Body Dysmorphic Disorder, also known as BDD, is “a chronic psychiatric disorder characterized by excessive preoccupation with an absent or minimal physical deformity (FranÃ§a, 1).” In today’s society, many people, specifically young women and girls, struggle with body dysmorphia due to the unrealistic standards set by society as to what is acceptable to be attractive and desirable; unfortunately a majority of the cases go undiagnosed. If one believes she/he does not fit within the margins of this criteria, they may suffer from self-confidence issues and insecurities, striving to be something that is ultimately unobtainable. Many of these victims reach out to plastic surgeons to “fix” their perceived flaws, whether physically visible or not. Many people today advocate loving oneself, regardless of shape, size, color, ethnicity, etc., making us believe it is unacceptable to compare themselves to another person, specifically those who obtain qualities that are achieved in an unhealthy manner (eating disorders, bulimia, etc.).Today, so many unrealistic beauty standards have been set, that many suffer mentally trying to be someone and something they are not. They feel this is what they need to look like in order to be and feel accepted. Once the victim realizes they cannot be satisfied until they are “fixed,” they then seek help from a plastic/cosmetic surgeon, ultimately acerbating their mental conditions. Evidently, Body Dysmorphic Disorder and plastic/cosmetic surgery go hand in hand. A major issue as a result of this relationship is that anyone can go and receive cosmetic treatment, as long as they are of age. Many plastic surgery offices do not screen for BDD, either because this would affect their work and income, or because they truly believe that every procedure they perform will be beneficial to the patient. The communication between psychologists and plastic/cosmetic surgeons needs to be more cohesive not only to prevent such surgeries from occurring, but to also prevent the patient from feeling as if altering their physical features is their only solution. In order to best treat patients with BDD while reducing levels of post-surgery dissatisfaction, patients should be pre-screened for BDD and psychologists and surgeons should be in frequent contact. 

Because Body Dysmorphic Disorder is a more recent phenomenon unknown to many, it is hard for people to believe or know the detrimental consequences of the disease. This is true, specifically for plastic surgeons and cosmetic surgeons because performing such operations are how they make a living. As a result, mental illness is not taken into consideration, resulting in victims suffering without knowing they have a BDD. Plastic and cosmetic surgery entices those who suffer from the disease because it is an automatic “fix.” Regardless of the negative effects of BDD, there are still many positive outcomes that can be gained both psychologically and physically if patients are having surgery in the correct state of mind, or if the surgery is being sought out to help a patient with their daily lives and their health and well-being. Dr. McCrary, a plastic and cosmetic surgeon who completed her residency at the Boston Medical Center, eventually becoming chief resident in the department of Plastic Surgery and the Plastic and Cosmetic Surgery Fellow, wrote an article on the benefits of plastic surgery. This article provides evidence supporting the benefits of plastic surgery. (McCrary). Not only cosmetic surgery improves one’s appearance, but it can also improve their health. In the article, McCary uses rhinoplasty as positive example of how cosmetic surgery not only benefits a person’s physical appearance, but medically as well. Rhinoplasty can correct breathing problems, or it may reduce snoring or completely rid the patient of it all together. She states that breast reduction can alleviate back pain and problems by removing excessive weight on the ventral side. Breast augmentation can correct posture, as the weight of new breasts needs to be supported more. Liposuction can benefit people by eliminating weight helping them lead a healthier life style which in turn can lower risk for heart conditions, improve blood pressure and cholesterol levels, and an ease in joint pain and stiffness. She claims that by improving your appearance, your social life could potentially skyrocket as other possibilities such as getting a new job or a promotion may result. McCrary states that evidence proves that beautiful people are more successful in today’s society. Not only will a patient improve appearances, but there are other benefits of plastic surgery, depending on the procedure. Dr. Norman Rappaport, a plastic surgeon with astounding credentials such as: Member of the American Board of Plastic Surgery, the National Board of Medical and Dental Examiners, and the North East Regional Board of Dental Experiment, and is also dual licensed in plastic surgery and dentistry. He provides the benefits of plastic surgery in an article on his practice’s website. Dr. Rappaport claims that if you look good, you feel good as well. He also believes that improving appearances is not the only benefit of plastic surgery, but increased self-confidence, improved physical health, enhanced mental health, more opportunities, and eliminating extra body weight are all benefits as well.

