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Body dysmorphic disorder in patients attending a dermatology clinic in Nigeria: sociodemographic and clinical correlates*

Background: Body dysmorphic disorder is a relatively common psychiatric disorder in the context of dermatology and cosmetic and plastic surgery but is underdiagnosed and underreported in Africa. Objective: To evaluate the prevalence of body dysmorphic disorder and symptoms of anxiety/depression and determine their sociodemographic and clinical correlates. Methods: A systematic random sampling design was made to recruit 114 patients with skin diseases. Sociodemographic and clinical data were obtained. The Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive-Compulsive Scale, Hospital Anxiety and Depression Scale was administered, and data were analyzed using SPSS 20. Results: Mean age of participants was 37.70±17.47 years, and 67/114 (58.8%) were females. Prevalence of body dysmorphic disorder was 41/114 (36.0%), and prevalence of anxiety/depression symptoms was 35/114 (30.7%). Prevalence of body dysmorphic disorder in patients with anxiety/depression symptoms was 15/41 (36.6%), and patients with facial disorders expressed the highest burden of anxiety/depression symptoms, in 15/35 (42.9%). Factors associated with significantly higher mean body dysmorphic disorder include age<50years (p=0.039), and anxiety/depression (p<0.001), education below high school was associated with higher mean anxiety/depression score (P= 0.031). In a binary logistic regression model, presence of anxiety/depression symptoms was predictive of body dysmorphic disorder (OR=10.0, CI: 4.1-28.2, p<0.001). Study limitations: the study is uncontrolled, conducted in a single source of care, thus limiting generalization to nonrelated settings. Conclusion Prevalence of body dysmorphic disorder is high among dermatology patients and most prevalent in facial disorders. Facial diseases are associated with the highest burden of anxiety/depression symptoms. This is a clarion call for dermatologists to routinely assess for body dysmorphic disorder and appropriately refer affected patients to mental health care.


INTRODUCTION
contemporary societies place a higher premium on appearance, and with the recent emergence and availability of ubiquitous social media, studies on feelings towards appearance become a subject of importance. 1 Therefore, this study is planned to evaluate the pre- Clinic is being run to date by two board-certified dermatologists with more than five years of experience in clinical diagnosis.
A cross-sectional design was made for systematic random sampling of participants. All  Clinical assessment: sociodemographic parameters including age, education, marital status, and ethnicity were documented using a semi-structured questionnaire. History was obtained for rash, edema, ulcers, and pruritus, and duration of the symptoms and the diseases was documented in weeks. Participants were examined in daylight for diagnosis of their skin diseases. Anthropometric parameters including weight, height, and waist and hip circumference were documented using standard criteria prescribed by the National Health and Nutrition Examination Survey III. Body mass index (BMI) was calculated using the formula weight/(height 2 ). 15 Clinical diagnosis was noted, and the part of the body most significantly affected by the skin diseases was recorded.
Assessment of symptoms of body dysmorphic disorder.
Participants were evaluated for BDD using the English version of the Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive-Compulsive Scale (BDD-YBOCS). 16 The BDD-YBOCS is a semi-structured, clinician-rated, 12-item instrument designed to assess the severity of BDD symptoms. The first ten items on the instrument assess excessive preoccupation, obsession, and compulsive behaviors related to dissatisfaction with physical appearance, while items 11 and 12 assess insight and avoidance respectively. The 12 items are rated on a 0-4 scale, where 0 indicates no symptoms and 4 indicates extreme BDD symptoms. The total maximum score obtainable is 48 when all the rated items are summed together. BDD was Body dysmorphic disorder in patients attending a dermatology clinic in Nigeria... dichotomized as present or absent, defined as present when the BDD total score is >12 and absent when the total score is less than 12. Permission to use the instrument was obtained from the senior author and copyright holder of the original version of the BDD-YBOCS.

Assessment of symptoms of anxiety and depression
Symptoms of coexisting anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS).
HADS is a validated and reliable outcome measure developed for detection of the state of anxiety and depression within the medical outpatient setting. It is a 14-item instrument with the first seven questions designed to examine for anxiety and the last 7 for depression. Each of the items is scored 0-3 with 21 as the highest obtainable score and 0 as the lowest. 17 Caseness, a score > 8 for anxiety and depression, was determined based on a large systematic review by Bjelland et al., with sensitivity 0.78 and 0.79 and specificity 0.9 and 0.83 for anxiety and depression, respectively. 18 The questionnaires were briefly pretested in a small population of patients before the commencement of the study.

Statistical analysis
Data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS 18) version 18 (SPSS, Chicago, IL, USA).
Frequencies of all the diagnosed skin diseases were estimated. All the categorical variables were analyzed using chi-square statistics, and continuous variables were analyzed using the Student t-test. The continuous skewed data were summarized using Mann-Whitney U statistics. All significant variables in the bivariate analysis were entered into a binary regression model as independent variables, and presence or absence of BDD was set as the dependent variable to determine the predictors of BDD. All the results of interest were represented in tables, and p-values < 0.05 were considered statistically significant.

RESULTS
The recruited participants were predominantly females, 67/114 (58.8%), with a mean age of 37.70±17.47 years. There was no significant difference in the mean age, educational attainment, marital status, ethnicity, or anthropometric parameters of the parti-       28 The study also demonstrated a 43% heritability concordance in monozygotic twins. 28 An interplay between genetics and the presence of body blemishes in susceptible parts of the body, irrespective of size, severity, and duration of symptoms, might be responsible for the development of BDD. Genetic studies are therefore needed to identify the BDD-related gene among Africans.
Previous studies have shown that BDD patients are highly somatic and distressed by the high level of non-BDD symptoms and poor well-being in domains of depression, anxiety, somatic symptoms, and anger-hostility. 9,11,29 Symptoms of anxiety and depression were highly prevalent (30.7%) in our cohort, and the presence of anxiety and depression predict the existence of BDD in a regression analysis. Similarly, a previous study also corroborated the coexistence of BDD with social phobia and obsessive-compulsive disorder. 7 Philip et al. 29 found depression as the psychiatric disorder most frequently associated with BDD. Perceived ugliness could present with depression and accompany suicidal ideation. 30 The study's limitations include the fact that it was not placebo-controlled and that it was cross-sectional and conducted in a single center, so the results may not be generalizable to unrelated settings. These limitations notwithstanding, the study's strength lies in its careful selection of participants. It was also the first survey to examine the prevalence of BDD among patients attending a dermatology clinic in Nigeria and it thus produces data in an area yet to be adequately explored in our region. The study employed well-validated, reliable, and tested instruments to generate the data.
The study also examined the prevalence of BDD and associations with common comorbidities, which could help provide the basis for collaborative care involving psychiatrists and psychologists.

CONCLUSION
The high prevalence of BDD in this study is a clarion call for dermatologists to reach beyond the clinical treatment of skin conditions and investigate symptoms of BDD by asking patients direct questions on how they feel about their appearance. Timely diagnosis and prompt referral to follow-up by mental health services aim to prevent future adverse consequences. q