Does Cosmetic Surgery Help Body Dysmorphic Disorder?

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ScienceDaily (Aug. 11, 2010) — A new study finds that while many who suffer from body dysmorphic disorder (BDD) seek cosmetic procedures, only two percent of procedures actually reduced the severity of BDD. Despite this poor long-term outcome, physicians continue to provide requested surgeries to people suffering from BDD. The study was recently published in Annals of Plastic Surgery.

Katharine A. Phillips, MD, is the director of the body image program at Rhode Island Hospital and a co-author of the paper. Phillips says, "BDD is a psychiatric disorder characterized by preoccupation with an imagined or slight defect in appearance which causes clinically significant distress or functional impairment. A majority of these individuals believe they have an actual deformity that can be corrected by cosmetic treatments to fix these perceived defects rather than seeking psychiatric intervention."
Phillips and her co-author, Canice Crerand, PhD, of The Children's Hospital of Philadelphia, reported in previous studies that BDD appears relatively common among individuals who receive cosmetic surgery, with reported rates of 7 to 8 percent in cosmetic surgery patients in the United States. Even with the high frequency of those with BDD seeking and receiving cosmetic procedures, few studies have more specifically investigated the clinical outcomes of surgical and minimally invasive cosmetic treatments, such as chemical peels, microdermabrasion, and injectable fillers).
In their new study, the researchers report that in a small retrospective study of 200 individuals with BDD, 31 percent sought and 21 percent received surgical or minimally invasive treatment for BDD symptoms. Nearly all of these individuals continued to have BDD symptoms, and some actually developed new appearance preoccupations. They also note that in a survey of 265 cosmetic surgeons, 178 (65 percent) reported treating patients with BDD, yet only one percent of the cases resulted in BDD symptom improvement. Phillips, who is also a professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, "These findings, coupled with reports of lawsuits and occasionally violence perpetrated by persons with BDD towards physicians, have led some to believe that BDD is a contraindication for cosmetic treatment."
The researchers found that the most common surgical procedures sought were rhinoplasty and breast augmentation, while the most common minimally invasive treatments were collagen injections and microdermabrasion. Three quarters of all the requested procedures involved facial features. The findings also indicate that more than a third of patients received multiple procedures.
In terms of long-term outcomes from procedures, only 25 percent of the patients showed an improvement in their appraisal of the treated body part and showed a longer-term decreased preoccupation. However, as noted by co-author Crerand, "Only two percent of surgical or minimally invasive procedures led to longer-term improvement in overall BDD symptoms."
The researchers also found that when treatment was sought, 20 percent of the procedures were not received. Cost was the most common reason for not receiving the requested procedure (30 percent), followed by physician refusal to perform the procedure (26 percent).Their findings also indicate that physicians were significantly less likely to refuse a surgical or minimally invasive treatment than other procedures (dermatological, dental and others). Phillips says, "This suggests that many surgeons were not aware of the patient's BDD or do not consider BDD a contraindication to treatment. In a survey of 265 cosmetic surgeons, only 30 percent believed that BDD was always a contraindication to surgery."
The researchers conclude, "This study provides new and more detailed information about receipt and outcome of surgical/minimally invasive procedures, and the findings indicate that there is a clear need to further investigate this topic in prospective studies. In the meantime, physicians need to be aware that psychiatric treatments for BDD such as serotonin reuptake inhibitors and cognitive behavioral therapy appear to be effective for what can be a debilitating disorder."
Also involved in the study is William Menard of Alpert Medical School. The study was funded through a grant from the National Institute of Mental Health.
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Eating Disorders, Liposuction & Middle Age

Eating Disorders at Middle Age, Part 1

Reprinted from Eating Disorders Review
By Katherine Zerbe, MD, and Diana Domnitei, BS
March/April 2004 Volume 15, Number 2 
©2004 Gürze Books

Until recently, the problem of eating disorders among middle-aged women was largely overlooked in psychiatry and medicine. The definition of middle life is somewhat arbitrary and in current flux, due in part to the increased longevity of people in the U.S. and Western Europe. This article focuses on increasing the knowledge of eating disorders in this population, which we define as the period of life between 35 and 65 years of age.

