Body Dysmorphic Disorder

Plastic surgeons increase patient psychiatric screenings

Body Dysmorphic Disorder | Johns Hopkins Medicine

The operation went off without a hitch. Another successful nose job — or so Dr. Ira Papel thought. Until the patient came back to his clinic threatening to shoot himself and others.

The police eventually defused the situation (and the troubled patient wasn’t armed). But the episode continues to weigh heavily on Papel.

“When you have a guy in your waiting room with a trench coat, his hands in his pockets, saying he has some guns — that’s pretty traumatic,” said Papel, medical director of the Facial Plastic Surgicenter of Baltimore, adding: “And all because he said his nose was not quite what he wanted.”


In hindsight, Papel suspects his former patient suffered from body dysmorphic disorder (BDD), a psychiatric condition defined by an obsession with imagined or slight defects in appearance. In that light, the man’s distress probably had more to do with his mental state than with Papel’s surgical skills, and the patient should never have had rhinoplasty to begin with.

BDD made headlines last month when Reid Ewing, a young actor on ABC’s “Modern Family,” wrote about his repeated plastic surgeries and body dysmorphia for the Huffington Post. Not one of the four doctors who operated on him did any mental health screening, Ewing wrote.


Papel believes that should never be the case. He’s one of a small but growing number of surgeons who are pushing to introduce formal screening tools in cosmetic surgery clinics nationwide. These doctors argue that psychiatric questionnaires offer a way both to protect patients from unwarranted medical treatment and to preemptively defend plastic surgeons from legal and physical attacks.

“We are not psychiatrists, we are surgeons,” said Dr. Lisa Ishii, a facial plastic surgeon at the Johns Hopkins School of Medicine. “So it’s unreasonable for us to guess whether someone has a mental illness” that would make that person unfit for treatment.

Text from the Body Dysmorphic Disorder Questionnaire

This idea is facing pushback, though, by many cosmetic surgeons who maintain that a doctor’s intuition while talking with prospective patients is good enough to pick up on any psychological problems.

“These patients are so smart,” said Dr. Rod Rohrich, a plastic surgeon at the University of Texas Southwestern Medical Center at Dallas. “They’re better than the questionnaire, which is why you really have to interview them.”

BDD affects an estimated 2 percent of the general population, and up to 15 percent of patients in cosmetic surgery clinics. The condition is best managed with antidepressants and psychotherapy, yet around half of all people with BDD seek appearance-enhancing treatments instead.

Few are happy with the outcomes.

Symptoms typically get worse after surgery, as patients continue to dwell on operated body parts or shift their focus to other perceived flaws. Feeling just as bad — if not worse — after aesthetic treatment, some patients lash out against their doctors.

In surveys, 40 percent of cosmetic surgeons and 12 percent of dermatological surgeons say that they have been intimidated or harassed by patients with symptoms consistent with BDD.

Most were threatened legally, some physically. At least five American plastic surgeons have been killed over the past 20 years — and for several of these murders, “there was evidence to suggest that patients were struggling with significant mental health issues,” said clinical psychologist David Sarwer of Temple University in Philadelphia, who ran the surveys.

In September, a Russian patient, upset over the results of several operations on his nose and ears, reportedly shot a plastic surgeon in revenge before turning the gun on himself.

That’s the most extreme consequence. But even lesser harassment can seriously disrupt a physician’s personal life and medical practice. For Dr. Angelica Kavouni, a labiaplasty specialist in London, mistakenly operating on someone with BDD meant a barrage of phones calls, emails, and requests for follow-up appointments.

“It’s a lot of time wasting,” she said. “These patients can wear you down.”

Plastic surgeons in the United States and elsewhere are not required by law to conduct psychological evaluations, though most commonly ask potential patients about their states of mind.

 Ishii, for example, inquires about expectations and motivations for surgery.

And she will turn away individuals who come in with overt red flags, such as having had multiple prior surgeries or an overblown fixation on a body part.

And yet, patients with BDD continue to slip past these safeguards. So, Ishii — herself a victim of vitriolic online comments from disaffected BDD patients — has turned to a questionnaire commonly used in mental health evaluations. Developed by Dr.

Katharine Phillips, a psychiatrist and leading BDD researcher at Brown University’s Warren Alpert Medical School, the screening tool asks individuals how much time they spend worried about body their image and the degree of emotional pain that causes.

While the test sometimes yields false positives, Phillips has shown that it almost never lets a patient with BDD pass by undiagnosed. It takes less than two minutes and can be completed on a computer tablet in the doctor’s waiting room.

Over four months last year, every adult patient who walked through Ishii’s clinic door filled out the questionnaire. Of the 122 who sought appearance-enhancing procedures (as opposed to reconstructive surgery), around 20 percent tested positive for BDD.

