Body Dysmorphic Disorder: Ethical Questions and Surgical Contraindications

The pursuit of beauty is a natural part of the human condition, but an obsessive desire to improve one’s appearance by fixing “flaws” that don’t exist is a serious mental illness. Body dysmorphic disorder (BDD) is a psychiatric condition in which a person is consumed with minimal or nonexistent flaws in their appearance.¹

While body dysmorphic disorder (BDD) is a psychiatric — not a dermatologic — condition, dermatologists and cosmetic surgeons are the clinicians most likely to see these patients come into their practices. An estimated 9% to 12% of patients visiting general dermatology clinics have BDD compared with 0.7% to 2.4% of the general population. The percentages climb to 8% to 37% in cosmetic dermatology clinics, raising ethical concerns about how to manage patients who do not typically need any dermatologic treatment at all.²

Understanding Body Dysmorphic Disorder

BDD is more than just a preoccupation with one’s appearance: People with this condition spend an average of 3 to 8 hours a day worrying about their perceived flaws, inspecting their appearance, and attempting to “fix” the flaws. The disorder has a particularly high rate of morbidity and mortality, with up to 80% of patients reporting suicidal ideation and 25% reporting suicide attempts.¹

Also known as dysmorphophobia, BDD was first added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. Today, the DSM-5 lays out 4 criteria for a BDD diagnosis:

1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
2. At some point during the course of the disorder, the individual has performed repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to the appearance concerns.
3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.¹

A survey of 265 members of the American Society for Aesthetic Plastic Surgery (ASAPS) revealed that 93% had encountered patients with “excessive concern or distress with minor or nonexistent appearance features,” 83% saw patients who were dissatisfied with past cosmetic procedures, and 81% had received unusual or excessive cosmetic surgery requests. Nearly a third of respondents (30%) had seen a patient who had trouble with day-to-day functioning because of their cosmetic concerns.³ In a similar fashion, in a survey of 260 American Society for Dermatologic Surgery (ASDS) members, 94% were aware of BDD.

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Hair and skin are the body areas that most vex people with BDD.⁵ Hair concerns mostly relate to hair loss but can also be about too much hair or the quality of hair anywhere on the body. Skin concerns typically involve acne, scarring, wrinkles, color (eg, too white or too red), veins, moles, and other “imperfections.”

Approximately 25% to 50% of people with BDD engage in pathologic skin picking in attempts to “fix” their flaws, a practice that can become a vicious cycle both by causing actual damage and exacerbating psychiatric symptoms.²

“At the time, it seems to the patient that picking will improve the[ir] appearance, although at the same time he or she knows full well that this is not the case and that picking can only make things worse,” said to Caroline S. Koblenzer, MD, a clinical professor of dermatology at Rowan University School of Osteopathic Medicine in Stratford, New Jersey, who published an article in Dermatology on the topic. “Thus, feelings of guilt and shame are greatly intensified by the action.”²

To Treat or Not To Treat

BDD is a contraindication for surgery according to the American Academy of Otolaryngology practice guidelines for rhinoplasty⁶ and the American College of Obstetricians and Gynecologists (ACOG) committee opinion on breast or labia surgery for individuals younger than 18.⁷ ACOG recommends youth requesting those procedures be screened for BDD and, if it’s suspected, referred to a mental health professional.

In the ASAPS survey, most respondents (84%) had also refused to perform surgery on a patient they suspected had BDD, although only half referred them for psychiatric assessment. Just 10% treated these patients as they would any other patient requesting cosmetic surgery.

“Some people are satisfied for a while after the procedure is done but almost never over the longer term,” Katharine Phillips, MD, a professor of psychiatry at Weill Cornell Medical College in New York, told Dermatology Advisor. “If they are satisfied with the specific procedure, they often develop a new preoccupation with a different body area.”

In the ASDS survey, 92% of respondents had turned down a cosmetic treatment request because of concerns about the patient’s mental health, and 62% refused to treat a patient suspected of having BDD.⁴ Of the 61% who realized after treating a patient that the patient likely had BDD, more than half thought the patient focused even more on the defect post procedure, and approximately half said the patient turned their attention to another defect.⁴

The ASAPS survey also found that 84% of surgeons had completed a procedure on a patient and then afterward suspected BDD. Most (82%) judged the patient’s outcome as poor in terms of their BDD symptoms, and 43% said the patient became more obsessed with their perceived flaw after the surgery. Another 39% reported that the patient no longer worried about the original flaw but then, as dermatologists had reported, became preoccupied with a different perceived defect.³

The potential consequences of providing cosmetic treatment to a patient with BDD can extend beyond ethical concerns.

“Clinicians who do such procedures are putting themselves at risk of poor clinical outcomes, legal action, and possible physical threats and even violence from the patient,” Dr Phillips said.

Physicians have been attacked and even killed by patients dissatisfied with a procedure or with not receiving treatment. In one survey, 40% of cosmetic surgeons reported being threatened by a patient with BDD: 29% legally, 2% physically, and 10% legally and physically, and dermatologic surgeons reported similar experiences.^3,4 Some patients with BDD have even described “fantasies about physically harming their surgeons.”³

Physicians should always refer patients with BDD to a mental health professional, Dr Phillips said, but she recommends not performing the procedure even if the patient refuses the referral.