Individuals may develop an eating disorder for the first time at middle life, but to date most patients described in the literature have had the problem for at least 10 years. While the manifest problem may be understood as a pathologic means of coping with changes in body image due to aging, the clinical course and motivation behind this maladaptive mechanism lead to different clinical presentations.

We want to increase awareness of this neglected clinical problem, to offer some recommendations for treatment, and to encourage others to augment the knowledge base by describing how eating disorders in middle life are both similar to and different from eating problems at other periods in the life cycle.

Introduction 
Despite the overall increased awareness of the negative effects of being overweight, as well as a greater than $15 billion diet industry, Americans are getting larger more quickly than the rest of the world. Nations like France, where people consume a diet rich in fatty foods such as cheese, cream and whole milk, manage to maintain an obesity rate of slightly over 6%. Americans, despite many "low-fat" and "no-fat" foods, maintain an average national obesity rate of over 40%. Current data argue that this disparity is related to larger portion sizes, higher stress levels, and lower levels of regular exercise, not to food itself. Our attitudes towards food govern the way in which we consume food and help explain why we eat so much. Likewise, a combination of physical, interpersonal, and cultural factors determine our body imageat any given point in the life cycle. Americans measure self-worth by appearance and make pejorative comments about their bodies despite objective measures to the contrary. How we will use or abuse food as we age is only one factor in how we alter that image to sustain a sense of self or of self-esteem.

According to a 1997 Psychology Today poll, which is the largest study on body image and eating disorders to date (involving more than 3,400 women and 500 men between 13-90 years of age), gaining weight is at the top of the list for negative influences on body image in both men and women.1 This was true even though most were of normal weight. Two-thirds of the women and a third of the men said that gaining weight produced the greatest detriment to their self-image. Nearly half of the women polled reported being preoccupied with weight and finding displeasure with their weight regardless of age. In contrast, the poll found that men of all ages were much less dissatisfied with their appearance. Those from 30-39 and 50-59 years old were most dissatisfied. Another large-scale survey, which included women up to age 75, found that more than 70% of women aged 30-74 were dissatisfied with their weight even though they were of normal weight.2 As women age, body dissatisfaction increases.

Biological Bedrocks 
Physiologic aging has various effects on the human body that also alter body image, particularly in women. Until age 60, women tend to gain 5-10 lb per decade of life. Body shape changes, skin loses its elasticity (i.e., crows' feet), and hair turns gray and thins. These normal lifecycle changes are likely to be particularly problematic for women because body fat deposition tends to increase with each developmental milestone, for example, puberty, pregnancy, and menopause.3

Body image can also be threatened by any medical problem, chronic illness, restriction in social activity, and change in relationships with family and friends (i.e., divorce, or becoming a grandparent). This gender-based finding likely contributes to the "normative discontent" women feel about their bodies, and may contribute to the initiation and/or maintenance of eating disorders and exercise addiction in middle life.

In clinical practice, we educate women that these biological facts about midlife transition are likely genetically based because females are: (1) born with more fat cells than males; (2) have slower metabolic rates than males; and (3) have different hormonal influences than males (i.e. estrogen, progesterone), which increase the likelihood of weight gain throughout the life cycle. Women may also feel worse about their bodies with age because of lowered energy levels and other sensory and motor changes.

While all body systems change with age, it appears that women worry most about their weight and skin. For example, skin changes can be the most devastating for women because they are the most visible and also are the target of increasing media pressure for change. Women are bombarded with suggestions about defying their age and urged to "lie about [their] age," leaving them with the impression that aging is bad and that they should not be satisfied with themselves when they see "crows' feet" or other signs of aging developing. The overall message is that aging is bad and wrinkles are worse, and that the only solution is to use products, reconstructive surgery, or virtually anything in order to achieve a younger, more ideal look.

Herein lies the difficult assessment that women must make about themselves in order to age successfully: Do they accept society's message that younger is better and strive for unattainable or unnatural ideals, or allow themselves to become internally self-worthy and maintain a positive body image despite some noticeable and possibly inevitable physiological shifts?

