Body Dysmorphic Disorder

A medical and legal perspective from Dr Darryl Hodgkinson and medical layer, Kate Williams

Body dysmorphic disorder (BDD) is defined by DSM-IV-TR (a text revision
of the DSM-IV Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition) as a condition marked by excessive pre-occupation with
an imaginary or minor defect in a facial feature or localised part of
the body.

The diagnostic criteria specify that the condition must be
sufficiently severe to cause a decline in the patient’s social,
occupational, or educational functioning. The most common cause of this
decline is the time lost in obsessing about the “defect”—one study found
that 68 per cent of patients in a sample of adolescents diagnosed with
BDD spent three or more hours every day thinking about the body part or
facial feature of concern. DSM-IV (Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition), assigns BDD to the larger category of
somatoform disorders, which are disorders characterised by physical
complaints that appear to be medical in origin but that cannot be
explained in terms of a physical disease, the results of substance
abuse, or by another mental disorder.

The earliest known case of BDD in medical
literature was reported by an Italian physician named Enrique
Morselli in 1886, but the disorder was 

By Editor, Jennie Lewis Teal

not defined as a formal diagnostic category until
DSM-III-R in 1987. The World Health Organization (WHO) did not add BDD
to the International Classification of Diseases (ICD) until 1992. The
word dysmorphic comes from two Greek words meaning “bad” or “ugly” and
“shape” or “form.” BDD was previously known as dysmorphophobia.”

Body Dysmorphic Disorder (BDD) can prove difficult to diagnose and
treat; experts agree on many of the prevalent symptoms however some of
these are also similar or precursors in cases of Obsessive Compulsive
Disorder (OCD) and Anorexia Nervosa. Research suggests cognitive
behavioural therapy (CBT) and selected serotonin reuptake inhibitors
(SSRIs) can be effective in managing BDD. The disorder is often prompted
and exacerbated by wider sociological or psychosocial factors, such as
the influence of mass media and popular culture. The prevalence of
physically “perfect” men and women in magazines and on television can
create pressure and anxiety in impressionable children and teenagers
which then carry through into adulthood, where they can develop into a
distorted perception of their own face and body.

There is little evidence to suggest BDD is inherited, however a lot
to suggest that it can be determined by parents’ perceptions of their
own physicality which in turn affects their children and has bearing on
their own physical perceptions. Some research suggests parents who are
critical of their children’s appearance are more prone to the disease.

According to the American Society for Aesthetic Plastic Surgery, the
number of children undergoing cosmetic surgery is on the rise. A number
of articles have been published of late noting trends in cosmetic
interventions in those aged 18 years and younger. USA Today reports,
“Pediatric plastic surgeons say they vet their patients carefully,
making sure eating disorders are not at play. And they watch closely to
sure it’s the child’s choice, not a pressuring parent or boyfriend or
the desire to look like a particular celebrity.”

“Lloyd Krieger, medical director of Rodeo Drive Plastic Surgery in
Beverly Hills, says his practice gets many calls from youngsters. We
turn away a good two-thirds of them after a phone evaluation,” he says.

The report goes on to quote Aviva Katz, a paediatric surgeon and
medical ethicist at Children’s Hospital of Pittsburgh of UPMC, and the
mother of twin five-year-old daughters, who says, “in theory, it’s all
very nice to say it would be best if we could raise our children without
the expectations of appearance. You want them to feel good and whole
within themselves without having the body that looks back at them in the
mirror be a model,” she says. “But that’s a challenge when we live in a
world with TV, movies and magazines”.

The Victorian Government, Better Health site identifies BDD as
causing severe emotional distress in sufferers. “It is not just vanity
and is not just something a person can just “forget about” or “get
over”. The preoccupation can be so extreme that the affected person has
trouble functioning at work, school or in social situations. It affects
men and women equally and usually starts in the teenage years. Suicide
rates of people with BDD are high.”

The effect the disorder has on the person’s life can range from mild
to extreme; lifestyle-limiting right through to socially crippling.
Symptoms include:

  • Hours spent obsessing over the perceived defect every day.
  • Guilt or distress about this preoccupation.
  • Anxiety about falling short of the “physical perfection” illustrated in mass media.
  • Need for reassurance about their looks from friends and family –
    this can also extend to a clinging friend who feeds their neuroses.
  • Ritualistic behaviour such as constant dieting and over-exercising.
  • Looking at their reflection in the mirror many times a day, conversely in some, an avoidance of mirrors is noted.
  • Reapplying heavy makeup many times a day and grooming to excess.
  • Social avoidance of situations which they feel will call attention to their defect.
  • Camouflaging or hiding the perceived defect with large dark glasses,
    big brimmed hats, long sleeves or many layers. This is noted as the
    most common symptom of the disease.
  • Requesting treatment of the perceived flaw by surgical or non-surgical means.