Screening and Treatment Decisions

The vast majority of evidence shows that patients with BDD are nearly always dissatisfied — and often their condition worsens — after dermatologic or cosmetic surgical interventions. More recently, some researchers have suggested that the issue is more ambiguous, with a handful of small studies suggesting that some patients with BDD may improve with a single procedure.

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A 2016 systematic review of 11 studies mostly found poor outcomes in patients with BDD who received cosmetic treatment but identified 3 studies showing positive outcomes in patients receiving rhinoplasty and labiaplasty.⁸ The trials were small, however, and had substantial methodologic limitations. Actual diagnosis of participants’ BDD was uncertain; it’s unclear whether patients also received psychiatric treatment (which could have accounted for positive outcomes); and the satisfaction rating tools used were potentially inadequate, particularly in assessing whether the patient might have transferred their obsession to a new flaw after being satisfied with treatment for the first.⁸

The lack of large high-quality randomized controlled trials limits the evidence, but the findings of existing evidence have led some experts to regard such trials as unethical, Dr Phillips told Dermatology Advisor.

That does not necessarily mean that patients with BDD should never receive dermatologic treatments, however. Although BDD is characterized by nonexistent or minimal “flaws,” patients may be treated for real concerns.

“Advice is a little more nuanced with acne,” Dr Phillips said. “Some patients with BDD do have mild acne, in which case treatment with conservative measures — not isotretinoin — can be considered in combination with psychiatric treatment.”

Dermatologic treatment may also be appropriate after a patient with BDD has received psychiatric treatment if they have damaged their skin through compulsive skin picking, Dr Phillips said, although treatment should be provided in collaboration with the mental health clinician treating the BDD.

Of the existing screening tools for BDD, Dr Phillips recommends the Body Dysmorphic Disorder Questionnaire- Dermatology Version (BDDQ-DV) as the one with the most appropriate psychometric properties for dermatology settings.⁹

Even before screening, however, several red flags may suggest BDD:

• Camouflaging perceived flaws, such as using heavy makeup, scarves, or gestures that cover their body, and having poor eye contact, seen by 30% of cosmetic surgeons in one survey³
• Evidence of skin picking or other injuries from attempts to self-correct perceived flaws, seen by 23% of cosmetic surgeons³
• Showing unusually demanding, angry, or aggressive behavior
• Repeatedly asking clinicians and staff for reassurance about how they look
• Believing others often stare, laugh at, or mock them for their appearance
• Requesting unusual appointment times, such as only when it is dark outside
• Wanting to look like a celebrity
• Having a history of lawsuits or prior surgeries they were dissatisfied with

In patients who screen positive for BDD, Dr Phillips recommends dermatologists and cosmetic surgeons ask the patient the following questions, which match up with both the BDDQ and the DSM-5 diagnostic criteria for BDD:

• Appearance concerns: Are you very worried about your appearance in any way? (OR: Are you unhappy with how you look?) If yes, Can you tell me about your concern? (Assess degree of deformity — nonexistent or slight?)
• Preoccupation: Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less? (OR: How much time would you estimate you think about your appearance each day?) Usually about an hour a day or more is consistent with BDD. 
• Repetitive behaviors: Is there anything you feel an urge to do over and over again in response to your appearance concerns? (Give examples, such as mirror checking, comparing with others)
• Distress or impairment: How much distress does this concern cause you? Does it cause you any problems socially, in relationships, or with school or work? Do you avoid social situations?

Clinicians can also ask/be aware of: 

• Expectations: “How do you anticipate your life will be different after this procedure?” Assess realistic vs unrealistic expectations
• Unusual requests (eg, vague or overly specific)
• History of cosmetic procedures
• What have you done to improve your appearance (anything that you do yourself)?
• Any prior procedures or requests? 
• Any dissatisfaction with prior treatments?
• How do your friends/family feel about you getting surgery? (they may recognize that the surgery is not indicated and may be discouraging it)
• Do you have a history of psychiatric problems or treatment? (Contact a mental health clinician)

References

1. Vashi NA. Obsession with perfection: Body dysmorphia. Clin Dermatol. 2016;34(6):788-791.
2. Koblenzer CS. Body dysmorphic disorder in the dermatology patient. Clin Dermatol. 2017;35(3):298-301.
3. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members. Aesthet Surg J. 2002;22(6):531-535.
4. Sarwer DB, Spitzer JC, Sobanko JF, Beer KR. Identification and management of mental health issues by dermatologic surgeons: a survey of American Society for Dermatologic Surgery members. Dermatol Surg. 2015;41(3):352-357.
5. Castle DJ, Phillips KA, Dufresne Jr RG. Body dysmorphic disorder and cosmetic dermatology: more than skin deep. J Cosmet Dermatol. 2004;3(2):99-103.
6. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: Improving nasal form and function after rhinoplasty. Otolaryngol Head Neck Surg. 2017;156(2_suppl):S1-S30.
7. Committee Opinion No. 686 Summary: Breast and labial surgery in adolescents. Obstet Gynecol. 2017;129(1):235.
8. Bowyer L, Krebs G, Mataix-Cols D, et al. A critical review of cosmetic treatment outcomes in body dysmorphic disorder. Body Image. 2016;19:1-8.
9. Picavet V, Gabriëls L, Jorissen M, Hellings PW. Screening tools for body dysmorphic disorder in a cosmetic surgery setting. Laryngoscope. 2011;121(12):2535-2541.