Recently, the problem of body dysmorphic disorders/dysmorphomania has acquired a particular importance in national aesthetic medicine. These patients require specialized psychological care rather aesthetic procedures. It is necessary to exclude possible harm from medical aesthetic manipulations and plastic surgery in these patients, to reduce the number of negative aspects in the work of specialists including protection from patient complaints. Indeed, the last ones significantly determine patient satisfaction with the quality of care. The main approaches to this problem are timely specialized care and early diagnosis of mental abnormalities.
According to the literature, the phenomenon of dysmorphophobia is still one of the most controversial and insufficiently studied in psychiatry. There are various definitions of this pathology. Italian psychiatrist Enrico Morselli (1886) first used the term “dysmorphophobia” to describe a painful disorder, “unpleasant sensations” with predominant idea of an imaginary physical handicap in a patient with “obsessive thoughts” [1].
Dysmorphomania is a psychotic mental disorder. In these patients, painful conviction in imaginary deficiency acquires a delusional character. Patients have no criticism to ones’ condition that is unresponsive to correction and often results negative behavior (self-mutilation, auto-aggression, and even suicide attempts in severe cases). Dysmorphomania is often comorbid with depression, as well as a tendency to eliminate imaginary deformities in any way. Patients are characterized by conviction that their imaginary defect is extremely unpleasant to others. To eliminate this defect, these patients appeal to cosmetologists or plastic surgeons for unjustified surgical interventions and manipulations. Elements of psychological pressure on physicians are common in these cases. Typical symptoms of dysmorphomania are photography sign and mirror sign (Abeli-Delmas), less often sign is Van Gogh’s syndrome (patients try to operate on himself or require a specific surgery) [2]. Dysmorphomania may be determined as obsessive compulsive disorder, since this disease is characterized by neurotic obsessive fear. This fear is based on belief in the presence of appearance defect or unreasonable overestimation of existing physical handicap. Patients cannot cope with personal experiences despite own criticism to these feelings. Dysmorphomania is a chronic disorder. According to the WHO data, 16% of people suffer from this form of social phobia.
There are several criteria for diagnosis of dysmorphophobia: severe concern about an alleged appearance defect followed by suffering or anxiety. Other signs are panic attacks, deep depression, social withdrawal and withdrawal from the family, social phobia, loneliness and social isolation, the desire to correct the defect by plastic procedure (repeated plastic surgery does not result the desired satisfaction). Some patients try to get rid of the “defect” on their own, for example, using a knife (in case of nevus or another feature of normal skin, etc.).
Dysmorphophobia is the basis of anorexia. These patients reject food intake, starve, adhere to strict diets, and insist on lipolytic therapy or plastic surgery for imaginary or excessively exaggerated obesity.
About 75% of patients with dysmorphophobia need psychiatric care instead dermatological or surgical treatment. Unadvisable treatment ultimately results chronic disease, high risk of infection, autodestruction and significant impairment of the quality of life. Despite significant clinical data, generally accepted approaches to diagnosis and treatment of dysmorphophobia are still absent. At the same time, there are no data on the prevalence of a certain personality disorder in patients with body dysmorphic disorder and relationship between body dysmorphic disorder and personality type [3].
Until recently, it was generally accepted that women and girls are prone to body dysmorphic disorders. Modern researchers argue that body dysmorphic disorder has a detrimental effect on both women and men. The so-called muscular dysmorphomania is typical for young men. An example would be schoolchildren seeing their own body as frail and weak, while it is absolutely proportional in reality. Trying to correct a contrived deficiency, young men spend a lot of time in gyms, use anabolic steroids and synthetic testosterone analogues [4].
A lesser known variant of cognitive disorders is orthorexia nervosa in young and middle age. This disorder results mental and physical impairment. It is an eating disorder with obsessive desire for “healthy eating” and avoiding many foods. People fixated exclusively on aesthetic appearance are prone to this disorder. There are no clear criteria for diagnosis of orthorexia at the moment. This diagnosis is not included in the ICD-10 and DSM-IV and cannot be formally established. However, physicians widely use the term “orthorexia” to describe eating disorders, social relationships, anxious-depressive and anxious disorders. Currently, the following theories are being actively investigated: orthorexia as an independent disease, orthorexia as a variant/stage in development of another eating disorder (anorexia or bulimia), orthorexia as a sign of personality disorder and orthorexia as a sign of obsessive-compulsive disorder (obsessive-compulsive syndrome). Bratman test may be used to diagnose orthorexia nervosa. The Roman questionnaire ORTO-15 (Institute of Food Sciences, University of Rome La Sapienza) is an alternative way to diagnose orthorexia. It is necessary to be aware of this cognitive disorder and recognize these patients in cosmetology and plastic surgery because the percentage of persons fixed on their appearance is much higher compared to overall population.
