A medical and legal perspective from Dr Darryl Hodgkinson and medical layer, Kate Williams

By Editor, Jennie Lewis Teal

DEFINITION: Body dysmorphic disorder (BDD) is defined by DSM-IV-TR (a text revision of the DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) as a condition marked by excessive pre-occupation with an imaginary or minor defect in a facial feature or localised part of the body.

The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient’s social, occupational, or educational functioning. The most common cause of this decline is the time lost in obsessing about the “defect”—one study found that 68 per cent of patients in a sample of adolescents diagnosed with BDD spent three or more hours every day thinking about the body part or facial feature of concern. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), assigns BDD to the larger category of somatoform disorders, which are disorders characterised by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.

The earliest known case of BDD in medical literature was reported by an Italian physician named Enrique Morselli in 1886, but the disorder was not defined as a formal diagnostic category until DSM-III-R in 1987. The World Health Organization (WHO) did not add BDD to the International Classification of Diseases (ICD) until 1992. The word dysmorphic comes from two Greek words meaning “bad” or “ugly” and “shape” or “form.” BDD was previously known as dysmorphophobia.”

http://medical-dictionary.thefreedictionary.com/body+dysmorphic+disorder

Body Dysmorphic Disorder (BDD) can prove difficult to diagnose and treat; experts agree on many of the prevalent symptoms however some of these are also similar or precursors in cases of Obsessive Compulsive Disorder (OCD) and Anorexia Nervosa. Research suggests cognitive behavioural therapy (CBT) and selected serotonin reuptake inhibitors (SSRIs) can be effective in managing BDD. The disorder is often prompted and exacerbated by wider sociological or psychosocial factors, such as the influence of mass media and popular culture. The prevalence of physically “perfect” men and women in magazines and on television can create pressure and anxiety in impressionable children and teenagers which then carry through into adulthood, where they can develop into a distorted perception of their own face and body.

There is little evidence to suggest BDD is inherited, however a lot to suggest that it can be determined by parents’ perceptions of their own physicality which in turn affects their children and has bearing on their own physical perceptions. Some research suggests parents who are critical of their children’s appearance are more prone to the disease.

According to the American Society for Aesthetic Plastic Surgery, the number of children undergoing cosmetic surgery is on the rise. A number of articles have been published of late noting trends in cosmetic interventions in those aged 18 years and younger. USA Today reports, “Pediatric plastic surgeons say they vet their patients carefully, making sure eating disorders are not at play. And they watch closely to be sure it’s the child’s choice, not a pressuring parent or boyfriend or the desire to look like a particular celebrity.”

“Lloyd Krieger, medical director of Rodeo Drive Plastic Surgery in Beverly Hills, says his practice gets many calls from youngsters. We turn away a good two-thirds of them after a phone evaluation,” he says.

The report goes on to quote Aviva Katz, a paediatric surgeon and medical ethicist at Children’s Hospital of Pittsburgh of UPMC, and the mother of twin five-year-old daughters, who says, “in theory, it’s all very nice to say it would be best if we could raise our children without the expectations of appearance. You want them to feel good and whole within themselves without having the body that looks back at them in the mirror be a model,” she says. “But that’s a challenge when we live in a world with TV, movies and magazines”.

http://www.usatoday.com/news/health/2009-06-24-cosmeticsurgery-kids_N.htm

The Victorian Government, Better Health site identifies BDD as causing severe emotional distress in sufferers. “It is not just vanity and is not just something a person can just “forget about” or “get over”. The preoccupation can be so extreme that the affected person has trouble functioning at work, school or in social situations. It affects men and women equally and usually starts in the teenage years. Suicide rates of people with BDD are high.”

http://www.betterhealth.vic.gov.au

The effect the disorder has on the person’s life can range from mild to extreme; lifestyle-limiting right through to socially crippling. Symptoms include:

• Hours spent obsessing over the perceived defect every day.
• Guilt or distress about this preoccupation.
• Anxiety about falling short of the “physical perfection” illustrated in mass media.
• Need for reassurance about their looks from friends and family – this can also extend to a clinging friend who feeds their neuroses.
  
• Ritualistic behaviour such as constant dieting and over-exercising.
• Looking at their reflection in the mirror many times a day, conversely in some, an avoidance of mirrors is noted.
• Reapplying heavy makeup many times a day and grooming to excess.
• Social avoidance of situations which they feel will call attention to their defect.
• Camouflaging or hiding the perceived defect with large dark glasses, big brimmed hats, long sleeves or many layers. This is noted as the most common symptom of the disease.
• Requesting treatment of the perceived flaw by surgical or non-surgical means.