The disorder is nothing
new, it’s only now that it’s getting more coverage in the media. If
Sigmund Freud’s patient of the early 1900s, Russian aristocrat Sergei
Pankejeff, (nicknamed the Wolf Man by Freud) had been alive today he
would likely be diagnosed with BDD. According to Wikipedia, “Pankejeff
had a preoccupation with his nose to an extent that it greatly limited
his functioning. A few years after finishing psychoanalysis with Freud,
Pankejeff developed a psychotic delusion. He was observed walking the
streets staring at his reflection in a mirror, convinced that some sort
of doctor had drilled a hole in his nose”

Over the years, a greater awareness of the disorder has helped
physicians diagnose and treat the symptoms of BDD. According to the free
medical dictionary site, if treated it appears the disorder can lessen,
“As of early 2005, the prognosis of BDD is considered good for patients
receiving appropriate treatment.
On the other hand, researchers do not know enough about the lifetime
course of body dysmorphic disorder to offer detailed statistics.
DSM-IV-TR notes that the disorder ‘has a fairly continuous course, with
few symptom-free intervals, although the intensity of symptoms may wax
and wane over time.’”

However recent UK reports suggest BDD may be on the rise. Recent
figures released by NHS Information Centre show that in the past year,
the UK National Health Service (NHS) has spent “£5.7 million on giving
471 patients liposuction and giving over 1600 patients nose jobs, tummy tucks and breast reductions.”

The criteria for receiving cosmetic treatments on the NHS are
stringent and patients would not qualify for these treatments purely for
cosmetic reasons. Many who received treatment are diagnosed as
suffering from body dysmorphic disorder. However doctors noted that
“being distressed by your looks” was not enough to warrant cosmetic
surgery, “there has to be significant evidence of the patient suffering
from body dysmorphic disorder before patients would be permitted to have
cosmetic surgery.”


Looking at their reflection in the mirror many times a day, conversely in some, an avoidance of mirrors is noted.Looking at their reflection in the mirror many times a day, conversely in some, an avoidance of mirrors is noted. 

A diagnosis is often achieved with the help of a self-report
questionnaire, such as the Multidimensional Body-Self Relations
Questionnaire (MBSRQ) or the short form of the Situational Inventory of
Body-Image Dysphoria (SIBID).

An ABC News report posted Dec, 2007, refers to a study published in
the journal Archives of General Psychiatry, led by University of
California psychiatry professor Dr Jamie Feusner which sheds light on
BDD. “Dr Feusner, who led the research, says his team performed
functional magnetic resonance imaging (FMRI) brain scans on 12 people
with the disorder as they viewed black and white images of other
people’s faces, and compared the results to those of people who do not
have BDD. They saw differences in how the right and left sides of the
brain worked in people with BDD, but no actual structural differences in
the brain.”

Dr Feusner is quoted as saying, “This is the first time where there’s
evidence that there is a kind of biological abnormality that may be
contributing to the symptoms – the distorted body image – in body
dysmorphic disorder.”

The article goes on to cover other findings of the same report which
suggest the disease can run in families and is more common in cases of
OCD. Dr Feusner is further quoted as saying he knows of patients who
have numerous rhinoplasties and breast augmentations and some who take
it to such extremes that they begin to look less and less “human.” He
added, “Invariably they are dissatisfied with the surgery and can end up
feeling even more hopeless afterwards.”

A Physician’s Perspective and Experience with BDD

By Dr Darryl Hodgkinson,
M.B., B.S. (Hons), F.R.C.S.(C) (Plast), F.A.C.S., F.A.C.C.S.
Double Bay, Australia



Body dysmorphophobia (BDD) is a psychiatric illness experienced by up
to 20 per cent of patients requesting cosmetic surgery. Because of its
diverse presentations, BDD should be searched out and recognised by the
plastic surgeon. Otherwise, the unwary operator will invariably have to
deal with a profoundly dissatisfied patient. Patients with BDD hate
their bodies and may seek out cosmetic surgery as a solution. However
they are invariably not satisfied despite the objective result. Many
eventually fall into the cosmetic surgical victim category of
“over-operation.” These patients need psychological counselling and
referral to psychiatrists with a special interest in body image.
Recognition and deferral of surgery for BDD patients is advised because
findings have shown the propensity of these patients to litigate,
threaten and even harm or kill their surgeon.




