After performing cosmetic surgeries for nearly a decade, Dr. Beverly Fischer, head surgeon at the Advanced Center for Plastic Surgery in Maryland, encountered a patient who would haunt her for years.
A young woman in her 20s, who had recently lost weight, was seeking nasal reconstruction surgery. "She told me, 'I don't want a cute turned-up nose, I just want it slightly smaller,'" said Dr. Fischer. "Everything she asked for sounded realistic. I operated on her and when she first came back she was like, 'I don't know if it's small enough. I don't know if I see much of a difference.' I told her that it takes close to a year for the swelling to go away and that she had to be patient."
This dissatisfaction with her surgery resulted in multiple visits to Dr. Fischer's office. The patient would come in, appointment or no appointment, requesting more surgeries, expressing dissatisfaction about teasing from family and friends, and worrying that she couldn't go out at night because she thought she looked like a trauma patient. "She was coming in every week complaining about something," said Dr. Fischer. "She was almost incapacitated to the point where she couldn't go out of her house anymore."
After Dr. Fischer suggested she see a psychiatrist, the patient, who felt offended by her comment, continued to harass Fischer and her staff, even bringing in her husband to chastise the doctor on her medical advice. "It got to be a nightmare," admits Fischer. "I just gave her back their money and told her that I couldn't communicate with her anymore, and that it was best if she left the practice."
What Dr. Fischer didn't know at the time was that her patient was suffering from body dysmorphic disorder (BDD), a body image disorder characterized by an obsessive preoccupation with some perceived defect in appearance. BDD causes those who suffer from it significant distress, and it's a difficult disorder to treat. Oftentimes, it is categorized as an obsessive-compulsive disorder, but while both conditions might share the same OCD-spectrum, researchers have found a significant difference between OCD and BDD: People with BDD tend to have poorer insight than OCD patients, and they tend to be more delusional.
Psychologists have found several effective treatments for BDD, such as cognitive behavioral therapy, psychotherapy, and medication therapy. However, many of those who suffer from BDD don't recognize it as a psychological disorder and seek to treat it as such—instead, some turn to cosmetic surgery to alleviate their symptoms. The most common cosmetic procedures include rhinoplasty ("nose job"), breast augmentation, liposuction, and minimally invasive treatments like collagen injections, chemical peels, and fillers, all of which correspond to areas of the body that BDD patients focus on the most.
After my nose job, my nose looked a little better, but my stomach took over for my nose.
The typical BDD patient is perfectionistic and over-focused on small details, meaning that cosmetic surgery often comes with a significant downside: The unrealistic expectations that patients have can lead to distress, dissatisfaction, and new appearance preoccupations—some patients simply "switch" their area of obsessive focus after surgery. In a 2011 study, for instance, one subject told researchers, "After my nose job, my nose looked a little better, but my stomach took over for my nose."
According to Dr. Katherine Phillips, a leading specialist in BDD since the mid-90s and author of several books including The Broken Mirror, the first and most definitive book on BDD, people with BDD tend to have a distorted body image. Researchers are learning that BDD patients have aberrations in their visual process in the way they see faces and objects. "They also have a tendency to obsess and to worry," said Phillips, "and when you combine these traits, it makes sense that BDD would almost never get better over the longer term with surgery."
This was the case for Lindsay*, a makeup artist from London, who suffered for years with BDD before deciding that surgery was the only way to cure her symptoms. "I was unhappy for a very long time with the way my stomach looked," Lindsay told Broadly in an email. "I wanted to do something about it. I consulted with a psychiatrist, psychologist, and a mental health nurse that I was seeing at the time, and they supported my decision to seek surgery."
In most cases, patients with BDD should avoid surgery altogether, experts say. While a small amount of patients may see improvement in their symptoms, many plastic surgeons believe that a BDD diagnosis is a contraindication to surgery, and that patients who receive cosmetic procedures often feel dismayed because their high expectations post-surgery have not been met. Often, when patients with BDD seek surgery, they believe that altering their appearance will solve issues in their lives, but many find the opposite to be true.
After the second surgery, which I thought would fix all the problems from the first surgery, I was happy for two days before more problems appeared.
After a full abdominoplasty, Lindsay was anything but happy. "After the first surgery, I felt amazing, but a couple of weeks later, I started to notice things that I didn't like, such as an uneven scar, loose skin, and fat on my hips," she recalled. "I was convinced that if I had another surgery to get rid of the excess skin and fat, I would be happy. After the second surgery, which I thought would fix all the problems from the first surgery, I was happy for two days before more problems appeared. I felt that my waist was so uneven that I looked deformed."
Twenty-four-year-old Tyler*, had a similar experience. Following his liposuction and male breast reduction surgery, he became fixated on his hair, a common appearance concern in men. "After the surgery, I started to think I was losing my hair," said Tyler. "I went through a stage where I would weigh myself maybe 15 to 20 times a day. I would go to the work bathroom and lift my shirt up to look at my body. I also started wearing hats to cover my head. I'm always trying to move my hair about to make sure it doesn't look like I'm balding."
Even though Tyler knows, on some level, that his appearance is now more in line with his imagined ideal, he has a hard time accepting that. "I know I've lost a lot of weight and I look better, but my mind can't comprehend it," he said. "Physically I can see it, but psychologically I can't."
