assessment in accordance with the research diagnostic criteria for TMD (RDC/TMD) guidelines and filled out the Symptoms Check List - Revised (SCL-90-R) instrument to investigate the presence of symptoms of psychopathology. Patients with myofascial pain, alone or combined with TMJ pain, endorsed the highest scores in all SCL-90-R scales and showed the highest percentage of abnormal values in the depression (DEP) and somatization (SOM) scales for the assessment of depressive and somatization symptoms. Nonetheless, anova revealed no significant differences between groups in any of the SCL-90-R scales, except than in the Positive Symptom Total Index (F = 3.463; P = 0.035), and the chi-squared test did not detect any significant differences between groups for the prevalence of abnormal scores in the DEP and SOM scales. The existence of a close association between pain and psychosocial disorders in TMD patients was supported by the present study. The null hypothesis is that no differences exist between patients with different painful TMD cannot be fully accepted for the presence of psychosocial disorders because of the trend evidencing higher SCL-90-R scores for myofascial pain patients, alone or combined with TMJ pain, with respect to TMJ pain alone.

Survey on Recent Suicidal Ideation Among Female University Hospital Physicians in Sweden and Italy (The HOUPE Study): Cross-Sectional Associations With Work Stressors

BACKGROUND Suicide rates among physicians are higher than in the general population, and rates among female physicians are particularly high. More female than male physicians report suicidal thoughts, with suicidal ideation being a well-recognized precursor of suicide. The urgent need to find the reasons for suicide risk in female physicians is underscored by societys increasing dependence on this group of health care providers. OBJECTIVE The aim of this paper was to identify potential risk and protective factors associated with recent suicidal ideation in female physicians. METHODS A cross-sectional survey analysis of work-related health, organizational culture, career paths, and working conditions was performed among permanently employed female physicians from the HOUPE (Health and Organisation among University Physicians in four European countries) study: 385 in Sweden and 126 in Italy. The main outcome measure was recent (within the prior 12 months) suicidal thoughts. RESULTS Overall, 13.7% and 14.3% of the participants from Sweden and Italy, respectively, reported suicidal thoughts within the prior 12 months. Among the physicians from Sweden, the most powerful multivariate model for such thoughts included 2 independent variables related to work: degrading experiences/harassment at work (odds ratio [OR], 3.03; 95% CI, 1.48-6.23), and work meetings to discuss stressful situations (OR, 0.36; 95% CI, 0.19-0.69). The model included self-diagnosis and self-treatment as a significant factor. Work meetings to discuss stressful situations were also in the multivariate model for the Italian physicians (OR, 0.21; 95% CI, 0.05-0.86), together with being given work assignments without adequate resources (OR, 5.0; 95% CI, 1.32-18.8). Significant non-work-related factors in the Italian model were younger age and seeking professional help for depression or burnout. CONCLUSIONS In both Sweden and Italy, work stressors have been identified that may increase the risk for suicide for female physicians. A potential protective factor was meetings to discuss stressful work experiences. These findings suggest that such meetings should be more broadly implemented.

The importance of recognizing body dysmorphic disorder in cosmetic surgery patients: do our patients need a preoperative psychiatric evaluation?

Abstract. Body dysmorphic disorder (BDD) is classified in DSM IV as a somatoform disorder. The main features of this condition are a persistent preoccupation with a supposed physical defect or the presence of a slight imperfection in appearance. If a real defect should exist, the importance given to this in determining self-appreciation causes an important impairment in social, affective, or other functioning areas. This affection causes the patient to ask for multiple esthetic treatments. In most cases such interventions do not produce positive results in improving symptoms and may induce a chronic situation. The aim of this report is to aid in recognition of BDD in patients requesting esthetic improvements and to study psychopathological comorbidities. A counseling service was established, and 56 patients (11 men, 45 women) were seen. There were two specific interviews, one for personality, psychotic, and mood disorders and the other for the diagnosis of BDD (SCID II 2.0 and MINIPLUS 5.0). The findings in this study confirm those reported previously: BDD is more frequent in this selected population than in the general population (53.6%). There is a high prevalence of mood and anxiety disorders. Among personality disorders the most frequent are borderline and obsessive-compulsive types. We emphasize the importance of increasing the collaboration between the esthetic surgeon and the psychiatrist to determine the true motivation for surgical improvement and to avoid esthetic surgery on patients with psychiatrist disorders.