There are 2 types of dysmorphophobia depending on severity of anxiety in social situations (externally oriented psychopathological disorders and internal perfectionism). These types differ in the structure of psychopathological syndrome, premorbid status, social adaptation, seeking for dermatological care, severity of autodestructive actions, comorbid psychopathological disorders, and response to therapy.
Dysmorphophobia subtype 1 in patients without signs of procedural disease is mainly based on schizoid personality disorder (sensitive schizoids); less common — anxious / avoidant personality disorder [5]. From childhood, these patients are distinguished by autism, fearfulness, inferiority complex, a tendency to self-deprecation and retention of psychogenic complexes. Social isolation, discomfort in human relations with difficult social contacts, introversion, turning to the sphere of internal experiences, poverty of emotional ties with others and hypersensitivity to situations attracting an attention of other people are typical. Dysmorphophobia with symptoms of social anxiety (subtype 2 of 1st type): 35 patients (8 men and 27 women aged 29.1±11.8 years). This subtype of dysmorphophobia has obsessive-phobic structure and includes social anxiety with obsessive fear of negative assessment (criticism, discussion) of appearance by others, situational avoidant behavior (professional and educational contacts, public speaking, and informal communication). Sensitive ideas on relationships are fragmentary and transient; they are mainly presented by episodic alertness regarding possible ridicule among familiar faces.
Dysmorphophobia type 2 is usually based on narcissistic (DSM-IV-TR, n=16), schizoid (n=7) and anankastic (n=3) personality disorders. Patients are characterized by high conceit, individualism, self-interest, self-confidence, inability to emotional empathy, lack of interest in social cohesion. Other common features are overestimation of own abilities, pathological egocentrism, inability to establish productive mutual contacts, recognize the right of other people for independent aspirations and own goals. Regarding appearance, these patients are tuned in to achieve the highest result and do not accept the slightest deviations from the “ideal” image. These features are partially defined as “increased aesthetics” and described in the literature as an innate property of patients with body dysmorphic disorder. Need for symmetry and proportionality of certain body parts was observed in all patients with this type of body dysmorphic disorder.
Psychopharmacotherapy is effective in 72.9% of cases and carried out differentially depending on the type of dysmorphophobia. In case of dysmorphophobia with externally oriented psychopathological disorders (80% of cases), monotherapy is effective (atypical antipsychotics for subtype 1 or selective serotonin reuptake inhibitors for subtype 2). Dysmorphophobia with internal perfectionism (58.8% of responders) requires a combination of drugs (atypical antipsychotics and selective serotonin reuptake inhibitor).
According to the Round Table “Anorexia — a phenomenon, threat or factor of self-affirmation in society”, priority is given to appearance rather professionalism among respondents aged 18–22 years. Girls would like to see themselves as the most beautiful rather the most interesting or intelligent. An exaggerated ideal of beauty are being promoted in the world. Women are particularly susceptible to pressure of this ideal from society and try to comply with it [6]. According to the American Society of Plastic Surgeons adolescents made up about 40% of patients in plastic surgery hospitals in 2013 [7]. Adolescents can insistently demand relatives’ permission for surgery, aggressively react to rejections and express suicidal intentions.
Dysmorphophobia is a persistent disease. Therefore, treatment should be comprehensive, differentiated and long-term. Both psychotherapy and drug treatment are applied. Antidepressants and tranquilizers may be prescribed. Cognitive-behavioral psychotherapy is the most effective [8]. Treatment is difficult. Analysis of 200 patients with body dysmorphic disorder showed improvement only in 3.6% of patients [9]. Features of disease including premorbid status, initial symptoms, structure of syndrome and its course, type of syndrome, form and stage of disease should be considered in treatment of dysmorphomania. Psychotherapy should consider the personality characteristics and age. Dissuasive psychotherapy is ineffective. Fake surgery is contraindicated.