BDD patients who are unhappy with the results of their surgeries can become depressed and have their symptoms worsen, according to the International OCD Foundation; others seek repeated surgeries. Actor Reid Ewing, star of the ABC television series Modern Family, penned an essay in 2015 for the Huffington Post about his experience with BDD and plastic surgery, expressing his regret over the numerous cosmetic procedures he'd undergone in an attempt to alleviate his symptoms. "I went back to the doctor several times in a frenzy," wrote Ewing, "but he kept refusing to operate on me for another six months, saying I would eventually get used to the change. I couldn't let anyone see me like this, so I stayed in complete isolation. When I went out, people on the street would stare at me, and when I visited my parents they thought I had contracted some illness."
Jessica*, a 31-year-old teacher from Australia, similarly felt that repeat surgeries would help improve her appearance. After undergoing multiple procedures at 18, including breast augmentation and ear pinning (a procedure that moves the ears closer to the head), she was convinced her breasts looked disfigured and sought the help of another doctor. "I saw a plastic surgeon in Perth, Australia, but he refused to perform the surgery because of my BDD and because I already had plastic surgery so young," she recalled. "I was desperate and flew under the radar to a cosmetic surgeon and took my chances of being 'botched' to have my dream breasts."
Following her second surgery, Jessica felt even worse. She sunk into a depression and her sense of self-loathing intensified: "I felt like all the happiness of having [my breasts] done totally left after the surgery." Researchers have found that patients who are dissatisfied with cosmetic procedures may experience social isolation, family problems, self-destructive behaviors and anger toward the surgeon and his or her staff.
I felt like all the happiness of having [my breasts] done totally left after the surgery.
According to David Sarwer, a clinical psychologist and associate dean of research and director of the Center of Obesity Research and Education at the College of Public Health at Temple University, anecdotal evidence suggests that patients who experience negative feelings after surgery may be more at risk of threatening or bringing a lawsuit against the plastic surgeon—or, even worse, to threaten or commit acts of violence against a surgeon or his or her staff.
Dr. Ira Papel, the head of cosmetic surgery at the Facial Plastic Surgicenter in Baltimore, told Broadly that he's found himself in several frightening situations with former patients. Following with what appeared to be a successful rhinoplasty, one patient was disturbed by the end results. "He couldn't function," said Papel. "He lost his job, he got divorced, because of something that no one could see." Another patient threatened his own life in the lobby.
To prevent situations like this from happening, Papel is now pushing for surgeons to utilize screening tools in cosmetic surgery clinics to detect patients who may have BDD. "The surgeon's responsibility is to at least try and recognize who these people are," Papel said.
A 2016 study published last December in the Journal of American Medicine found that routine use of BDD questionnaires for patients seeking cosmetic surgery could improve patient care. In an interview with CBS in January, Dr. Lisa Ishii, the study's author, noted that she was surprised at the high prevalence of BDD among cosmetic surgery patients. "The other surprise was just how poor we were as surgeons at picking it up," she said.
"I think it can be difficult to identify BDD patients in a surgery setting, and it can be challenging," said Phillips. "The surgeon just needs to ask the right questions, and they're pretty straightforward and simple." Sarwer has some suggestions: In addition to BDD screeners, he said, there are other telltale signs that surgeons can look for. "If patients come in and they say, 'I don't like the bump on my nose,'" said Sarwer, "and the surgeon is having a difficult time identifying or seeing the bump, or if somebody says, 'I don't like the blemishes on my skin,' and there are very few blemishes that are visible, these are some of the signs. This can be signal number one."
He couldn't function. He lost his job, he got divorced, because of something that no one could see.
But other experts warn against relying too much on questionnaires may prove ineffective. Dr. Rodney Rohrich, editor-in-chief of the journal Plastic and Reconstructive Surgery, told CBS that many people with body dysmorphic disorder will intentionally try to deceive medical experts. "One of the hallmarks of BDD patients is they don't like to be found out," he said. "If they're found out, they leave. These patients are very smart—most won't even want to do this [BDD] questionnaire because they're so smart."
Lindsay claims she was neither asked about her BDD symptoms by her doctor, nor was she was given a screener, and she wasn't eager to divulge her struggles with the disorder. "My regular primary care physician and the surgeon that performed the operation were unaware that I had BDD," said Lindsey. "I knew that they wouldn't operate on people with the condition, and I was convinced I would be thrilled with any result as long as it was better than what I had, so I didn't tell them."
While most experts agree that cosmetic surgery isn't a viable treatment for BDD, Phillips emphasizes that there are effective ways to treat the disorder. "The excellent news is that we have two kinds of treatment," said Phillips. "SRIs (serotonin reuptake inhibitors) and CBT. These medication and therapy treatment usually work for people with BDD. And if one medicine doesn't work, you can try another. Most patients with BDD get better over time with these treatments."
For Jessica, life has gotten easier since her second breast augmentation nine months ago. She's started therapy and now takes SRIs on a routine basis, and she says her thoughts about her body have improved. "I still have BDD symptoms," she said, "but I'm so much happier now. CBT and medication therapy are the best things I've ever done for myself."
* Names have been changed