Body Image Distortions by body dysmorphic disorder (BDD)

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Body Image Distortions: A common psychological condition in cosmeticsurgery cases.

Arthur J. Anderson, Ph.D.
Clinical Psychologist & Psychotherapist

Deborah Sandler

One of the most common psychological conditions associated with cosmetic surgery is a condition commonly referred to as Body Dysmorphic Disorder (BDD). BDD is a distressing body image condition that involves excessive preoccupation with physical appearance in a 'normal' appearing person. This condition is often associated with intrusive thoughts of body dissatisfaction, avoidance of exposure to body images situations, such as mirrors in public places, and excessive body checking and comparisons with others. Thus, in its extreme form it can be quite debilitating and cause a great deal of anxiety and dis-satisfaction.
However, as with most psychological conditions, there is a wide range of difference in how these excessive negative self image thoughts and avoidance behaviours are presented. The differences range from a 'normal' level of self consciousness to severely debilitating effects of anxiety and depression in more severely afflicted people. In fact, a great number of ‘normal’ cases in the less severe end of this continuum have been treated solely with cosmetic surgery with remarkable results. Though cases such as these fall along the continuum of body image distortion difficulties they are generally at the mild, more functional end and not the severely obsessive BDD sufferer. In mild cases such as those above, not only has the individual been satisified in their new appearance but they have found new satisfaction in their self concept and method of relating to others as well. Cosmetic surgery has been shown to help reduce or eliminate many of the associated features of mild BDD, without resorting to psychological treatment or counseling. However, for most forms of BDD, a combination of cosmetic change, medication and psychotherapy has been shown to have the greatest effect.

It is not uncommon for certain people today to be overly distressed at the reflection they see in the mirror. The degree of distress can vary widely from client to client, with some people suffering serious anxiety over what they see as intolerable aspects of their body and others who feel that a quick change will be of benefit to them in their private or personal lives. Whatever the reason a client has for presenting at a cosmetic surgery clinic, the desire for positive change and/or transformation is what they actually seek through a change in their appearance. The belief is that if the change is made in the appearance, the psychological benefit will follow.

This psychological effect of cosmetic surgery sometimes needs to be assisted with the help of counselling and/or psychotherapy. The cosmetic surgery procedures they undergo can ‘fill in’ the gap in appearance they have always felt to be there and help make these people feel complete and whole for the first time in their lives. Certainly there are those who are disfigured through accident and/or tragedy in their lives and crave the cosmetic changes that will make them whole again. However, those suffering from BDD, without having been diagnosed as having any type of disfiguration, require an external augmentation or adaptation to force the image they see in the mirror to be equal or try to conform to that which they believe themselves to be. In short, the image in the mirror must match the image in their heads if the BDD sufferer is to obtain relief from the constant comparisons with others and constant feelings of being inferior or ‘less than’ others.

In more severe cases, where the emotional distress and avoidance behaviors becomes too much for people, psychiatrists, psychologists or psychotherapists are often consulted in addition to cosmetic surgeons to change both the external, physical reasons for the distress and the internal perception these people have of themselves.; all in an attempt to make positive changes and transform themselves. However, such severe cases are rare; less than 3 per 200 persons walking the street. More typically, the only intervention for mild cases that is required is cosmetic surgery and physical changes, with psychological and counseling supports to help these individuals integrate into their lives better after the cosmetic changes have been made. In many ways, this is similar to depressed patients taking medications such as prozac to stabilize them before they embark on the more long term changes that psychotherapy can bring.

It must be noted that when clients present body image issues to a psychiatrist or psychologist, they are more than likely to get a clinical diagnosis of BDD. Afterall, that’s what psychiatrists and psychologists are trained to look for when their client mentions the host of symptoms and signs associated with body image dissatisfaction. However, as a psychologist and psychotherapist with more than 15 years combined experience, we have often asked ourselves if body dissatisfacition is a true disorder, when everybody in the world pays attention to their body’s shape, their clothes, and appearance in relation to the norms of others in their cultures. In our society, with global advertising and mass media bombarding us with images of what we ‘should be’, it is often difficult to make a diagnosis of BDD when people are just doing what society has told them to do; Be dissatisfied- with your body, face, size, hair colour, make up, age, etc., and do something about it (generally by purchasing a product).