Pathogenesis of dysmorphophobia and dysmorphomania is based on hereditary impairment of neurotransmitter metabolism, low serotonin level, impaired dopaminergic regulation and gamma-aminobutyric acid deficiency. According to the theory of low serotonin level, these patients positively respond to selective serotonin reuptake inhibitors (higher availability of serotonin for other nerve cells). The researchers confirmed the role of vitamin D in cognitive disorders and relationship between age-related cognitive impairment and choline-, dopamine- and serotonergic insufficiency. Herbal medicines and nootropics, in particular, ginkgo, choline, cortexin, piribedil are proposed for treatment, prevention and correction of cognitive impairment.
The authors emphasize no data on the prevalence of certain personality disorder in patients with body dysmorphic disorder and relationship between body dysmorphic disorder and personality type [10]. There are several reports devoted to psychological characteristics of patients with chronic skin diseases and candidates for plastic procedures, but psychological status of patients is still unclear [11]. Treatment of dysmorphomania syndrome is not sufficiently disclosed. In 80% of cases, body dysmorphophobia occurs in adolescents aged 13–20 that can cause auto-aggressive actions considering the consequences of ideas about own imperfection. Features of dysmorphophobic and dysmorphomanic disorders, as well as psychological characteristics of patients are still poorly studied. Analysis of social and psychological factors, affective states of patients is important [12].
Correction of seemingly insignificant cosmetic problem becomes important due to its influence on emotional state and self-consciousness of a person. In the above-mentioned 3 groups of patients, various evidences on the lack of any defects or inadvisability of surgical interventions were completely ignored, while refusal of correction was perceived as a verdict on a terrible diagnosis. The subjects were incurable, the ideas of inferiority completely determined behavior of this group of patients. Some patients had thoughts of self-correction at home after repeated visits to plastic surgeon and refusal of surgery. Dynamics of disease was accompanied by repeated visits and subsequently acquired an endogenous character as dysmorphomania or full-fledged Cotard’s syndrome. Hysterical, exalted and hypothymic persons prevailed. It is unclear whether the personality type has a direct connection or it is the main factor of dysmorphomanic disorders. Another question is decrease of the quality of life considering neurotic and endogenous nature of disorders.
V.E. Medvedev et al. [13] revealed a heterogeneous spectrum of mental disorders: dysmorphophobia was detected in 26% of patients, anxious-phobic disorders — in 23.1% of patients, obsessive-compulsive disorders — in 11% of patients, depression — in 32% of patients, delusional disorders — in 7.5% of patients. The authors found the phenomenon of dissatisfaction with one’s own appearance in patients without cosmetic defects. It was associated with various mental disorders (depressive, dysmorphophobic, anxious-phobic, obsessive-compulsive and delusional disturbances). Dysmorphophobic disorders in patients with anorexia nervosa and bulimia nervosa significantly influence their affective state, contribute to anxiety and depression, worsen psychological component of the quality of life. These processes eventually lead to impairment of functioning up to social maladjustment and disability. Comprehensive study of the quality of life in these patients with alternative questionnaires will optimize treatment strategy. The most effective treatment should include modern drug (psychotropic and somatotropic) therapy, individual nutritional restoration programs with participation of nutritionists, various types of psychotherapy and long-term medical and social rehabilitation [14]. Patients in plastic surgery and cosmetology hospitals demonstrate high social functioning, adaptation and quality of life without direct relationship between social level and patient satisfaction. There was a significant incidence of character accentuations by hysterical and sensitive types. Mental maladjustment is the main motivation for aesthetic intervention in 50% of cases. Incidence of mental disorders was 91.89%. Moderate neurotic disorders prevailed (mainly dysmorphophobia and anxiety). Behavioral stereotype with repeated aesthetic operations is typical [15]. Follow-up indicates no improvement and even, on the contrary, mental deterioration of patients after cosmetic or surgical treatment. Moreover, various mental disorders contribute to persistent dissatisfaction with one’s own appearance in the absence of cosmetic defects [16]. In the above-mentioned 5 groups, psychopathological syndromes were realized within personality disorders, schizophrenia, affective (bipolar affective disorder, recurrent depressive disorder, etc.) and organic (mixed) disorders.
These psychopathological complexes can not only cause the patient’s dissatisfaction with own appearance and determine appealing to a plastic surgeon/cosmetologist, but also complicate postoperative period and increase the risk of dissatisfaction with treatment outcomes. Decision-making on surgical or cosmetological procedure should be based on physical and psychiatric status of the patient (mental history, causes of body dissatisfaction and need for aesthetic correction).
