State of Affairs in the World of BDD

Body Dysmorphic Disorder (BDD) is a disabling condition that until recently has been largely ignored. However, it is estimated that 1-2 % of the general population has BDD, nearly 5 million people in the US alone (Gorbis 2004b, Bohne et al. 2002, Otto et al. 2001).

Sufferers of BDD worry excessively and unreasonably about some flaw in their appearance that may be minimal or even nonexistent (Gorbis & Kholodenko 2005, Phillips et al. 1993). These excessive worries and fears prompt sufferers to ritualize their behaviors by constantly checking the supposed defects in mirrors, seeking reassurance of their images from others, obtaining unnecessary cosmetic and/or dermatological procedures, and even conducting self-surgeries (Rosen et al. 1995, Phillips et al. 2000, Veale 2000, Phillips et al. 2005). These obsessive concerns and compulsive behaviors cause significant emotional distress and often significantly interfere with global functioning (DeMarco 1998, Gorbis & Anan’Yev 2004).

By its nature, BDD is highly comorbid with other psychopathologies, including OCD or OC Spectrum Disorders (29%), Major Depression (59%), Social Phobia (35%), and Substance Use Disorders (49%) (Phillips et al. 1999, 2005). In fact, over 50% of patients suffering from BDD have reported that the emotional distress of the disorder contributed to their substance use, and more than 30% have attempted suicide at least once (Grant et al. 2005).

BDD is not simply dissatisfaction with a body image, as we all tend to complain about a crooked nose, flabby stomachs, or becoming bald, which may all be factual. In BDD, patients suffer from a body image distortion that is internalized through social factors (e.g., peer pressure, parental critique, etc.) and/or, as of yet, an undefined neurological deficit (Slaughter & Sun, 1999). This internalized misperception creates disproportionate fears in the patient, whom relieves the anxiety through compulsive behaviors, such as persistently checking the perceived flaw in mirrors and reflective surfaces.

According to Maxwell Maltz (1960), a renowned authority of plastic surgery and the father of cybernetics, the issue of self-esteem is a vital component and determinant of a person’s self-image. Patients with BDD always present with negative self-esteem, low self-confidence, and a distorted self-image. They tend to seek external validation of their self-image and self-worth, and appearance determines their self-esteem to a great extent.

Although BDD was first recognized in 1886 by the Italian physician Morselli who called it dysmorphophobia or “fear of ugliness,” only recently has this condition received much attention. Plastic surgery has become increasingly available in the last 15 years, and has been viewed with more approval and tolerance from the general public (Mulkens & Jansen 2006). In the United States, 10.2 million cosmetic surgery procedures were carried out in 2005 (American Society of Plastic and Reconstructive Surgeons (ASPS),

2006), which represents an increase of nearly 700% since 1992 (ASPS, 1992). Although cosmetic medical treatments were previously the exclusive domain of plastic surgeons, today physicians from various specialties (e.g., dermatologists, ear, nose and throat specialists, and dentists) offer such treatments (Sarwer & Crerand, 2004).

Of recent years, the media has also been paying a great deal of attention to cosmetic surgery. For instance, the reality television show, Extreme Makeovers, has people undergo a complete make-over within about six weeks while showing the before, during, and after process of multiple surgeries. The media obsessively focuses on and gossips about those celebrities who have undergone the scalpel. On a more ethical standpoint, many documentaries on the devastating condition and treatment of BDD have been broadcasted on such television programs as the Discovery Channel, MTV, 20/20, The Learning Channel (TLC), and BBC among many other news programs. Thus in general, the public may experience a much lower threshold for deciding to undergo plastic surgery due to changes in the medical community, advances in technology, and the large increase in advertisements and media attention (Sarwer & Crerand, 2004).

