There can be multiple reasons why a patient is seeking aesthetic procedures. A recent study, published in JAMA Dermatology, found that patient motivations consisted of seeking improvements in the following: aesthetic appearance (e.g. looking younger), physical health (e.g. preventing worsening of physical conditions), and psychosocial wellbeing (e.g. feeling more confident about onesself) (Maisel et al, 2018). However, in some cases, a serious psychological disorder, body dysmorphic disorder (BDD), may be the primary reason why a patient is seeking aesthetic treatment. Dey et al (2015) showed that around 13.1% of patients seeking cosmetic surgery had BDD. Due to this prevalence and the potential negative effects of aesthetic treatment on patients with BDD, practitioners must be able to catch this disorder and refer patients to mental health professionals for proper diagnosis.
Body dysmorphic disorder: the disease of self-perceived ugliness
BDD, or the disease of self-perceived ugliness, is a psychiatric disorder in which afflicted individuals have a pervasive distortion of their self-image, usually by having persistent preoccupations, or obsessions, with a particular part of their body (American Psychiatric Association (APA), 2013). Common obsessions of appearance include the nose, mouth, eyelids, muscles, breasts, and penile size in males. Research has suggested that compared to individuals without BDD, individuals with BDD show abnormal brain activity when processing visual information, and this suggests that these individuals have a distorted self-image in their minds (Feusner et al., 2010). The greatest challenge for BDD patients is to learn to accept that their physical defect does not exist, or if it does, to accept it without the all-consuming desire to change it.
BDD is also characterised by compulsions, or repetitive behaviours and mental acts, to alleviate the anxiety they feel from their self-perception of their appearance (APA, 2013). Some common compulsions found in individuals with BDD include seeking reassurance, comparing and contrasting their looks with others, mirror checking, mirror avoiding, and masking and camouflaging their perceived flaws. BDD patients must be helped to realise that these compulsive behaviours not only fail to reduce their anxiety, but indeed cause and stimulate it.
These obsessions and compulsions are time-consuming and can significantly interfere with an individual's daily functioning (APA, 2013). For example, the author previously encountered a patient who showed up to the location of her birthday party 32 hours late because she was absorbed in perfecting her face with make-up and facial wraps. Additionally, individuals with BDD often change their social and professional lifestyles to avoid appearing in public. They may also withdraw from society, which could cause them to lose their job, fall behind in school, or have failing relationships with other people.
By its nature, BDD is highly comorbid with other psychopathologies, such as obsessive compulsive disorder (OCD), excoriation disorder (skin picking), trichotillomania, major depression, social phobia, and substance abuse. High delusionality and suicidality are associated characteristics that make BDD a very dangerous disorder. Therefore, designing a treatment plan for patients with BDD must focus on the individual as a whole and target their specific symptomatology. Since BDD is a psychiatric disorder, it requires psychiatric treatment rather than aesthetic treatment, which rarely leads to successful outcomes in patients with BDD. Proper treatment for BDD can include medication (e.g. selective serotonin reuptake inhibitors (SSRI's)), cognitive-behavioural therapy (CBT), exposure and response prevention (ERP), psychoeducation, and family support led by an expert in BDD.
Impacts of aesthetic treatment on individuals with body dysmorphic disorder
Not only are aesthetic procedures performed on individuals usually unsuccessful in achieving patient satisfaction, they often have a negative impact on the patient's overall wellbeing. Plastic surgery or aesthetic procedures usually prove no benefit in patients with BDD, because no matter how good the results are, they are never good enough, and the obsession is still present. Although an aesthetic procedure can physically correct a flaw, patient satisfaction is only temporary, as BDD obsessions can shift to other body parts and symptoms can worsen (Phillips, 2005). This creates a snowball effect of a continuous cycle of obsessions, anxiety, compulsions, and relief.
A patient will obsess over a flaw, get anxiety from the obsession, compulsively seek out an aesthetic procedure to relieve the anxiety, find temporary relief, then obsess over another flaw, get anxiety from that obsession, compulsively seek out another aesthetic procedure, find temporary relief, and then find another perceived flaw to obsess over. This cycle will continue on and on, worsening the BDD and the severity of the obsessions and compulsions. If the cycle is not stopped, these patients may repeatedly seek surgery and show signs of addiction to cosmetic surgery due to the impulsive nature of BDD itself.
Patients who are dissatisfied with their aesthetic procedures may feel guilty and/or angry with themselves or their practitioner for not improving their appearance. As a result, there have been reports of individuals with BDD retaliating against their practitioners via lawsuits, physical assaults, and in some cases, even murder (Sweis et al, 2017). Not only are aesthetic procedures on BDD patients dangerous for the patients themselves, but they can also be dangerous for the practitioners.
Identifying patients with body dysmorphic disorder
The major concern is that BDD is not always recognised by plastic surgeons, aesthetic practitioners and general practitioners. BDD can take years to diagnose after onset, due to the notorious secretiveness of BDD patients about their preoccupations, likelihood to seek non-psychiatric help instead of psychiatric help, and inadequate training of aesthetic practitioners, plastic surgeons, dermatologists, and even psychologists in spotting and redirecting a BDD patient.
» To tackle this problem, practitioners must educate themselves on body dysmorphic disorder, whether it be by taking educational classes, connecting with professionals in the field of psychology or reading informational websites and articles «
To tackle this problem, practitioners must educate themselves on BDD, whether it be by taking educational classes, connecting with professionals in the field of psychology, and/or reading informational websites and articles. Since BDD can be a very sensitive topic, practitioners must be mindful and treat each patient with respect and in a non-judgmental manner when addressing this issue.
BDD must be screened for prior to any aesthetic procedures. Questionnaires should be given to all potential patients and should include questions enquiring about how many surgeries they have had, what the level of satisfaction was from their previous surgeries, if their self-image changed after the first surgery, how upset they are with the targeted body part, and how many hours a day they check or look at that body part. Specific screening tools have been developed and validated for the purpose of identifying patients with BDD, such as the BDD Questionnaire-Dermatology Version (BDDQ-DV) and Dysmorphic Concern Questionnaire (DCQ) (Danesh et al, 2015). Based on the results of these questionnaires and general interviewing during the initial consultation, practitioners will have a better sense of their patient's motivations. If BDD is suspected, it is important for practitioners to refer these individuals to a psychologist or psychotherapist who is an expert in BDD so that they can give a proper diagnosis and recommend further treatment.
Conclusion
Ultimately, individuals with BDD will not benefit from aesthetic procedures. The only treatment that can help them in the long-term is a surgery of the mind, to rewire and change their distorted body images, rather than cosmetic surgery which acts to physically, temporarily fix their flaws. Treating these individuals with aesthetic procedures and without a proper mental health referral can actually negatively affect the lives of the patients and even the lives of the practitioners. It should be stressed to practitioners to determine the motivators of a patient's request for aesthetic treatment. With a full understanding of the patient through screening and interviewing, practitioners will be better able to make a decision that puts their patient's overall quality of life first.