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Body Dysmorphia and Plastic Surgery
Allison Kyle, RN
ody dysmorphic disorder is a mental disorder characterized by a preoccupation with some aspect of one’s appearance. In cosmetic surgery, this preoccupation can be overlooked by practitioners resulting in a discrepancy between expected and realistic outcome. Identifying the characteristics of this disorder may be crucial to the practitioner–patient relationship in the plastic surgery setting.
Cosmetic Surgery is no longer the hidden secret of middle-aged housewives. In recent years, elective procedures intended to enhance and restore the years gone by have become more common and accepted in our culture. Botox parties and lunch-time facelifts have become familiar water cooler conversation among the middle-class social set, with the intent to make age the unknown factor in a society that focuses on youth and beauty. However, practitioners in the business of beauty are learning that there is more to the patient seeking cosmetic surgery than meets the eye. Reality versus perception is at the forefront of patient care and it is the priority of the practitioner to identify underlying mental issues that may affect patient outcomes.
DEFINITION OF BODY DYSMORPHIC DISORDER
“Body dysmorphic disorder (BDD) is defined as a mental disorder characterized by a preoccupation with an imagined defect in one’s appearance” (Veale, 2004). This preoccupation can result in severe distress
or impairment or both in social, occupational, and other areas of functioning (Phillips, 2004). Although this disorder can lead to suicide it is typically underrecognized in clinical settings (Phillips, 2004). BDD affects men and women with near equal frequency although areas of preoccupation will differ (Ahmed, 2011). Men are more likely to focus on muscle size, whereas women often are obsessed with legs and breasts (Ahmed). There is no data regarding BDD and race. Although a direct relationship has little documentation, speculation leads to the belief that cultures with an elevated emphasis on physical attributes may be more likely to have this disorder (Ahmed). Onset of BDD is common in adolescence and young adulthood, with the course of the disorder being chronic (Ahmed). BDD is not a unique disorder (Sarwer, Crerand, & Didic, 2003). Approximately 1%–2% of the general population is affected and approximately 4%–5% of patients seeking treatment in outpatient settings are affected (Sarwer et al.). No extensive study has been conducted to determine the prevalence of BDD in the general population (Sarwer et al.). However, smaller studies have suggested that the incidence of BDD in cosmetic surgery patients is higher than the estimate for that of the general population (Sarwer et al.). The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) defines BDD as follows: 1. Preoccupation with an imagined defect in appearance. If there is a slight anomaly present the concern is excessive. 2. The preoccupation causes clinically significant distress and or impairment in the functioning. 3. The preoccupation cannot be attributed to another mental disorder (Ahmed, 2011). Because of the nature of symptoms, patients with BDD will typically present to their cosmetic surgeon (Ahmed, 2011). It is imperative for practitioners to obtain a detailed history and if necessary refer to psychiatry (Ahmed). A thorough history focused on BDD symptoms can be an accurate diagnostic tool (Ahmed). While obtaining a clinical history, certain
Allison Kyle, RN, is an FNP student completing her degree through the University of Cincinnati. She is currently a full time front office nurse for two plastic surgeons at a busy practice in Houston, Texas. Although her nursing experience is diverse, she has spent the last 8 years working in plastics in the office setting. The author declares no conflict of interest. Address correspondence to Allison Kyle, RN, 10565 Katy Freeway Suite 100, Houston, TX, 77024 (email@example.com). DOI: 10.1097/PSN.0b013e31826a9d90
Plastic Surgical Nursing
Copyright © 2012 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited.
craniomaxillofacial structures. reconstruction. 1. 97 WHAT IS PLASTIC SURGERY According to the American Society of Aesthetic Plastic Surgery (ASAPS). and other basic sciences are fundamental to the specialty. “Plastic surgery deals with the repair. There are multiple tools available for assessing the extent of BDD. or replacement of physical defects of form or function involving the skin. gery. this tool asks specific and guided questions to determine whether the diagnostic criteria for a diagnosis are met. It is imperative that practitioners recognize the disorder prior to or early on in treatment to ensure a healthy and realistic outcome. 3. the number for men has increased 88% since 1997. there is a growing consensus that cosmetic surgery may be considered a contraindication for patients with BDD (Picavet et al. The plastic surgeon uses cosmetic surgical principles both to improve overall appearance and to optimize the outcome of reconstructive procedures. In an electronic survey conducted by ASAPS in 2001.. the Body Dysmorphic Disorder Questionnaire-Dermatology Version and the Dysmorphic Concern Questionnaire were validated in a cosmetic dermatology setting (Picavet et al. An estimated 6. Appropriate screening tools for BDD patients seeking cosmetic surgery is limited (Picavet et al. Although routinely used in a psychiatric setting.. As clinical data continues to emerge. approximately 14 million cosmetic procedures were performed in 2011 (Tehrani. The three main categories of plastic surgery. Thought process: focus on physical appearance with emphasis on perceived defect. Of the six. Unauthorized reproduction of this article is prohibited. 2009). they have yet to become routine in cosmetic surgery (Picavet et al. external genitalia or cosmetic enhancement of these areas of the body. pathology. irritability.behaviors will emerge in patients with BDD. 2011). and anxiousness may be present. physiology. Behaviors illustrated include: compulsive mirror checking or avoidance. In a recent study released by the American Society of Plastic Surgeons. Of all procedures completed.). and the Yale-Brown Obsessive Compulsive Scale. Most surgeons still underestimate the prevalence of BDD in their patients (Picavet et al. extremities. Gabriels.). IDENTIFYING BODY DYSMORPHIC DISORDER IN PLASTIC SURGERY PATIENTS The awareness of aesthetic surgeons in relationship to BDD has grown in past decades (Picavet. 