What Is Body Dysmorphic Disorder and How Does It Relate to Plastic Surgery Addiction?
Body Dysmorphic Disorder (BDD) also known as Body Dysmorphia and Body Dysphoria or Body Dysphoric Disorder is a relatively unknown disorder involves preoccupation and excessive distress caused by an imagined or extremely small defect somewhere visible (to the individual) on their body. According to Phillips & Crino (2001), “Research findings indicate that body dysmorphic disorder is relatively common, causes notable distress and impairment in functioning, and is associated with markedly poor quality of life.” When it becomes so distressing it interferes with a person’s functioning in a main area of their life such as work, home-life, self care or social relationships it is considered a disorder. Once it reaches this stage often other symptoms develop which are efforts to cope with or “cure’ the “defect”, such as through extreme plastic surgery and/or repeated plastic surgery procedures. This can lead to plastic surgery addiction.
Likely, the most famous case of cosmetic surgery addiction was Michael Jackson. Other celebrities reportedly addicted to cosmetic surgery procedures include:
Joan Rivers - Comedienne Joan Rivers, who was never shy about her multiple facelifts, a brow lift, botox, soft tissue fillers, jaw implants, multiple nose jobs, veneers, blepharoplasty (eye work), liposuction, cheek implants, and breast implants.
Jane Fonda - Actress Jane Fonda has said that she regrets going overboard with cosmetic surgery procedures
Alicia Douvall - Model Alicia Douvall has had over 350 plastic surgery procedures to date, costing almost, $2.5 million.
Donatella Versace - Wife of famed designer, Donatella Versace has had face and neck lifts and has changed her forehead, her cheeks, her lips, and has also lowered her eyebrows.
Sarah Burge - Former Playboy model, Sarah Burge is listed in the Guinness Book of World Records for having over 100 plastic surgeries.
Lil’ Kim - Rapper Lil’ Kim s It appeared she had her skin bleached, her eyes reshaped, multiple nose jobs Botox in her cheeks, and a reshaped jawline.
Cher - Singer Cher has had a ton of cosmetic surgeries over the years. These have included nose jobs, refined eyes, and lots of Botox.
Diagnosing Body Dysmorphic Disorder
Mental disorders are classified based on the Diagnostic and Statistical Manual Fifth Edition (DSM-5). According to the DSM-5 the criteria for being diagnosed with Body Dysmorphia include:
Appearance preoccupations: There must be a preoccupation with at least one nonexistent or slight defect or flaw in their physical appearance. “Preoccupation” is usually conceptualized as thinking about the perceived defects for an hour or more a day. When an individual is distressed about and preoccupied with an obvious appearance flaws such as those that are easily noticeable at conversational distance, this is not considered BDD. Instead, it is diagnosed as “Other Specified Obsessive-Compulsive and Related Disorder”.
Repetitive behaviors: The person must perform repetitive, compulsive behaviors in response their concerns about their appearance. These compulsions can be behavioral and observable such as mirror checking, reassurance seeking, or frequently changing clothes. Other compulsions often associated with BDD are mental acts for example, constantly comparing one’s appearance with that of other people. (Individuals who don’t meet this criteria even if they meet all the other ones, are not diagnosed with BDD. They receive the diagnosis of “Other Specified Obsessive-Compulsive and Related Disorder”).
Clinical significance: The problem must result in “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” This helps to seperate those with BDD who need treatment from what are considered “normal” concerns about appearance that generally do not need to be treated.
- Differentiation from an eating disorder: If the individual’s obsessions involve preoccupations with being too fat or weighing too much, it’s important to determine if these concerns better fit an eating disorder. Only if the criteria for an eating disorder are not met can BDD be diagnosed. It is possible to have both an eating disorder and BDD.
- Specifiers: There are two specifier which can identify subgroups of BDD. These are Muscle dysmorphia which is a preoccupation with concerns that that one’s body is too small or lacking is sufficient muscles. The Insight specifier refers to the degree to which the person is convinced that their beliefs about their appearance are true. Levels of insight include “with good or fair insight,” “with poor insight,” and “with absent insight/delusional beliefs.”