Looking at their reflection in the mirror many times a day, conversely in some, an avoidance of mirrors is noted.

The disorder is nothing new, it’s only now that it’s getting more coverage in the media. If Sigmund Freud’s patient of the early 1900s, Russian aristocrat Sergei Pankejeff, (nicknamed the Wolf Man by Freud) had been alive today he would likely be diagnosed with BDD. According to Wikipedia, “Pankejeff had a preoccupation with his nose to an extent that it greatly limited his functioning. A few years after finishing psychoanalysis with Freud, Pankejeff developed a psychotic delusion. He was observed walking the streets staring at his reflection in a mirror, convinced that some sort of doctor had drilled a hole in his nose”

http://en.wikipedia.org/wiki/Body_dysmorphic_disorder

Over the years, a greater awareness of the disorder has helped physicians diagnose and treat the symptoms of BDD. According to the free medical dictionary site, if treated it appears the disorder can lessen, “As of early 2005, the prognosis of BDD is considered good for patients receiving appropriate treatment. On the other hand, researchers do not know enough about the lifetime course of body dysmorphic disorder to offer detailed statistics. DSM-IV-TR notes that the disorder ‘has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time.’”

http://medical-dictionary.thefreedictionary.com/body+dysmorphic+disorder

However recent UK reports suggest BDD may be on the rise. Recent figures released by NHS Information Centre show that in the past year, the UK National Health Service (NHS) has spent “£5.7 million on giving 471 patients liposuction and giving over 1600 patients nose jobs, tummy tucks and breast reductions.”

The criteria for receiving cosmetic treatments on the NHS are stringent and patients would not qualify for these treatments purely for cosmetic reasons. Many who received treatment are diagnosed as suffering from body dysmorphic disorder. However doctors noted that “being distressed by your looks” was not enough to warrant cosmetic surgery, “there has to be significant evidence of the patient suffering from body dysmorphic disorder before patients would be permitted to have cosmetic surgery.”

http://www.cosmeticsurgerybible.com/2009/news/hundreds-getfree-cosmetic-surgery-on-the-nhs/659

A diagnosis is often achieved with the help of a self-report questionnaire, such as the Multidimensional Body-Self Relations Questionnaire (MBSRQ) or the short form of the Situational Inventory of Body-Image Dysphoria (SIBID).

http://medical-dictionary.thefreedictionary.com/body+dysmorphic+disorder

An ABC News report posted Dec, 2007, refers to a study published in the journal Archives of General Psychiatry, led by University of California psychiatry professor Dr Jamie Feusner which sheds light on BDD. “Dr Feusner, who led the research, says his team performed functional magnetic resonance imaging (FMRI) brain scans on 12 people with the disorder as they viewed black and white images of other people’s faces, and compared the results to those of people who do not have BDD. They saw differences in how the right and left sides of the brain worked in people with BDD, but no actual structural differences in the brain.”

Dr Feusner is quoted as saying, “This is the first time where there’s evidence that there is a kind of biological abnormality that may be contributing to the symptoms – the distorted body image – in body dysmorphic disorder.”

The article goes on to cover other findings of the same report which suggest the disease can run in families and is more common in cases of OCD. Dr Feusner is further quoted as saying he knows of patients who have numerous rhinoplasties and breast augmentations and some who take it to such extremes that they begin to look less and less “human.” He added, “Invariably they are dissatisfied with the surgery and can end up feeling even more hopeless afterwards.”

http://www.abc.net.au/news/stories/2007/12/04/2109144.htm?site=news

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A Physician’s Perspective and Experience with BDD

By Dr Darryl Hodgkinson,
M.B., B.S. (Hons), F.R.C.S.(C) (Plast), F.A.C.S., F.A.C.C.S.
Double Bay, Australia

ABSTRACT:

Body dysmorphophobia (BDD) is a psychiatric illness experienced by up to 20 per cent of patients requesting cosmetic surgery. Because of its diverse presentations, BDD should be searched out and recognised by the plastic surgeon. Otherwise, the unwary operator will invariably have to deal with a profoundly dissatisfied patient. Patients with BDD hate their bodies and may seek out cosmetic surgery as a solution. However they are invariably not satisfied despite the objective result. Many eventually fall into the cosmetic surgical victim category of “over-operation.” These patients need psychological counselling and referral to psychiatrists with a special interest in body image. Recognition and deferral of surgery for BDD patients is advised because findings have shown the propensity of these patients to litigate, threaten and even harm or kill their surgeon.