The Scope of the Problem
Body image derives from conscious and unconscious processes, a manifestation of internal and external promptings that have been shaped over the years by life experience, media images, and feedback from other people. Separating out the potential developmental antecedents of the body image disturbance that has led to and helped nurture the eating disorder allows the patient to better understand herself, her life, and the struggles that have shaped her into who she is today.

As a whole, 89% of the women polled by Psychology Today wanted to lose weight. The average woman is 5'5" tall and weighs 140 lb, but would like to weigh 125 lb, a desire that 15% of women said would be worth sacrificing more than five years of their lives to achieve. Another 24% of the women surveyed would sacrifice three years of their lives to achieve their desired weight.1

It is no surprise that preoccupation with body image affects a woman's sense of herself. For over 56% of women in our society, being a woman entails preoccupation and dissatisfaction with her overall appearance and body size. This desire to diet runs deeper than just a willingness to restrict calories and to exercise. Instead, it goes far beyond, to a pathological "I'll do anything" mindset to lose weight. This mentality is most commonly associated with women in their adolescent or young adult years. Thus, it is not surprising that 62% of females 13-19 years old are dissatisfied with their weight. What has been neglected and unrecognized is the larger percentage of older women who are dissatisfied with their body weight. This dissatisfaction with body weight rises to 67% in females over the age of 30.1 Today's young women are being initiated to feelings of body dissatisfaction at a young age; these attitudes about their bodies stay with them and later prevent a normal transition into middle life.

Because middle-life is usually viewed as that time when men and women have achieved identity and a personal sense of power, one begins to wonder why a focus on body image is so pervasive in this age group. Body dissatisfaction is not only higher than in past years, it has been accelerating-from 25% in 1972 to 38% in 1985 to 56% in 1997.1

Diets leave women unsatisfied with the results. In 2001, over 93% of liposuction patients were women between the ages of 17 and 74 years old, but 98.7% were within 50 lb of their ideal chart weight. While the procedures have been improved and significant medical complications (e.g. bleeding, pulmonary emboli) have decreased, the success of liposuction does not address the increasingly negative body image of millions of women who believe that weight reduction or body fat removal will make them happier and healthier human beings. It seems as though the alternative of liposuction only addresses part of the problem, namely the female desire to come closer to the slender ideal, while it fails to resolve the negative body image that fuels the self-defeating dieting that often precedes and follows such procedures. Consideration of these facts makes clinicians wonder if women who seek plastic surgery at middle life should be screened for an eating disorder.

References, Part 1. 
Garner DM. Psychology Today, February 1997.
2. Allaz AF, Bernstein M, Rouget P, et al. Body weight preoccupation in middle age and ageing women: A general population survey. Int J Eat Disord 1998; 23: 287.
3. Tiggemann M. Body Image Research Summary: Body Image and Aging. Body Image & Health Inc. Research Summaries 1999.

(In Part 2, in the following issue, the authors address clinical presentations of these disorders and outline recommendations for treatment.

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Inpulse Control Behavior

There are many other disorders that have qualities involving repetitive thoughts and behaviors, akin to Obsessive-Compulsive Disorder (OCD). These disorders are sometimes called as Obsessive-Compulsive Spectrum Disorders(OC Spectrum Disorders) because of the similarities. Not only that, but some experts believe that these disorders may all have similar underlying neurobiological causes as OCD. Neuroimaging studies taken of the brain show similar activity between OCD and certain OC spectrum disorders. As well as having similarities to OCD, OC Spectrum Disorders are also very comorbid with OCD and vice versa. Many spectrum disorders are classified as impulse control disorders — where impulsivity can be thought of as seeking a small, short term gain at the expense of a large, long term loss.

OC Spectrum Disorders

Tourette's Disorder (also known as Tourette's Syndrome): A tic disorder that appears before the age of 18. Symptoms consist of multiple motor tic (such as twitching for no reason) and vocal tics (such as swearing for no reason) that occur, although not necessarily at the same time. Tics are recurrent physical movements or vocalizations with no apparent cause. Many studies have reported OCD symptoms in 50 percent of Tourette's disorder sufferers, with some studies showing rates as high as 74 percent. Studies have shown that 6 percent of OCD sufferers have Tourette's Disorder, with as many as 35 percent having some symptoms. Learn more about Tourette's...

