Important to Discuss? By Connie Hiers, MD, FACS

Body Dysmorphic Disorder (BDD)

What it is and why is it important to diagnose?

By Connie Hiers, MD, FACS

Body Dysmorphic Disorder (BDD) is a mental illness that involves obsessing over a real or imagined flaw in appearance. For the “Body,” the flaw can be in any area, but is usually visible and often on the face. “Dysmorphic” is the sense of unease with one’s appearance or gender identity. “Disorder” is the state of confusion or disruptive functioning. All of us have things we may not like and would like to change. However, it is not normal when such things cause emotional distress. The flaw may be minor or imagined and patients may spend several hours a day checking their appearance.

BDD cannot be cured, but it can be helped and managed. There are over 200,000 cases reported in the US yearly. The International Obsessive Compulsive Disorder Foundation estimates that 1 out of 50 in the US struggle with BDD. No lab testing or imaging can diagnose this illness, but BDD questionnaires can be a good starting place to screen patients with potential risks. This population is small, but often seen in cosmetic medical, oral and mental health practices. It often begins in adolescence and may go undiagnosed for years. It affects men and women equally, but the concerned areas do vary. Men tend to focus more on genitals, height, muscular, body build and excessive body hair. Women tend to focus more on breasts, hips, legs, weight and skin. Both sexes often focus on facial features, especially noses.

Triggers for BDD often begin in childhood. They may include traumatic events, emotional conflict, mental or physical abuse or neglect, family dysfunction, bullying and social media influences. Genetics and brain function may often play a role.

Signs and symptoms of BDD include spending an hour or more focusing on appearance or the perceived flaw. They may perform repetitive and time-consuming behaviors like looking in the mirror, grooming, picking at the skin or even hiding the area. Patients may seek constant reassurance that the defect is not visible or too obvious. They are often self-conscious and may not want to go out in public. They may be anxious around others, especially strangers. It is hard for them to focus at work or school, and may drop out or fail classes, quit or be fired from jobs for poor performance. Often, they have diminished relationships with family, friends and difficulty with intimate relationships. Some are so self-conscious that they even have difficulty leaving the house. Also, they may be burdened with financial troubles or even bankruptcy. A few may even have suicidal ideations or attempts. BDD patients in healthcare may be difficult to spot and are difficult to treat. Patients are preoccupied with a physical flaw, minor or invisible to others. They tend to seek doctor after doctor to validate their concerns and surgically remove “the flaw.” However, they are still unhappy after surgery, may be difficult to deal with post operatively, and then move on to another doctor. Patients think that surgery will be the cure for depression or anxiety and may even become addicted to surgery. Often, they have multiple surgeries on the same area and the surgeries can make the altered perception worse

by reinforcing skewed thinking. Even if patients get excellent results, they fail to see the improvement or think they are still unattractive. They believe the flaw is the source of their unhappiness and failures. Many do not acknowledge the disorder and do not seek help.

Red flags for medical personnel include patients being overly complimentary, especially when meeting for the first time. They have a history of seeing many doctors for the same problem, and have had multiple cosmetic procedures, especially in the same area. Rhinoplasty is often a common surgery the BDD seek. When patients use medical terms related to their procedures, like “spreader grafts” for rhinoplasty, this could be a red flag. Good candidates for surgery have a healthy selfimage and want to improve a specific area.

Advice for the healthcare provider is to give enough time during the consultation to listen to the complaints. Always have a nurse, MA, or a witness present and document the complaints. If the physician is concerned that BDD may be an issue, questionnaires can be used as a screening tool. If the questionnaire shows risks for BDD, the physician should refer the patient to psychiatry for an evaluation. Always, do not overpromise results from surgery.

Risks to healthcare providers may include unhappy patients, verbal criticism, negative reviews, complaints to the Texas Medical Board and malpractice suites. Aggression and violence have been reported and even murder of the physician.

Also, there is another risk that is often not realized that some patients are not emotionally competent to give legal consent for the procedure. This can lead to more legal suites for battery and even the possible loss of license to practice medicine.

Many websites offer BDD questionnaires as a quick screen for patients and sample questions may be used and graded yes/no or on a scale of one to five for never to always, or none to severe.

1. How many times a day do you check yourself in the mirror? 2. What extent do you feel unattractive, flawed, or ugly? 3. Does this cause you distress? 4. How often do you avoid social activities? 5. How much time do you think about your appearance? 6. How often does your appearance interfere with school, work, or relationships? 7. Is your appearance the most important aspect of who you are? 8. How worried are you about your appearance?

For happier patients and healthcare workers, psychological reasons for elective cosmetic procedures and realistic results should be discussed with all patients. If a patient is not realistic about the defect or the result, then perhaps surgery is not the best answer. Counseling and a psychiatric evaluation may be needed instead.

References: 1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, published by American Psychiatric Association, Washington, DC. 2. Websites:

A: www.bddfoundation.org/information

B: www.lifespn.org

C: www.bdd.iocdf.org

D: www.timberlineknolls.com

E. Mental Health America – www.mhanational.org

Connie Hiers, MD, FACS is a board-certified plastic surgeon who has been in private practice for 37 years. She graduated from the University of Texas Medical School in Houston, now McGovern Medical School. She is a member of the Bexar County Medical Society.