With all the benefits of plastic surgery, we cannot forget the negative. Body Dysmorphic Disorder has many detrimental effects on the lifestyles of those struggling with the disease. Since recorded history, physical appearance has always been a prevalent factor within any society (FranÃ§a, 1). BDD is “a complex mental disease in which patients are excessively preoccupied by a minor or absent physical deformity that causes severe distress and decreases the quality of life (FranÃ§a, 3).” With such unseen deformities and invasive thoughts, the patient is left only with the option to succumb to their impulses, resulting in either plastic or cosmetic procedures. Cosmetic procedures rarely bring satisfaction to the patient, which in turn intensifies the effects of the BDD.  This reason alone proves that cosmetic and plastic surgeons should pre-determine if their patients have the disease before they undergo surgery. By assessing a patient for BDD, they can provide a punctual referral and treatment. Dr. Anthony Youn, a board-certified plastic surgeon and an award-winning author explains that many of these victims seek plastic surgery, but then continue to receive treatment after the initial procedure until their face, body part, etc. are completely disfigured (Youn). As a result, their self-confidence levels plummet, making their body perception worse than when they began getting surgery. One of the main reasons BDD is so understudied is because there are very few patients suffering from the disease that actually reach a psychiatrist (Varma, Anukriti, Rastogi). Many of the victims are frequent patients in dermatologist, cosmetologist, and plastic surgery offices, and many of these doctors know very little about the disease, thus preventing the patients from being diagnosed with the disorder, as well as getting referred to the correct doctor (pshychiatrists). With an increase from 8.5% to 15.0% of BDD in dermatologic patients, and about 2.9% to 53.6% percent in patients who seek cosmetic treatments, this makes dermatologists and surgeons the first physicians to have contact with those patients suffering from BDD (Conrado, Luciana, et al). These statistics are frightening, furthering the idea that there needs to be a higher awareness of the disease among the medical field. Evidently, as a result, “non-psychiatric treatments are generally not considered to be beneficial for these patients (Conrado, Luciana, et al).” With this said, there are always other ways to treat the disease, and it should be communicated to the patient by the surgeon in hopes they consider seeking help. 

Background information suggests that there is very little management of the disease. BDD is generally handled by a psychiatrist, who then provides the patient with different medications, as well as psychotherapy. SSRI’s, serotonin-reuptake inhibitors, are a group of antidepressants that are known to reduce symptoms in at least 50% of BDD patients, and are the main source of medicinal treatment for the disease (Varma, Anukriti, Rastogi). Other types of treatments are psychotherapy, or a combination of psychotherapy and medication. In order to be diagnosed with BDD, the person “must be preoccupied with a perceived defect in his or her physical appearance; if a small anomaly is present, the person’s concern must be notably excessive. The preoccupation must cause considerable distress or interfere with social, occupational, or other important areas of functioning (Wilhelm, Sabine, et al.,).”  Body Dysmorphic Disorder can be confused with many other conditions, resulting in misdiagnosis. BDD “cannot be diagnosed if the symptoms are better accounted for by another disorder (Wilhelm, Sabine, et al.,).”  These disorders include eating disorders, Obsessive Compulsive Disorder, Depression, Social Phobia, Anorexia, or Schizophrenia (Wilhelm, Sabine, et al.,).  When dealing with BDD, a patient should be sympathetically approached, and then referred to a psychologist, where psychologic and medicinal treatment is provided (Vashi, 790). Selective Serotonin Reuptake Inhibitors (SSRI’s) and cognitive behavioral therapy have the highest rates of effectiveness in regard to treatment (Vashi, 790). BDD is an extremely difficult disease not only to diagnose, but to deal with as well. It is a mental disorder that many people do not understand, and there is only so much a person can do when their life is overtaken by an internal battle with themselves.  Because most people do not actually know that they have the disease, this means they do not know they need professional help, nor do they seek it. If BDD is correctly diagnosed, the surgeon can then educate the patient on the disease. They would also be obliged to let them know that plastic surgery is generally not successful in treating or curing the perceived defects, and that there are other treatments that are effective (Dufresne, et al., 459). The doctor can refer the patient to a psychiatrist where medication, psychotherapy, and cognitive-behavioral therapy can be provided, as stated above. Overall, there are many factors that contribute to the diagnosis of the disease, but none of it can happen without first recognizing that someone has it. Recognition is imperative within the cosmetic/plastic surgery world, as some doctors can identify the disease in their patients before it is too late, and can then refer them to a mental health professional or psychiatrist to help the patient cope with the disease. 

