Body Dysmorphic Disorder (BDD) is a psychological disorder in which the affected person is excessively concerned about and pre-occupied with perceived defects of their face and/or body features. The obsession with body image can be all consuming to the point where occupational and/or social functioning is impaired. The disorder is frequently associated with anxiety disorders, social withdrawal and clinical depression. In fact, many people suffering with BDD also have a depression diagnosis as well as obsessive compulsive disorder, social phobia, and chronic social anxiety. BDD sufferers have a more than double rate of completed suicide and a suicide ideation rate of 80%. Men and women are affected equally. There is no specific cause for BDD, but is thought to be a combination of psychological, emotional, biological, and environmental factors.
Many patients with BDD are able to hide their diagnosis from plastic surgeons by down-playing the crisis within and may appear just another vain patient which all Plastic Surgeons are used to seeing. In my experience, many of these people actually have small, but visible problems that may be described as much worse than the actual problem. These patients usually have consulted with other Plastic Surgeons and have learned not to be too dramatic regarding the perceived defect so as to get the surgery desired. It is only after surgery that the full extent of the problem is revealed. Basically, these patients, if operated on, cannot be satisfied with the result even if photographic documentation shows improvement. One way to identify these people pre-operatively is that they frequently do not see the problem in photographs, but will readily show you in the mirror or on their face. Since these people generally spend at least an hour per day studying their visage, they can in detail describe the nature of the problem even though it may be “within normal limits.”
Many of these people describe in detail and quite convincingly how their defect has kept them from employment and socialization. They reveal chronic low self-esteem and exhibit paranoid ideation thinking that everyone notices the problem and is secretly mocking. They frequently will have a litany of “friends” that reinforce the severity of the problem. If left untreated, the symptoms persist or even worsen over time. The diagnosis is usually obvious, but can be documented with any of a number of BDD questionnaires available on-line. Even with the chronic and unremitting nature of the disorder, it is treatable with cognitive behavior therapy and medications such as Prozac®. It is uniformly true that Plastic Surgery to address the perceived deformity is never a good idea and in many cases can cause harm to the patient (psychologically).
The most common complaints have to do with the nose, face, and skin issues. It is well known that the nose and facial features are psychologically charged ones even for those without BDD. A poor self-image leads to a chronic loss of self-esteem and destroys any quality of life for those sufferers. Referring these individuals for psychiatric evaluation is necessary, but seldom happens unless there is family support for the intervention. I have also noticed a higher than usual incidence of anorexia and/or bulimia in these patients.
Realistically, as a plastic surgeon one should never be caught off guard by the BDD patient as these people have a very difficult time hiding their diagnosis even if they know they will be turned down for surgery.