Psychopathology and Clinical Features in an Italian Sample of Patients with Myofascial and Temporomandibular Joint Pain: Preliminary Data

Objective: Aim of this study was to provide data on the relationships between psychopathological variables and temporomandibular disorders (TMD). Sixty-three TMD patients were investigated using clinical and anamnestical psychiatric informations and psychopathological measures. Methods: Three groups of TMD patients were recruited according to the Research Diagnostic Criteria for TMD guidelines: a group of patients presenting myofascial pain alone (RDC/TMD axis I group I), a group with temporomandibular joint (TMJ) pain alone (RDC/TMD axis I group IIIa, IIIb), and a group presenting both myofascial and TMJ pain. Two secondary groups were identified on the basis of the presence/absence of myofascial pain. The study design provided a psychiatric interview and psychometric assessment including the Symptom Check List-90-Revised (SCL-90-R), the Hamilton Depression Rating Scale (HDRS), and the Hamilton Anxiety Rating Scale (HARS). Results: -Psychiatric evaluation: Myofascial pain patients had higher scores for personal psychiatric history and a history of more frequent psychotropic drug use. -HDRS and HARS: The sample presented scores indicating mild depressive symptoms and moderate anxiety symptoms. -SCL-90-R: The global sample showed acute levels of psychological distress as measured by the GSI score (Global Severity Index). Myofascial pain patients scored higher than TMJ pain patients in the GSI (p = .028), PAR (paranoia; p = .015), PSY (psychoticism; p = .032), and HOS (hostility; p = .034) subscales. Conclusions: TMD patients showed elevated levels of depression, somatization, and anxiety. These characteristics did not differ significantly between patients with myofascial or TMJ pain. Other specific psychopathological dimensions, detected with SCL-90-R, appeared to be closely associated to the myofascial component.

Work Environment and Recent Suicidal Thoughts Among Male University Hospital Physicians in Sweden and Italy: The Health and Organization Among University Hospital Physicians in Europe (HOUPE) Study

BACKGROUND Male and female physicians are at elevated suicide risk. The work environment has become a focus of attention as a possible contributor to this risk. The potential association between work environment and suicidal thoughts has been examined among female physicians in several countries, and significant findings have been reported. OBJECTIVE The purpose of this study was to examine the role of the work environment in relation to suicidal thoughts among male university hospital physicians in 2 European countries. METHODS Cross-sectional multivariate analysis was performed to identify significant associations between work-related factors and suicide risk among male physicians from the Health and Organization among University Hospital Physicians in Europe (HOUPE) study. The dependent variable was termed recent suicidal thoughts, which includes having thought about suicide and/or having thought about specific ways to commit suicide within the previous year. Adjusted odds ratios (ORs) and CIs are reported. RESULTS Of the 456 Swedish (56%) and 241 Italian (39%) male physicians who participated, 12% of the physicians from each country reported affirmatively regarding recent suicidal thoughts. Degrading work experiences were associated with recent suicidal thoughts for the Swedish and Italian physicians (OR = 2.1; 95% CI, 1.01-4.5; OR = 3.3; 95% CI, 1.3-8.0, respectively). Role conflict was associated with recent suicidal thoughts among the Swedish physicians (OR = 1.6; 95% CI, 1.1-2.2). Support at work when difficulties arose appeared to be protective for the Swedish physicians (OR = 0.7; 95% CI, 0.5-0.96). Italian physicians with little control over working conditions had an increased risk of recent suicidal thoughts, whereas confidential discussions about work experiences appeared to be protective (OR = 0.6; 95% CI, 0.4-0.9). CONCLUSION Attention should be paid to the work environment as it relates to suicide risk among male university hospital physicians, particularly to bolstering social support and preventing harassment.

Personality, temperament and clinical scales in an Italian Plastic Surgery setting: what about body dysmorphic disorder?

Objective. Applications for aesthetic surgery may provide a good vantage point for assessing the psychiatric and personological aspects of subjects seeking cosmetic enhancement. Body dysmorphic disorder is relatively frequent (6–15%) among plastic surgery and dermatology patients. The aim of our study was to analyse the psychopathological profile, personality and temperament of 27 patients requesting aesthetic surgery procedures and compare them with 21 normal controls. Methods. The Mini International Neuropsychiatric Interview Plus 5.0 (MINIPLUS 5.0), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory, Y form (STAI), State-Trait Anger Expression Inventory (STAXI), Neo Five Factor Inventory (NEO-FFI), and Tridimensional Personality Questionnaire (TPQ) were used. Results. The dysmorphophobics in our sample (n=10) presented higher BDI, STAI and STAXI-state scores than the non-BDD patients (n=17) and controls (n=21); high rates of comorbidity, particularly with major depressive disorder, social phobia and obsessive-compulsive disorder; higher NEO-FFI scores for neuroticism and lower ones for extraversion, consciousness and openness to experience, compared with the control group. Significant differences in temperament were observed on the HA (Harm Avoidance) scale, with higher scores in the BDD than in the other two groups, particularly on the HA1 (anticipatory worry/uninhibited optimism) and HA4 (fatigability and asthenia/vigour) subscales. Conclusion. Our BDD patients were more depressed, more anxious and angrier with their present situation than controls. Although preliminary, our data are in keeping with the personality characteristics traditionally described in dysmorphophobic patients, considered to be sensitive, asthenic, shy, introverted, reserved and socially avoidant.

