by Megan M. Kelly, PhD, Elizabeth R. Didie, PhD, & Ashley S. Hart, PhD
Reasons for Cosmetic Treatments
Since appearance concerns are the focus of BDD, individuals with this disorder commonly seek out and receive cosmetic treatments to correct their perceived “flaws” instead of psychiatric treatments. Individuals with BDD seek out cosmetic treatments in order to reduce body dissatisfaction related to their appearance concerns, and believe that changing their appearance with these treatments will resolve these appearance concerns (Mulkens et al., 2012). However, these treatments don’t usually make their appearance concerns disappear, often the level of distress and degree of concern remain unchanged, and in some cases, the appearance concerns may get worse (Crerand et al., 2005; Phillips et al., 2001).
Types of Cosmetic Treatments
Phyllis Duarte shares her son’s struggles with Body Dysmorphic Disorder (BDD) and discusses its negative impacts on the entire family.
- Cosmetic surgery is a commonly sought treatment for individuals with BDD, with 26%-40% of individuals with BDD pursuing cosmetic surgery.
- In two studies, 71%-76% sought and 64%-66% received some type of medical treatment for BDD (e.g., surgical, dermatological, dental).
- In American cosmetic surgery samples, 7%-8% of individuals meet criteria for BDD and in international cosmetic populations, the prevalence rates vary greatly, ranging between 3%-53%.
- Cosmetic rhinoplasty is one of the most common cosmetic surgical procedures received by individuals with BDD because preoccupations with the nose is one of the most common preoccupations in BDD. Research on individuals seeking rhinoplasty found that 21% met criteria for BDD. According to this study, patients with BDD are different from patients without BDD who normally seek rhinoplasty – they tend to be younger, more depressed, more anxious, are more preoccupied by thoughts about their nose, have more compulsive behaviors, and have poorer psychosocial functioning.
- Skin concerns are another common BDD concern and as a result, dermatologists are the physicians most often seen by individuals with BDD.
- Prevalence rates of BDD in dermatology settings range from 9%-15%. One recent study showed that 14% of individuals in cosmetic dermatology settings met criteria for BDD compared to 7% in general dermatology settings (Conrado et al., 2009). The most common dermatological treatments that were sought in this study were the use of topical agents, chemical peels, plastic surgeries, nonablative lasers, fillers, systemic isotretinoin, and botulinum toxin.
- In addition, compared to individuals with BDD in general dermatology settings, individuals with BDD in cosmetic dermatology settings are more likely to be dissatisfied with the treatment outcome.
- Individuals with BDD also seek out other types of cosmetic procedures, including dental and other aesthetic treatments. In one study, 4.2% of dental patients met criteria for BDD compared to 1.5% in a general population sample (De Jongh, Aartman, Parvaneh, & Ilik, 2009).
- Another study of orthodontic patients indicated that 7.5% met criteria for BDD (Hepburn & Cunningham, 2006).
- Two studies have investigated the prevalence of BDD in reconstructive surgical settings (e.g., breast reconstruction), and found that 7%-16% of patients showed symptoms consistent with BDD.
- Individuals with BDD also seek out treatments from paraprofessionals, for instance, seeking electrolysis, hair plugs, and other types of nonmedical treatments.
Effect of Cosmetic Treatment on Individuals with BDD
Dr. James Claiborn discusses the link between suicide and Body Dysmorphic Disorder (BDD). He also discussed how plastic surgery can negatively impact those with BDD.
If you are in a crisis, or you are ever feeling suicidal or unsafe please go to your local emergency room, call 911 or call the suicide prevention hotline at 800-273-8255.
Most individuals with BDD continue to be dissatisfied with their appearance following cosmetic treatment. Amongst a sample of 200 patients with BDD who received cosmetic surgery, the most common outcome was no change in the severity of BDD symptoms (Phillips et al., 2001). In a sample of individuals with BDD who received surgical and minimally invasive procedures for their appearance concerns, 25% showed a longer-term improvement in their preoccupation with the treated body part, but only 2.3% of surgical and minimally invasive procedures led to longer-term improvement in overall BDD symptoms (Crerand, Menard, & Phillips, 2010).
Research on dermatology patients with BDD indicates that they are often dissatisfied with and have a poor response to dermatology treatments. In addition, clinical observations indicate that appearance preoccupations may shift to other body areas following cosmetic treatments. In some patients, BDD symptoms may become more severe following cosmetic treatments.
