In today’s society, many people, specifically young women and girls, struggle with Body Dysmorphic Disorder due to the unrealistic beauty standards set by society as to what is acceptable to be attractive and desirable; unfortunately, a majority of the cases go undiagnosed. Patients suffer mentally trying to be someone and something they are not, and feel that what they are trying to achieve is what they must look like in order to be and feel accepted. If one believes she/he does not meet the set criteria of perfection set by society, they may suffer from self-confidence issues and insecurities, striving to be something that is ultimately unobtainable. Many of these victims turn to plastic surgeons to “fix” their perceived flaws, whether physically visible or not. Although the most recent trend seems to be advocating self-love regardless of shape, size, color, ethnicity, etc., some people find this difficult to comprehend, still striving for perfection in an unhealthy manner (eating disorders, bulimia, etc.,). The old adage “perception is reality” applies in these cases. Once the victim realizes they cannot be satisfied until they are “fixed,” they 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. BDD is a harmful disorder that is not sufficiently understood by plastic surgeons, which is a major contribution to the fact the disease is often underdiagnosed. Because BDD is not sufficiently understood, this leads to negative outcomes and high rates of post-surgery dissatisfaction if it is not recognized promptly and patients are not informed of how to properly treat the disease.  Pre-screenings and partnerships with therapists should be common practice in plastic surgery offices to decrease post-surgery dissatisfaction and help patients get the mental healthcare they need. 

Body Dysmorphic Disorder has many detrimental effects on the lifestyles of those struggling with the disease. BDD is known as “a chronic psychiatric disorder characterized by excessive preoccupation with an absent or minimal physical deformity (Franasa, 1).” Since recorded history, physical appearance has always been a prevalent factor within any society (Franasa, 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 (Franasa, 3).” With such unseen deformities and invasive thoughts, many patients feel their only option is to succumb to their impulses, resulting in either plastic or cosmetic procedures. 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. If no assessment is conducted and plastic surgery is received, patients’ risk, in most cases, having their self-confidence levels plummet, making their body perception worse than when they began getting surgery. As a result of worsening their body perception, they may then become fixated on another part of their body and seek surgery to “fix” that as well. Undeniably, the disease becomes an obsession with perfection, which results in an obsession with plastic surgery. In America, around 7%-8% of individuals with BDD seek cosmetic, dermatologic, or plastic surgery, and rates from 2.9%-53% have been recorded internationally (Crerand, Canice E., et al., 1). Evidently, BDD is often a disorder kept secret by the patient, and the patient generally does not convey their appearance concerns to the surgeon, and in most cases, nor does the doctor ask (Phillips, 39). Many patients also have said that they would not talk about their BDD to the doctor unless asked, because most patients that know they have the disorder feel ashamed of it (Phillips, 39). They worry that if they introduce the topic of their suffering, they are making themselves more vulnerable for ridicule by both the doctor and themselves (Phillips, 39). Potential patients need to understand that should not worry the doctor will think the disorder and their condition is superficial or foolish or that if they mention their “defect,” that the doctors and/or others will then notice it and focus on it more, which would cause them to become more self-conscious and ashamed. Another aspect victims of BDD fear is that whoever they open up to will try and reassure them that they look fine, but that is not what they want to hear. Because even though whoever they are expressing their feelings to may tell them their honest opinion, the sufferer may interpret their response as a fabrication and that they only told them they looked fine to make them feel better (Phillips, 39). They risk feeling not good enough if they voice their concerns. They may also feel foolish to have mentioned their problems and that the mental pain they have been enduring is not being taken seriously or can be understood. Overall, BDD is a mental game between the patient and their brain, impairing how they function on a day-to-day basis. Because people who suffer from the disease fear ridicule if they mention their weakness (BDD), this becomes a leading contributor as to why the disease is so understudied and unknown. 