As with everything else, the official criteria for BDD related interventions has a scale where the client needs to be in a state of distress so severe that no other course of action can be taken other than cosmetic surgery, medication for anxiety, and cognitive psychotherapeutic treatment for body image distortion. However, this three pronged approach is only appropriate for the most severe cases. Generally, most individuals respond to improvements in their body, or medication, or psychotherapy by themselves.

The average client who presents at cosmetic surgery clinics is generally not suffering from serious forms of distress due to body image conditions such as severe BDD. Many cosmetic surgeons will not perform cosmetic surgery on clients suffering from serious forms of BDD because the condition itself entails the dis-satisfaction of the body no matter how perfect it is, and hence a surgeon may find him/herself performing corrective surgery over and over in a bid to remedy something that may or may not be an ‘actual’ problem. The vast majority of people who present for elective cosmetic surgery due of body dissatisfaction are not in this severe BDD range, and can obtain a level of physical improvement though cosmetic procedures that greatly enhances their self perception and self acceptance in a way that therapy alone may take much longer to achieve.

Fiona’s case demonstrates how cosmetic procedures can improve self-perception and improve quality of life for the typical client with body dissatisfaction issues. Fiona is not her name, of course, but an alias she chose to protect her identity. Fiona was always ashamed of her breast size and never wore revealing bathing suits or did anything that would bring any attention to herself. In fact she generally hid her breasts with poor posture and oversized clothing.

After discovering a lump in her right breast, Fiona sought psychotherapeutic help for her fear of cancer and her feelings about herself. Thankfully the lump turned out to be benign and was surgically removed. However, this procedure left her with a rather large scar that only punctuated her feeling about her breast size and her negative feelings about herself as a woman. It was only then that she turned to cosmetic surgery to not only remove the scar, but augment her breast size.

Though the scar from the removal of the lump could not addressed, she met with a surgeon and scheduled a breast augmentation procedure. Fiona entire perception of herself and her femininity changed after this cosmetic enhancement. Her concerns over her scar then became a minor issue, as her overall appearance had changed to more adequately match Fiona’s ideal model of what breasts and women should look like. Her only complain after her BA was that her breasts were not close enough together. This is a common complaint after surgery, but one that can be addressed by additional surgery at a later date. The major change here was that after her cosmetic surgery, Fiona felt at least ‘as good as – if not better than’ other women in her age group. She began to walk taller and had much more confidence in her daily life.

On our own website,, we find that in all cases of cosmetic change to improve self image, there has been a positive response to the cosmetic procedure. Even in those relative rare instances, when cosmetic procedures have ‘gone wrong’ and required a second cosmetic procedure, we have found that those clients would rather have a ‘re-do’ than give up the idea of cosmetic surgery. Clients who would not otherwise show their face or body - find a satisfaction in showing their new photos on the site in a bid to help others too. This shows a high level of determination to succeed and change certain aspects of the self and improve their overall level of self-acceptance. This is a welcome relief to all therapists and shows a level of self help that may not be achievable elsewhere.

In our own practices, we see many clients, like Fiona, who are either about to undergo cosmetic surgery or have already undergone cosmetic surgery. All of these clients share one thing in common. They all want to look as happy on the outside as they feel on the inside and are willing to undergo the discomfort and cost of cosmetic surgery to get that look. Though many argue that it is the ‘inner person that counts’ , it is the outer appearance that we are most often judged on. Our outward appearance often dictates the level of attention we will receive, how seriously our opinions are taken, and how well we are treated by others. This social interaction effect has a powerful impact on our self estimation. The positive response to an improved outward appearance can by itself transform a life into something more than it was and perhaps into something it needed to become all along.

