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Surgery and Cosmetics

Magda Blessmann Weber

Body Dysmorphic Disorder

Magda Blessmann Weber

Friday, June 20, 2008


Body dysmorphic disorder (BDD), a relatively common psychiatric disorder, was first described in 1886 as dysmorphophobia by Morsellini,1 and is currently included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defined as a formal diagnosis category. Its onset is usually during adolescence and is characterized by an excessive concern with a minimal or nonexistent appearance defect.2

Because symptoms are related to body appearance, these patients frequently go to a dermatologist or cosmetic surgeon. As such, a small number of patients presenting to these specialists qualify for a psychiatric diagnosis of BDD. It is important to note that some concern with our appearance is healthy, and we must recognize this difference in those presenting with symptoms of BDD.

Patients with BDD have markedly poor quality of life (QOL) and psychosocial functioning across the domains of work, school, social relationships, household, leisure activities, satisfaction and psychological distress. QOL is even poorer when compared with major depression and acute severe medical conditions. BDD is a public health issue with great socio-economic impact due to the high number of visits to the doctor's surgery.

The perceived physical anomaly may involve the shape and size of the whole body or be centered on a single unit, such as the face, nose, skin or hair. Despite having the same prevalence between genders, male patients with BDD complain more about the genitals, height and presence of excessive hair, whereas female patients complain more about the face, breasts, hips and legs.3 Patients who are concerned about their face often pick compulsively and in some cases cause life-threatening injuries. These patients are a challenge to treat and to establish a good doctor-patient relationship with.4

The diagnostic criteria for BDD listed in DSM-IV are:2

  1. Excessive concern with an imagined or minimal defect;
  2. Preoccupation that causes major distress or even impaired occupational or social functioning; and
  3. Concerns that are not caused by another psychiatric disorder.


Despite being a common disease, BDD is still under-diagnosed even in psychiatric settings. Studies in cosmetic surgery report an incidence rate of 15%, whereas in dermatology, the rate is reported as 11.9%.5,6 The prevalence of BDD is higher in unmarried or divorced patients, with an incidence rate of around 66%.7

Phillips and Diaz7 demonstrated that nearly half of patients suffering from BDD had previously sought treatment from a dermatologist and one third had requested cosmetic surgery. Approximately 20% of these patients actually received cosmetic surgery and two thirds of them reported no changes in, or worsening of, their appearance.

Clinical features

Patients with BDD are easily identified in dermatologic and cosmetic surgery settings because they usually request treatment for minimal or nonexistent defects. It is important to identify BDD because of the great morbidity and potentially poor outcomes associated with the disorder. BDD is time-consuming, with patients spending more than 1 hour per day thinking about or dealing with the abnormality. Patients also present with compulsive behaviors, such as excessive checking of the perceived appearance in mirrors, camouflaging the perceived deformity, combing, styling, or washing.4

Mirror gazing is the most common behavioral habit. Veale and Riley8 demonstrated that patients feel more distressed before looking in the mirror and an inordinate amount of time is spent in this activity. They can spend up to 73 minutes in a single session of mirror gazing.

BDD is a chronic disease with only 9% of patients experiencing full remission and 21% experiencing partial remission over 1 year of follow up. This is particularly problematic because individuals have unusually poor functioning and QOL, depending on the severity of their BDD.9

Physicians should ask themselves two questions: is it better to perform the surgery even though the patient will probably be disappointed at the end of it or should the patient be referred to a psychiatrist prior to any surgery being performed? It is also important to remember that referring a patient to psychiatric treatment is not an easy task, and is not necessarily associated with a successful outcome.

