Body dysmorphic disorder (BDD) is a mental health condition that is difficult to diagnose; it can cause a great deal of suffering, and treatment is often complex and challenging. The main symptom is a subjective feeling of ugliness or of a physical defect that the patient believes is evident to others, despite the fact their appearance is within the parameters of normality.1 The DSM-IV states that diagnosis is confirmed when the patient suffers clinically significant distress or functional impairment.2

Individuals with BDD worry about how they look; they feel unattractive or even hideous. The focus is usually on the face or head, but patients may be preoccupied with any part of the body, or the entire body. Appearance-related apprehension is difficult to control and people with this disorder spend many fretful hours mirror checking and attempting to hide the perceived defect or flaw. It is a chronic and distressing condition that can lead to severe social, academic and family difficulties.3

BDD is often under diagnosed because patients are too ashamed to talk about their symptoms and, if not specifically contemplated, it is easy to miss.4 The prevalence of BDD in the general population is around 2%.5 Higher prevalence rates have been reported among adolescents (3.6%).6 Prevalence in dermatological clinics is between 10% and 12%.7

Although the onset of BDD is usually during adolescence, patients are commonly diagnosed after many years of suffering. This is due to the fact that BDD is often unidentified and many youngsters seek non-psychiatric medical treatment, primarily from dermatologists and surgeons.4

There are several links between acne and BDD:

• 1)

  Developmental: the average age of onset (16 years) coincides with the appearance of acne in adolescence8;

• 2)

  Phenomenological: body image is largely based on the skin; facial acne is the area of most frequent concern9;

• 3)

  Compulsive behaviours: 93% of patients with BDD and compulsive excoriation is related to acne.10 Sixty-four percent of BDD cases that include tanning behaviour are associated with acne.11

Youngsters with acne represent a risk group and should therefore be screened for BDD by a dermatologist. Appearance-specific questions are not asked in dermatological outpatient consultations and the disorder may not be detected. Psycho-education should be offered to patients, as well as the possibility to be referred to a mental health specialist.

The aim of this work was to undertake a pilot study for screening acne patients for BDD in a dermatology out-patient clinic and to observe the relationship between the possible cases of BDD and sociodemographic and clinical variables.

The prevalence of BDD found among the acne patients who underwent our screening programme was similar to rates found in other studies with acne sufferers and general dermatological populations. Uzun et al.14 reported a prevalence of 9% among BDD patients with mild acne, almost the same result as that of the present study (8.6%). In another study with BDD acne patients, Bowe et al.15 found a prevalence of between 14% and 21%, depending on the degree of severity of the acne used as the criterion. Research on general dermatological patients has revealed a prevalence of BDD of between 6% and12%,7,9 which is similar to the findings of this present work.

As previously mentioned, there were statistically significant differences between BDD and non-BBD patients with the variables time period of suffering acne and age at the time of the screening (not onset of acne). It is possible that BDD can only be clinically identified after a certain period of time suffering acne, and at a certain age; it is also possible that the disorder appears in a subclinical manner and the screening test is unable to detect the problem. Although subsyndromal BDD may begin at the age of 13, the condition is significantly more prevalent between the ages of 15 to 18 than from 12 to 14, therefore, when BDD appears in relation to the preoccupation caused by acne it is probable that there is a time period before the full symptomology develops and diagnosis can be confirmed.8

This study found a significant association between BBD and having acne on the chest. All the patients who screened positive for BDD, and had acne on the chest, were women; a reflection of the importance of this area of the body for female corporal self-image. Despite the fact that no significant differences were found among the general study population regarding sex and BDD, in the case of this particular variable there seems to be no room for doubt.

This research is not without its limitations: Firstly, a much larger sample population would have produced more statistical power. Secondly, when establishing which participants should be included as BDD patients in accordance with the criterion of severity it would have been better to use an acne severity scale instead of just the categories of mild, moderate or severe. These two issues will be taken into account in the development of a future project and it should be underlined that the present work was designed as an initial pilot study.

In conclusion, it is worth remembering that the patients who screened positive for BDD in our study, spend an average of 2hours a day thinking and worrying about their appearance. This fact is a reminder of the importance of correctly diagnosing and treating BDD as the condition clearly has a serious and negative impact on the lives of those affected by it. In the words of Enrico Morselli, who first described the disorder, “The life of the dysmorphic patient is truly miserable; in the midst of their daily routines, conversations, while they are reading, eating, in any place and at any moment, they are trapped by the doubt of deformity...”.1