In January 2007, People Magazine covered the topic, “Obsessed with Plastic Surgery,” in which Eda Gorbis, Ph.D., LMFT showed how a patient suffering from BDD can be treated with her novel technique using “crooked fun house” mirrors. The goal of the crooked mirror is to externalize that internal self-image that is cognitively distorted (Gorbis 2004a, Gorbis 2003). The crooked mirror not only puts a person’s self-image into perspective, but also sheds light onto the cognitive-distortions through the use of humor. In doing so, patients learn to come to terms with themselves, accept themselves with their imperfections, and begin to rebuild a more accurate mental picture of themselves along with their flaws.

However, since sufferers of BDD are more or less convinced that the solution to their problem is to improve their image, it is to no surprise that they are also more likely to view plastic surgery as their only option to change their appearance. With the increased availability of plastic surgery, BDD patients are, nonetheless, turning to cosmetic medical treatments again and again and again. This population tends to be under-diagnosed due to the fact that few patients with BDD have come forth admitting their condition has a psychiatric cause. Rather they are increasingly turning up in offices for cosmetic procedures. However, on a caveat, few BDD patients are ever satisfied with their body image due to their unrealistic expectations of outcome triggered by the distortion of their internalized self-image.

Currently, up to 15% of cosmetic surgery patients comprise of individuals suffering from BDD. Of those who opt for cosmetic surgery, only 7.3% of all treatments lead to both a decrease in concern about the treated body part and an overall improvement in BDD. Generally following treatment, patients worry more about another body area, develop new image concerns, become more concerned about minor imperfections in the treated area, or worry that an improved body part will become ugly again (Phillips et al., 2001). In a study conducted by Veale (2000), out of 25 patients with BDD who had undergone a total of 46 cosmetic procedures, 9 patients had performed their own Do it Yourself (DIY) surgery, in which they attempted to alter their appearance themselves (e.g. by using a staple gun). Even when patients were (partly) satisfied, the preoccupation transferred to a different area of the body.

This incapacitating condition of the BDD population has not only raised concerns from the media and mental health professionals. More and more plastic surgeons are increasingly alarmed by those patients who are continuously dissatisfied and who repeatedly seek surgery for the same area(s). Recently, Michael J. Gunson, D.D.S., M.D. from the Center for Corrective Jaw Surgery in Santa Barbara sought assistance from the Westwood Institute for Anxiety Disorders, Inc. for one of his patients who appeared to be suffering from BDD. Specifically, the patient had undergone several previous jaw surgeries performed by other surgeons, which Dr. Gunson had to correct. However, although the facial features appeared adequate following Dr. Gunson’s surgery, the patient continued to be dissatisfied while purposely wrenching one side of her face as to camouflage the perceived flaw. After consulting on this particular patient and gaining more information on the severity and treatment of this population, Dr. Gunson invited Westwood Institute for Anxiety Disorders, Inc. to speak on this topic at their national annual conference for plastic surgeons. He expressed the importance of disseminating knowledge of BDD to other plastic surgeons in order to increase their awareness and ethical responsibilities of individuals suffering from this condition.

Considering the grave dangers of treating patients with BDD, it warrants necessity for plastic surgeons and other cosmetic treatment professionals to recognize these patients within their population. However, many studies indicate that preoperative psychiatric screenings are rarely performed by plastic surgeons or other cosmetic treatment professionals (Thomas,

Sclafani, Hamilton, & McDonough, 2001). The findings and expressed concerns from some plastic surgeons evidently indicate that psychiatric evaluation of this condition and the patient’s motivation for treatment should be a standard practice in cosmetic treatment settings. As the Center for Corrective Jaw Surgery has sought collaboration with Westwood Institute for Anxiety Disorders, Inc., it is essential for other medical practitioners to collaborate with mental health professionals to identify and provide appropriate treatments for patients suffering from BDD.

Eda Gorbis, Ph.D., LMFT
Director
Westwood Institute for Anxiety Disorders, Inc.

Jenny C. Yip, Psy.D.
Director of Education
Westwood Institute for Anxiety Disorders, Inc.

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