Cross Cultural Aspects of BDD

By Fugen Neziroglu, PhD and Nicole Lippman

Concerns about appearance are not only commonplace in the United States, but are also present in other cultures around the world. The perception and value placed on beauty is subjective, but common culture-specific notions of physical attractiveness exist. Across many cultures, body dysmorphic disorder contains similar clinical features, but some presentations are culturally specific. For example, Japanese case reports discuss eyelids as the feature focus, which is a rare physical complaint in the Western culture (Hunt, Thienhaus, & Ellwood, 2008).

Comparing BDD in the USA and European Countries

Prevalence rates of patients with body dysmorphic disorder within cosmetic medical settings vary from country to country. It is estimated that in the United States, patients with BDD within cosmetic medical settings vary from 5% to 15% (Ishigooka et al., 1998; Sarwer et al, 1998a; Veale et al, 2003), compared to a prevalence rate of 9.1% in Europe (Aouizerate et al., 2003). Few studies have been done in Europe and some have compared the American population to their respective countries. Bohne, Keuthen, Wilhelm, Deckersbach and Jenike (2002) investigated the prevalence of body image concerns and body dysmorphic disorder in a sample of American students and compared this data to a sample of German students using the Body Dysmorphic Disorder Questionnaire and similar measures. Results indicated that the majority of American participants were very concerned with the appearance of parts of their body and that 29% endorsed preoccupation with these concerns. Out of 101 American participants, four met DSM-IV criteria for body dysmorphic disorder that caused significant distress and functional impairment. As compared to the sample of German students, significantly more American than German participants endorsed body image concerns and significantly more American than German students were preoccupied with their concerns. American students also had significantly lower levels of body esteem as compared to their German counterparts. They further reported that body esteem was significantly correlated with self-esteem and depressive, anxiety and obsessive-compulsive symptoms.

In the Netherlands, Mulkens, Kerzel, Merckelbach, and Jansen (2006) investigated the psychiatric condition of nine dissatisfied patients after cosmetic surgery. Results showed that five out of nine participants scored in the dysfunctional range on several questionnaires that assessed BDD, depression, perceptual abnormalities and personality disorders. Prevalence rates of cosmetic surgery and BDD are lacking in the Netherlands but private hospitals are reporting more cases of cosmetic surgery procedures. The media has also been participating in displaying the increased attention to physical concern. ‘Make me beautiful,’ a Dutch version of the American show ‘Extreme Makeovers,’ shows people undergoing a total makeover within six weeks, while they stay isolated in a clinic, away from family and friends.

BDD in South America

According to the International Society of Aesthetic Plastic Surgery (ISAPA), plastic surgery in South America is very prevalent. Borda, Neziroglu, Santos, Donnelly and Rivera (2011) examined the prevalence, quality of life, and presentation style of body dysmorphic disorder in depressed Argentine adolescents where there is a disproportionate rate of body dissatisfaction. Results indicated that depressed Argentine adolescents had significantly higher scores on various assessments compared to non-depressed participants. In addition, participants reporting body dysmorphic symptoms also reported significantly higher scores on these assessments as well. These results suggest that bodily concerns and preoccupations are severe in the Argentine population and particularly in depressed adolescents. This may be a result of the cultural emphasis placed on physical appearance, particularly in women, as well as the popularity of plastic surgery.

In Brazil, Fontenelle et al. (2006) conducted a long-term study of patients with body dysmorphic disorder. The prevalence rate of body dysmorphic disorder in this clinical population who was seeking treatment at a facility specializing in obsessive compulsive spectrum disorders was 12%. According to the Huffington Post, Brazil is the second biggest consumer of plastic surgery and because cosmetic procedures have become so pervasive, doctors are now offering them to many impoverished Brazilians at discounted rates. In addition, Brazil offers plastic surgery procedures at an average of two thirds less than in the United States and Canada, making it a hot spot for tourists to come to have their procedures completed. For example, a face-lift in Brazil costs approximately $3,000 as compared to a face-lift in the U.S. which can range from $7,000 to $15,000.

BDD in the Middle East

When looking at a cultural that is both western and middle eastern at the same time, Cansever, Uzun, Donmez and Ozsahin (2003) investigated the rate and clinical features of body dysmorphic disorder among female college students in Turkey. Body Dysmorphic Disorder was found to be present in 4.8% of the sample, as diagnosed using the DSM-IV criteria. Forty four percent of the participants were dissatisfied with their appearance and endorsed that the head/face area and the hips were the areas of most common concern. There still remains a lack of research in the area of cross cultural differences in body dysmorphic disorder despite the high prevalence rates and functional impairment in individuals who are diagnosed with the disorder.

BDD Across the Globe

According to the American Society of Plastic Surgeons, plastic surgery spending is up 3 percent over 2010, with Americans spending $11 billion dollars on plastic surgery in one year. According to a global survey by the International Society of Aesthetic Plastic Surgery (ISAPA), the United States is ranked first as the most surgical procedures being performed, while China, Brazil and India are all close seconds.  On a per capita basis, Colombia, Brazil, Italy, Greece and South Korea (ranked from fifth to first respectively) lead the world in plastic surgeries. The U.S. is number one in breast augmentation and abdominoplasty (“tummy tuck”), Brazil is number one in blepharoplasty (surgical modification of the eyelid) and rhinoplasty (“nose job”) while double eyelid surgery is the most common plastic surgery procedure performed in South Korea, Taiwan, Thailand and Hong Kong.

These staggering numbers may have bigger implications that include the prevalence of body image concerns across a variety of cultures. More attention is needed in this area in order to be most effective at successfully treating individuals with body dysmorphic disorder.