SIGNS OF BDD:

To the surgeon, a minimum defect, a variation in size or shape, or a minimal scar catastrophised into dislike or disgust is an alert or red flag suggesting BDD. The excessively made up or doll-like patient, or the patient with a clinging friend, parent or relative also can signal an alert. The difficulty arises in assessing the degree of disability exhibited by those with a minor disorder and in detecting the more subtle presentation that can become florid symptomatology after cosmetic surgery.

As many as six to 15 per cent of patients presenting to the plastic surgeon for cosmetic surgery may be experiencing BDD. [13] Patients with previous surgery, especially those with multiple surgeries who are still dissatisfied could likely be experiencing BDD. The cosmetic surgical junkie is a red flag candidate. It is estimated that males who undergo rhinoplastic surgery are three times more likely than females to be dissatisfied with their surgery.[7] The outcome of cosmetic surgery for each patient must be judged both in psychological terms and for objective changes because patient expectations are mostly psychological or psychosocial. [11] We need to realise that the expectation of external factors improving (i.e., enhancement of social networks, relationships, and employment) is paramount for the patient. Hence a dissatisfied patient may attribute failed external factors to the perceived unsuccessful cosmetic surgery operation. The solution becomes more surgery, which compounds a pre-existing unresolved, psychosocial problem. If patients regard cosmetic surgery as a life panacea or epic-changing event, they are likely to be disappointed when the physical changes do not lead to the anticipated social outcome. After surgery, pain, numbness, minor healing problems or complications will accentuate anxieties in all patients, especially the BDD patient, resulting in the exacerbation of symptoms or a BDD attack and leading to feelings of anger, hopelessness and despair.

DIAGNOSTIC TESTS FOR BDD:

Psycological evaluation of patients is not standard in clinical plastic surgery practice. However, questioning of motivation and interview techniques to ascertain the patient’s degree of realism is standard. The fact that 50 per cent of patients presenting for cosmetic surgery are receiving psychotropic medications and that 27 per cent are taking antidepressants suggests that perhaps some standard psychological tests should be introduced into the initial cosmetic surgical consultation. [9]Only a few authors have suggested this as a routine. [15]

A suspicion of BDD may indicate the use of a simple standard questionnaire such as the Body Dysmorphic Disorder Questionnaire. [12] A more specific diagnostic questionnaire is the Body Dysmorphic Disorder Examination Self Report. [3] To determine the severity of BDD, Phillips [12] developed the BDD-YBOCS for the use of interviewing mental health care professionals in assessing the severity of the disorder. This tool is more likely to be used as a clinical research tool by a psychiatrist. The diagnosis is confirmed by a psychiatrist following the criteria outlined in the DSM-4 for BDD. The plastic surgeon’s suspicion or red flags, perhaps with the aid of a screening BDD questionnaire, should alert him to refer the patient to a psychologist or psychiatrist who can confirm the diagnosis and initiate treatment if the diagnosis is confirmed.

TREATMENT OF BDD:

Once BDD is suspected or identified, avoidance of surgery is paramount, and referral to a mental health care professional is obligatory. Cognitive behaviour therapy is a mainstay treatment for dealing with the behavioural components of BDD. Such therapy focuses on response, prevention, and behavioural change. Medications complement the behaviour therapy. Seratonin reuptake inhibitors in particular are clinically helpful as they also are for the treatment of anxiety disorders. The prescribing and management for these patients is out of the plastic surgeon’s realm and should be left to the treating psychiatrist.

CONSEQUENCES OF SURGERY FOR PATIENTS WITH BDD:

All surgeons have had, or will have, the unfortunate experience of operating on patients who become profoundly dissatisfied with the surgical outcome even when, objectively, the result is satisfactory. It is likely that many of these patients had no diagnosis of BDD before their operations. A minor problem such as wound healing, scarring, numbness,or persistent bruising can trigger profound dissatisfaction or the BDD “attack.” No amount of encouragement or support will mitigate the disappointment of these people, and they become the total focus of you and your staff’s working and out-of-office time, often at the expense of other patients in the practice. The stress levels of the treating surgeon and staff are increased dramatically. This worsens if the dissatisfied patient begins to threaten the physician with violence. Unchecked, the BDD patient often proceeds to litigation. Bodily harm and even murder of a surgeon is a possible, but unlikely, sequence.

The three following cases, two that I unwittingly managed with surgery and another that I reviewed for a colleague, demonstrate the diverse but disturbing sequelae of operating on patients with BDD.