Other Features of Body Dysmorphic Disorder
Body Dysphoria is associated with a number of additional features which increases the amount of distress of reflects the distress those suffering from the disorder feel. Not everyone with body dysmorphic disorder experience the exact same features but they do suffer from enough of them to cause significant distress.
Body Dysmorphia is associated with frequent rituals. These rituals may be based on time, such as being carried out every hour, or on the manner in which a behavior is carried out out such as checking perceived facial defects in a specific order. The person may stare at the perceived defect in the mirror for hours or examining it to see if it’s getting worse, as many as three to eight hours a day. Thus, Body Dysphoria has been said to have an obsessional quality to it, and may be related to obsessive compulsive disorder.
For some, the disorder becomes so bad they avoid all social situations due to being afraid of having a panic attack. Negative thoughts about the perceived defect and how it implies something there is something implicitly wrong with them overall can lead to the symptoms worsening. It has been estimated that one third of individuals with this disorder experience so much distress they feel as if they are literally dying from shame and disgust. In addition, due to high rates of social isolation and depression individuals with BDD have a high risk of suicide (Veale, 2004) with as many as one quarter of individuals suffering from this disorder killing themselves.
For those who are continuing to attempt to cope with the “defect” a common way they do this is through the use of heavy makeup even stage makeup. When the symptoms worsen significantly, people with body dysmorphic disorder no longer perceive makeup or other superficial means as sufficient for covering up the deficit any longer. Frequently, the next step is plastic surgery.
Body Dysmorphic Disorder and Plastic Surgery Addiction
It has been demonstrated that there is a higher rate of Body Dysmorphia in individuals having plastic surgery than in the general population. Yet, Sarver, Crerand and Didie (2003) state that from preliminary findings it has been shown that “persons with BDD do not benefit from cosmetic treatments and frequently experience a worsening of their BDD symptoms”. They conclude, due to this outcome, it is critical to discover a reliable method of identifying BDD in cosmetic surgery patients prior to any procedures being performed. One method suggested for accomplishing this is use of the Dufresne Body Dysmorphic Disorder Questionnaire to screen patients. Patients who score high on this screen indicating the presence of BDD can then be referred to the proper mental health professional for treatment.
Rhinoplasty in particular of all the cosmetic surgeries available appears to have the strongest effect on a person’s psychological functioning and is also among the most frequently type of plastic surgery people with Body Dysmorphia undergo. This procedure is often pursued for quite small alterations in the nose and so plastic surgeons often perform the procedure based on subjective rather than objective or measurable flaws.
This higher than normal rate of rhinoplasty in individuals with body dysphoric disorder has been supported by a study which showed that a significant number of people who complain about features related to their nose and present for cosmetic surgery have signs of BDD. More disturbing, in over 200 patients studied over the course of a year and a half, the researchers discovered through a pre-surgery questionnaire that over 40% of patients seeking rhinoplasty met criteria for the disorder. Whereas it had been thought that individuals undergoing plastic surgery, in particular rhinoplasty, had some limited features of body dysphoria, these results suggest that these patients actually often actually meet criteria for the disorder.
Overall, for individuals with body dysmorphic disorder, rhinoplasty has been shown to result in a disproportionately high degree of perfectionistic and obsessional qualities. These qualities were almost certainly already present but perhaps not previously exhibited until brought to the surface when the surgery didn’t meet the individuals expectations. This frequently resulted in seeking additional surgery from other surgeons due to complaints about the results of the previous surgical procedures. Ultimately, many people undergoing multiple rhinoplasty procedures wound up disfigured. This resulted from too much bone and cartilage being removed or damaged such that the nose did actually become a deformity and in cases fully collapsed. This outcome in individuals with BDD led to further distress and the need for intensive psychotherapy.
At this point most surgeons refuse to attempt to repair the damage due to there not being a high probability of success, with the nose always showing signs of some deformity that could not be reversed. Additionally, few patients have the high fees necessary to pay for the extensive procedure involved which are not generally covered by insurance. By this point, it has generally been agreed that the individual has BDD and is in need of psychological help, but this would have benefited the patient far more if referred sooner. The question is why patients who show signs of Body Dysphoric Disorder aren’t referred before the problem leads to multiple plastic surgeries resulting in real deformities.