One area for concern is the risk of suicidality and violent behavior in some individuals with BDD who seek cosmetic treatments. Rates of suicidality in individuals with BDD are quite high, including suicidal ideation and suicide attempts. In some cases, individuals with BDD can become depressed following cosmetic treatments, because they are upset about the lack of improvement in their symptoms or what they perceive to be a procedure that made their appearance look worse.
Although there is little research on the association between cosmetic treatments and risk for suicidality, studies of women who have sought breast augmentation have shown suicide rates that were two to three times higher than rates in the general population. Higher rates of suicidality in this population may be related to BDD psychopathology, although a direct link has not been made. In addition, there is an increased risk of violent behavior towards physicians providing cosmetic treatments. In one study, 2% of cosmetic surgeons indicated that they had been physically threatened by a patient with BDD (Sarwer, 2002).
Since cosmetic treatments for BDD rarely resolve symptoms of BDD, and in some cases, make symptoms worse, cosmetic treatments are not recommended for this disorder. Several evidence-based treatments exist for BDD that are associated with improvement in symptoms and functioning, including serotonin reuptake inhibitors (SRIs), and cognitive-behavioral therapy.
Aouizerate, B., Pujol, H., Grabot, D., Faytout, M., Suire, K., Auriacombe, M., Martin, D. Tignol, J. (2003). Body dysmorphic disorder in a sample of cosmetic surgery applicants. European Psychiatry, 18, 365-368. doi:10.1016/j.eurpsy.2003.02.001
Bowe, W. P., Leyden, J. J., Crerand, C. E., Sarwer, D. B., & Margolis, D. J. (2007). Body dysmorphic disorder symptoms among patients with acne vulgaris. Journal of the American Academy of Dermatology, 57, 222-230. doi:10.1016/j.jaad.2007.03.030
Castle, D. J., Molton, M., Hoffman, K., Preston, N. J., & Phillips, K. A.(2004). Correlates of dysmorphic concern in people seeking cosmetic enhancement. Australian and New Zealand Journal of Psychiatry, 38, 439-444. doi:10.1080/j.1440-1614.2004.01381.x
Conrado, L. A. (2009). Body dysmorphic disorder in dermatology: Diagnosis, epidemiology and clinical aspects. Anais Brasilieros de Dermatologia, 84, 569-581. doi: 10.1590/S0365-05962009000600002.
Cotterill, J. (1996). Body dysmorphic disorder. Dermatologic Clinics, 14, 457–463. doi:10.1016/S0733-8635(05)70373-9
Crerand, C. E., Sarwer, D. B., Magee, L., Gibbons, L. M., Lowe, M. R., Bartlett, S. P.,Whitaker, L. A. (2004). Rate of body dysmorphic disorder among patients seeking facial cosmetic procedures. Psychiatric Annals, 34, 958–965.
Crerand, C. E., Menard, W., & Phillips, K. A. (2010). Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Annals of Plastic Surgery, 65, 11-16. doi:10.1097/SAP.0b013e3181bba08f
Crerand, C. E., Phillips, K. A., Menard, W., & Fay, C. (2005). Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics, 46, 549–555. doi:10.1176/appi.psy.46.6.549
De Jongh, A., Aartman, I. H., Parvaneh, H., & Ilik, M. (2009). Symptoms of body dysmorphic disorder among people presenting for cosmetic dental treatment: A comparative study of cosmetic dental patients and a general population sample. Community Dental and Oral Epidemiology, 37, 350-360. doi:10.1111/j.1600-0528.2009.00469.x
Dufresne, R. G., Phillips, K. A., Vittorio, C. C.,& Wilkel, C. S. (2001). A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatologic Surgery, 27, 457–462. doi:10.1046/j.1524-4725.2001.00190.x
Harth, W., & Linse, R. (2001). Botulinophilia: Contraindication for therapy with botulinum toxin. International Journal of Clinical Pharmacology and Therapeutics, 39, 460–463.
Hepburn, S., & Cunningham, S. (2006). Body dysmorphic disorder in adult orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics, 130, 569–574. doi:10.1016/j.ajodo.2005.06.022
Hollander, E., Cohen, L. J., & Simeon, D. (1993). Body dysmorphic disorder. Psychiatric Annals, 23, 359-364.
