significant damage to the person’s life. The syndrome tends to be chronic and can lead to complete social withdrawal. Students drop out of school. Professionals quit jobs. The patient may undergo major depression, and even commit suicide. The BDD patient is not in need of surgery at all but requires treatment, which will involve cognitive behavioral therapy and medication, usually the same types that are used in obsessive-compulsive disorder.
Typically, most of the patients with BDD are requesting some sort of facial plastic surgery (more than any other part of the body). Also their desire for surgery is absolutely obsessive. Before the diagnostic term of BDD was coined in the 1980s, these patients were called “insatiable.” BDD patients are very good are trying to hide the fact that their preoccupation is abnormal. Such “insatiable” patients are not always easy to spot. Although the symptoms are unmistakable, it may take time to discover them. So how can a good surgeon know for sure?
Returning to the case of LISA: She didn’t speak much of her personal life so it was not possible to find out what was happening there. However, during the course of my treatment, I found that she had already had undergone 5 nose surgeries and 4 breast surgeries that were performed by other physicians. She came to see me because she wanted Caucasian eyes. Westernized eyelid surgery is very common in Asian, so I did the surgery. At first she seemed pleased with the results. Then she came back for another screening and wanted to have her nose done again—a sixth surgery, and I refused. The big question is when to say “no more.” One year later she came back to have a facelift, which of course was not needed at all, so I said no. She became upset and went to see another surgeon. I don’t know what became of her.
My rule of thumb is that if there is a huge gap between perceived defect and the degree of emotional distress it is causing the patient, then I don’t’ operate. BDD patients are preoccupied with small or no existing defects. But this is not what constitutes the problem. Appraising a defect is very subjective. For one surgeon it could be nothing and for another surgeon the defect could be deemed dramatic. So what counts is the intensity of the patient’s emotional distress due to the defect. The emotional intensity is measured by just how much the patent’s life patient is being interrupted by thinking about the defect, and how many times the patient is willing to repeat surgery to correct a defect that really isn’t apparent at all.