Body dysmorphic disorder (BDD) is a somatoform disorder characterized by a preoccupation with a defect in appearance (American Psychiatric Association, 1994). Either the defect is imagined or, if a slight physical anomaly is present, the individual's concern is markedly excessive. To fulfill diagnostic criteria, the preoccupation should last for at least an hour a day and cause significant distress or impairment in social, occupational or other important areas of functioning. Prevalence rates in the general population are reported to range from 0.7% to 2% (Cotterill, 1996, Phillips, 1996, Faravelli et al., 1997 and Otto et al., 2001).
BDD is frequently associated with other Axis I disorders, such as major depression, obsessive–compulsive disorder, social phobia, panic disorder, and substance abuse (Brawman-Mintzer et al., 1995, Veale et al., 1996, Perugi et al., 1997, Phillips and Diaz, 1997, Hollander and Aronowitz, 1999, Castle and Morkell, 2000 and Gunstad and Phillips, 2003). Axis II diagnoses are also common in BDD patients. Findings reported in the psychiatric literature indicate that 53–87% of BDD patients receive a diagnosis of one or more personality disorders, 48–57% have two or more disorders, 26% have three or more, and 4% have at least four comorbid diagnoses (Veale et al., 1996, Cohen et al., 2000 and Phillips and McElroy, 2000). Cluster C (Anxious) disorders are the most frequent, ranging from 16% to 82%; less common are Cluster B (Dramatic) disorders, ranging from 12% to 76%, and Cluster A (Odd) disorders, ranging from 10% to 40% (Hollander et al., 1993, Neziroglu et al., 1996, Veale et al., 1996, Cohen et al., 2000 and Phillips and McElroy, 2000).
These patients may repeatedly pursue surgical treatment for the imagined defect. Such treatment rarely produces improvement and, indeed, may cause the condition to worsen. Estimates of BDD prevalence in patients applying for cosmetic surgery range from 2% to 40% (Andreasen and Bardach, 1977, Ishigooka et al., 1985, Koda et al., 1994, Pertschuk et al., 1998, Sarwer et al., 1998a, Sarwer et al., 1998b, Phillips et al., 2000 and Carroll et al., 2002). In such cases, there is a need for preoperative psychiatric assessment to prevent serious psychopathological consequences after the surgical intervention (Rohrich, 2000, Sarwer et al., 2003, Grossbart and Sarwer, 2003 and Veale et al., 2003).
Personality disorders are often present in patients seeking cosmetic surgery. According to Napoleon (1993), 71% of these patients receive an Axis II diagnosis. The most common personality disorders are narcissistic (25%), dependent (12%), histrionic (10%), and borderline (9%). The high frequency of borderline and narcissistic personality disorders has been reported by other authors as well (Koda et al., 1994 and Grossbart and Sarwer, 1999).
Studying the relation between BDD and personality disorders could help to define the characteristics of patients pursuing aesthetic surgery. One hypothesis is that personality disorders represent a diathesis for the onset of dysmorphic symptoms inducing patients to apply for a surgical correction (Maffei and Fossati, 1997).
