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The BDD patient: What is our obligation?

Article-The BDD patient: What is our obligation?

Dr. Hodgkinson
The psychological aspects of cosmetic surgery are just as important as the technical aspects.

Understanding motivation, expectations and assessing how a patient responds to the normal post-operative period or a complicated post-operative period is vitally important to a successful cosmetic surgical practice.

We have become more aware that a sub-group of patients suffers from Body Dysmorphic Disorder (BDD). These patients will likely be profoundly disappointed with your surgical results and may threaten you; they may disrupt your staff, can litigate or physically abuse or attack staff or yourself. Identification and avoidance of unwittingly operating on these patients is critical to avoiding these disturbing sequelae.

Psychiatric illness

BDD is a psychiatric illness classified as a somatic disorder by DMS-4.

Two percent of the population suffers from this disorder and the incidence is rising.

Females predominate and the disorder begins to manifest itself usually in adolescent years and is usually progressive. Cosmetic surgeons and dermatologists encounter these patients more and more frequently as they seek help for seemingly insignificant physical problems.

These patients hate their bodies, describing minor discrepancies as "ugly," "disgusting," "terrible" or "horrible" and similar epithets. They are fixated on their perceived deformity and spend hours in a day, touching, picking, avoiding mirrors or repeatedly looking at mirrors or taking digital photographs of themselves with their mobile telephone cameras.

These patients often avoid social contact and initiate family disturbances because of their perceived facial or bodily deformity.

It has been estimated that up to 7 percent to 20 percent of patients presenting for cosmetic surgery have been reportedly suffering from BDD. The "over-operated" patient and the secondary rhinoplastic patient are prime candidates.

Referral responsibility

Identification and referral to a mental healthcare specialist (psychologist or psychiatrist) is our responsibility rather than being cajoled into unwittingly performing an operative procedure.

Having an awareness of this disorder and being alert during the physician interview is basic and now more surgeons are using or considering using routine psychological valuations to try and identify the unsuitable surgical candidate.

A specialized questionnaire, the BDDQ, helps to target the sufferer. We are not, however, trained psychologists and I do not believe that we should be expected to treat these patients. Finding a friendly referral source is in the patient's best interest. Psychiatrists usually treat these patients with extensive long-term cognitive therapy or SSRI medications (selective serotonin release inhibitors).

High stakes

Unfortunately, the diagnosis may become evident only after we have operated on these patients.

Angry, persistent threats by these patients will paralyze you and your staff. These patients' insatiable dissatisfaction can be the result of a BDD "crisis" which can lead to their suicide.

Of the murders of surgeons by patients that have been recorded, one half of the perpetrators were BDD patients. Failure to identify the BDD patient is not necessarily a defense in litigation brought against the surgeon when the litigant is dissatisfied by his or her surgical results.

A popular book by Katharine A Phillips — "The Broken Mirror" — is recommended to understand this disorder. Further references are listed in an article I wrote on this subject.

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