Cosmetic surgery is changing the face of the world. Commonly confused with plastic surgery, cosmetic surgery is very different when it comes to the overall goal of the procedure. Cosmetic surgery is meant to improve or enhance the look of the patient, and plastic surgery is to correct a defect so it can function properly and appear normal (Haivay). Cosmetic Surgery is common for people to turn when there is an aspect of their body they are not fond of. But sometimes, even though it may seem just superficial, there can be deeper psychological issues that will cause the patient to be dissatisfied with the results of the procedure. David Petro sought out a cosmetic surgeon in his twenties for a hair transplant because he felt as if he had an “unacceptable amount of hair loss” (BDD Foundation). Soon after, his symptoms of body dysmorphic disorder (BDD) rapidly increased. David’s lifelong struggle with BDD caused him to live a life in constant depression. He worked as a trustee at the Body Dysmorphic Disorder Foundation in hopes to improve the understanding of BDD and to increase its awareness (Phillips A). He later began to tell his brother about other issues he had with his body that included his nose, jawline, forehead, and asymmetric face (BDD Foundation). David was in his thirties when he was found dangling off a cliff, ready to take his own life. After being admitted to the hospital, David told his family how much he regretted not jumping, and that he would simply find a different way to end his life there in the hospital (ibid). He succeeded March 12, 2015. BDD causes people to obsess over minuscule flaws so drastically, it can eventually alter the way they go through and view everyday life (Feusner). Patients suffering from BDD often go undiagnosed which can have detrimental results; therefore, surgeons have a responsibility to care for the mental and physical health of their patients. The body dysmorphic disorder questionnaire (BDDQ) is an easy self-evaluation exam that can help diagnose BDD in cosmetic surgery patients. 

Originally named “dysmorphophobia”, BDD is also sometimes referred to as “Imagined Ugliness Syndrome” (BDD Foundation). Calm Clinic states the word dysmorphophobia was used originally because BDD was believed to be a phobia that one’s body part(s) is “repulsive or will become repulsive” to anyone that sees it. The switch to the term BDD occurred in the 1980s when it was determined that there is no way to avoid any physical defects; therefore, it cannot be considered a phobia (BDD Foundation). However, dysmorphophobia can now be used as one, of many, symptoms of BDD (Pruthi). BDD more formally describes a mental disorder that causes people to misperceive minor defects as major flaws (Feusner). One key to understanding BDD is determining the amount of anxiety a person has affiliated with rejection and humiliation in any form of social situations (BDD Foundation). If untreated, BDD is commonly associated with other mental diseases such as severe depression, anxiety, and Obsessive Compulsive Disorder (OCD) (Pruthi). 

An Italian psychiatrist, Eric Morselli, was one of the firsts to diagnose BDD (BDD Foundation). Back in 1891, Morselli thought “dysmorphophobia” was a new form of insanity that caused a person suffering to believe they are completely hideous (ibid). Calm Clinic states that dysmorphophobia was originally diagnosed as an anxiety disorder where one suffers from social anxiety, due to the fear of their hideousness. Nothing states what happened to the patients after they were diagnosed, whether they were let free or held captive in an insane asylum. But the diagnosis is now much more accurate and there are medications and psychiatric treatments that are helpful in relieving patients from their suffering. 

There has been research conducted on the different ways BDD can affect a person, and change their behavioral patterns, but there has been no research to determine what can cause a person to develop BDD. Dr. Sandhya Pruthi, at the Mayo Clinic, has a hypothesis revolving around a child growing up in an abusive relationship and learning that they have very little self-worth. A person with relatives that suffer from OCD, BDD, anxiety or depression are more genetically predisposed to develop BDD at some point in their life (BDD Foundation). People who are sensitive to criticism are also more likely to develop BDD (ibid). This could be because they often shy away from confrontation and do not defend themselves in situations where they are being picked on or talked down to. This eventually causes people to internalize imperfections in themselves, and worry about how noticeable they are to others (BDD Foundation). 

One of the most difficult aspects of BDD revolves around the person’s certainty that the perceived flaws are real, making it hard for friends, family, and doctors to convince them otherwise (Pruthi). A French psychiatrist by the name of Pierre Janet diagnosed a woman with BDD after she had kept herself housebound for five years (BDD Foundation). Convinced she had a “dark, thick” mustache, she refused to speak up for herself in fear of her neighbors using the mustache against her (ibid). She was raised in a house with strict parents who were full of negative criticism that she never learned how to deal with. She is a prime example of how being raised in a negative environment can cause a person to be extremely self-conscious, and eventually develop conditions such as BDD.  