Body Dysmorphic Disorder: Is currently classified by the DSM-IV-TR as a somatoform disorder. The main feature of this disorder is the obsession over an imagined physical defect or anomaly in a person of normal appearance. Any part of the body can be obsessed about, such as a nose or simply being unattractive, but the most common symptom is usually over a perceived facial flaw. Body dysmorphic disorder can be very debilitating — with one study showing that as many of one third of its sufferers become housebound. The sufferer becomes obsessed with worry and rituals much like a person suffering from OCD. In the same way an OCD sufferer will check the stove numerous times to see if its turned off, a sufferer of body dysmorphic disorder will repeatedly look at their appearance in the mirror. Some studies have shown a lifetime 12 percent comorbidity rate with body dysmorphic disorder for people suffering from OCD. Studies have also shown that between 37-56 percent of people with body dysmorphic disorder have some history of OCD. More about body dysmorphic disorder...

Trichotillimania: Classified as an Impulse Control Disorder. People with Trichotillimania cannot stop themselves from pulling hair from their body, which results in noticeable hair loss. People with trichotillimaia will pull hair from any part of their body, but the most common pulling takes place with scalp hair, with eyebrow and eyelash pulling also being very common. Some people will pull hair from numerous parts of their body and some people from only one part. The hair pulling is often described as a compulsion that is disturbing to the person, much in the same way as someone suffering from OCD being distressed by a compulsion. More about trichotillimania...

Eating Disorders: Made up of two categories with two specific diagnoses: the first being Anorexia Nervosa and the second Bulimia Nervosa. A third eating disorder,Binge Eating, is mentioned in the DSM-IV-TR as a diagnosis that requires further study. Anorexia nervosa is defined as a failure to maintain a healthy, normal body weight through restriction of eating, or eating then purging. Bulimia nervosa is characterized by binge eating with a feeling of no control during binge eating episodes. The person must then compensate by fasting, purging or extreme exercise to prevent weight gain. Those suffering from bulimia and anorexia have obsessions about food, body image and the preparation of food. They also have rituals about diet, exercise, eating and food preparation. Sometimes a person suffering from an eating disorder will initially have obsessions about body image or food eaten, which then change into traditional OCD symptoms such as contamination, allowing them to meet OCD criteria. The overlap of symptoms between body dysmorphic disorder and anorexia nervosa is so high that the DSM-IV-TR lists anorexia with a specific exclusion criteria if the obsession is solely regarding weight. Studies showing eating disorder patients to have OCD symptoms have been as low as 11 percent and as high as 88 percent. Studies have also shown that 7 percent of those suffering from anorexia also have OCD, and 10 percent for Bulimia. Learn more about eating disorders...

Depersonalization disorder: Listed in the DSM-IV-TR as a dissociative disorder, it is defined by a feeling of being detached from ones mind or body (as if the person were floating outside of their body). People often feel as is they are not in control of their body or speech, and can feel a lack of affect. The actual experience of depersonalization is fairly common among normal functioning people, and also occurs during drug use. The depersonalization of someone suffering from depersonalization disorder is severe, frequent, unwanted and interferes with ones life. Depersonalization disorder frequently occurs during other disorders such as schizophrenia and depression, and therefore is not diagnosed when it appears only during these other disorders. OCD and depersonalization disorder have similar onset and a similarly chronic course. In much the way a person suffering from OCD suffers from unwanted, repetitive thoughts, so to does a person suffering from depersonalization disorder. More about depersonalization disorder...

Hypochondriasis: Involves an abnormal, excessive obsession regarding ones health. People who have hypochondriasis misinterpret bodily signals as being signs of apocalyptic events, e.g. a headache to be a sign of a brain tumor. The person will visit the doctor numerous times for reassurance, but continue to believe there's a problem despite being told they are perfectly fine. These obsessions contain similarities to OCD contamination fears and checking rituals. Read more about hypochondriasis....

