Does cosmetic surgery help body dysmorphic disorder?

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.