Ishii conducted follow-up interviews and referred most of those individuals to a psychiatrist for further evaluation. No patient who scored negative for BDD and underwent cosmetic surgery later demonstrated the kinds of problems indicative of a mental illness.

“This is a fantastic screening tool,” Ishii said, “and it can be easily incorporated into the flow of our practices.”

Ishii published her experiences with the BDD questionnaire earlier this year in the journal JAMA Facial Plastic Surgery. Together with Papel and others, she is now working on a follow-up study comparing the screening tool against the informal assessments many cosmetic surgeons do with new patients.

Dr. Mark Constantian is skeptical. Years back, he tried giving the BDD questionnaire — the same one that Ishii and Papel are using — to around 50 prospective rhinoplasty patients at his private practice in Nashua, N.H.

These individuals saw right through the screening tool, Constantian found, and they responded less than truthfully about their states of mind. “The questions were too transparent,” he said.

“Patients filling it out wanted to qualify for surgery, and they understood what I was asking, even obliquely.”

Papel concedes that the questionnaire isn’t perfect. But neither is the status quo. “Time and again we get fooled,” Papel said. “If we can catch anybody that has a serious problem and steer them in the right direction, then it’s beneficial.”

Illustrations by Dom Smith/STAT 


International OCD Foundation | Scientific and Clinical Advisory Board

Body Dysmorphic Disorder | Johns Hopkins Medicine

  • Michael Jenike, MD, ChairProfessor of Psychiatry, Harvard Medical School, Boston, MAFounder,OCD Program, Massachusetts General Hospital, Boston, MAFounder,OCD Institute McLean Hospital, Belmont, MA
  • Sabine Wilhelm, PhD, Vice ChairProfessor, Harvard Medical School, Boston, MAChief of Psychology, Massachusetts General Hospital, Boston, MADirector, OCD Program, Massachusetts General Hospital, Boston, MA
  • Jonathan S. Abramowitz, PhDProfessor of Psychology and Neuroscience,University of North Carolina at Chapel Hill, Chapel Hill, NC
  • Susanne Ahmari, MD, PhDAssociate Professor of Psychiatry, University of PittsburghDirector, Translational OCD Laboratory
  • Throstur Bjorgvinsson, PhDAssociate Professor of Psychology, Harvard Medical School, Boston, MADirector, Behavioral Health Partial Program, McLean Hospital, Belmont, MADirector, Houston OCD Program, Houston, TX
  • Kevin Chapman, PhDPrivate PracticeLouisville, KY
  • James Claiborn, PhDPrivate PracticeSouth Portland, ME
  • Lisa Coyne, PhDAssistant Professor, Department of Psychiatry, Harvard Medical SchoolFounder and Senior Clinical Consultant, McLean OCD Institute for Children and AdolescentsDirector and Founder, New England Center for OCD and Anxiety, Boston, MA
  • Darin Dougherty, MDAssociate Professor of Psychiatry, Harvard Medical School, Boston, MADirector, Division of Neurotherapeutics, Massachusetts General Hospital, Boston, MAOCD Institute McLean Hospital, Belmont, MA
  • Denise Egan Stack, LMHCDirector, Atlantic Center for Behavioral HealthBoston, MA
  • Jamie Feusner, MDAssociate Professor of Psychiatry at UCLA, Los Angeles, CADirector, UCLA Adult OCD ProgramDirector, UCLA Eating Disorder and Body Dysmorphic Disorder Research Program
  • Martin E. Franklin, PhDAssociate Professor of Clinical Psychology in PsychiatryUniversity of Pennsylvania, Philadelphia, PADirector, Child and Adolescent OCD, Tic, Trich & Anxiety Group (COTTAGe), Philadelphia, PA
  • Jennifer Freeman, PhDProfessor, Alpert Medical School of Brown UniversityDirector of Research and Training, Pediatric Anxiety Research Center, Bradley Hospital
  • Randy Frost, PhDProfessor of PsychologySmith College, Northampton, MA
  • Wayne K. Goodman, MDChair, Menninger Department of Psychiatry and Behavioral Sciences,Baylor College of Medicine, Houston, TX
  • Jonathan Grayson, PhDThe Grayson LA Treatment Center for Anxiety and OCDLos Angeles, CA
  • Benjamin Greenberg, MD, PhDProfessor of Psychiatry and Human Behavior, Brown University, Providence, RIDirector, COBRE Center for Neuromodulation, Butler Hospital, Providence RIProvidence VA Medical Center, Providence, RI
  • Jonathan Hoffman, PhD, ABPPCo-Founder and Clinical Director,NeuroBehavioral Institute/NBI Ranch, Weston, FL
  • Nancy Keuthen, PhDAssociate Professor of Psychology, Harvard Medical School, Boston, MACo-Director, Trichotillomania Clinic and Research Unit,Chief Psychologist, Obsessive Compulsive Clinic,Massachusetts General Hospital, Boston, MA
  • Sony Khemlani-Patel, PhDClinical Director, Bio Behavioral InstituteGreat Neck, NY
  • Adam B. Lewin, PhD, ABPPAssociate Professor and Program Director,OCD and Related Disorders Behavioral Treatment Program,University of South Florida, St. Petersburg, FL
  • Charles S. Mansueto, PhDFounder and Director, Behavior Therapy Center of Greater Washington, Silver Spring, MD
  • Professor, University of Florida, Gainesville, FLDirector, Center for OCD, Anxiety and Related Disorders
  • Patrick McGrath, PhDAssistant Vice President, Residential Services,Clinical Director, Center for Anxiety and OCD,Alexian Brothers Behavioral Health Hospital, Hoffman Estates, ILFoglia Family Foundation Residential Treatment Center, Elk Grove Village, ILAmita Health
  • Dean McKay, PhDProfessor of Psychology, Fordham University Bronx NYFounder and Co-Director, Institute for Cognitive Behavior Therapy and Research, White Plains, NY