Compulsive Skin Picking: Also called onychophagia, compulsive skin picking involves the picking of ones skin in a repetitive manner so that the skin is noticeably damaged. This disorder is an impulse control disorder similar to trichotillimania, and just like trichotillimania, usually centers around the face, but can involve any part of the body. People will pick at things on the skin such as freckles, pimples, sores, moles, etc., but will also pick at imagined defects. Read about compulsive skin picking and scratching and the related compulsive nail biting...

Possible OC Spectrum Disorders

Compulsive Sexual Behavior (CSB): CSB is a very broad category with many types of sexual behaviors. Generally though, CSB is divided into two categories: paraphilic and non-paraphilic. Paraphilic sexual behaviors are irregular sexual behaviors that are obsessive and compulsive (pedophilia, voyeurism, exhibitionism, frotteurism, etc.). Non-paraphilic behaviors are normal sexual behaviors taken to levels so extreme they cause extreme distress and impairment. There is great debate as to whether CSB is an addiction, an impulse control disorder, an obsessive-compulsive disorder, or even a mood disorder. But it is clear that certain types of CSB are driven by both obsessions in compulsions. Read about sexual compulsivity and medication treatments...

Olfactory Reference Syndrome: The obsessive, irrational fear that ones body is emitting a foul and unpleasant odor that may offend others. This fear can of course be obsessed about much like an OCD fear (e.g. contamination). More about olfactory reference syndrome...

Pathological Gambling: Doesn't appear in the DSM-IV-TR as its own disorder, but could be classified as an impulse control disorder. Pathological gambling is characterized by an obsessive need to gamble. More about pathological gambling...

Autism/Asperger's Disorder: Autism is a pervasive developmental disorder that begins in early childhood. It is characterized by severe deficits in the ability to communicate and interact with others. Also present in autism are repetitive behaviors and a limited range of interests, which of course is where its similarities to OCD lie. Asperger's is basically a milder form of autism   with sufferers usually having a higher level of functioning. More about autistic disorder...

Obsessive-Compulsive Personality Disorder: OCPD is a personality disorder involving an overwhelming need for organization, order, and perfectionism. A personality disorder affects a persons' thoughts and actions and negatively, compromising their ability to deal with common life issues and relate to others. This disorder has a name very similar to obsessive-compulsive disorder, but is not the same thing. More about Obsessive-Compulsive Personality Disorder...

Intermittent Explosive Disorder: An impulse control disorder characterized by episodes of uncontrollable rage and anger. Someone with this disorder will just blow up in a violent, uncontrollable rage   sometimes called a "rage attack." This behavior is out of proportion to the act that caused the response, and is not caused by any substance, such as medication or alcohol.

Pyromania: An impulse control disorder that involves intentionally setting a fire for gratification. Prior to setting a fire the person will obsess and be tense, and after compulsively committing the act, will feel relief and gratification. The fire setting is not done for any personal reasons, such as revenge, anger, monetary gain, etc., nor is it done in any sort of state of psychosis. Merely it is an obsession that must be acted upon.

Kleptomania: An impulse control disorder characterized by the impulsive need to steal. Like pyromania the act is not done for personal reasons, such as monetary gain or revenge (in fact, a person with kleptomania will sometimes replace the item they steal after the fact), nor is it done because of another disorder, such as anti-social personality disorder or bipolar disorder (a.k.a. manic depression). Similar to OCD or pyromania, the person will obsess about their thought, e.g., stealing   and feel tension and anxiety. Upon acting compulsively by stealing, a kleptomaniac feels momentary relief from their obsession. More about kleptomania...

What Is Body Image?

What Is Body Image?  A great quetion...

Body Dysmorphic Disorder - When the Mirror Lies

No matter how much weight is lost, or no matter how much food is thrown up, the person with anorexia or bulimia will constantly see the same overweight, vile, failure in the mirror. This typically leads to very destructive and even deadly methods of weight loss in a desperate attempt to lose the distorted perception - in this case, fat (failure). It is very hard, though, for anyone that does not have an eating disorder to be able to understand just how someone could do this to themselves - go through hospitilizations and near death experiences even - but continually see themselves so distorted. Even though Body Dysmorphic disorder isn't just shown in cases of eating disorders (someone afflicted with BDD can obsess not about weight, but instead about their hair, nose, chest, etc.), it still hurts and ruins the lives of whoever is afflicted with it.

