Body dysmorphic disorder and cosmetic surgery: are surgeons too quick to nip and tuck?

Most of us have some insecurities about how we look, and some aspects of our appearance that we might secretly wish were different. But for people with body dysmorphic disorder, these issues become an obsession and constant focus of concern.

Body dysmorphic disorder is a psychiatric condition that leads people to adopt extremely distorted negative beliefs about their appearances: seeing themselves to be ugly, malformed, misshapen or hideous. Such beliefs do not reflect the reality of how they appear to others. The degree of concern and distress they may feel about their appearance is vastly out of proportion to any actual physical “defect”.

A small minority of the population is believed to experience the condition. One study found about 2.3% of participants had the condition.

The mirror is a major problem for people with body dysmorphic disorder. Some sufferers become fixated with mirror checking, with hours of their day absorbed in inspecting their appearance. Mostly this checking is counter-productive, making them feel worse and increasing their distress.

Other people with the condition may avoid mirrors altogether. Some can even have catastrophic reactions should they happen to glance at themselves in a reflective surface such as a shop window. Lots of sufferers conceal themselves under hats, scarves, wigs, dark glasses or excessive layers of makeup or concealing clothing in an attempt to hide their supposed defects.

Body dysmorphic disorder should not simply be dismissed as an expression of extreme vanity or insecurity about looks. This condition often leads to substantial distress and social and occupational impairment. Rates of depression are high, while suicide is not an uncommon outcome for those who do not receive appropriate treatment. Many avoid social situations for fear of others judging them negatively because of how they look.

Cosmetic solutions?

Because people with body dysmorphic disorder “see” themselves as having a cosmetic problem, it’s not surprising they often seek a cosmetic “solution”.

The highest rates of body dysmorphic disorder are found among people using cosmetic services like plastic surgeons, cosmetic dermatologists and cosmetic dentists. One study found up to 70% of people with body dysmorphic disorder had sought cosmetic procedures, and half had received such interventions.

The tragedy is that cosmetic procedures – by definition – do not solve the underlying psychological problem. They leave a majority of sufferers worse off: they pay for the procedure and suffer the pain and inconvenience of it, yet “see” the resulting cosmetic outcome as unsatisfactory, even if objectively the result is excellent.

This often leads to requests for more treatments, with ensuing worsening of the mental state of the patient and increasing frustration on behalf of the cosmetic specialist. The situation can become so heated that legal action, physical threats and even homicide have been known to be perpetrated by body dysmorphic disorder patients.

How can these outcomes be avoided?

Cosmetic interventions of all types are becoming increasingly accessible to a wider public. Therefore, it would be ideal for cosmetic specialists routinely to screen for body dysmorphic disorder.

Australian cosmetic specialists are not mandated to screen for body dysmorphic disorder and there’s no available information on the proportion of cosmetic clinics that screen for the condition. From my experience of speaking to patients who have sought cosmetic intervention, screening is variable at best.

There are certainly some practitioners who are very aware of the risks associated with body dysmorphic disorder and ensure their clients are screened and offered referral for further help if required. Unfortunately, too often screening is not performed and patients suffer as a consequence.

Screening should be mandated for people seeking any cosmetic procedure that might be seen as “enduring”: this includes surgical procedures. My colleagues and I have developed a questionnaire for practitioners, which through a series of simple questions can help diagnose body dysmorphic disorder.

For those who may body dysmorphic disorder, careful further questioning and referral to a body dysmorphic disorder specialist is required. A range of psychological therapies (such as cognitive behaviour therapy) and medications (mostly antidepressants) can be very effective at treating the condition’s underlying problems.

Simply providing cosmetic clinics with screening tools won’t guarantee all doctors accurately assess for body dysmorphic disorder. This is because we cannot expect all clients to answer questionnaires truthfully. However, in my experience, having seen hundreds of people with body dysmorphic disorder, they usually do.

At the end of the day, it would be ideal if cosmetic specialists did everything in their power to fulfil their ethical obligations. To not screen and then deliver cosmetic procedures to people who may have body dysmorphic disorder goes against the medical dictum “first do no harm”.

David Jonathan Castle does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.