A Publication of Skin Deep World
Written by Boris Ackerman, M.D.

After watching shows like Dr. 90210, Extreme Makeover, The Swan, and Nip Tuck, you may find yourself gazing into the morrow with a more critical eye. The hype of plastic surgery has lead some to take drastic measures to correct imperfections like an annoying pooch under the belly button or a slight flare in the nostrils. But what if a serious psychological condition, Body Dysmorphic Disorder (BDD), is the underlying factor for choosing cosmetic surgery?

BDD is a preoccupation with an imagined physical defect or an exaggerated concern about a slight defect in appearance. Individuals with this disorder see themselves as ugly and often turn to plastic surgeons to fix their appearance. Any body part can become the focus of attention, but the most common areas of preoccupation are the fact, skin and hair. While many people are unhappy with parts of their body, individuals with BDD allow this preoccupation to significantly impair their social life and performance at school or work. Sufferers tend to spend several hours a day scrutinizing and trying to conceal their perceived “flaw.” They may camouflage themselves excessively with body position, posture, clothing, makeup, a hand, hair or a hat.

The Social Disconnection

Individuals with the disorder may find it very difficult to meet new people or make friends because of the intense fear of being judged negatively. In many cases, the individual may severely limit contact with others or avoid social exposure altogether. When BDD becomes a chronic problem, the person withdraws from society, may drop out of school and sink into such a deep depression that he or she contemplates suicide as a solution to their profound distress.

BDD has symptoms in common with Obsessive Compulsive Disorder (OCD) – a person may constantly check a reflection in a mirror or engage in elaborate grooming rituals. The obsession may progress to the point that the person develops a delusional disorder, which can induce great fear in the patient. They may feel like they are infected with parasites or have excessive concerns about body odor.

Rather than seeking psychiatric treatment, many individuals with BDD turn to plastic surgeons or dermatologists for help. In fact, studies show that about tow to seven percent of patients who undergo plastic surgery have BDD. Patients diagnosed with BDD are not appropriate candidates for plastic surgery. Based on the limited studies that are available, most patients with BDD who have had plastic surgery are dissatisfied with the results and often then become preoccupied with another part of their body. The patient may seek multiple surgeries and never be satisfied with the results. Sufferers tend to spend several hours a day scrutinizing and trying to conceal their perceived “flaw.” They may camouflage themselves excessively with body position, posture, clothing, makeup, a hand, hair or hat.

It is very difficult to diagnose individuals with BDD because often they are extremely secretive about their condition and try to hide the symptoms. Additionally, many health professionals are unaware that BDD is a psychiatric disorder and can be treated. As standard procedure, plastic surgeons consult with all prospective patients to evaluate the individual as a candidate for surgery. A typical consultation requires discussing the individual’s medical history and discussing what he or she hopes to achieve from plastic surgery, including goals and expectations, which should be realistic.

Many plastic surgeons are aware of various psychiatric disorders. They look for:

• Body image perceptions that are distorted and not realistic
• Impaired work or social functioning due to a physical complaint
• History of multiple procedures to correct a minor “defect”
• General signs of depression or anxiety
• General signs of social phobia or obsessive compulsive disorder

A plastic surgeon may directly address any characteristic behaviors noticed. This may include skin picking, compulsive mirror checking or camouflaging. If BDD appears to be present, the plastic surgeon should refer the patient to his or her primary physician or a psychiatrist for a psychiatric evaluation before following through with surgery. Ultimately, the plastic surgeon will use personal judgment to decide whether the patient would benefit from surgery. Generally though, according to The American Society for Aesthetic Plastic Surgery, many patients who seek treatment from plastic surgeons for minor imperfections do not have BDD and are, in fact, excellent candidates for plastic surgery.

Individuals with BDD often respond positively to cognitive behavioral therapy as well as the use of serotonin-reuptake inhibitors (also knows as SRIs or SSRIs). These include Prozac, Paxil and Zoloft and appear to be effective for a majority of people with BDD. However, there have not been enough controlled clinical studies to clearly define the best treatment approach for this disorder.

Even though there are effective treatments for BDD, most sufferers seek and receive treatments that don’t work.  These ineffective treatments include surgery, dermatologic treatment, dental treatment and other non-psychiatric procedures.  People with BDD can waste much time and money on these treatments, and often end up disappointed or angry when they do not feel the relief they are seeking.

Various health organizations are funding programs to spread the word about BDD and research the disorder further, and internet sites such as bddcentral.com have formed support groups for those suffering from BDD. 

If you or someone you know has exhibited any of the following symptoms, be aware that self perceptions may be distorted by a treatable disorder. Please seek guidance from a licensed specialist or physician.

• Frequently comparing your appearance with others’ or scrutinizing the appearance of others.
• Often checking your appearance in mirrors and other reflective surfaces.
• Camouflaging the perceived defect with clothing, makeup, a hat, your hand, your posture, or in some other way that divers attention from the defect.
• Seeking cosmetic surgery, dermatologic treatment or other medical treatment when doctors or other people have said such treatment isn’t necessary.
• Questioning and “fishing for compliments” –seeking reassurance about the flaw or attempting to convince others of its apparentness.
• Anger or resentment toward those who do not see your perceived flaw.
• Excessive grooming (i.e. repeatedly combing hair, shaving, cutting hair, applying makeup and/or concealers).
• Frequently touching the defect.
• Picking and touching your skin to make it smooth.

Such behaviors can make the disorder worse and can ultimately lead to depression, periods of denial, and avoiding or altogether hiding mirrors.

Boris M. Ackerman, M.D., is a board-certified plastic surgeon specializing in facial rejuvenation with endoscopy, laser liposculpture and breast surgery. He was one of the first surgeons in California to utilize the laser in plastic surgery. He has been in private practice in Newport Beach, Calif., since 1987 and is on staff at Hoag Hospital in Newport Beach, Calif. He is an active member of the American Society of Plastic and Reconstructive Surgeons and the Orange County Medical Association. He has recently appeared on the Discovery Channel’s Plastic Surgery Before and After and MTV’s I Want a Famous Face.