To the surgeon, a minimum defect, a variation in size or shape, or a
minimal scar catastrophised into dislike or disgust is an alert or red
flag suggesting BDD. The excessively made up or doll-like patient, or
the patient with a clinging friend, parent or relative also can signal
an alert. The difficulty arises in assessing the degree of disability
exhibited by those with a minor disorder and in detecting the more
subtle presentation that can become florid symptomatology after cosmetic

As many as six to 15 per cent of patients
presenting to the plastic surgeon for cosmetic surgery may be
experiencing BDD. [13] Patients with previous surgery, especially those
with multiple surgeries who are still dissatisfied could likely be
experiencing BDD. The cosmetic surgical junkie is a red flag candidate.
It is estimated that males who undergo rhinoplastic surgery are three
times more likely than females to be dissatisfied with their surgery.[7]
The outcome of cosmetic surgery for each patient must be judged both in


psychological terms and for objective
changes because patient expectations are mostly psychological or
psychosocial. [11] We need to realise that the expectation of external
factors improving (i.e., enhancement of social networks, relationships,
and employment) is paramount for the patient. Hence a dissatisfied
patient may attribute failed external factors to the perceived
unsuccessful cosmetic surgery operation. The solution becomes more
surgery, which compounds a pre-existing unresolved, psychosocial
problem. If patients regard cosmetic surgery as a life panacea or
epic-changing event, they are likely to be disappointed when the
physical changes do not lead to the anticipated social outcome. After
surgery, pain, numbness, minor healing problems or complications will
accentuate anxieties in all patients, especially the BDD patient,
resulting in the exacerbation of symptoms or a BDD attack and leading to
feelings of anger, hopelessness and despair.


Psycological evaluation of patients is not standard in clinical
plastic surgery practice. However, questioning of motivation and
interview techniques to ascertain the patient’s degree of realism is
standard. The fact that 50 per cent of patients presenting for cosmetic
surgery are receiving psychotropic medications and that 27 per cent are
taking antidepressants suggests that perhap
s some standard psychological tests should be introduced into the
initial cosmetic surgical consultation. [9]Only a few authors have
suggested this as a routine. [15]

A suspicion of BDD may indicate the use of a simple standard
questionnaire such as the Body Dysmorphic Disorder Questionnaire. [12] A
more specific diagnostic questionnaire is the Body Dysmorphic Disorder
Examination Self Report. [3] To determine the severity of BDD, Phillips
[12] developed the BDD-YBOCS for the use of interviewing mental health
care professionals in assessing the severity of the disorder. This tool
is more likely to be used as a clinical research tool by a psychiatrist.
The diagnosis is confirmed by a psychiatrist following the criteria
outlined in the DSM-4 for BDD. The plastic surgeon’s suspicion or red
flags, perhaps with the aid of a screening BDD questionnaire, should
alert him to refer the patient to a psychologist or psychiatrist who can
confirm the diagnosis and initiate treatment if the diagnosis is


Once BDD is suspected or identified, avoidance of surgery is
paramount, and referral to a mental health care professional is
obligatory. Cognitive behaviour therapy is a mainstay treatment for
dealing with the behavioural components of BDD. Such therapy focuses on
response, prevention, and behavioural change. Medications complement the
behaviour therapy. Seratonin reuptake inhibitors in particular are
clinically helpful as they also are for the treatment of anxiety
disorders. The prescribing and management for these patients is out of
the plastic surgeon’s realm and should be left to the treating


All surgeons have had, or will have, the unfortunate experience of
operating on patients who become profoundly dissatisfied with the
surgical outcome even when, objectively, the result is satisfactory. It
is likely that
many of these patients had no diagnosis of BDD before
their operations. A minor problem such as wound healing, scarring,
numbness,or persistent bruising can trigger profound dissatisfaction or
the BDD “attack.” No amount of encouragement or support will mitigate
the disappointment of these people, and they become the total focus of
you and your staff’s working and out-of-office time, often at the
expense of other patients in the practice. The stress levels of the
treating surgeon and staff are increased dramatically. This worsens if
the dissatisfied patient begins to threaten the physician with violence.
Unchecked, the BDD patient often proceeds to litigation. Bodily harm
and even murder of a surgeon is a possible, but unlikely, sequence.

The three following cases, two that I unwittingly managed with
surgery and another that I reviewed for a colleague, demonstrate the
diverse but disturbing sequelae of operating on patients with BDD.


