Our goal with this blog is to become the ultimate online resource for high-quality, evidence-based information regarding women's wellness. Several of us are plastic surgeons and we want to empower you to make informed decisions when it comes to plastic surgery, given the myriad of surgical and nonsurgical treatments and providers available in today's digital age.

But we also want to tackle some of the tough stuff. The truth is, not everyone does well after plastic surgery...and we're not talking Botched. Today, we want to raise awareness for body dysmorphic disorder (BDD).

What is BDD?

Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by significant preoccupations and concerns over aspects of one’s appearance, which are either slight or not observable to others. For example, individuals with BDD may be concerned that their hair is too messy, nose is crooked, and skin is too red. Due to these appearance concerns, a person with BDD may engage in repetitive and time-consuming behaviors, such as mirror checking, changing clothes, and researching information online to hide, fix, or change one’s appearance.

The defining feature of BDD is that the concerns are “dysmorphic”—the perceived flaws are not observable to others and thus one’s excessive preoccupation reflects a distorted view of one’s own appearance. This means that individuals who have actual physical defects, such as burn victims, and are concerned about how they look would not meet criteria for BDD, although their concerns may still warrant clinical attention. This logic also applies to individuals whose primary concerns are weight- and shape-related (e.g., being too heavy) and are in fact, overweight or obese, as these concerns would not be “dysmorphic” in nature.

BDD afflicts approximately 30 million people in the general U.S. population(1). This rate is even higher among nonclinical samples, and even more among patients presenting for cosmetic surgery and dermatology clinics. BDD affects both men and women approximately equally, although body parts of concern may differ by gender (men may worry more about their build and thinning hair, whereas women may be more concerned with their skin and stomach area). Typically, BDD develops in adolescence (age 12-13) and tends to have a chronic, unremitting course.

Why is identifying BDD critical to a plastic surgeon (and other cosmetic providers)?

Up to 76% of patients with BDD seek consultation for cosmetic procedures and up to 60% of patients with BDD actually undergo potentially unnecessary surgical procedures for their perceived defects (2). In one survey of the members of the American Society for Aesthetic Plastic Surgery (ASAPS), 84% of surgeons reported that they had operated on a patient who they believed was appropriate for surgery, only to realize after the operation that the patient had BDD— and 82% of these surgeons believed that these patients had a poor postoperative outcome (3). Another study of 200 patients with BDD who underwent surgical and minimally invasive cosmetic procedures found that only 2.3% of these patients experienced a positive outcome as a result of their procedure (4).

Although patients with BDD frequently seek plastic surgery to address their perceived defects in appearance, numerous studies actually show that the great majority of patients with BDD tend to have poor satisfaction and negative outcomes following surgery. It is therefore critical for cosmetic surgeons to identify patients with BDD and manage them appropriately, as surgery will likely NOT help. As physicians, we all take the Hippocratic Oath and one of the promises within that oath is “first, do no harm.” The risks simply outweigh the benefits for cosmetic surgery in patients with untreated BDD (see below for treatment options). Unfortunately, a recent study showed that cosmetic surgeons have a poor ability to screen for BDD (5). And most of us know…if you consult with enough surgeons, you may find one willing to operate on you.

Although as plastic surgeons, we seek perfection, no plastic surgery procedure has a perfect outcome. Even in the best of hands, most patients experience some degree of an adjustment period following a cosmetic procedure. Although the vast majority of patients who undergo cosmetic surgery do well and are ultimately delighted by their results, the reality is that surgical success is determined not only by improvement in physical appearance, but intimately related to emotional and psychological outcomes. The fundamental problem in BDD is one of body image, rather than one of physical appearance. Therefore, changing physical appearance without improving body image is akin to chasing a moving target.

How do you evaluate BDD?

Like many other psychiatric disorders, BDD is known as a disorder rather than a disease because we do not fully understand its etiology. Thus, our methods for evaluating BDD rely on clinical interview and behavioral observations. The current diagnostic system in the U.S. is the Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition (1).

To meet criteria for BDD, one’s areas of concerns cannot be noticeable to others (or may only be slightly noticeable to others) and the individual must have engaged in repetitive behaviors at some point to address these concerns. The clinician must also disentangle appearance concerns related to other disorders, such as eating disorders, obsessive-compulsive disorder, social anxiety disorder, and skin picking disorder.

Individuals with BDD commonly hold a belief that their perceived flaws are in fact highly noticeable to others, and that people who actually have BDD are very attractive- an argument for why they do not have BDD. These beliefs may reflect a firm conviction in physical etiologies for the disorder, rather than psychological/psychiatric ones, and suggests a particularly distorted body image.

How do you treat BDD?

For a psychologist, the most challenging aspect of treatment is getting someone with BDD to become interested in a nonphysical, nonpsychiatric treatment. However, individuals with BDD tend to be more willing to try a psychiatric intervention once they have tried some other treatments to no avail.

The first-line psychological treatment for BDD is cognitive-behavioral therapy. It is a time-limited (22 sessions max), skills-based intervention that targets problematic thoughts/beliefs and behaviors that maintain the cycle of distress, and ultimately teaches patients to become their own therapists. We have found this treatment to be effective even for people who strongly believe that their distress is due to physical rather than psychological factors.

One of the cornerstone concepts in cognitive-behavioral therapy is understanding the difference between physical appearance (how you look) and body image (how you feel about how you look), and considering the possibility that continued efforts to change/improve one’s physical appearance may still leave one unhappy with how one looks and may not be worth the costs. Typically, after treatment, patients report feeling more accepting of their bodies and themselves, and that even if some concerns remain, they have a reduced impact on their lives. There have been three randomized controlled trials testing the efficacy of cognitive-behavioral therapy, relative to waitlist or no treatment, and these studies show that CBT is associated with at least 50% reduction of symptoms by posttreatment.

The first-line pharmacologic treatment for BDD is with selective serotonin reuptake inhibitors, such as Prozac®, Celexa®, Lexapro®, Luvox®, Zoloft®, and Paxil®. Typically, treatment is effective only at higher doses and for longer durations than for the treatment of depression. Studies show that about two-thirds to three-quarters of people see a 30% reduction of symptoms with these kinds of medications.

Does this resonate with you? Find further reading and resources below:

International OCD Foundation: https://bdd.iocdf.org/expert-opinions/
Body Dysmorphic Disorder Foundation: http://bddfoundation.org
Association for Behavioral and Cognitive Therapies: http://www.abct.org/
Wilhelm, S. (2006). Feeling Good About the Way You Look: A Program for Overcoming Body Image Problems. New York: Guilford Press.
Phillips, K. A. (2005). The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press.

References
1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, DSM-5. Washington D.C., American Psychiatric Association.
2. Phillips KA, Grant J, Siniscalchi J, et al. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics. 2001;42:504–10.
3. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survery of American society for aesthetic plastic surgery members. Aesthet Surg. 2002;22(6):531-5.
4. Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Annals of Plastic Surgery. 2010;65:11–16.
5. Joseph AW, Ishii L, Joseph SS, et al. Prevalence of body dysmorphic disorder and surgeon diagnostic accuracy in facial plastic and oculoplastic surgery clinics. JAMA Facial Plast Surg. 2016 Dec 8. [Epub ahead of print]

By Angela Fang, Ph.D. - Clinical Psychologist and BDD Expert
and Leslie Kim, MD, MPH - Facial Plastic Surgeon and Co-Founder