Body Dysmorphic Disorder: When It's More Than "Let Down"

This is in no way an attack on anyone or a matter of disbelief of the viable reason for depression you may be going through. This is a proven concern and the rate of incidence is alarming.  Depression can be from medications, anesthesia, mental trauma, pre-existing psychological disorders, unrealistic expectations or post-operative pain, complications, lack of communication, surgeon error or normal after effects that the patient was not aware he or she would experience.

I actually did not believe in nor did I agree with disorders such as the newly diagnosed Body Dysmorphic Disorder (BDD) until I came across several patients who in fact DID have it and kept getting surgery to attain a happiness that surgery would never bring them.

Mark B. Constantian, M.D., F.A.C.S. recently reported in article aimed at diagnosing BDD in secondary rhinoplasty patients:

"Prior to surgery, an estimated 75% had true functional pathology, undiagnosed, yet real, surgical problems, or "unremarkable" personalities (i.e. not perfectionistic, depressed, or demanding)

Only one-quarter had, in the surgeon's judgment, minimal defects, an unreasonable attitude toward the defect, or depression, though the indications for surgery remained valid.

On the other hand, the results illustrated how difficult it is to identify the rare patient with BDD, a mental disorder characterized by a slight or imagined body defect that triggers severe emotional distress; the nose is the source of distress in nearly half of all cases." (Constantian, MB: Identify BDD patients prior to rhinoplasty; Cosmetic Surgery Times, June 2001)

If the above is true 1 out of every 4 secondary or tertiary rhinoplasty patients who read this page have BDD. I tend to think that is a little too high of a calculation but it is food for thought and should be considered by all of us.

The below information is in no way an accusation but is provided solely for the purpose of research and awareness. This is not a hypocritical statement either because although there is a fine line between what is healthy and what is not over obsessing and having your nose consume you is very unhealthy indeed. I honestly could live without a revision but I have to undergo a turbinate cauterization anyway - while "under" I might as well fix the dent. The turbinate cauterization is actually going to hurt more than the cosmetic part of the surgery. I know, I know, you're thinking, "whatever you have to tell yourself, girl!"

Anyway, I have provided this in case someone you may know may need help or has a self image disorder - know the signs. This is a very serious disorder and leads to years of unnecessary body modification and severe depression - sometimes even suicide! You could save your friend years of anguish and maybe even their life.

As a matter of fact rhinoplasty is the top procedure among those who experience post-surgical depression, along with liposuction, face lift and facial implants. Unfortunately rhinoplasty is also the top procedure of persons with self image disorders...

Body Dysmorphic Disorder (BDD)
Another important aspect is to realize that Body Dysmorphic Disorder MAY be a problem. Please do not get defensive until you truly understand the boundaries and symptoms of this disorder. 

The standard or typical description of BDD by the American Psychiatric Association:

  • Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
  • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition  (also known as DSM-IV). Copyright 1994 American Psychiatric Association. 

Symptoms of Body Dysmorphic Disorder

  1. Frequently comparing your appearance with that of others; scrutinizing the appearance of others

  2. Often checking your appearance in mirrors and other reflecting surfaces.

  3. Camouflaging the perceived defect with clothing, makeup, a hat, your hand, your posture, or in some other way that diverts the attention of the "defect"

  4. Seeking cosmetic surgery, dermatologic treatment, or other medical treatment for appearance concerns when doctors or other people have said such treatment isn't necessary

  5. Questioning and "fishing for compliments"; seeking reassurance about the flaw or attempting to convince others of its apparentness

  6. Anger or resentment towards those who do not see your perceived flaw

  7. Excessive grooming (i.e. combing hair, shaving, cutting hair, dyeing hair, applying makeup and/or concealers)

  8. Avoiding mirrors and reflective surfaces

  9. Frequently touching the defect

  10. Picking and touching your skin

  11. Repeatedly measuring the disliked body part

  12. Excessively reading or searching the internet about the defective body part

  13. Excessive exercise or dieting

  14. Avoiding social situations in which the perceived defect might be exposed

  15. Frequent absenteeism from school or your place of employment because you feel "ugly"

  16. Failure to uphold a job for fear of someone seeing your perceived "defect"

  17. Failure to hold a job because you are depressed about your appearance

  18. Avoiding leaving the house for fear of someone seeing your perceived "defect"

  19. Feeling very anxious and self-conscious around other people because of the perceived defect

But it really goes further than this. Speaking as a patient and a person who has come across patients who have been diagnosed with such and who have had extensive surgery - these patients don't want to hear it, they don't want to admit it and they think most surgeons, psychiatrists or even friends are against them. I am not saying this to sound like some sort of know-it-all or to only "prove" that  am not on "your side" if this pertains to you. I am in fact going out on a limb here because this IS a very sensitive, yet important factor, of revision rhinoplasty. I am only going to give you my honest opinions and observations, as well as proven statistics and articles written by respectable doctors. 