Kate, an attractive 20-year-old caucasian woman presented for breast
enlargement. Her request was for 600 ml increase, based on her aim to
become a Penthouse centrefold model. I acquiesced and provided a larger
than normal DD result. Within 12 months, the patient requested even
larger implants – 800 ml. The request was denied. She then wished to
have facial enhancement involving larger lips, cheek implants,
rhinoplasty and laser resurfacing. What followed was a conservative
rhinoplasty, a bilateral Terino shell silicone implant and laser
resurfacing. Initially, the patient was satisfied with the result, but
she did begin wearing huge sombrero-like hats and became heavily made
up, using extreme amounts of cosmetics. She soon requested another
rhinoplasty, saying she wanted her nose to be small and look “operated
upon.” After I refused to reoperate, she ignored my counsel not to
destroy a perfectly good surgical result and found a surgeon willing to
operate on her nose. Her surgically treated nose gave her a bizarre
simian appearance, toward which she was ambivalent. Her interpersonal
relationships with older, married men and the suicide of a peer male
boyfriend accompanied the unhappy consequences of her cosmetic surgery. I
asked Kate if she thought she should never have started with cosmetic
surgery, and she concurred. Kate demonstrates the trap of repeated
surgeries, which eventually did lead to a deformity, justifying her own
delusions of unattractiveness.


Brad a 25-year-old male actor, presented
for an assessment of his nose, having previously had three
rhinoplasties, two of them performed by recognised plastic surgeons. All
three surgeons had refunded the patient their surgical fees after he
became profoundly dissatisfied with their efforts. A slight deformity of
the nasal dorsum and irregularity of the glabella attributable to lack
of infrastructure of the nasal bones were confirmed by computed axial
tomography (CAT) scan. Multiple consultations followed, together with
communication with two of the previous surgeons. The patient claimed
that his acting career had been adversely affected by his nasal
appearance. A conservative rhinoplasty was agreed upon, and a slight
modification of the dorsum and osteotomy to narrow the bony vault was
performed. Immediately, the patient was dissatisfied and would not hear
that swelling was still present six weeks post operatively. The patient
returned repeatedly, bringing with him a


female partner
from whom he regularly sought reassurance and confirmation of his
distress and inability to work. He demanded a refund of his surgical
fee. After refusing this initially, I referred the problem to my medical
indemnity company, who after reviewing all documents and photographs,
recommended that I not acquiesce to the patient’s demands.

When I informed Brad of my indemnity company’s decision, he rained
down a litany of abuse, saying that he would get the surgeon (myself)
and was on his way to get his money. These threats were reported to the
local police, who contacted Brad, advising him not to proceed with his
threats and not to contact the office. I have not heard from the patient
since. However, to my angst, I have been notified that Brad is a member
of my local private tennis club, and I am now not comfortable playing
at that club. Brad illustrates how dissatisfaction occurs quickly after
surgery and can become violent. It also points to the fact that male
secondary rhinoplastic cases are of particular concern in BDD.



Janene’s file was sent to me for review by the indemnity company of a
colleague in another state of Australia. Preoperatively, the patient, a
41-yearold woman, had a doll-like facial appearance. She was
fastidiously attired and complained of wrinkles around her eyes, some
crows’ feet, and some excessive skin in her upper eyelids. The surgeon,
skilled at laser blepharoplasty, suggested a modest removal of upper lid
skin and lower lid laserbrasion of the patient’s wrinkles. The
procedures were performed without complications. At three months, the
patient showed no lag ophthalmia, minimal pigmentary changes, and good
elimination of crows’ feet and lower lid wrinkles. Janene was, however,
profoundly dissatisfied, saying that her life had been ruined. She wrote
a 25-page letter of complaint to the State Medical Board and arrived at
the surgeon’s office on Christmas Eve demanding her clinical notes. The
local police had to be summoned to remove her from the premises. Janene
pursued her complaint through the Health Care Complaints Commission.

Her case was subsequently heard and brought before the State Medical Board. A di
sciplinary hearing of the operating surgeon then ensued. This patient
represents the “doll-like” perfectionist obsessed with her appearance
who has no minimal deformity, but is unwittingly subjected to surgery by
a colleague.


