Depression After Surgery and Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is a psychological condition that is marked by an extreme dislike or unreasonable criticism of one's physical appearance. Most people are occasionally upset about how they look or about one aspect of their body. That is not BDD. Someone with BDD believes they are ugly or that their nose is hideous or that some other aspect of their body is utterly unacceptable to them and everyone else. The most curious part of BDD is that there is usually no real defect. Most people with BDD look perfectly fine. BDD has been linked to obsessive-compulsive disorder and may play a role in eating disorders.
BDD tends to start in adolescence, which is a time when people can be very sensitive about their appearance. Patients with the disorder who start to obsess about their nose, for example, may have rhinoplasty done to fix the problem, but are never satisfied with the results and more likely will suffer from after surgery depression. They may end up getting revision after revision and are still not happy.
At one time, I did not believe BDD existed. Then I came across several patients who did have it and who kept getting surgery to attain happiness that surgery would never bring them. I once thought this behavior stemmed from standard neuroses or obsessive-compulsive disorders, or even extreme insecurity issues. But it seems there are other, deep-seated underlying issues at work.
Mark B. Constantian, MD, FACS, of Nashua, NH, has studied BDD in patients who requested revision rhinoplasty:
Prior to surgery, an estimated 75% had true functional pathology, undiagnosed, yet real, surgical problems, or "unremarkable" personalities (i.e. not perfectionistic, depressed, or demanding)
Only one-quarter had, in the surgeon's judgment, minimal defects, an unreasonable attitude toward the defect, or depression, though the indications for surgery remained valid.
On the other hand, the results illustrated how difficult it is to identify the rare patient with BDD, a mental disorder characterized by a slight or imagined body defect that triggers severe emotional distress; the nose is the source of distress in nearly half of all cases. (Constantian, MB: Identify BDD patients prior to rhinoplasty; Cosmetic Surgery Times, June 2001)
If the above is true, one out of every four people who are looking for information about a second or third revision rhinoplasty have BDD. I think that ratio is a little too high, but it is food for thought and should be considered by all of us. Unfortunately, rhinoplasty is the most common procedure requested by people with self-image disorders.
"BDD and secondary, tertiary, etc., rhinoplasty is most often seen in males" according to Dr. Constantian. The American Academy of Cosmetic Surgery recognizes that 2% of cosmetic surgery patients have it. That statistic may seem low to you, but it appears that this 2% are more likely to be rhinoplasty and liposuction/lipoplasty patients. When you do the math, that's a lot of nose jobs.
The information here about BDD is provided to make you aware of the problem. There is a fine line between what is healthy and what is not. Obsessing about your appearance and having thoughts about your nose consume you is very unhealthy indeed.
I can tell you that having a rhinoplasty changed my self-esteem for the better. I had a wide, bulbous-tipped nose and now I don't and I am happy about that. But I was happy with the results. If you obsess about how your nose looks when everyone else says you look fine and are unhappy enough to have two or more rhinoplasties, you should consider the fact that your nose may not be the problem.
I have provided this information in case you or someone you may know has a self-image disorder. You should know the signs. This is a serious disorder and can lead to years of unnecessary body modification and severe depression, and sometimes even suicide! You could save yourself or your friend years of anguish.
Do not get defensive until you truly understand the symptoms of this disorder. And if you feel you are getting defensive, then that may be another symptom. Why would you get defensive if something does not apply to you?
The standard description of BDD by the American Psychiatric Association, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (known as DSM-IV), is:
• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).
Symptoms of Body Dysmorphic Disorder :
1. Frequently comparing your appearance with that of others; scrutinizing the appearance of others.
2. Often checking your appearance in mirrors and other reflecting surfaces.
3. Camouflaging the perceived defect with clothing, makeup, a hat, your hand, your posture, or in some other way that diverts the attention of the "defect"
4. Seeking cosmetic surgery, dermatologic treatment, or other medical treatment for appearance concerns when doctors or other people have said such treatment isn't necessary.
5. Questioning and "fishing for compliments"; seeking reassurance about the flaw or attempting to convince others of its apparentness.
6. Anger or resentment towards those who do not see your perceived flaw
7. Excessive grooming (i.e. combing hair, shaving, cutting hair, dyeing hair, and applying makeup and cosmetics)
8. Avoiding mirrors and reflective surfaces
9. Frequently touching the defect
10. Picking at and touching your skin
11. Repeatedly measuring the disliked body part
12. Excessively reading or searching the internet about the defective body part
13. Excessive exercise or dieting
14. Avoiding social situations in which the perceived defect might be exposed
15. Frequent absenteeism from school or your place of employment because you feel "ugly"
16. Failure to uphold a job for fear of someone seeing your perceived "defect"
17. Failure to hold a job because you are depressed about your appearance
18. Avoiding leaving the house for fear of someone seeing your perceived "defect"
19. Feeling very anxious and self-conscious around other people because of the perceived defect
But BDD disorder really goes further than this. I speak as someone who has had plastic surgery and who has come across patients who have been diagnosed with such disorders and had extensive surgery. These patients don't want to hear it, they don't want to admit it, and they think surgeons, psychiatrists or even friends are against them if they bring the subject of BDD up.
I am not saying this to sound like a know-it-all or to prove that am not on your side if this pertains to you. I am very much on your side. I am going out on a limb here because this is a very sensitive, yet important factor, in primary and revision rhinoplasty. I am giving you my honest opinions and observations, as well as statistics and articles written by respectable doctors.