When I first began researching long ago with plastic surgery, in general, I noticed that the diagnosis of BDD was very common and, in my opinion, too often given with a prescription for medications as if it were candy. I admit it, at first I was very disappointed with the psychiatric society, in general, passing out the BDD diagnosis in the same trend as ADD (Attention Deficit Disorder) until I realized that there was an increasing trend in plastic surgery with persons who were diagnosed with BDD or typical clinical depressions. 

It must be said that although it is difficult to diagnose BDD if you are not trained to recognize the symptoms, these individuals who are afflicted with such do slip through the cracks and onto the operating table and wind up becoming even more depressed and withdrawn from society after their secondary, tertiary, and so on, revision surgeries. The plastic surgeon, although not having gone through extensive training in psychiatry, becomes experienced in turning patients away who fit certain criteria or give a surgeon a "bad feeling" or "red flag". 

I am not against those who have certain issues having surgery but it MUST be realized that surgery will not help those who are afflicted with these disorders. It will not make you a different person, or make you more popular, get you more dates or make you a super model. Many BDD patients are not in the mental state to recognize what is considered attractive by most or even by themselves. They really don't know what they want but they know that they don't want to look like they presently do. But if given the chance to have the exact result desired - the dysmorphia is still present and presents a problem in the healing stages. The patient then becomes obsessed even further and convinced that he or she is ugly in general - not to mention, unsatisfied with a result that is considered by most to be exemplary.

You may argue that it is the patient that must be satisfied with his or her result, and you are very right - they should be and that is what is truly important. But if the patient does not KNOW what is attractive to them and will always be unsatisfied with the outcome it is very unhealthy. If they are not capable of accepting a great outcome and see fault where there is none. What then?

"BDD and secondary, tertiary, etc.  rhinoplasty is most often seen in males" according to Dr. Mark B. Constantian. It has also been noted by The American Academy Of Cosmetic Surgery that 2% of cosmetic surgery patients have it. That may seem low to you but of this 2% it is most often observed in rhinoplasty and liposuction/lipoplasty patients. When you do the math - that's  a lot of nose jobs.

This is in no way an attack on your person but a means with which to ask yourself if you are truly in possession of an unattractive nose or an outstanding one. Please seek help or at least research this disorder even if you do NOT think you have it. It is good to read up on and you just may realize that you have more in common with some BDD patients than you'd think. At the very least you could understand the pains that others who DO have BDD go through and perhaps help someone with your knowledge. I do ask that you do NOT research BDD for the sole reason of fooling or tricking a plastic surgeon into thinking that you are "normal" and I use that term very loosely. Of course we all have our different opinions and preferences for what is attractive however repeated dissatisfaction and obsessing is both unhealthy and dangerous, when we repeatedly hear that everything is fine and that we are imagining it - it pays to listen sometimes. Do yourself or someone you know a favor and know the warning signs before it's too late.

Suggested Reading on Body Dysmorphic Disorder


cover The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder  by Katharine Phillips, M.D. - click the book to buy or read excerpts

review coming soon!  

cover The Adonis Complex: The Secret Crisis of Male Body Obsession by Harrison G. Pope Jr., MD; Katharine A. Phillips, MD; Roberto Olivardia, PhD - click the book to buy or read excerpts

I read this book to help to better understand body dysmorphic disorder.  Although I am not a licensed psychologist I do have experience in interviewing persons with image disorders, or those who teeter at the threshold while battling daily with low self esteem poor body image.  There is an amazing number of people who are unhappy with their bodies - unfortunately some of these may never be comfortable with their body image.

This book covers the male aspect of body dysmorphic disorder ranging from obsessive weightlifting to extreme dieting or supplementation.  Males are no different from females in their desire to look their best. Due to the majority of porn targeted at men - for years it was thought image disorders were a thing only women were plagued by.  Wanting to look like Barbie or a centerfold seemed common for women.  Yet for men, seemed to detract from their masculinity.  This book helps show the side of the coin where it isn't how you FEEL about your masculinity that questions it somehow - but how you LOOK.  Many men feel that if their biceps are not hard as steel or their middles cut like a diamond, they somehow do not measure up.  Welcome to the world of what psychologists call the "Adonis Complex" hence the book's name.

