The Psychodermatological Interface: Exploring Body Dysmorphic Disorder Evidence, Prevalence and Management in Acne Vulgaris Patients: A Literature Review

Body dysmorphic disorder overview

BDD is a mental illness characterized by an obsessive, upsetting, or debilitating fixation on one’s perceived physical imperfections.^[6] According to earlier research, body dysmorphic symptoms, including repetitive behaviors, impairment, and appearance preoccupation, are dimensional constructs that lie on a spectrum. Key elements of body image disorders include appearance-based self-objectification and appearance-based social comparison, both of which are continuously facilitated by social media.^[7] The renowned psychopathologists Emil Kraepelin and Pierre Janet initially described BDD in the 1800s.^[6] BDD is described as an obsession with a real or perceived minor fault in one's appearance in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV). The DSM-5 and the American Psychiatric Association both classify BDD as an obsessive-compulsive disorder (OCD). Significant stress or emotional distress, including sadness, anxiety, concern, depression, and other negative thoughts or feelings, is the second diagnostic criterion for borderline personality disorder.^[8] According to Hakim et al. (2021 the most reported sites of BDD were the skin [81.6%]), with an overall prevalence of 13.9%.^[9] Patients with skin conditions may experience significant psychological distress.^[10]

Acne vulgaris causation

The common, chronic inflammatory condition known as AV affects the pilosebaceous unit, which includes the hair follicle and sebaceous gland.^[11] Acne’s exact etiology is unknown, but it is believed to be related to genetics, androgen induced excessive sebum production, changed sebaceous duct keratinization in hair follicles, Propionibacterium acnes colonization of hair follicles, and immuno-inflammatory responses.^[12] Additionally, due to increased androgen production by the gonads and adrenal glands, as well as enhanced sensitivity of androgen receptors, the syndrome typically manifests at the onset of puberty.^[11] Acne is thought to be substantially influenced by an imbalance between omega-6 and omega-3 fatty acids.^[13] People who have acne experience psychological as well as physical effects. Numerous authors have reported that acne sufferers, particularly in adolescent populations, have higher rates of psychiatric comorbidities such as depression, anxiety, and suicidality.^[12]

Correlation with evidence

AV is a persistent skin disorder that can significantly alter a person's physical appearance. This feature of the illness is known to substantially lower psychological well-being and quality of life, hence bolstering the connection between psychiatric and dermatological morbidity.^[20] As seen by the 27% of dermatology outpatients with AV who tested positive for BDD, more than one in four acne patients may have clinically relevant appearance distortion or preoccupation focused on their acne lesions or skin appearance. A study conducted in India screening 115 dermatology outpatients found a high screening positive rate for body dysmorphic disorder and a substantial co-occurrence of depression, anxiety, and stress.^[21] Another report among 104 Polish acne patients reported an approximate of 17%of acne patients showing clinically relevant body dysmorphic concerns. They had also noted an increased risk for BDD among the subgroup of females, sex, and younger age.^[12] A study in Pakistan also noted that nearly one-third of acne patients had BDD features, particularly repetitive appearance-related behaviors such as mirror checking and camouflaging.^[15] These results imply that AV has a significant psychosocial burden that frequently veers into the realm of psychopathology, in addition to being a cosmetic or dermatological burden.

Notably, both studies show that BDD is more strongly correlated with subjective perception, length of disease, and psychosocial stressors than with objective acne severity. There was no significant direct relationship between BDD status and clinician-rated acne severity (lesion count, severity grading); rather, BDD among acne patients was substantially correlated with longer disease duration and greater levels of subjective stress, anxiety, and depression.^[2] Body-dysmorphic concerns were more strongly predicted based on the perceived stigma in society and the female gender than on the severity of acne. This was observed when individuals with similar clinical severity had significantly varying risks of BDD depending on their perceptions of psychological distress or stigma.^[21] These influencing factors were highlighted by a study done in the Philippines that found that female patients with mild acne were more likely to show symptoms of BDD than male patients with severe acne. These subjective elements of AV are quite significant in establishing the connection between AV and the onset of body dysmorphic disorder.

Other psychological problems associated with AV

Its onset during adolescence may worsen the emotional and psychological challenges of adolescence and result in developmental problems like sexuality, socialization, and body image.^[22] In several case series, patients with AV accompanied by psychological illnesses, including anxiety, depression, and suicidal thoughts, have been reported. It is estimated that anxiety is a factor that worsens the illness in 74% of acne patients. Some behavioral strategies are developed in people with AV, such as avoiding eye contact and being the centre of attention in social situations or with people of the opposite sex, particularly if the acne lesions are on areas like the hands and face that could negatively impact the person’s body image.^[18]

In a quantity, Acne can sometimes lead to psychological issues, including melancholy, social anxiety, or low self-esteem. Additionally, concerns centred on acne may be deeply ingrained in basic psychiatric conditions, including psychosis and OCD. Numerous studies have shown that psychiatric comorbidities of acne include anxiety, depression, OCD, delusional illness, personality disorder, body image issues, and social phobias. The study revealed a substantial difference in anxiety severity between males and females [p<0.001], with mild, moderate, and severe degrees significantly predominating in males and very severe, then severe, and mild degrees predominating in females. Additionally, some studies have found that women with AV are more likely than men to have anxiety and a lower quality of life.^[23]

Participants reported avoiding settings where they felt more exposed (e.g., photographs, at parties, changing rooms, swimming pool/beach), highlighting the major role appearance-related worries play in humiliation and lost self-confidence.^[24] A person’s facial appearance affects how they feel about their body image. Increased psychological effects like worry, despair, low self-esteem, and a negative self-image are linked to severe acne. Mental health problems are more common in cases with more severe acne and later puberty. An increased risk of anxiety, depression, and suicidal thoughts is associated with acne. It can have major psychological effects; the degree of guilt, dissatisfaction, and social engagement are all influenced by the severity of the illness, which can also leave persistent scarring with long-term effects.^[19] AV has an impact that goes beyond looks; it is linked to feelings of despair, loneliness, unhappiness, and unattractiveness. Psychosocial stress, recognized mental illnesses, and even suicidal thoughts have all been connected to acne. Acne sufferers who receive systemic treatment are more prone to experience interpersonal and psychological difficulties as well as some neuropsychiatric disorders.^[25] Acne was strongly, positively, and significantly correlated with depression (r = 0.630), anxiety (r = 0.661), and stress (r = 0.758), according to Pearson’s correlation analysis (p < 0.001). Consequently, skin problems negatively affect people, particularly in terms of mental health, quality of life (QoL), and acceptance of one’s own image Table 1.^{[2,4,5-7,17-19,22,23,25,26]}

Psychological medicine role in body dysmorphic disorder

It has been demonstrated that cognitive behavioral therapy (CBT) is effective in treating BDD.^[27] According to recent research, CBT is effective in treating BDD; in fact, several studies suggest that CBT is the gold standard for treating BDD.^[28] CBT should be made available as the first-line treatment for all young people with BDD, according to the National Institute for Health and Care Excellence (NICE) guidelines. Selective serotonin reuptake inhibitors) are also suggested by the NICE guidelines as a second-line treatment for adolescents aged 12 to 18 who have moderate to severe functional impairment associated with BDD and who have not responded well to cognitive behavioral therapy.^[29] When given flexibly in a specialized setting, multimodal treatment for teenage BDD is beneficial in the short and long term. More access to specialized care is necessary, given the significant costs of BDD to individuals and society.^[30] The encouraging results of digital interventions to increase access to care, as well as new treatments that need more research.^[31]