The most popular hypothesis revolves around the affects society and social media on women, starting at a really young age. Around the age of twelve, children begin to experience drastic changes in their bodies, both in how they look and how they feel. Dr. Sandhya Pruthi believes BDD can begin to affect a person in their early adolescence because of bullying and teasing revolving around acne and body image that are commonly associated with puberty (Mayo Clinic). Soon after this stage begins, societal and personal pressures begin to increase around certain beauty expectations, and what defines a man or a woman. However, the media plays the largest role later in life. Portraying unrealistic body expectations through Photoshop, makeup, and the constant reminder a woman’s body is “unsightly” or needs to be controlled with diet to match the computer-modified women on billboards (Pruthi). Since BDD becomes most common during adolescence, it usually takes people fifteen or more years to seek treatment from a dermatologist or a cosmetic surgeon (Prevalence of BDD). BDD is also more common in countries and cultures that emphasis the importance of beauty, especially in women (ibid). To some beauty is all about the external look, and to others it is about strength and confidence. Social media is constantly shaming women if their external body is not flawless, but how are women supposed to gain confidence when they are constantly being put down for something they have no control over? Mental health is extremely important in believing in one’s self, and people suffering from BDD do not have the mental stability needed to live a happy, confident life.

BDD can affect both men and woman, but it is more common in women because of the high levels of societal pressure for women to look a certain way. For men, most problem areas deal with genitals, body build, and hair loss (Prevalence of BDD). For women, most concerns revolve around skin, stomach, weight, breast, buttocks, thighs, legs, hips, and body hair (Prevalence of BDD). 

People that suffer from BDD are infatuated with one or more flaws in their appearance (BDD Foundation). These perceived flaws or defects are often so minor they go completely unnoticed by other people (BDD Foundation). Common symptoms are similar to concerns people have in everyday life, but people with BDD have extreme concerns that cause them to always be overly stressed about the perceived flaw. The difference is that people with BDD are always preoccupied with how they look and are constantly checking in any reflective surface, or avoiding them all together (Pruthi). Dr. Jamie Feusner is a BDD specialist that noticed people can portray these obsessive concerns for any part of the body; however, it is most common for people to have concerns about problem areas from the neck up. More specifically with nose, lips, wrinkles, overall complexion, acne, and hair (Pruthi). People who express any of the listed concerns frequently reach out to dermatologists and cosmetic surgeons to “fix” or remove the problem area (Feusner). However, if a doctor does not diagnose BDD, the patient can experience an increase in symptoms after the procedure, which can cause some to become depressed or suicidal (BDD Foundation).

Dr. Robert Burke and other surgical members of the American Board of Cosmetic Surgery (ABCS) view cosmetic surgery as the perfect gateway for people to open the doors to a life of self-worth and self-satisfaction (American Society of Plastic Surgeons). Dr. Eric Swanson says, “Patient satisfaction is the most important measure of surgical success”, (ibid). Breast augmentation surgeries are the most common of all cosmetic procedures in the United States, and because of this it is important to understand why so many women are choosing to have this procedure (ibid). The words “breast augmentation” are commonly associated with breast implants, but the term can also refer to breast reductions. Women with very large breasts often have a lot of issues with back pain, neck problems, posture, and finding a comfortable position to sleep in, so seeking cosmetic surgery would vastly improve their quality of life and mobility (Coila). A study by Surgeon Dr. Eric Swanson of two hundred twenty-five women who received breast reduction surgeries, revealed a satisfaction rate of 98% (American Society of Plastic Surgeons). A breast reduction is not solely for women either. Men with gynecomastia develop breasts due to an imbalance of estrogen and testosterone (Pruthi). For these men, cosmetic surgery to remove their breasts would allow them to be confident in their own skin again. Imagine the one thing you hate most about yourself being removed from your body with only a little scar as a reminder. However, while cosmetic surgery fixes the physical body, it may trigger detrimental mental problems after the procedure. 

There are many risk factors involved with cosmetic surgery, or any surgery, besides BDD. All surgeries have risks of complication such as infection, recovery, and rejection of implants (Coila). All surgeries have expensive costs that are not always covered by insurance (Coila). Some cosmetic surgery patients may want approval from their family before going under the knife. And some have unrealistic expectations. Most people with BDD expect cosmetic surgery to fix a superficial problem, when they do not realize the most important problem is in their head. This causes patients to be disappointed when they come out of surgery and find something different they dislike about their body. According to the Body Dysmorphic Disorder Foundation, 25% of surveyed people with BDD had attempted suicide within the past year. Most suicide attempts are done by breast augmentation patients (Doheny). Even though breast augmentations have dramatically high satisfaction rates with breast reduction procedures, it is not the same for people that receive breast enlargement surgeries. Lead investigator Loren Lipworth analyzed about 3500 women and found that there is little to no risk of suicide within the first ten years of the breast augmentation surgery (ibid). The risk of suicide grew continuously to a fourfold risk after ten years, and a sixfold risk after twenty years (ibid). 