Ishigooka, J., Iwao, M., Suzuki, M., Fukuyama, Y., Murasaki, M., & Miura, S. (1998). Demographic features of patients seeking cosmetic surgery. Psychiatry and Clinical Neuroscience, 52, 283–287. doi:10.1046/j.1440-1819.1998.00388.x
Koblenzer, C. S. (1985). The dysmorphic syndrome. Archives of Dermatology, 121, 780-784. doi:10.1001/archderm.1985.01660060094029
Mulkens, S., Bos, A. E., Uleman, R., Muris, P., Mayer, B., & Velthuis, P. (2012). Psychopathology symptoms in a sample of female cosmetic surgery patients. Journal of Plastic, Reconstructive, & Aesthetic Surgery, 65, 321-327. doi:10.1016/j.bjps.2011.09.038
Phillips, K. A. (2009). Understanding body dysmorphic disorder: An essential guide. New York: Oxford University Press.
Phillips, K. A., Dufresne, R. G., Jr., Wilkel, C. S., & Vittorio, C. C. (2000). Rate of body dysmorphic disorder in dermatology patients. Journal of American Academy of Dermatology, 42, 436–441. doi:10.1016/S0190-9622(00)90215-9
Phillips, K. A., Grant, J., Siniscalchi, J., & Albertini, R. S. (2001). Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics, 42, 504–510. doi:10.1176/appi.psy.42.6.504
Phillips, K. A., McElroy, S. L., Keck, P. E., Pope, H. G., & Hudson, J. I. (1993). Body dysmorphic disorder: 30 cases of imagined ugliness. American Journal of Psychiatry, 150, 302-308.
Phillips, K. A., McElroy, S. L., & Lion, J. R. (1992). Plastic surgery and psychotherapy in the treatment of psychologically disturbed patients. Plastic and Reconstructive Surgery, 90, 333-335.
Phillips, K. A., & Menard,W. (2006). Suicidality in body dysmorphic disorder: A prospective study. American Journal of Psychiatry, 163, 1280–1282. doi:10.1176/appi.ajp.163.7.1280
Sarwer, D. B. (2002). Awareness and identification of body dysmorphic disorder by aesthetic surgeons: Results of a survey of American Society for Aesthetic Plastic Surgery members. Aesthetic Surgery Journal, 22, 531–535. doi:10.1067/maj.2002.129451
Sarwer, D. B., & Crerand, C. E. (2008). Body dysmorphic disorder and appearance enhancing medical treatments. Body Image, 5, 50-8. doi:10.1016/j.bodyim.2007.08.003
Sarwer, D. B., Wadden, T. A., Pertschuk, M. J., & Whitaker, L. A. (1998). Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plastic and Reconstructive Surgery, 101, 1644–1649. doi:10.1097/00006534-199805000-00035
Sarwer, D. B., & Crerand, C. E. (2004). Body image and cosmetic medical treatments. Body Image, 1, 99–111. doi:10.1016/S1740-1445(03)00003-2
Uzun, O., Basoglu, C., Akar, A., Cansever, A., Ozsahin, A., Cetin, M., & Ebrinc, S. (2003). Body dysmorphic disorder in patients with acne. Comprehensive Psychiatry, 44, 415–419. doi:10.1016/S0010-440X(03)00102-0
Vargel, S., & Ulusahin, A. (2001). Psychopathology and body image in cosmetic surgery patients. Aesthetic Plastic Surgery, 25, 474– 478. doi:10.1007/s00266-001-0009-7
Veale, D., Boocock, A., Gournay, K., Dryden, W., Shah, F., Willson, R., & Walburn, J. (1996). Body dysmorphic disorder. A survey of fifty cases. British Journal of Psychiatry, 169, 196–201. doi:10.1192/bjp.169.2.196
Veale, D., De Haro, L., & Lambrou, C. (2003). Cosmetic rhinoplasty in body dysmorphic disorder. The British Association of Plastic Surgeons, 56, 546–551. doi:10.1016/S0007-1226(03)00209-1
Vindigni, V., Pavan, C., Semenzin, M., Grana, S., Gambaro, F. M., Marini, M.,…Mazzoleni, F. (2002). The importance of recognizing body dysmorphic disorder in cosmetic surgery patients: Do our patients need a preoperative psychiatric evaluation? European Journal of Plastic Surgery, 25, 305–308.
Vulink, N., Sigurdsson, V., Kon, M., Bruijnzeel-Koomen, C.,Westenberg, H., & Denys, D. (2006). Body dysmorphic disorder in 3–8% of patients in outpatient dermatology and plastic surgery clinics. Ned Tijdschr Geneeskd, 150, 97–100.