CASE STUDY 1: KATE

Kate, an attractive 20-year-old caucasian woman presented for breast enlargement. Her request was for 600 ml increase, based on her aim to become a Penthouse centrefold model. I acquiesced and provided a larger than normal DD result. Within 12 months, the patient requested even larger implants - 800 ml. The request was denied. She then wished to have facial enhancement involving larger lips, cheek implants, rhinoplasty and laser resurfacing. What followed was a conservative rhinoplasty, a bilateral Terino shell silicone implant and laser resurfacing. Initially, the patient was satisfied with the result, but she did begin wearing huge sombrero-like hats and became heavily made up, using extreme amounts of cosmetics. She soon requested another rhinoplasty, saying she wanted her nose to be small and look “operated upon.” After I refused to reoperate, she ignored my counsel not to destroy a perfectly good surgical result and found a surgeon willing to operate on her nose. Her surgically treated nose gave her a bizarre simian appearance, toward which she was ambivalent. Her interpersonal relationships with older, married men and the suicide of a peer male boyfriend accompanied the unhappy consequences of her cosmetic surgery. I asked Kate if she thought she should never have started with cosmetic surgery, and she concurred. Kate demonstrates the trap of repeated surgeries, which eventually did lead to a deformity, justifying her own delusions of unattractiveness.

CASE STUDY 2: BRAD

Brad a 25-year-old male actor, presented for an assessment of his nose, having previously had three rhinoplasties, two of them performed by recognised plastic surgeons. All three surgeons had refunded the patient their surgical fees after he became profoundly dissatisfied with their efforts. A slight deformity of the nasal dorsum and irregularity of the glabella attributable to lack of infrastructure of the nasal bones were confirmed by computed axial tomography (CAT) scan. Multiple consultations followed, together with communication with two of the previous surgeons. The patient claimed that his acting career had been adversely affected by his nasal appearance. A conservative rhinoplasty was agreed upon, and a slight modification of the dorsum and osteotomy to narrow the bony vault was performed. Immediately, the patient was dissatisfied and would not hear that swelling was still present six weeks post operatively. The patient returned repeatedly, bringing with him a female partner from whom he regularly sought reassurance and confirmation of his distress and inability to work. He demanded a refund of his surgical fee. After refusing this initially, I referred the problem to my medical indemnity company, who after reviewing all documents and photographs, recommended that I not acquiesce to the patient’s demands.

When I informed Brad of my indemnity company’s decision, he rained down a litany of abuse, saying that he would get the surgeon (myself) and was on his way to get his money. These threats were reported to the local police, who contacted Brad, advising him not to proceed with his threats and not to contact the office. I have not heard from the patient since. However, to my angst, I have been notified that Brad is a member of my local private tennis club, and I am now not comfortable playing at that club. Brad illustrates how dissatisfaction occurs quickly after surgery and can become violent. It also points to the fact that male secondary rhinoplastic cases are of particular concern in BDD.

CASE STUDY 3: JANENE

Janene’s file was sent to me for review by the indemnity company of a colleague in another state of Australia. Preoperatively, the patient, a 41-yearold woman, had a doll-like facial appearance. She was fastidiously attired and complained of wrinkles around her eyes, some crows’ feet, and some excessive skin in her upper eyelids. The surgeon, skilled at laser blepharoplasty, suggested a modest removal of upper lid skin and lower lid laserbrasion of the patient’s wrinkles. The procedures were performed without complications. At three months, the patient showed no lag ophthalmia, minimal pigmentary changes, and good elimination of crows’ feet and lower lid wrinkles. Janene was, however, profoundly dissatisfied, saying that her life had been ruined. She wrote a 25-page letter of complaint to the State Medical Board and arrived at the surgeon’s office on Christmas Eve demanding her clinical notes. The local police had to be summoned to remove her from the premises. Janene pursued her complaint through the Health Care Complaints Commission.

Her case was subsequently heard and brought before the State Medical Board. A disciplinary hearing of the operating surgeon then ensued. This patient represents the “doll-like” perfectionist obsessed with her appearance who has no minimal deformity, but is unwittingly subjected to surgery by a colleague.