Currently, the problem of dysmorphophobia in psychology has not been sufficiently studied. There is a shortage of national researches devoted to this issue. Most manuscripts are reviews or case reports. The number of foreign studies is significantly more that may be due to higher detection rate of disease in the West.
In this regard, it is necessary to clarify personality disorders and their communication with ideas of inferiority of physical self-awareness and one’s own personality. Moreover, development of differential diagnostic criteria for neurotic and psychotic levels of personality and body perception disorders, as well as analysis of management of these patients and preparing the guidelines for plastic surgeons are required.
There are 3 categories of people with undesirable plastic surgery:
— patients with mental disorders;
— patients who cannot stop and constantly subject themselves to surgeries, as well as those who want not only to correct one or several defects, but undergo a large number of surgeries at once.
— people striving for complete perfection.
People inclining to constant improvement of something in their appearance and discovering flaws which actually do not exist are common patients of plastic clinics. These ones are rarely satisfied with the result. Age of such patients ranges from 20 to 30 years. Many people, especially women, require plastic surgery due to some dramatic changes in their lives. Divorces, emotional problems and problems in personal life contribute to a woman’s desire to change completely. Usually, any specialist convinces these patients to avoid interventions or emphasizes advisability of only a single operation.
Importantly, only 29% of people appealing for plastic surgery do not have any personality disorders and accentuations. Personal characteristics of patients who underwent surgery for a minimal physical defect include withdrawal, communication difficulties, imbalance, tension, suspicion, suggestibility, impulsivity and guilt [17]. Increased anxiety is revealed in about 70% of cases [18]. Depression occurs in 50% of cases. V.E. Medvedev et al. [19] reported similar incidence of depression in patients of plastic surgery hospitals and overall sample of patients. Previous suicide attempts are observed in 23–29% of patients. Neurotic disturbances including obsessive-compulsive disorder, eating disorders, social phobia and hypochondriacal disorder occur in 20-30% of cases [20]. Incidence of schizophrenia (ICD-10 F20) among patients of aesthetic surgeons reaches 4.1%, percentage of patients with mental disorders — 8.6%. These values significantly exceed general population (0.85-1.0%) [21]. It is hypothesized that permanent desire to improve own appearance (polysurgical addiction) typical for aesthetic surgery patients may be a consequence of dysmorphophobia. Approximately 20% of patients in cosmetic surgery receive antidepressants or regular psychological care [22]. In these cases, recommendations of attending psychiatrist or psychotherapist should be considered prior to decision making on plastic surgery [23]. Interpersonal relationships, problems with employment and stressful situations are common features of these patients [24, 25]. Risk factors of low subjective satisfaction with postoperative outcome are young age, high expectations, male gender, previous unsatisfactory results of cosmetic or surgical interventions, minimal physical deformities, motivations based on issues in interpersonal relationships (for example, the desire to get married faster), previous body dysmorphic disorders, disapproval from the patient’s relatives, their protest against surgery [26–28]. Certain plastic surgeries (for example, liposuction, rhinoplasty, mammoplasty, circular facelift) are associated with a high risk of patient negative reactions to postoperative outcome. Nevertheless, surgery usually increases self-esteem, improves emotional state and social functioning [29]. Some authors emphasize no positive changes in quality of life and mental state. Risk of postoperative exacerbation of psychopathological disorders (dysmorphophobia) and personality disorders was noted [30]. Some studies revealed an increase in suicide rate by 1.54-4.26 times in patients after augmentation mammoplasty compared to general population [31].
Our recommendation is simple screening of patients for BDD using a questionnaire. We have developed a questionnaire (Application), duration of test is no more than 5 minutes.
In case of high score, cosmetologists or plastic surgeons should think whether the patient’s desire for plastic correction is really due to true physical defect. If aesthetic defects that the patient wishes to correct are classified as non-existent or insignificant, this patient potentially meets the BDD criteria.
Additional questions should follow survey if BDD is suspected. Medical history of the patient with mental disorders is especially important: has he ever experienced depression, anxiety or other mental problems?
Depression and anxiety are often associated with BDD and physicians better recognize these problems.
It is important to identify suicidal thoughts during examination. The risk of suicide is very high in patients with BDD. If the patient approves of his thoughts of suicide, an urgent psychiatric care is necessary.