When I first began researching plastic surgery, I noticed that the diagnosis of BDD disorder was very common and, in my opinion, too often given along with a prescription for medications. I admit that at first I was very disappointed with the psychiatric community for passing out the BDD diagnosis until I realized that there really was an increasing group in plastic surgery of persons who were diagnosed with BDD.
Although it is difficult to diagnose BDD if you are not trained to recognize the symptoms, individuals with it slip through the cracks and wind up becoming very depressed. They end up withdrawn from society after their surgery, and even more so after a second, third, and so on, revision surgeries.
A good plastic surgeon becomes experienced at turning away patients who fit certain criteria of BDD or who otherwise give the surgeon a bad feeling. Plastic surgeons have learned to understand that nothing they do can give a BDD patient what he or she wants. A BDD patient can never be helped with cosmetic surgery and often becomes a problem patient for the surgeon.
I am not against those who have certain issues having surgery, but surgery will not help those with BDD and similar disorders. It will not make you a different person, or make you more popular, get you more dates, or make you a super model. Many BDD patients are not in the mental state to recognize the features that are considered attractive by most or even by themselves. They really don't know what they want. All they know is that they don't want to look like they presently do. But even given the chance to have exactly the looks they want, the dysmorphia is still present and they are unhappy. They then become obsessed even more and further convinced that they are ugly.
You may argue that it is the patient that must be satisfied with his or her result, and they should be. But if the patient does not know what is attractive anymore and will always be unsatisfied with the outcome, it is very unhealthy.
You have to ask yourself if you truly have an unattractive nose. Seek help or at least research BDD even if you do not think you have it. It is good to read up on it and you just may realize that you have more in common with some BDD patients than you'd think. At the very least, you could understand the pains that those with BDD go through and perhaps help someone with your knowledge. Repeated dissatisfaction with appearance and obsessing over it is both unhealthy and dangerous. If you are repeatedly being told you look fine and that you are imagining the imperfection, you might want to listen. Do yourself or someone you know a favor, and know the warning signs of BDD.
Suggested Reading on Body Dysmorphic Disorder
Books
The Adonis Complex: The Secret Crisis of Male Body Obsession by Harrison G. Pope Jr., MD; Katharine A. Phillips, MD; Roberto Olivardia, PhD
This book covers the male aspect of BDD ranging from obsessive weightlifting to extreme dieting or supplementation. Men are no different from women in their desire to look their best. For years it was thought that image disorders were a thing only women were plagued by. Wanting to look like Barbie or a centerfold seemed common for women. This book helps show the side of the coin where it isn't how you feel about your masculinity that questions it somehow - but how you look. Many men feel that if their biceps are not hard as steel or their middles cut like a diamond, they somehow do not measure up.
I have come across so many men who feel they must look their best no matter what and constantly worry what they eat or how they look. Many aren't hitting the gym for strength or jogging for great distances in the heat for cardiovascular health, they are striving to become an ideal that is unattainable.
The Adonis Complex covers symptoms to look out for and offers understanding to the many men who are determined to have the body of a Roman god and will do almost anything to get there. A must-read if you are a man that need answers or have concerns. Male body dysmorphia is sometimes compared to anorexia nervosa and can be equally harmful. Even if you do not feel you have an image disorder, if you are active in the gym, you can use this book to help understand those you may come into contact with at your gym. While there is nothing wrong with wanting to look our best or feeling better, letting this desire take over our social life is unhealthy and should be addressed.
Appearance Obsession: Learning to Love the Way You Look by Joni E. Johnston
I believe beauty is relative. This book is written by a clinical psychologist who was bombarded by family members nudging her towards perfection throughout childhood. It saddens me because I know so many women who feel the exact same way. I wonder how much the media has to do with this all. Isn't it the consumers who buy the magazines that portray the waif-thin models? Aren't we supposed to be looking at the clothes and not the body?
Society and even our own family members may show intentional, or unintentional, favoritism to those whose appearances shine.And I don't mean from an oily T zone. I mean true beauty. Everyone would be lying if they say that they don't feel better when they look their best than when they have gained a little (or more) weight, have a break out or have nothing to wear. We have all been affected by how we look to ourselves and how others believe we look.
Some may argue that this book is not for those who need to lose weight or have plastic surgery and that it is more for people who are attractive and are "too sick to see it." That is ludicrous. This book is helpful for all people in all walks of life who may be uncomfortable with the way they look. It is about being unhappy or self-conscious with your appearance, not how maybe you are a little over or underweight than the next person. It is about feeling the need to look good and realizing what can be changed healthily.
This book is a first person account of the author's pain growing up and realizing how events can trigger neuroses or lack of esteem at a very young and impressionable age. It contains questionnaires and surveys to determine your level of self-esteem and how much you are affected by media coverage of the beautiful. Personally I am a little tired of hearing it is the media's fault. People know what is attractive to them, it isn't like we are that impressionable.
I still recommend this book, however, I like the way it is written and enjoyed reading and comparing the author's experiences. It contains helpful advice and offers support on a seemingly individual level. Just don't allow yourself to use the media as a crutch for any lack of esteem you may have. I think there are more issues at stake that cause image problems, such as personal experiences, relationships or lack thereof, chemical imbalances, and random incidents that can all trigger low self esteem.
The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder by Katharine Phillips, MD
Review coming soon! If you'd like to see page experts or review this book for purchase please click here.
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