Diagnosing Body Dysmorphic Disorder After Multiple Plastic Surgery Procedures
Given the knowledge that exists regarding the relationship between multiple cosmetic surgeries, especially rhinoplasty, and Body Dysphoria it is concerning that physicians who take an oath to “do no harm,” agree to perform additional procedures despite the likelihood of poor results and irreversible outcomes. However, this can be understood in light of the fact that individuals who want more surgery learn how to present their history in a manner that ensures that doctors will agree to perform the procedure. This includes not informing their doctor about previous surgeries so that the surgeon isn’t aware of what he or she is facing until in the midst of surgery or even afterwards.
A major red flag is when the patient admits to a previous cosmetic surgery (often hiding multiple others) and describes the anguish they experienced due to the results of the previous procedure. They will often describe how the previous procedure has ruined their lives. They may even bring drawings and pictures to point out where the mistakes were made and what they believe needs to be fixed. When the surgeon examines the patient and sees that the surgery was competently performed with no visible signs of a negative outcome despite the patients often histrionic presentation, the physician and family and friends should beware.
People with BDD also often alter their lifestyles to avoid appearing in public to prevent people they know and whom they may have an attachment from becoming too familiar with their perceived defect. As their perception of their defect grows they fear that others will be disgusted with their appearance and reject them. Those with body dysphoria also spend excessive amounts of time trying to look presentable.
However, they often miss important events, like family members weddings and graduation due to not feeling that they ever look good enough. When these characteristics are present in those requesting plastic surgery, it is possible they have had other procedures in the past and care should be taken in accepting them as patients.
In general, those with Body Dysmorphic Disorder undergo cosmetic surgery procedures but as these will never fix the perceived defect, they are always at risk for developing a plastic surgery addiction. People with BDD often feel driven to undergo excessive multiple procedures. They often appear obsessed with fixing their perceived deformity, to the point that Body Dysmorphic Disorder is considered to be related to obsessive compulsive disorder.
Sometimes those with BDD become so obsessed with their appearance they will perform surgery on themselves when no doctor will agree to do so. Most of these self performed procedures do not go well, and then do need a plastic surgeon to repair the damage. Individuals who go to this extreme generally have a history of multiple plastic surgery procedures and are so addicted that the thought of doing surgery on themselves seems reasonable.
This degree of obsessing over a slight or absent perceived defect to the point a person mangles their appearance with self performed surgery is a definite red flag that the individual has a plastic surgery addiction quite possibly due to the obsessive symptoms of Body Dysphoric Disorder.
A final important red flag that signals that the surgeon may be dealing with a case of BDD is that reassurance not only doesn’t help but actually makes matters worse. When the surgeon says that, according to the patients stated goal, the result of the previous procedures were successful and they cannot improve upon it, the patient either comes up with alternate “deformities” they want corrected or storms from the office in search of another surgeon.
General Guidelines for Helping Someone with BDD and Plastic Surgery Addiction
BDD and plastic surgery addiction are not difficulties that can be easily addressed. It takes time, commitment, and the proper guidance to improve everyone’s peace of mind and quality of life. Each person is different and needs to overcome their problems at their own speed. It is important to understand that the process can be lengthy and to remain patient and positive about recovery.
Recommendations for Physicians
Experts on Body Dysmorphic Disorder recommend that prior to taking on a case where one or more other procedures have already been performed, the surgeon obtain a complete medical history detailing any previous surgeries. It is best if the physician consults personally with the previous surgeon to get his or her observations and interpretations of the patients presentation prior to surgery and response after surgery. This can identify many patients with BDD unless they fail to disclose that other medical records exist. It will also provide additional, perhaps missing information, if the surgeon can interview friends or relatives of the person seeking surgery but this can only be done with the consent of the patient. Obviously, informed consent must be obtained in any of these conditions.
At the same time, if the surgeon can tell that other procedures have been performed, asking the patient about these procedures can be enlightening. If they don’t want to disclose or discuss these procedures and don’t want their current surgeon to contact a previous attending surgeon for information, care should be taken in deciding whether or not to perform another cosmetic procedure.