  • E. Katia Moritz, PhD, ABPPCo-Founder and Clinical Director,NeuroBehavioral Institute/NBI Ranch, Weston, FL
  • Tanya K. Murphy, MDChair, Developmental PediatricsProfessor, University of South Florida, St Petersburg, FLJohns Hopkins All Children’s Hospital, Baltimore, MD
  • Gerald Nestadt, MDProfessor of Psychiatry and Behavioral Sciences,Director, OCD Clinic,Johns Hopkins Hospital, Baltimore, MD
  • Fugen Neziroglu, PhDProfessor, Hofstra University, Long Island, NYCo-Founder, Director, Bio-Behavioral Institute, Great Neck, NY
  • Bunmi O. Olatunji, PhDProfessor, Vanderbilt University, Nashville, TNDirector of Clinical Training, Department of Psychology, Vanderbilt University
  • Michele Pato, MDProfessor and Vice Chair for Research,Director, Institute for Genomic Health,
Department of Psychiatry/College of Medicine,
SUNY Downstate, Brooklyn, NY
  • Fred Penzel, PhDWestern Suffolk Psychological ServicesHuntington, NY
  • Katharine A. Phillips, MDProfessor of Psychiatry, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NYAdjunct Professor of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI
  • John Piacentini, PhD, ABPPProfessor of Psychiatry and Biobehavioral Sciences,Director, Child OCD, Anxiety, and Tic Disorders Program, UCLA Semel InstituteUCLA, School of Medicine, Los Angeles, CA
  • Anthony Pinto, PhDAssociate Professor of Psychiatry, Hofstra University, Long Island, NYDirector, Northwell Health OCD Center, Zucker Hillside Hospital, Glen Oaks, NY
  • Christopher Pittenger, MD, PhDAssociate Professor of Psychiatry, Yale University, New Haven, CTDirector, Yale OCD Research Clinic, New Haven, CT
  • C. Alec Pollard, PhDProfessor Emeritus of Family & Community Medicine,Saint Louis University School of Medicine, St. Louis, MODirector, Center for OCD & Anxiety-Related Disorders,Saint Louis Behavioral Medicine Institute, St. Louis, MO
  • Steven J. Poskar, MDOCD NYCNew York, NY
  • Peggy M.A. Richter, MDAssociate Scientist, Sunnybrook Health Sciences CentreToronto, Canada
  • Bradley C. Riemann, PhDChief Clinical Officer, Rogers Memorial HospitalOconomowoc, WI
  • Carolyn Rodriguez, MD, PhDAssistant Professor of Psychiatry and Behavioral Sciences, Stanford University School of MedicineDirector, Translational OCD Research Program, Stanford University School of MedicineDirector, Stanford Hoarding Disorders Research Program, Stanford University School of Medicine, Stanford, CAStaff Psychiatrist, VA Palo Alto Health Care System, Palo Alto, CA
  • Sanjaya Saxena, MDUniversity of California at San DiegoLa Jolla, CA
  • H. Blair Simpson, MD, PhDProfessor of Psychiatry, Columbia University Medical Center, New York, NYDirector, Anxiety Disorders Clinic, New York State Psychiatric Institute, New York, NY
  • Gail Steketee, PhDProfessor and Dean Emerita, Boston University School of Social Work, Boston, MA
  • S. Evelyn Stewart, MDAssociate Professor, University of British Columbia, Vancouver, CAFounding Director, Provincial  OCD Program, BC Children’s HospitalResearch Director, Child, Youth, and Reproductive Mental Health, BC Children’s Hospital
  • Eric A. Storch, PhDVice Chair and Head of Psychology, Professor,Menninger Department of Psychiatry & Behavioral Sciences,
Baylor College of Medicine, Houston, TX
  • Kiara R. Timpano, PhDAssociate ProfessorUniversity of Miami, FL
  • Odile A. van den Heuvel, MD, PhDProfessor of Neuropsychiatry, Amsterdam UMC, Amsterdam Neuroscience, NetherlandsChair ENIGMA-OCD consortium
  • Barbara L. Van Noppen, PhDAssociate Professor, Vice Chair for Faculty Development,Keck School of Medicine, University of Southern California, Los Angeles, CA
  • Aureen P. Wagner, PhDThe Anxiety Wellness CenterCary, NC
  • Allen Weg, EdDDirector, Stress & Anxiety Services of New JerseyEast Brunswick and Florham Park, NJ
  • Monnica T. Williams, PhD, ABPPAssociate Professor, University of Connecticut, Storrs, CTFounder and Clinical Director, Behavior Wellness Clinic, CT
  • Robin Zasio, PsyD, LCSWFounder and Director, The Anxiety Treatment Center, Sacramento, CAFounder and Director, The Compulsive Hoarding Center, Sacramento, CA Founder and Director, The Cognitive Behavior Therapy Center, Sacramento, CA
  • Edna B. Foa, PhD, EmeritusProfessor, Clinical Psychology in PsychiatryDirector, Center for the Treatment and Study of AnxietyUniversity of Pennsylvania, Philadelphia, PA
  • John H. Greist, MD, EmeritusProfessor Emeritus, Psychiatry – University of Wisconsin School of Medicine and Public HealthAffiliate Professor, Cell Biology and Neuroscience – Montana State UniversityVisiting Scholar, Department of Psychiatry – University of Arizona College of MedicineChief Medical Officer – MERET Solutions
  • Lorrin M. Koran, MD, EmeritusProfessor of Psychiatry and Behavioral SciencesStanford University Medical Center, Stanford, CA
  • David Pauls, PhD, EmeritusProfessor of Psychiatry (Genetics), Emeritus,Harvard Medical School, Boston, MAMassachusetts General Hospital, Boston, MA
  • Judith L. Rapoport, MD, EmeritusChief, Child Psychiatry Branch,National Institute of Mental Health, Bethesda, MD
  • Steven Rasmussen, MD, EmeritusProfessor of Psychiatry and Human Behavior,Chair, Psychiatry and Human BehaviorBrown University, Providence, RI
  • Scott L. Rauch, MD, EmeritusChair, Partners Psychiatry and Mental Health, Boston, MAPresident and Psychiatrist in Chief, McLean Hospital, Belmont, MAProfessor, Harvard Medical School, Boston, MA
  • Susan Swedo, MD, EmeritusChief, Pediatrics & Developmental Neuroscience Branch,National Institute of Mental Health, Bethesda, MD