Body Dysmorphic Disorder and its relationship with the outcomes of plastic and cosmetic surgery is not a topic that has been studied rigorously, but there are plenty of studies that support the idea that there needs to be a stronger tie between mental health professionals and surgeons. In the article/study published by Laura Bowyer, “A Critical Review of Cosmetic Treatment Outcomes in Body Dysmorphic Disorder,” she reviews literature and discusses the controversial topic of the outcomes of plastic and cosmetic surgery upon individuals with BDD. In a very few number of studies she and the co-authors reviewed, there were reports that surgery was helpful for a group of individuals with BDD (Bowyer, et al., 10). However, after reviewing the studies, they came to the logical conclusion that even though the evidence they found indicated some patients with BDD could potentially have a reduction in symptoms post-surgery, it is very hard to come to a direct conclusion that any patient diagnosed with BDD pre-surgery will have a reduction in symptom’s post-surgery (Bowyer, et al., 12). Other conclusions suggest that one of the main areas to worry about regarding this disease was the initial, accurate detection and evaluation of the disease, both medically and clinically (Bowyer, et al., 16). A survey taken by members within the American Society for Aesthetic Surgery and the American Society for Dermatologic Surgery concluded that a vast majority of doctors refuse to operate on a patient if they even suspect BDD. Another conclusion from this survey was that over 80% of these surgeons reported not knowing that they were treating a patient with BDD until after the surgery. To prevent this from happening, there are ways that plastic and cosmetic surgeons can diagnose and/or manage the patients that enter their office with BDD. One way is through screening questionnaires that can be given in both cosmetic and mental health offices (Bowyer, et al., 16). Another problem regarding pre and post-surgery results in patients with BDD is the fact that many doctors may not even consider BDD an implication for them to perform work on a patient. This generally is a result due to the lack of knowledge about the disease, and ultimately calls for an increase in mental health workers to communicate and inform cosmetic/plastic surgeons and raise awareness of the disease. The connection between psychiatrists, cosmetologists, and plastic surgeon professionals allows for the correct screenings that will ultimately help decrease post-surgery dissatisfaction rates in patients with the disease. 

Body Dysmorphic Disorder has a high frequency in patients who seek cosmetic or plastic surgery. In America, around 7%-8% of individuals with BDD seek surgery, and rates from 2.9%-53% have been recorded internationally (Crerand, Canice E., et al., 1). Even though the rates of patients with BDD who seek cosmetic surgery have been accounted for, there are very few statistics investigating the outcomes of such treatments. In the article written by Canice Crerand (Ph.D.), William Menard (B.A.), and Katharine Phillips (M.D.), “Surgical and Minimally Invasive Cosmetic Procedures Among Persons with Body Dysmorphic Disorder,” it is said that in a study of 25 patients with BDD who sought out surgical treatment, most of them were dissatisfied post-surgery and some with even worse conditions than prior to getting the surgery (Crerand, Canice E., et al., 1). In another study they investigated, 81% of the 50 patients who had cosmetic surgery performed reported post-surgery dissatisfaction. In a study of 250 patients where 66% received treatment for their BDD, the post-surgery outcome had not altered their disorder at all, meaning it did not improve or worsen their symptoms. In a smaller study, 7 out of 10 patients seeking surgery to fix a “minimal defect” had BDD (Crerand, Canice E., et al., 2). Evidently, in post-surgery follow-ups, those patients reported to still have BDD and developed more appearance issues (Crerand, Canice E., et al., 2). A survey given to 265 cosmetic surgeons, 178 of them reported having given treatment to patients with BDD, and only 1% of these patients had some sort of improvement (Crerand, Canice E., et al., 2). 1% is an extremely small number out of all the patients those doctors have performed surgery on. With such high rates of post-surgery dissatisfaction, many of these patients then seek more cosmetic or plastic surgeons to fix what the previous doctor(s) failed to fix in the surgery and/or surgeries already performed. In a study performed by Dr. Veale, 76% of 289 patients with BDD sought plastic or cosmetic surgery, and around 66% of them actually received it (Sarwer, Crerand, 107). In another study, 83% of all cosmetic procedures that patients with BDD acquired had no change or an increase in BDD symptoms (Sarwer, Crerand, 108). Overall, the rates of dissatisfaction in patients with BDD receiving plastic or cosmetic surgery are high enough to draw attention to this side of the plastic surgery world that has been concealed for too long. 