Recommendations for Friends and Family
Family members and friends of the patient who are aware of a history that indicates body dysmorphic disorder, or multiple plastic surgery procedures that seem extreme or excessive should seek help in learning how to discuss this with their loved one. This is especially important in cases where a surgeon has been convinced by the patient to perform additional, unnecessary plastic surgery. While a surgeon may not be able to determine the surgical history of a patient who hides information from them, most times important individuals in the person’s life are aware of their history as they have observed their recoveries, or even perhaps helped care for them after plastic surgery procedures.
Some techniques that can help loved deals with someone suffering from BDD and plastic surgery addiction include the following:
- Problem-solve behavior related to the person's symptoms and set consistent boundaries with behaviors that effect your family life such as the length of time the person spends in the bathroom when getting ready in the morning.
- Avoid blaming the person. It is not the fault of the person who has it, and nor is it the fault of friends or family members, who may feel responsible for 'causing' their loved one's problems.
- Encourage the person to get help and show support for them find help through therapy, medication or both. Be patient even if the person seems to be losing ground at times. Reinforce their gains and be understanding when they fall off the horse.
- Maintain as normal of a family routine as possible. BDD and plastic surgery addiction can complicate life but don't adapt or put family life on hold. Help your friend of family member to maintain as normal a lifestyle as possible.
- Don't make excuses for the person or take on their responsibilities.
- Don't participate in their disorder such as trying to help them find magic solutions such as non-intrusive cosmetic procedures. This is not the lesser of evils and despite it being easier than fighting their tendency to seek out plastic surgery.
- Providing support does not mean letting yourself be drawn into debates about the individual's appearance, or reassuring them about the way that they look.
- If the person is in therapy, ask if you can participate in an effort to determine how to reduce then eliminate your involvement in their BDD and plastic surgery addiction. This will help them perceive your change in behavior as helpful even if it's stressful in the short term and not as punishment.
- Anticipate how you will cope with the individual becoming stressed or upset by your new way of reacting to them and their symptoms. Create a plan that you can both are aware of and agree upon if they become angry or violent.
- While their behavior likely seems maladaptive to you, expecting them to simply give it up without having anything else to fall back on can be destructive leading to worsening problems in the long run. Before asking them to give up something the rely on to prevent what they perceive to be intolerable anxiety, make sure they have developed other skills and techniques. Prompt them to use these new strategies and reinforce them doing so.
Remember that they are invested in their behavior and that it is based on real perceptions and is not just an attempt to gain attention. While there may be genetic or physiological contributions to the person's symptoms, there is a reason the behavior developed. It may be a means of coping with something they otherwise find impossible to deal with.
If worse comes to worse, if a surgeon doesn't refuse to carry out additional procedures which are ill advised the person may have to be prevented from pursuing the surgery. Mental health law in the UK and US permits a patient to be hospitalized against their will if they are perceived to be a threat to themselves or others. However, it can be difficult to make a case for this in incidents of BDD and plastic surgery addiction.
If you are convinced that they will come to harm with additional medical procedures it may take finding a lawyer who will need to get a court order to have your loved one hospitalized. If it comes to this, keep in mind that while you may feel guilty, you are doing what is in your loved ones best interests. The help they are getting will allow them to lead a normal life and return to a previous level of functioning where they have a positive and realistic perception of their appearance.
American Psychiatric Association, (2013). The Diagnostic and Statistical Manual, 5th Edition.
Eppley, B. L. Plastic Surgery and Anti-Aging Strategies, American Society of Plastic Surgeons. Retrieved September 7, 2011.
Eppley, B. Explore Plastic Surgery, Archive for the 'body dysmorphic disorder' Category. Retrieved September 7, 2011.
Phillips, K. A. & Crino, R. D. (2001). Body dysmorphic disorder, Current Opinion in Psychiatry, 14: 113-118.
Sarwer, D.B., Crerand, C.E., & Didie, E.R., (2003). Body Dysmorphic Disorder in Cosmetic Surgery Patients. Facial Plastic Surgery, 19: 7-18.
Simberlund, J., & Hollander, E. (2017). The Relationship of Body Dysmorphic Disorder to Obsessive-Compulsive Disorder and the Concept of the Obsessive-Compulsive Spectrum. Body Dysmorphic Disorder: Advances in Research and Clinical Practice, 481.
Veale, D., (2004). Journal of Postgraduate Medicine, 80:67-71.
Questions & Answers
© 2018 Natalie Frank