Body Dysmorphic Disorder by Dr Henri Gaboriau

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A beautiful 28-year-old Eurasian woman, who we will call “Lisa”, recently came to me to have eyelid surgery. This is not at all an uncommon request by Asian women.

In the last ten years, there has been an increase of 58% of cosmetic surgeries performed on Asians. Lisa was half Asian and she was still wanted more Caucasian looking eyes. I performed the eyelid surgery for Lisa and she was very happy with the results. Only it didnÂ’t stop there…I later discovered she had already had five nose surgeries and four breast enhancementsÂ…next she demanded a faceliftÂ…

As a plastic surgeon I must distinguish between a patient who is experiencing a normal dislike of some aspect of her appearance and the patient who is actually suffering from a psychiatric disorder called Body Dysmorphic Disorder (BDD). Is it not uncommon for many of us to occasionally experience a mild dissatisfaction with our appearance. As many as one third of the population may not be happy with the way they look.

However, the way people feel about their appearance might have very little to do with how they actually look as even exceptionally attractive people experience a moderate dislike of their appearance. You only have to look at the number of procedures undertaken by some celebrities such as Cher and Michael Jackson who might be examples of BDD sufferers. The dislike of oneÂ’s own appearance is also enough to cause some occasional anxiety or depression. And it is all entirely normal and a very human feeling which does not last.

In BDD which often begins in adolescence, this feeling becomes chronic and has similarities with Obsessive-Compulsive Disorder. BDD is not a common occurrence. In the general population, the rate is around 2%. In those who opt for cosmetic surgery and aesthetics the figures would of course be higher. The results of various studies estimate this from 7% to 33%.

Whatever the statistics the patients share a common characteristic which is that they are constantly preoccupied with an imagined physical defect in appearance or a grossly exaggerated worry about a minimal defect.

Technically BDD is characterized by an excessive preoccupation with imagined defects in physical appearance. People with BDD are obsessed by the idea that some part of their body — their hair, nose, skin, hips, whatever — is ugly or deformed, when in truth it looks normal. BDD may focus on moles, freckles, acne, minor scars, facial or body hair, or the size and shape of their breasts or genitalia. People with BDD may spend an excess of time looking in the mirror, be forever fixing their hair, or wear heavy makeup or sunglasses inside as a form of camouflage. They may make multiple medical visits or have surgical procedures to correct the imagined defect.

Are you suffering from BDD – questions you should answer..honestly?
• Do you camouflage some aspect of your appearance with hands, clothing, a hat, or makeup?
• Do you fear ridicule in social situations, have a limited social life, and experience social anxiety?
• Do you make multiple visits to dermatologists or plastic surgeons?
• Do you undergo repeated surgical procedures to change perceived defects?
• Do you undergo surgery and aesthetic procedure that fail to make you feel better about yourself?
• Do you go from one extreme to another – constantly looking at yourself in shop windows or avoiding mirrors and your reflection altogether?
• Do you incessantly groom your hair and re-apply make up?
• Do you repeatedly examine parts of your body that you perceive to be ugly or defective?
• Do you constantly think about your perceived ugliness or defects?
• Does your obsession with your appearance cause problems with your personal relationships and/or your career?

The saddest aspect of BDD is that the preoccupation with the purported defect causes significant damage to relationships with friends and family. The syndrome tends to be chronic and can lead to complete social withdrawal. Students drop out of school and professionals quit jobs. The patient may undergo major depression, and even commit suicide. The BDD patient is not in need of surgery at all but requires psychological medical treatment, which might involve cognitive behavioral therapy and even medication, similar to that used in obsessive-compulsive disorder.

Typically, most of the patients with BDD are requesting some sort of facial plastic surgery (more than any other part of the body). Also their desire for surgery is absolutely obsessive. Before the diagnostic term of BDD was coined in the 1980s, these patients were labeled “insatiable”. But BDD patients are very good are trying to hide the fact that their preoccupation is abnormal. Such “insatiable” patients are not always easy to spot. Although the symptoms are unmistakable, it may take time to discover them. So how can a good surgeon know for sure?

Returning to the case of “Lisa”: She didn’t speak much of her personal circumstances so it was not possible to discover if she had problems there. However, during the course of my treatment, I found she had already had undergone five nose surgeries and four breast surgeries that were performed by other physicians. She came to see me because she wanted Caucasian eyes. Westernized eyelid surgery is a very common request for Asian women, so I did the surgery.

At first she seemed pleased with the results. Then she came back for another screening and wanted to have her nose done again—a sixth surgery and I refused. The big question is when to say “no more”. One year later she came back to have a facelift, which of course was not needed at all, so again I said no. She became upset and went to see another surgeon. Sadly, I do not know what became of her.

My rule of thumb is that if there is a huge gap between perceived defect and the degree of emotional distress it is causing the patient, then I donÂ’tÂ’ operate. BDD patients are preoccupied with small or no existing defects. But this is not what constitutes the problem. Appraising a defect is very subjective.

For one surgeon it could be nothing and for another one the defect could be dramatic. So what counts is the intensity of the patientÂ’s emotional distress due to the defect. The emotional intensity is measured by just how much the patentÂ’s life patient is being interrupted by thinking about the defect, and how many times the patient is willing to repeat surgery to correct a defect that really isnÂ’t apparent at all.

Most importantly it must be remembered that cosmetic surgery will not change your life.

Dr Henri P Gaboriau is Director of Sammamish Center for Facial Plastic and Reconstructive Surgery Seattle T: +1 425-898-1228 Email: practicemanager@sammamishfacial.com