In our celebrity-fixated culture, we are constantly exposed to aspirational images of attractiveness. It is hardly surprising that, with the exponential growth of the means to change appearance via cosmetic procedures, increasing numbers of people are becoming focused on appearance as the primary determinant of self-worth.
Body Dysmorphic Disorder (BDD) is defined as a preoccupation with an imagined or slight deficit resulting in significant emotional distress or impairment. The problem with this broad definition is that it describes many people requesting cosmetic procedures.
Those with BDD experience extreme responses to imagined or exaggerated ‘defects’. They see a distorted face where others see normality, and hold that belief with delusional intensity. It is important to understand just how disgusted they are by the part in question; this is not just about attractiveness, it is about feeling disfigured and unacceptable to others.
They often develop a range of compulsive checking and concealing behaviours. ‘Mirror-gazing’ is common and they can become ‘locked’ in the mirror. They often develop suicidal ideation.
Those with BDD describe intrusive thoughts about the body part, often associated with a compulsive need to act. Therefore, they seek treatment even when discouraged, have further procedures even when dissatisfied with outcome, and may engage in harmful ‘self-surgery’. They tend to be resentful, sensitive to criticism, blaming others for their difficulties and lacking insight, rigid in their beliefs about the body part and its effect on their lives.
Such patients present to aesthetic practitioners rather than to psychologists. They are often very persistent in their demands, and can ‘doctor-shop’ until they get someone to treat them.
Why not just carry out the surgery? After all, that is what the patient desperately wants, and a caring practitioner, recognising a troubled individual determined on treatment, might well argue that it is better she/he does the procedure rather than someone else less skilled at some downtown clinic.
Unfortunately, the reality is that for most patients with BDD, a procedure to resolve the anomaly actually causes harm in that it generally does not remove the preoccupation, or it may be displaced to another body part. They are dissatisfied and can become litigious. In the meantime, their psychological state worsens, they become increasingly preoccupied with the problem and are disinclined to develop any alternative strategies for coping with their difficulties. The risk is that the procedure can intensify rather than resolve BDD.
It is essential to the wellbeing of these troubled individuals that the clinicians they approach are able to recognise that they are suffering from BDD and need a psychological rather than a surgical approach. They should have sufficient training to be able to recognise the warning signs and make the appropriate referral.
With the ever-increasing growth of cosmetic procedures, clinicians should be sure that they are not harming their patients. Encouraging these patients to accept a referral to psychology may be challenging, but it is the safest way forward.