"In the past 10 years, there have been four plastic surgeons murdered by their patients. And the vast majority of patients who have killed their doctors had some element of BDD," says W. Gregory Chernoff, M.D., a facial plastic surgeon with private practices in Indianapolis, Santa Rosa, Calif. and Newport Beach, Calif., and associate clinical professor, department of otolaryngology, Indiana University School of Medicine.
By way of defining the condition, he says, "More than 90 percent of women and 80 percent of men take an active interest in their outward appearance. The problem occurs when that interest becomes an obsession" with a physical defect, often minor or imagined."That's important from a cosmetic surgery standpoint, because if one does anything to a patient with BDD, even provide skincare, those patients have a tendency to swear that one has made them look worse. No matter how one reasons with them, they can become a tremendous nightmare to a practice. It's a good example of when a doctor needs to say no" to potentially troublesome patients, Dr. Chernoff says.
Behavioral clues can help physicians identify and diagnose such patients, he says.
"Usually," he explains, "their perceived problem is much less evident to the outward eye than to them. They may have a small mole on their cheek that they think the whole world notices, when, in fact, one sometimes must get closer than conversational distance to see it. From a standpoint of patient history, these people check their appearance in mirrors repeatedly. For example, it's not normal for a man to carry a mirror in his briefcase that he frequently looks at. And sometimes, these patients avoid mirrors like the plague. Often, they compare themselves to others" unfavorably.
Dr. Chernoff adds, "At the same time, they're often very critical of other people's appearances. They'll often ask others whether they think they look as good as other people. Many times, they'll come in for a consultation and try to convince a physician that there's something wrong with the way they look. When one asks historically, others have tried to convince them that the problem is minimal or nonexistent. Many times they try to hide that feature" with clothing, hats or by turning their heads.
Such patients furthermore tend to spend exorbitant amounts of time grooming, including arranging their hair or applying makeup, Dr. Chernoff says. "Many of them are chronic skin pickers," he adds.
BDD sufferers also exhibit what he calls "the relentless pursuit of perfection, by going to multiple cosmetic surgery offices, seeking multiple treatments by multiple doctors and openly criticizing doctors who previously treated them. They will play to one's ego, saying things such as, 'I've heard so many good things about you. Surely you'll be able to help me when no one else has.'"
BDD sufferers also possess telltale attitudes about their looks, Dr. Chernoff says.
"They believe other people are always noticing this feature, and that their lives have been adversely affected by it — 'I never have the job I want or the relationship I want' are common complaints," he says. "And many of these patients are housebound or only come out at night."
Dr. Chernoff says that, according to previous research, the most common reasons BDD sufferers will schedule consultations are for problems with (in descending order) the skin, hair, nose and eyes.