2011). and interpersonal skills to achieve problem resolution and patient satisfaction” (Kita. ASAPS reports that 92% of patients were female. According to Picavet. misleading (Picavet et al.000 of these surgeries performed (Tehrani).. Their use and implementation can be time consuming and if not properly interpreted. Jorissen. which are related to the defect for up to 1 hr or more a day (Ahmed). the varied patient population would most certainly present with BDD. 2011). and free tissue transfer and replantation is necessary.).6 billion dollars was spent by Americans on cosmetic surgical procedures in 2010. For 2011. operative judgment. All patients with suspected BDD should undergo a comprehensive mental status examination. 2012). comparing the perceived defect in the bodies of others. technical expertise. with more than 300. Patients with BDD are also more likely to have thoughts and behaviors. Competency in plastic surgery implies an amalgam of basic medical and surgical knowledge. The most common are the National Institute of Mental Health Obsessive Compulsive Scale. breast and trunk. musculoskeletal system. Also distortion of reality in relationship to the defect (Ahmed. six different screening tools for BDD in cosmetic surgery were identified. Special knowledge and skill in the design and surgery of grafts.). . 2011). Although women continue to be the more prevalent gender seeking surPlastic Surgical Nursing ❙ July-September 2012 ❙ Volume 32 ❙ Number 3 Copyright © 2012 American Society of Plastic Surgical Nurses. and requiring constant reassurance from others that their defect is normal. 84% of physicians reported having treated a patient they preoperatively believed to be appropriate for surgery. ethical behavior. all modified for BDD (Picavet et al. the most popular cosmetic surgery procedure was breast augmentation. Mood: feelings of depression.). hand. the Clinical Global Impression Scale. Thought content: suicidal and homicidal ideation. & Hellings. Accordingly. all saw a rise in numbers (Tehrani). flaps. Ahmed suggests the examination should include the following. With these statistics.). and minimally invasive cosmetic procedures. Anatomy. compulsive grooming.. 2. for diagnosing and assessing BDD. only to realize postoperatively the patient had BDD (Picavet et al. cosmetic surgery procedures. reports and studies show that patients with BDD will not benefit from cosmetic surgery and some may exhibit more symptoms of the disorder (Picavet et al. Structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) is the most commonly used diagnostic instrument for the diagnosis of an extensive range of psychiatric disorders. reconstructive surgeries. In a systematic review conducted by Picavet et al.
The Laryngoscope. from http://www. 67–71. 2009). 98 Plastic Surgical Nursing ❙ July-September 2012 ❙ Volume 32 ❙ Number 3 Copyright © 2012 American Society of Plastic Surgical Nurses. Retrieved February 15. from http://plasticsurgery. 2012. By utilizing screening tools in practice.pdf Heyes. Screening tools for body dysmorphic disorder in a cosmetic surgery setting. (2003).yahoo.html Veale. Patients are being shown the negative body defects. REFERENCES Ahmed. Kita. 121. K. the need for valid screening tools seems to be a necessity. 73–93. 12–17. E. based on improving flaws (Heyes. Further research and testing needs to be explored for the development of valid and effective screening tools. Picavet. 2012. . Retrieved April 11. which they may not have previously noted (Heyes). while identifying challenges that may impact healing and outcomes. What is plastic surgery?.. Sarwer. practitioners can gain knowledge about the goals and expectations of patients. medscape. Body dysmorphic disorder: recognizing and treating imagined ugliness. K. What is the responsibility of the practitioner in this role? As the prevalence of cosmetic procedures rises. Psychiatric manifestations of body dysmorphic disorder. Cosmetic surgery national data bank statistics. Body & Society. (2004). C.com/stateplastic-surgery-despite-economy-cosmetic-proceduresmore-130348790. and the practice of plastic For more than 81 additional continuing education articles related to surgical nursing. L. Retrieved May 1. The state of plastic surgery: Despite the economy. cosmetic procedures are more popular than ever. Gabriels. This limitation is a definitive contrast to the estimated prevalence of BDD in cosmetic surgery (Picavet et al. Phillips. Practitioners. surgery itself can only benefit by the regular use of screening tools for BDD. World Psychiatry. from http://emedicine. D. 3(1).2011).uwa. (2009). Retrieved May 1. (2011). go to NursingCenter. I. Unauthorized reproduction of this article is prohibited. & Hellings. Tehrani.edu. N. Even body parts previously immune to such scrutiny have become commonplace on the list of possible improvements (Heyes)... (2005). from http://news. Cosmetic surgeons many times must advertise their skills and recruit patients. M. (2009). Jorissen.). 15(4). C. Facial Plastic Surgery. 7–17. 2012. Postgraduate Medical Journal. P. Body dysmorphic disorder in cosmetic surgery patients. (2012).com/od/ historyofplasticsurgery/a/what_is_PS. 2535–2541. D. (2011). 19(1). V. Practitioners now rely on the before and after to embody the positive outcome of cosmetic surgery (Heyes). patients.au/~jimberger/CC_ Reality_Challenges_Opportunities/Resources_CC_R_C_O/ References/2005Cosmetic%20Surgery%20stats. Diagnosing culture: Body dysmporphic disorder and cosmetic surgery.com/article/291182-overview#showall American Society for Aesthetic Plastic Surgery.. (2004). Body dysmorphic disorder. Crerand.com/CE. & Didic. 2012. IMPLICATIONS OF BODY DYSMORPHIA IN PLASTIC SURGERY Surgeons performing cosmetic procedures are unlike other physicians.. 80(940). Plastic surgery affects not only the physical being of patients but also the emotional being of patients.cwr.htm.about.