References:
3. Claiborn J, Redrick C: The BDD workbook. New Harbinger Publications Inc., 2002.
7. Guyuron B, Bolchari F: Patient satisfaction following rhinoplasty. Aesth Plast Surg 20:153-157, 1996.
9. Meningaud JP, Benadiba L, Servant JM, Herve C, Bertrand JC, Pelicie Y: Depression, anxiety, and quality of life amongst scheduled cosmetic surgery patients: Multicentre prospective study. J Craniomaxillofac Surg 29:177-180, 2001
11. Perrogon F: Aesthetic surgery, patient’s opinion. Quantitative and qualitative analysis of aesthetic surgery results of 481 survey and 50 records of “dissatisfied patients”. Ann Chir Plast Esthet (France) 48:307-312, 2003.
12. Phillips KA: The broken mirror. Oxford University Press, Oxford, pp.45-46, 242, 1986.
13. Sarwer DR, Wadden TA, Pertschuk MJ, Whitaker LA: Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconst Surg 101:1644-1649, 1998.
15. Terino E, Flowers R: The art of alloplastic facial contouring. Mosby, Saint Louis, p 328, 2000.

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A Legal Perspective on BDD

By Kate Williams,
Principal Lawyer in Medical Law,
Slater & Gordon Lawyers, Sydney.

Dr Hodgkinson’s article concerning the body dysmorphic patient carefully sets out the disorder’s criteria for diagnosis. It sensibly provides a course of action to take with such patients who either have this disorder or whom a surgeon suspects has this disorder. In recent times this condition has been the subject of much media coverage. Cases have been cited from throughout the world of requests for radical surgery which has included most shockingly, requests for amputation of healthy limbs and other potentially disfiguring surgery. Mercifully this would be a rare request. Through Dr Hodgkinson’s research he quotes that as many as six to 15 per cent of patients presenting to the plastic surgeon may be experiencing BDD. This is not an insignificant figure.

Whatever the physical and/or mental health consequences are of acquiescing to the requests for such surgery, the discussion of the legal issues concerning the management of these patients, however, deserves no less attention. Despite many of the requests made to plastic surgeons for surgery that are dangerous and unrealistic, a clinician should be aware of a number of medico-legal issues.

CAPACITY TO CONSENT TO PROCEDURES IF MENTALLY INCAPACITATED

It is a threshold right that competent adults have the right to self-determination with respect to their wishes and have the right to determine what is done to their bodies, including the medical treatment they received. A doctor, of course, is not entitled to treat a patient without the consent of the patient.

It is generally assumed that a patient’s consent makes the medical treatment requested lawful. If a doctor has actual knowledge that a patient has body dysmorphic disorder, the issues of capacity to provide consent for a medical procedure is relevant.

Under the Common Law in most jurisdictions in Australia there is a presumption that a person has legal capacity. In some situations even if a person suffers a mental disorder, it does not necessarily mean that the presumption of capacity is displaced.

Under legislation in New South Wales a person lacks capacity in relation to a matter if at the material time he or she is unable to make a decision for themselves in relation to the matter because of an impairment or disturbance in the function of the mind or the brain. I do not consider that body dysmorphic disorder would be a disturbance such that it would be considered as affecting a patient’s ability to make or give informed consent at the time of consenting to surgery or a procedure.

IS THE TREATMENT APPROPRIATE MEDICAL TREATMENT?

The primary issue is whether the surgery requested has any possible therapeutic benefit to the patient upon which the operation will improve or benefit the patient’s appearance. It is likely that a person with body dysmorphic disorder will not derive any improvement and if anything, it will further aggravate their mental health.

If there is no therapeutic benefit in such requested cosmetic surgery, the question that arises as to the basis upon which such surgery may be regarded as lawful. In Dr Hodgkinson’s example in Case Study No. 1 (Kate), it was a good example of sensible competent practice when dealing with such patients. It was correct to refuse the further request for surgery. The appropriate standard of care ought to be that surgeons should refuse further treatment. At the front of the surgeon’s mind should be “is there therapeutic benefit to performing surgery?” If no benefit can be considered possible, further surgery should be refused.

RISK MANAGEMENT

I sometimes think that doctors and in particular, surgeons, believe they are the only professionals who have difficult clients. On considering this type of patient, the first thing that came to mind which is analogous to this situation was the vexatious litigant. This is a person who is shown to be habitually and vexatiously litigious without reasonable grounds or cause or excuse. I fortunately have only experienced this type of client once in my career.

I consider that this analogy has clear parallels with the Body Dysmorphic Patient. In both scenarios, medical and legal, the following steps ought to be taken:

1. I cannot endorse highly enough the questionnaire outlined by Dr Hodgkinson in his report. It is clear and should filter out the personality traits of a body dysmorphic patient.
2. Thorough, obsessive and careful notes of all consultations.
3. Refusal to perform surgery.
4. Integrity and compassion at all times, above all.