It must be noted that serious cases of BDD exists and it is a very distressing disease to both the sufferer and the families of these individuals. Body Dysmorphic Disorder only came into being as a diagnostic category a few years ago. However, as a phenomena it has probably existed for thousands of years. The basic problem in identifying any psychiatric disorder is to determine if persons suffering from the disorder could be included in an existent category of illness of if a new category should be created. This involves an examination of the causes of the disorder, the presentation of symptoms, duration and course of the disorder, and severity of presentation. A case was made to include BDD in DSM IV because it met the criterion of a diagnostic category at the time with a relatively small body of research. However not a great deal is actually known about the aetiology or the various manifestations of the phenomena now referred to as BDD.

From the professional literature on the subject and from my own personal practice observations, it appears that there may be two major sup populations of patients who suffer from BDD; those with a form of BDD that appears to be biogenic in nature and those whose symptoms appear to arise from a personality disturbance or neurotic presentation. As with obsessive compulsive disorder (OCD), biogenic forms of BDD respond well to medication and psychotherapy. From my experience, individuals with this type of BDD do not generally seek change through cosmetic surgery. Occasionally there are those who break this mold but generally the obsession subsides with medication and psychotherapy and they readapt to their appearance as it is.

With the personality disturbance of the second sub population though, often psychotherapy, cosmetic surgery and medication are required to make the difference. I include cosmetic surgery here because any perceived deformation or inadequacy for this type of BDD is seen as unacceptable and a blockage to happiness. Thus, surgery removes the inadequacy and the blockages to happiness and contentment with self image. Well that’s the theory anyway. The difference between these individuals and the more obsessive compulsive type of BDD sufferer lies in the pathogenesis or progression of the disease over the years. Incomplete or dysfunctional areas of personality development that produce body image distortions and dissatisfaction/depression are by nature more immutable to change than those of a more biogenic nature and thus, they fill the waiting rooms of cosmetic surgeons (and psychotherapists) more often and for a longer period than the obsessive BDD sufferers.

Though many of individuals with both forms of BDD often switch their focus to different body parts after each surgery, eventually many of these individuals come to accept themselves as they eventually become. Psychotherapy and medication often speed along this process of self acceptance. However it must be stressed here that what I am describing relates only to mild forms of body image disturbances, and not severely afflicted individuals, including those who wish to have limbs amputated.

I think there is a lot of confusion in the public’s mind about BDD because what they read about in psychiatry journals. Psychiatric and Psychology Journals address BDD in terms of the most severe manifestations of the disorder. Often with individuals who wish to have limbs amputated and other grotesque surgeries to alter themselves in severe and often bizarre ways. However from my practice experience most people who suffer from BDD and associated body image disturbances do not fall into the extreme camp of an obsessive compulsive BDD sufferer. Most people who consider cosmetic changes have sensed some inadequacy or blemish associated with their body image and wish to alter that to something that more closely approximates what they should (in the patients opinion) look like. This mild form of body disturbance may not even be severe enough to be labeled BDD but is part of the same phenomena that ranges from normal to severely dysfunctional along a continuum. This is consistent with most disturbances in psychology and psychiatry as well.

All that being said, I do believe that ALL prospective patients for cosmetic surgery be screened by a mental health professional for BDD and not by cosmetic surgery counsellors who are often there to sell surgery and do not always have the patients best interest at heart. However, most surgeons I have encountered tend to ignore the mental health issues they are presented with and almost never refer even severe BDD patients for psychiatric and psychological assessment.

Finally, there is little large scale objective research in the area of BDD. Most of what we know of the disorder came from one book by one author and multiple case studies of a variety of individuals. A few exploratory studies have also been done in this area that substantiate the fact that some phenomena is occurring that involves perception of body image and depression/dissatisfaction associated with this perception. Thus judgements as to validity or invalidity of claims about nosology, aetiology, presentation, course, risk factors, prognosis, duration or severity of BDD must be withheld until all the evidence is in. In the meantime, we all do what we can with what we’ve been given.

Given the options of cosmetic change, medication, and psychotherapy the decision is ultimately up to the consumer. By utilising all their options for change, the changes they make can be pleasing, healing and enduring. In the end its up to all of us to choose our own path. Knowledge makes that choice easier.


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