At one time or another we all worry about our appearance, but when you wake up degrading your nose, hair, chest, WEIGHT, etc. and then continuing to have these thoughts all day, that's when there is a problem. Closely linked to other disorders and psychiatric conditions, Body Dysmorphic Disorder (termed shortly BDD) is a serious disorder that is growing fast. People that suffer from BDD not only dislike some aspect of how they look, they're preoccupied severely with it. Most get to the point where it is very hard to go outside or sit down comfortably, or go to work and talk to others, without thinking the No Iframes self-degrading thoughts about their flaws. The thoughts soon over take the person's mind and it is all he/she can think about.

The problem, though, is that all of these self-degrading thoughts about a perceived flaw are distorted. Many, many times the supposed flaw doesn't even exist, or an "imperfect" body part is blown entirely out of proportion. However, the person themselves cannot see that what they believe is distorted. Many hold the belief that they are seeing all of this, therefore it MUST be true. This is one of the main reasons that it is so hard for people on the "outside" to try and convince even the most severely emaciated people with anorexia that they are not fat or failures - the people with anorexia and/or bulimia themselves literally cannot look in the mirror and see the same person that everyone else sees.

Kinda like a cloud i was up way up in the sky
and i was feeling some feelings you wouldn't believe
Sometimes i don't believe them myself
and i decided i was never coming down
Just then a tiny little dot caught my eye
It was just about too small to see
but i watched it way too long
...and that dot was pulling me down-NIN

It's estimated that Body Dysmorphic Disorder affects 1 in 50 people, mostly teenagers and 20-somethings with either a gradual or abrupt onset. Often the person is a perfectionist, like most people with eating disorders. Nothing is good enough because the person cannot see that what they have done is absolutely fine, or that they are on the border of near death (in the case of anorexia and extreme weight loss). Low self-esteem is a trademark of those with BDD as they feel like colossal failures for their perceived physical flaws.

BDD can lead or take after other psychiatric problems as well. Depression, obsessive compulsive disorder, eating disorders, anxiety issues, agoraphobia, and trichotillomania (hair pulling) are all problems that commonly follow or trigger BDD.

One person that I know that is in treatment for BDD and other issues became afflicted after a rape. Although she doesn't fit the common statistics in that she is 32 and Latino, the BDD immediately showed itself after the incident. She felt that the rapist was "inside of her" somehow and making her "ugly and disgustingly horrid from the inside out." She began to check her face and nude body in the mirror. At her worse, she was doing this about 5 hours a day. She felt degraded and disgusting from what happened to her, believing that only something that was disgusting and worthless and ugly could be raped. Eventually, the isolation and weird habits pushed her family to convince her to get help (thankfully). It took a lot of persistence, though, since she did not believe there was a problem, even in her most severely depressed times.

treatment

Often Body Dysmorphic Disorder is mis-diagnosed because doctors tend to have a lack of familiarity with the disorder. Many times those afflicted feel so ashamed and worthless that they down-play the problem or do not even recognize that they need help, so they end up staying in hiding. Families may even trivialize this problem, not realizing that this extreme distortion cannot be resolved through "getting over it" or calling it a "phase." However, when you or someone you know is ready to accept help and is willing to get it, there are therapists out there that specialize in treating distortion cases while new methods of treatment for Body Dysmorphic Disorder are currently being studied.

One recent study was made where 17 individuals, all diagnosed with BDD, spent 4 weeks of daily 90 minute sessions with therapists. Cognitive behavior therapy was used to treat their conditions. Further treatment for Body Dysmorphic Disorder included having them exposed to their perceived physical defect, and they were prevented from engaging in any behaviors that increased the discomfort and triggered the BDD more. In the cognitive behavior therapy the individuals were also taught how to resist compulsive behaviors and face avoided situations. At the end of this study, a significant decrease was found in the individuals' pre-occupations and time spent engaged in destructive behaviors and thoughts.

Common anti-depressants were also used to help further the treatment. Prozac, Zoloft, Paxil, Luvox, and Anafranil are all common anti-depressants that are used to treat this disorder (as well as depression), and they have all been show to help stop the behaviors associated with Body Dysmorphic Disorder.