Chicago — Body dismorphic disorder (BDD), characterized by preoccupation with an imagined defect in appearance, is rare, occurring in an estimated 1 to 2 percent of the U.S. population, yet Mark B. Constantian, M.D. — whose practice is almost exclusively dedicated to rhinoplasty — sees a lot of this disorder. The nose is the most common body feature involved in BDD.
Dr. Constantian, who is an adjunct assistant professor of surgery at Dartmouth Medical School, Hanover, N.H., and in private practice in Nashua, N.H., says BDD patients can be hard to identify prior to surgery.
All of these patients are upset, and many of them have seen other physicians who have dismissed them. Yet the problem is real. It may be subtle but that doesn't mean the patient is imagining it, Dr. Constantian says."After I operate on (a BDD patient) and the operation goes successfully, the patient goes off the deep end." That, he says, is when he knows what he's really dealing with.
Recognizing the symptoms
Dr. Constantian says he operated on a handful of patients with the disorder many years ago without recognizing the symptoms. Interestingly, most of those who are later identified as having BDD get very good results.
"I certainly don't get perfect results every time, but the ironic thing is that in all of these BDD patients I've achieved exactly what the patient wants. The nose looks normal, even though they've had multiple prior surgeries. That's finally what makes their hyper-distressed complaints obvious," says Dr. Constantian.
Dr. Constantian tells Cosmetic Surgery Times he's learned that people with BDD will often perceive surgeons to be sort of a "white knight" figure who will rescue them from their unhappiness.
"Even though what they are asking for is a rhinoplasty, they're really looking to be taken care of and they have a tremendous fear of abandonment," he says.
Dr. Constantian warns surgeons to be wary of patients who are particularly needy, clingy or dependent.
Anecdotal experience has led Dr. Constantian to theorize that many BDD patients have experienced emotional abuse in childhood. One example he described is a male patient who admitted that he was made to repeatedly look at photographs of his nose from as early as seven years of age.
"His stepfather made him submit to the photographs expressly for the purpose of showing him that his nose was deformed," explains Dr. Constantian. This abuse, he points out, can manifest in fears of abandonment and, in the case of people with BDD, can result in them using statements like, 'You betrayed me,' when they perceive their surgical outcome as less than ideal.
"That's where the fantasy comes from," says Dr. Constantian. "Childhood abandonment leads to shame and a need to be taken care of, and a huge fear of a new abandonment. They react to the surgeon as if he or she were a spouse, not a physician. Just like Narcissus, these patients only know themselves, or value themselves, by their appearance."
The bottom line, according to Dr. Constantian, is that BDD patients are always bad surgical candidates – no matter how good their results.