3. Claiborn J, Redrick C: The BDD workbook. New Harbinger
Publications Inc., 2002. 7. Guyuron B, Bolchari F: Patient satisfaction
following rhinoplasty. Aesth Plast Surg 20:153-157, 1996. 9. Meningaud
JP, Benadiba L, Servant JM, Herve C, Bertrand JC, Pelicie Y: Depression,
anxiety, and quality of life amongst scheduled cosmetic surgery
patients: Multicentre prospective study. J Craniomaxillofac Surg
29:177-180, 2001 11. Perrogon F: Aesthetic surgery, patient’s opinion.
Quantitative and qualitative analysis of aesthetic surgery results of
481 survey and 50 records of “dissatisfied patients”. Ann Chir Plast
Esthet (France) 48:307-312, 2003. 12. Phillips KA: The broken mirror.
Oxford University Press, Oxford, pp.45-46, 242, 1986. 13. Sarwer DR,
Wadden TA, Pertschuk MJ, Whitaker LA: Body image dissatisfaction and
body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconst
Surg 101:1644-1649, 1998. 15. Terino E, Flowers R: The art of
alloplastic facial contouring. Mosby, Saint Louis, p 328, 2000.



A Legal Perspective on BDD

By Kate Williams,
Principal Lawyer in Medical Law,
Slater & Gordon Lawyers, Sydney.

Dr Hodgkinson’s article concerning the body dysmorphic patient
carefully sets out the disorder’s criteria for diagnosis. It sensibly
provides a course of action to take with such patients who either have
this disorder or whom a surgeon suspects has this disorder. In recent
times this condition has been the subject of much media coverage. Cases
have been cited from throughout the world of requests for radical
surgery which has included most shockingly, requests for amputation of
healthy limbs and other potentially disfiguring surgery. Mercifully this
would be a rare request. Through Dr Hodgkinson’s research he quotes
that as many as six to 15 per cent of patients presenting to the plastic
surgeon may be experiencing BDD. This is not an insignificant figure.

Whatever the physical and/or mental health consequences are of
acquiescing to the requests for such surgery, the discussion of the
legal issues concerning the management of these patients, however,
deserves no less attention. Despite many of the requests made to plastic
surgeons for surgery that are dangerous and unrealistic, a clinician
should be aware of a number of medico-legal issues.


It is a threshold right that competent adults have the right to
self-determination with respect to their wishes and have the right to
determine what is done to their bodies, including the medical treatment
they received. A doctor, of course, is not entitled to treat a patient
without the consent of the patient.

It is generally assumed that a patient’s consent makes the medical
treatment requested lawful. If a doctor has actual knowledge that a
patient has body dysmorphic disorder, the issues of capacity to provide
consent for a medical procedure is relevant.

Under the Common Law in most jurisdictions in Australia there is a
presumption that a person has legal capacity. In some situations even if
a person suffers a mental disorder, it does not necessarily mean that
the presumption of capacity is displaced.

Under legislation in New South Wales a person lacks capacity in
relation to
a matter if at the material time he or she is unable to make
a decision for themselves in relation to the matter because of an
impairment or disturbance in the function of the mind or the brain. I do
not consider that body dysmorphic disorder would be a disturbance such
that it would be considered as affecting a patient’s ability to make or
give informed consent at the time of consenting to surgery or a


The primary issue is whether the surgery requested has any possible
therapeutic benefit to the patient upon which the operation will improve
or benefit the patient’s appearance. It is likely that a person with
body dysmorphic disorder will not derive any improvement and if
anything, it will further aggravate their mental health.

If there is no therapeutic benefit in such requested cosmetic
surgery, the question that arises as to the basis upon which such
surgery may be regarded as lawful. In Dr Hodgkinson’s example in Case
Study No. 1 (Kate), it was a good example of sensible competent practice
when dealing with such patients. It was correct to refuse the further
request for surgery. The appropriate standard of care ought to be that
surgeons should refuse further treatment. At the front of the surgeon’s
mind should be “is there therapeutic benefit to performing surgery?” If
no benefit can be considered possible, further surgery should be


I sometimes think that doctors and in particular, surgeons, believe
they are the only professionals who have difficult clients. On
considering this type of patient, the first thing that came to mind
which is analogous to this situation was the vexatious litigant. This is
a person who is shown to be habitually and vexatiously litigious
without reasonable grounds or cause or excuse. I fortunately have only
experienced this type of client once in my career.

I consider that this analogy has clear parallels with the Body
Dysmorphic Patient. In both scenarios, medical and legal, the following
steps ought to be taken:

  1. I cannot endorse highly enough the questionnaire outlined by
Dr Darryl Hodgkinson

About Dr Darryl Hodgkinson

Dr. Darryl J. Hodgkinson is recognized world-wide as an expert in cosmetic plastic surgery with more than thirty years of experience in both cosmetic and plastic/reconstructive surgery.

Dr. Hodgkinson did his plastic surgical training at the prestigious Mayo Clinic in the United States and is amongst an elite group of a very few surgeons to hold two degrees in plastic surgery from American Board of Plastic and Reconstructive Surgeons and the Royal College of Surgeons, Canada.

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