To decrease post-surgery dissatisfaction rates, there is a method called the Body Dysmorphic Questionnaire, which was developed for psychiatric use and then modified to be more like a “Likert” scale from 1 to 5, 1 inferring no defect and 5 being severe defect, in regard to the yes and no responses of the questionnaire (Dufresne, et al., 458). It has been recorded that the BDDQ has had “good sensitivity (100%) and specificity (89%) in a psychiatric setting,” but not the same within a dermatologic setting.  In one specific study, patients going in for a cosmetic surgery consultation were given this questionnaire in which they were to provide their answers before the consultation (Dufresne, et al., 458). If they marked on the questionnaire that they had complications with their appearance and/or were preoccupied with how they looked, they then answered two more questions where they were required to rate how critical their impairment was on a scale of 1 to 5. If the patient reported that it caused them to avoid certain things, they were then to answer yes/no questions that dealt with the interference within their academic, occupational, social, and other daily activities. This questionnaire and a one-on-one evaluation with the plastic surgeon and the patient without the doctor knowing the patient’s responses to the BDDQ were crucial for this study. Evidently, the study found that the questionnaire combined with an assessment of the severity of the disease and/or defect led to high sensitivity and specificity for diagnosis of BDD within a dermatologic practice setting. In this study specifically, 15% tested positive for the disease, and in a study dealing with a larger control group of 298 people, 12% tested positive. However, because this questionnaire is only used by so many practices, it can almost be confirmed that the true rate of BDD within dermatologic/cosmetic patients is much higher than the 12% reported. With the disorder being recorded to be from 0.7%-2.2% in the general population, the disorder is much more prevalent than what the world knows it to be today. If surgeons truly care about the wellbeing of their patients, there would be no hesitation on their part to offer this questionnaire to their patients, meeting one-on-one to gain some insight on their reasoning for their potential surgery, and to make sure it is not because they suffer from BDD. Not only would post-surgery dissatisfaction rates significantly decrease, but the surgeon could potentially be saving his patient from increasing the severity of the disease and providing them with a safer treatment method by referring them to a mental health professional instead. This is where the relationship between surgeons and psychiatrist’s is crucial, as greater communication between the two would increase the ability to prevent the patient from becoming addicted to plastic surgery and ultimately not obtaining the desired results. Also, with the help of a psychiatrist, they will learn ways to deal with the disease, whether that be medication, psychotherapy, etc., and potentially learn to love themselves for who they are and not how they look. 

 Body Dysmorphic Disorder has many severe affects, causing complications for those who are obsessed with plastic surgery to make them perfect in the eyes of society. It controls their lives. Unsuspecting individuals that are unaware they have BDD frequently turn to plastic or cosmetic surgery to get a quick “fix”. Reid Ewing, an actor who plays Dylan in “Modern Family” had a severe case of BDD. He fell into the trap of undergoing numerous cosmetic procedures to “fix” the way he looked. Reid reflected that one of his biggest mistakes was getting plastic surgery to begin with and having to deal with the side effects of BDD in the years to follow (Ewing). Reid claimed, “Before seeking to change your face (or any body part), you should question whether it is your mind that needs fixing,” ultimately summing up the disease as a whole. Even celebrities fall victim to this disease, considering a major part of their lives is constantly in the limelight with people judging how they look, how they dress, how skinny they are, etc. In the end, the severity of this disease and its prevalence could be lessened if surgeons made an effort to screen for BDD before performing surgery and promptly referring patients to a psychiatrist or mental health professional. 