Body Dysmorphic Disorder has not been extensively studied, and is evidently unknown to many, it is hard for people to believe or know the detrimental consequences of the disease, which may be a reason why it is so underdiagnosed. 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 et al). Ultimately, the diagnosis of the disease lies within the hands of the surgeons whom the victims of BDD seek help from for perceived “flaws.” This leaves the surgeons responsible, in the majority cases, for referring their patients to receiving the correct help they need, which rarely happens because of the lack of research on the disease. Many people, specifically health professionals, are unaware that BDD is a known disorder, which in turn requires psychiatric treatment (Phillips, 39). Even though it has been present but unknown for the longest time, it only entered the Diagnostic Manual (DSM), in recent years (Phillips, 39). 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. One of the conclusions suggests 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 over 80% of the surgeons reported not knowing that they were treating a patient with BDD until after the surgery was completed. There is a fine line between ordinary patients seeking cosmetic surgery where BDD related concerns do not pertain to them and patients who have a clearly excessive mindset about receiving surgery for a minimal flaw (Wilhelm, Sabine, et al.,). With surgeons not understanding BDD and not correctly diagnosing their patients prior to surgery, many negative outcomes can result. 

Many Body Dysmorphic Disorder victims are frequent patients in dermatologist, cosmetologist, and plastic surgery offices, and many of these doctors know very little about the disease, causing a rise in post-surgery dissatisfaction rates. When doctors only know brief information of BDD, this prevents the patients from being diagnosed with the disorder and potentially getting referred to the correct doctor (psychiatrists) they need for help. The negative outcomes of surgeons not understanding BDD are frightening, ranging from worsening symptoms due to post-surgery dissatisfaction rates to the patient undergoing more treatment(s) to fix what they thought their previous treatment was going to fix, but only worsened it. A 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 (Bowyer, et al., 16). 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. In an 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,” cites 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 50 patients who had cosmetic surgery performed reported post-surgery dissatisfaction. 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). With such high rates of post-surgery dissatisfaction, many 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). In a study of 450 patients who received a total of 1,313 non-psychiatric treatments, only 5% of the treatments reported to decrease and completely rid of the patients’ concern about the body part treated, as well as improved their BDD symptoms (Wilhelm, Sabine, et al.,). Cosmetic and plastic surgery is rarely effective for BDD, and in many cases, can make the symptoms worse (Wilhelm, Sabine, et al.,). 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. 

It is a known fact that there is very little management of Body Dysmorphic Disorder. 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. Even though the disease can be recognized and treated before mistakes are made, there are recorded instances, very few, where plastic and cosmetic surgery have improved cases of BDD.

Although there are no positive attributes to Body Dysmorphic Disorder, there have been recorded cases where surgery has not affected a patients BDD, or there was satisfaction post-surgery in the patients with BDD. Plastic and cosmetic surgery, in general, can cause both psychological and physical benefits if patients are seeking surgery in the correct state of mind (without Body Dysmorphic Disorder), or if the surgery is being sought out to help them with their daily lives, their health, and their well-being.   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 (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 1% of these patients had some sort of improvement (Crerand, Canice E., et al., 2). Even though 1% is such a small fraction, it still proves that in some cases, but not many, there is a chance of improvement for patients who seek surgery for their Body Dysmorphic Disorder. In a very few number of studies Laura Bowyer and her co-authors reviewed within her article, “A Critical Review of Cosmetic Treatment Outcomes in Body Dysmorphic Disorder,” there were reports, without going into great detail, that surgery was actually beneficial for a group of individuals with BDD (Bowyer, et al., 10). Dr. McCrary, a plastic and cosmetic surgeon, wrote an article on the benefits of plastic surgery, providing evidence supporting the benefits of plastic surgery (McCrary). Not only does cosmetic surgery improves one’s appearance, but it can also improve their health. Rhinoplasty, nasal plastic surgery, can correct breathing problems, or it may reduce snoring or completely rid the patient of it all together, while 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, and Liposuction can benefit people by eliminating weight helping them maintain 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. Dr. Norman Rappaport, a plastic surgeon with astounding credentials, 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.

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 few 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. 
