Body Dysmorphic Disorder (BDD), formerly referred to as “Imagine Ugliness Syndrome” affects a greater percentage of the aesthetic population than most realize. Furthermore it presents a true potential problem for both the provider and patient.
It has been reported that approximately 2 to 7 percent of plastic surgery patients, 9 to 15 percent of dermatology patients, 10 percent of maxillofacial patients, 7 percent of oculoplastic surgery patients and 21 percent of patients seeking rhinoplasty are affected by this disorder. BDD is a DSM IV diagnosis characterized by excessive concern with an imagined or minimal defect. Patients spend at least an hour per day thinking about their perceived defect. This preoccupation causes distress and impairs work, social or personal functioning.
The average age of onset is 17 years old, but it can occur in older adults who are overly concerned with aging. The incidence is equal in males and females.
BDD has a high association with other mood disorders, particularly major depression. Up to 29 percent of these patients will attempt suicide, more commonly women with perceived facial deformities.
In the clinical setting, these patients will be demanding with excessive requests for aesthetic procedures. They often are dissatisfied with previous procedures and expect that an aesthetic procedure will solve all their problems. If denied by one provider, they may “doctor shop” until they find someone who will attempt to meet their demands.
There are a few simple screening tactics that one can use with patients to try to weed out BDD patients. It is important to find out their motivation for treatment, their expectations, their previous psychiatric history, and to observe their behavior in the office. If the patient seems suspicious, further detailed questions can be asked, or a referral to a psychiatrist can be made.
When and if a cosmetic procedure is performed, 70 percent of patients with BDD will be dissatisfied with the result. They may destabilize and find new defects, and few will threaten the provider with a lawsuit or even violence.
The bottom line with BDD in the aesthetic practice is to be aware of the signs, and if suspected, refer for a psychiatric evaluation. Overcome the tendency toward action rather than inaction, which may be sparked by patient pressure. Always stop to consider the patient’s best overall interest and live by one of the principle precepts of medical ethics: First, do no harm.