Why don't academic physicians seek needed professional help for psychological distress?

PURPOSE Suicidal thoughts, burnout and other signs of psychological distress are prevalent among physicians. There are no studies concerning help-seeking for psychological distress among university hospital physicians, who face a particularly challenging, competitive work environment. We compare psychologically-distressed university hospital physicians who have not sought needed help with those who have sought such help. We thereby aim to identify factors that may hinder help-seeking and factors that may trigger seeking help. METHODS Analysis was performed among university hospital physicians reporting recent suicidal thoughts and/or showing other indications of current psychological ill-health. These distressed physicians were a subgroup (42.7%) from the cross-sectional phase I HOUPE study (Health and Organization among University Hospital Physicians in Europe): 366 from Sweden and 150 from Italy. Having sought professional help for depression or burnout was the outcome variable. Multiple logistic regression was performed with socio-demographic factors as covariates. RESULTS Altogether 404 (78.3%) of these distressed physicians had never sought professional help for depression/burnout. Physicians who were currently involved in medical research, taking night call, surgical specialists, male, or Italian were least likely to have sought help. Physicians who faced harassment at work or who self-diagnosed and self-treated were more likely to have sought help. CONCLUSION Very few of these university hospital physicians with signs of psychological distress sought help from a mental-health professional. This has implications for physicians themselves and for patient care, clinical research, and education of future physicians. More study, preferably of interventional design, is warranted concerning help-seeking among these physicians in need.

Associations between Confidentiality Requirements, Support Seeking and Burnout among University Hospital Physicians in Norway, Sweden, Iceland and Italy (the HOUPE study)

Concerns about protecting patients privacy are experienced as a limitation in the opportunity to obtain and utilize social support by many physicians. As resources of social support can modify the process of burnout, patient confidentiality may increase risk of this syndrome by interfering with proper stress adaptation. This study investigates if experiencing limitations in seeking social support due to confidentiality concerns are associated with burnout. University hospital physicians in four European countries completed measures of burnout, (Index) of Confidentiality as a Barrier for Support (ICBS), and factors of social resources and job demands. Linear regression analysis showed that ICBS was significantly associated with the burnout dimension of Exhaustion and not with Disengagement. These findings were present when controlling for factors known to diminish or increase the likelihood of burnout. These results are the first to demonstrate that patient confidentiality is associated with burnout in the process of stress management among physicians.

Psychological and Psychiatric Traits in Post-bariatric Patients Asking for Body-Contouring Surgery

BackgroundsObese patients, mainly females, feel uncomfortable and unsatisfied with their physical appearance; they have a wrong perception of their image and consequently diminish their self-esteem, sometimes showing difficulties in functional areas such as work, relationship, social activity. Beside health concerns, improving their appearance and body image are often common motives for weight loss in obese individuals and after weight loss about 30% of bariatric surgery patients undergo plastic surgical correction of excessive skin. The authors investigated psychological and psychiatric traits in post-bariatric patients undergoing body-contouring surgery to underline the strong correlation between psychiatry and obesity and avoid unsatisfactory results in post-bariatric patients.MethodsThe Mini International Neuropsychiatric Interview, Beck Depression Inventory II, Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder Tridimensional Personality Questionnaire, Body Uneasiness Test, Barratt Impulsiveness Scale 11, and Binge Eating Scale were performed in 36 post-bariatric patients looking for plastic surgery and 21 controls, similar for clinical features, not seeking shape remodelling.ResultsMuch different psychiatric pathology characterizes cases, including current body dysmorphic disorder and previous major depression and anxiety disorders, impulsivity, binging and body uneasiness are other common traits.ConclusionsIn post-obesity rehabilitation, a strong collaboration between the plastic surgeon and psychiatrist is recommended to reduce the number of non-compliant patients. Preoperative psychological assessment of the body-contouring patient should be a central part of the initial plastic surgery consultation, as it should be for all plastic surgery patients.Level of Evidence IIThis 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 http://www.springer.com/00266.