Body Dysmorphic Disorder and Cosmetic Surgery Outcomes

Posted March 28, 2015 in Home, Patient Safety

Pablo Picasso's Girl Before a Mirror

Pablo Picasso’s Girl Before a Mirror

Body Dysmorphic Disorder (BDD) is a socially isolating belief that one’s body is unusually defective. It effects 1-2% of the population, and is equally prevalent in women and men. BDD is defined as a preoccupation with an imagined or trivial defect in appearance, causing clinically significant distress or impairment in social, occupational, or other functioning. BDD can manifest as a strong desire to hide, or fix the defect.

Body Dysmorphic and Plastic Surgery Patients

Most people with Body Dysmorphic Syndrome become socially isolated, but some seek the care of a Plastic Surgeon for correction of their problem. Unlike most plastic surgery patients; however, BDD patients do not always have a physical flaw, and those who do tend to have exaggerated concern about what seems to be a minor flaw. Even if the defect can be corrected with Plastic Surgery, BDD patients do not get the usual relief that most Plastic Surgery patients get. This can lead to continued distress, repeated operations and, as confirmed in a new study, more surgical complications. More on this below.

Body Dysmorphic Disorder Research

BDD was described by Enrico Morselli in 1886, as dysmorphophobia. One hundred years later, it made its way into the DSM-III-R, and last month an article published by Austin J. Woolley and Julian D. Perry in the American Journal of Ophthalmology confirmed what Plastic Surgeons have know about the disorder. The article entitled Body Dysmorphic Disorder: Prevalence and Outcomes in an Oculofacial Plastic Surgery Practice confirmed the important aspects of how BDD affects, and can complicate, plastic surgery.

Picasso - Tete de Femme - Jacqueline

Picasso – Tete de Femme – Jacqueline

BDD and Eyelid Surgery (Blepharoplasty)

The article focused on a consecutive series of 728 Blepharoplasty patients who were screened with the Dysmorphic Concern Questionnaire. 50 patients (6.9%) scored greater than 9, and were classified as positive for BDD. While this is higher than the percentage expected in the general population, it is not unusually high for patients seeking cosmetic surgery. The BDD group was then compared to a group of 150 control patients (who scored less than or equal to 8).

Characteristics of Body Dysmorphic Patients

Significant differences (confidence interval of 95%) were demonstrated. Patients in the positive questionnaire screening group were:

  • Significantly younger (P = .004)
  • Had more eyelid surgeries (P = .007)
  • Experienced higher rates of complications after surgery (P = .002)
  • Reported higher postoperative pain scores (P = .034)
  • Required more reoperations (P = .050)
  • Had a higher technician word count compared to the control group (P = .003)

While you might expect these types of findings, the magnitude of the differences always surprises me.
For example, the reoperation rate for BDD patients was 22.7% compared to 6.9% in the control group. Perhaps this is understandable, given the subjective nature of reasons for reoperations, coupled with the BDD patient’s strong desire to fix a problem, even if it is slight or imaginary. Moreover, the complication rate for BDD patients was 19.1% compared to 0% in the control group. Complications are much more objective. Was there a component of sabotage in the BDD group? Because how one feels about the outcome of eyelid surgery, should not lead to such a significant increase in outcomes like infections or bleeding.

BDD vs. OCD

The American Psychiatric Association classifies all recognized mental disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The latest edition, the DSM-5 (2013), categorizes Body Dysmorphic Disorder in the obsessive–compulsive spectrum, along with anorexia and muscle dysmorphia. Unfortunately, Body Dysmorphic Disorder manifests in greater levels of depression and a greater fear of social interaction than Obsessive Compulsive Disorder (OCD).

Patterns of BDD Behavior

Patients with BDD are prone to compulsive or repetitive behavior, and solutions often give only momentary relief. Typical patterns of behavior include:

  • Camouflaging (clothing, makeup, hair, hats)
  • Comparing themselves to others in terms of appearance
  • Seeking plastic surgery
  • Constantly checking the mirror
  • Skin picking

Plastic Surgery is not the Cure

Picasso – Tete de Femme - Jacqueline - Same painter, same woman, different view of the world.

Picasso – Tete de Femme
Same painter, same woman, a more connected view of the world.

While the physical deformity in BDD may be minor or absent, the distress experienced is real. Seeking Cosmetic Plastic Surgery may be a symptom, but Plastic Surgery is not the cure. Cognitive behavior therapy seems more effective than medication, but both modalities are used. Interestingly, patient improvement is associated with an increase in the number and quality of connections between the orbitofrontal cortex and the amygdala. Both these areas of the brain are involved in decision making, while the amygdala also helps with emotional reactions and processing memory. More connected inside. More connected to the outside, and less Body Dysmorphia.