The word “cosmetic” alone indicates there is no medical need for a procedure to take place, which is why psychiatric problems are common for these types of unnecessary procedures (Erickson). The mental effects of BDD often cause patients to suffer from other disorders such as anxiety, OCD, social anxiety disorder, depression, and eating disorders (Umbach). It is also possible, given the similarity of the symptoms of the listed disorders, that one disorder can be misdiagnosed as another (ibid). If one disorder is misdiagnosed, the likelihood of a negative outcome is very slim due to the similarities in brain activity (Pruthi). Some examples of BDD treatments that have been proven effective are cognitive-behavioral therapy and antidepressant medications (Umbach). Easy patient is assessed, using the principle of individuality, and given their own treatment plan based on their mental state (BDD Foundation). The purpose of cognitive-behavioral therapy is to teach the patients to recognize irrational and unhealthy thoughts, and to replace them with positive ones (Umbach). Filtering the brain with positive thoughts is proven to drive a person to live a more positive left style (ibid). Antidepressant medications are most frequently used with patients that suffer from depression, but antidepressants can also be used to “relieve” obsessive and compulsive symptoms often seen in BDD and OCD (ibid). 

 Research conducted by BDD expert Katherine Phillips showed that BDD affects one in fifty people, which is about five million people in the United States alone. Her research also showed that BDD is often diagnosed with other psychiatric diseases such as anxiety, depression, and OCD (Prevalence of BDD). BDD is frequently associated with depression because people avoid social interactions and make themselves house bound to avoid situations where it is possible for somebody to notice their flaw (ibid). Some patients, even after being diagnosed with BDD, refuse to seek psychiatric help and directly seek cosmetic surgery to fix, or remove, their problem area (Kacar). If a mentally unstable BDD patients undergoes cosmetic surgery it will ultimately make their condition worse. This is why an astounding 80% of BDD patients consider suicide after receiving a cosmetic procedure (Kacar). Because BDD is a psychiatric disease, it can have major effects on how a person chooses to live their everyday life. 

Professor Schweitzer works for the University of Melbourne Australia Department of Psychiatry, and has developed a four aspect pre-operative psychological assessment for cosmetic surgeons to do with a patient before a cosmetic procedure is discussed (Erickson). The four aspects are motivation, expectations, risk, and anxiety (ibid). Is the patient’s motivation for surgery internal or from an external influence? Are the patient’s expectations realistic or unrealistic? Does the patient fully understand the associated risks and possible complications of surgery? How anxious is the patient? Pre-operative assessments and preparation are critical in having high levels of patient satisfaction. If a patient has BDD, the surgeon will never achieve a level of high patient satisfaction because of the underlying problem of BDD (Erickson). 

One example of a pre-operative psychiatric evaluation that is already being used is the Body Dysmorphic Disorder Questionnaire (BDDQ) (Erickson). The BDDQ has proven to have 100% sensitivity and 92.3% specificity in cosmetic dermatology (Kacar). In a Turkish study by Dogruk Kacar, a BDD specialist, of 318 cosmetic dermatology patients, 17.3% of patients showed preoccupations with their appearance and 6.3% of patients were formally diagnosed with BDD. This information was determined by having the patients complete the BDDQ (Kacar). The biggest problem with the BDDQ is that it is a self-evaluation exam. Many patients can be in denial about how severe their condition is, causing them to put less than accurate answers on the questionnaire (Kacar). In Kacar’s study there is also the factor that sixteen patients refused to take the questionnaire for unknown reasons. With the vast increase in cosmetic surgery procedures taking place within the past century, the importance of diagnosing patients with BDD is increasing as well. BDD is prevalent in 15% of cosmetic surgery patients, and the number is on the rise with more doctors screening for psychological disorders like BDD (Kacar).

There are no current laws that require cosmetic surgeons to perform any form of psychiatric exam before they consider a patient for surgery (Erickson). All surgeons should be required to test their patients for BDD, and a good way to do that is by using the BDDQ. Prior to introducing the patient to their different procedure options, the surgeon should be required to assess the mental state of the patient. If a BDDQ was set by the American Society of Plastic Surgeons that made all surgeons screen for BDD, the mental health of all persons would benefit greatly. With the accuracy of the BDDQ, the number of patients attempting suicide would also greatly decrease. After the BDDQ has been placed, if a patient shows too much concern for their problem area, the surgeon should be responsible for sending the patient to a psychiatrist before they can be evaluated again for surgery. Doing this will help save the lives of those suffering that may become suicidal, and will also help with the overall mental health of the United States.