I have come across so many men who feel they must look their best no matter what and CONSTANTLY worry what they eat or how they look and still walk around in sweats without showing an inch of abdominal flesh.  Many aren't hitting the gym for strength or jogging for great distances in the heat for cardiovascular health - they are striving to become an ideal which is unattainable.

The Adonis Complex covers symptoms to look out for and offers understanding to the many men who are determined to have the body of a Roman God and will do almost anything to get there. A definite read if you a male and in need of answers or have concerns which need to be quelled.  Male body dysmorphia is sometimes compared to anorexia nervosa and can be equally harmful.  Even if you do not feel that you have an image disorder, if you are active in the gym and are concerned with "ideal" body fat percentages perhaps you could look upon this book to help understand those you may come into contact with at your gym.  While there is nothing wrong with wanting to look our best or feeling better when we do look tanned and tone - putting ourselves into harms way or letting this desire take over our social life is unhealthy and should be addressed.

cover Appearance Obsession: Learning to Love the Way You Look   by Joni E. Johnston - click the book to buy or read excerpts

I first must say that I believe beauty is relative.  This book is written by a clinical psychologist who was bombarded by family members nudging her towards perfection throughout childhood.  It saddens me to know that I know SO many women who feel the exact same way and I wonder truly how much the media does have to do with this all.  Is it not the consumers who buy the magazines which portray the waif-thin models?  After all aren't we supposed to be looking at the clothes and not the body?  

We all know that there are two sides to every coin but we also know that society and eve our own family members may show intentional, or unintentional, favoritism to those whose appearances shine.  And I don't mean from an oily T zone.  I mean true beauty.  Everyone would be lying if they say that they don't feel better when they look their best than when they have gained a little (or more) weight, have a break out or "have nothing to wear".  We have all been affected by how we look to ourselves and how others believe we look.  

Some may argue that this book is not for those who truly "need" to lose weight or have plastic surgery and that it is more for people who are attractive and are "too sick to see it". This is ludicrous - beauty is relative and that is just another ridiculous arm of society depicting what is more attractive than the other.  This book is helpful for ALL people in ALL walks of life which way be uncomfortable with the way they look.  It is about being unhappy or self conscious with the way you look, not how maybe you are a little over or underweight than the next person - it is about feeling the need to look good and realizing what can be changed healthily.

This book is a first person account of the authors pain growing up and realizing just exactly how events can trigger neuroses or lack of esteem, at a very young and impressionable age.  It contains questionnaires and surveys to determine your level of self esteem and just how much you are affected by media coverage of the beautiful.  Personally I am a little tired of hearing that it is JUST the media's fault.  People know what is attractive to them - it isn't like we are THAT impressionable.  Nature takes precedence - Read Nancy Etcoff's "Survival of the Prettiest" for a not so new look at what drives us to become attracted to those who are "beautiful".

I still recommend this book, however - I like the way it is written and enjoy reading and comparing the author's experiences. It contains helpful advice and offers support ion an seemingly individual level  Just don't allow yourself to use the media as a crutch for any lack of esteem you may have.  I think there are far more issues at stake to cause image problems - such as personal experiences, relationships or lack thereof, chemical imbalances and random incidents can all trigger low self esteem.

Online Support Groups
We are not affiliated with the groups below but have provided the information for your convenience.

Excerpts from this page published in Teen Decisions: Body Image (The Gale Group; Thomson-Gale, Greenhaven Press 2002)
Jacobson WE, et al.  Psychiatric evaluation of male patients seeking cosmetic surgery.  Plast Reconstr Surg, 26:356, 1990
Phillips KA, et al.  body dysmorphic disorder.  Am J Psychiatry 148:1, 1991.
Pertschuk M.  Psychosocial considerations in plastic surgery.  Clin Plast Surg   18:11, 1991
Tardy, ME.  Rhinoplasty:  The Art and Science, Volume II, Saunders press, 1997
Goin M, Rees T, Plast Surgery, 27:3, 1991 
Constantian, MB: Identify BDD patients prior to rhinoplasty; Cosmetic Surgery Times, pp21-22, June 2001


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