In most patients with BDD, the surgical success is extremely poor. After receiving surgery, the patient will claim that it has failed to improve the defect and, even if the surgeon could convince them that the surgery has improved the imperfection, the patient will often turn their attention to another part of their body. Moreover, in some cases, the patients will take legal or physical actions against the doctor.10 In male patients, the violence can be serious, especially when associated with the use of anabolic steroids.11

Some clues to identify patients with BDD are as follows:4

  1. Excessive concern with, or distress over, minor or nonexistent appearance flaws;
  2. Difficulty functioning with problems at work or social avoidance;
  3. Skin picking;
  4. Camouflaging apparent appearance flaws by wearing heavy makeup or a hat;
  5. Reassurance seeking or excessive grooming;
  6. Referential thinking, such as the belief that others are taking special notice of them because of how they look;
  7. Dissatisfaction with previous dermatologic or surgical treatment;
  8. Unusual or excessive requests for cosmetic procedures; and
  9. Belief that the procedure will transform their life or fix all of their problems.

Once BDD is suspected, there are some questionnaires that can be used as a useful screening tool in the cosmetic and dermatological setting such as "The Body Dysmorphic Disorder Questionnaire".12  Not only the doctor but all of the clinic staff must pay attention to these patients, as to diagnose the disease as early as possible and to give them the correct treatment.

Dermatologists must be trained to identify BDD in dermatologic specific diseases such as acne. Patients with acne are likely to meet criteria for a diagnosis of BDD and are twice as likely to meet these criteria if they are being treated with isotretinoin or have received isotretinoin in the past. Even after the successful treatment of acne, BDD symptoms may persist, with the patient's concerns shifting to another feature13.


Patients with BDD have been described as some of the most difficult patients for dermatologists to treat. Besides having no apparent results, treatments can lead to an exacerbation of the disease. The consequences can be devastating, with some patients attempting suicide.14

Dermatologic or surgical treatment alone is usually ineffective, whereas psychiatric treatment, including serotonin reuptake inhibitors and cognitive behavioral therapy, are often more effective. Some patients, including those who pick the skin, could benefit from the combination of dermatological and psychiatric treatments.15

Dermatologists must demonstrate to patients that they understand their concerns and suffering, and explain that psychiatric treatment will help relieve their symptoms. It must be clear that the dermatologic treatment should not be interrupted, and that the patient will have two specialists to treat them. This approach may help in getting the patient to agree to see a psychiatrist.


BDD is still an under-recognized disease, despite its severity and morbidity. Dermatologists and cosmetic surgeons must pay attention to patients presenting with symptoms of BDD and refer them to psychiatric treatment. Moreover, researches in the area of BDD must be highly informed to better understand and treat these patients.


  1. Morsellini E. Sulla dismorfofobia e sulla tafefobia. Bull Acad Med Genova 1886; 6:110. apud Jakubietz M, Jakubietz RJ, Kloss DF, Gruenert JJ. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007; 119:1924-30.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, D.C.: American Psychiatric Association, 1994.
  3. Jakubietz M, Jakubietz RJ, Kloss DF, Gruenert JJ. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007;119:1924-30.
  4. Phillips KA, Dufresne Jr RG. Body dysmorphic disorder: a guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-43.
  5. Ishigooka J, Iwao M, Suzuki M et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283-7.
  6. Phillips KA, Dufresne Jr RG, Wilkel C et all. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol 2000;42:436-41.
  7. Phillip KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 1997;185:570-7.
  8. Veale D, Riley S. Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder. Behav Res Ther 2001;39:1381-93.
  9. Phillips KA, Pagano ME, Menard W, et al. A 12-month follow-up study of the course of body dysmorphic disorder. Am J Psychiatry 2006;163:907-12.
  10. Glaser DA, Kaminer MS. Body dysmorphic disorder and the liposuction patient. Dermatol Surg 2005;31:559-60.
  11. Phillips KA, Castle DJ. Body dysmorphic disorder in men. BMJ 2001;323:1015-6.
  12. Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001;27:457-62.
  13. Bowe WP, Leyden JJ, Crerand CE, et al. Body dysmorphic symptoms among patients with acne vulgaris. J Am Acad Dermatol 2007;57(2):222-30.
  14. Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detection and treatment in a surgical dermatology practice. Dermatol Surg 2004;30:1391-99.
  15. Williams J, Hadjistavropuolo T, Sharpe D. A meta-analysis of psychological and pharmacological treatments for body dysmorphic disorder. Behav Res Ther 2006;44:99-111.