We analyzed 126 patients at the Institute of Plastic Surgery and Cosmetology (Moscow) and the network of plastic surgery and cosmetology clinics “Vip Clinic”. BDD was observed in 4.7% (6 out of 126) of patients appealing to plastic surgeons and cosmetologists (3.17% (4 out of 126) and 1.6% (2 out of 126), respectively). These results are similar to international data.
Thus, despite significant incidence of hysteroid and sensitive personality disorders, socio-psychological portrait of patients appealing for plastic surgery includes high social functioning, social adaptation and quality of life. There was no direct correlation between social functioning and quality of life, and depression mediates patient subjective satisfaction with own social functioning. More than 34% of patients have high personal anxiety in mental maladjustment. Emotional sphere of coping is the most problematic. Indeed, non-adaptive coping strategies were registered in 17.7% of cases. Sexual dissatisfaction is predominant motivation for surgery that is similar to literature data [32].
No psychological complaints and predominant subclinical or moderate disorders complicate diagnosis. We suggest questionnaire survey of the primary patient in plastic surgery and cosmetology for analysis of further treatment strategy.
It should be noted that psychology and plastic surgery are two interrelated branches of science. People wanting some changes in their appearance should recognize and change a lot in their thoughts. Therefore, any plastic surgeon must subtly understand the human soul and understand patients’ motivation, i.e. one should have necessary psychological knowledge and skills [33].
Application. Screening questionnaire for BDD (Kruglik E.V., Aronov P.V., 2020)
Dear patient! You are invited to fill out a questionnaire. The questions relate to your feelings and experiences that you may have had within the past 2 weeks. These data will be valuable for your doctor to resolve your problem and improve your quality of life.
There are no right or wrong answers here. Answer without thinking too long. Immediate answers are more consistent with your condition than the results of long thinking. Select the most appropriate answer for each question.
1. Many people pay attention to their reflection in a mirror or other reflective surface, such as a shop window, or touch their face. How often do you intentionally do this?
1) about 40 times or more daily;
2) about 20 times or more daily;
3) about 10 times or more daily;
4) about 5 times or more daily;
5) I never pay attention.
2. In your opinion, to what extent your appearance currently does not suit you, do you consider yourself unattractive or “it’s not me”?
1) very ugly or “not me”;
2) noticeably unattractive;
3) moderately unattractive;
4) slightly unattractive;
5) reasonably attractive.
3. To what extent does your appearance currently upset you?
1) not upset at all;
2) slightly upsetting;
3) moderate upsetting;
4) noticeably upsetting;
5) extremely distressing.
4. How often does your appearance currently cause you to avoid public events or speaking?
1) I always avoid;
2) I avoid about 3/4 of cases;
3) I avoid about 1/2 of cases;
4) I avoid about 1/4 of cases;
5) I never avoid.
5. To what extent are you concerned about your appearance now?
1) not at all concerned;
2) slightly concerned;
3) moderately concerned;
4) significantly concerned;
5) extremely concerned.
6. What is the effect of your appearance on relationship with a partner or dating?
1) no effect;
2) mild effect;
3) moderate effect;
4) obvious effect;
5) extreme effect.
7. How often people pay attention to your appearance and does it affect your relationships with other people?
1) no effect;
2) mild effect;
3) moderate effect;
4) obvious effect.
8. To what extent does your appearance currently interfere with your work or study? (Please, rate this aspect even if you are not working or studying, we are interested in your ability to work or study).
1) no effect;
2) mild effect;
3) moderate effect;
4) obvious effect.
9. To what extent does your appearance currently interfere with your social life (communication with other people, for example, going to cafes, restaurants, theaters, concerts, excursions, etc.)?
1) no effect;
2) mild effect;
3) moderate effect;
4) obvious effect.
10. To what extent do you feel that your appearance is the most important aspect of who you are?
1) not at all;
2) mild feeling;
3) moderate feeling;
4) mostly;
5) completely.
Each answer is numbered. All answers are summed considering their numbers. This value is used for preliminary screening.
Higher scores are associated with more severe stress and risk of BDD. If your score is 40 or more, we recommend survey for BDD. If your score 30 — 40, you can have BDD and benefit from examination. If your score less than 30 points, you are unlikely to have BDD.
You can repeat the questionnaire at any time throughout the treatment to see if there are any changes in your symptoms.
The authors declare no conflicts of interest.