‘Snapchat dysmorphia’ fuels new, cartoonish plastic surgery requests, experts say

Body Dysmorphic Disorder | Johns Hopkins Medicine

People are seeking extreme measures to look their Snapchat filters. Buzz60's Sean Dowling has more.

More plastic surgeons are seeing clients' Snapchat-filtered photos as they field requests for enhancements, a trend some are saying fuels body dysmorphic disorder (BDD).

Snapchat, a social media app known for photo messages that disappear, offers a face filter feature with options that allow users to easily edit away blemishes and enhance lips and eyes. Boston University School of Medicine researchers – in a recent article published in JAMA Facial Plastic Surgery – say this is fueling “Snapchat dysmorphia.”

People who suffer from BDD suffer extreme stress and anxiety over their appearance. The mental disorder can lead to depression and suicidal thoughts or behaviors, the Mayo Clinic notes. 

The authors of the JAMA article say easily accessible photo edits such as those in Snapchat and Facetune are “altering people’s perception of beauty worldwide” in a dangerous way that feeds into BDD tendencies. Fine lines, red spots and moles can digitally disappear with a swipe, and people want to achieve that look permanently. 

A study published last year by Johns Hopkins University School of Medicine researchers found that about 13 percent of patients asking for cosmetic surgery suffer from BDD.

Patrick Byrne, director of Facial Plastic and Reconstructive Surgery at Johns Hopkins University School of Medicine and a member of the American Academy of Facial Plastic and Reconstructive Surgery, told USA TODAY a week rarely goes by without one of his patients taking out their phones and showing him selfies. Often, they prefer to show him imperfections in photos compared to his in-office mirror, he said.

Those who show him Snapchat-morphed images usually ask him for “absurd and unrealistic” results, he said. 

The most common procedures those clients, typically between 17 and 22 years old, ask for: oversized eyes and lips, narrowed jaw lines, refined nose and flawless skin. 

“Many young people do not seem to distinguish or care that the goal they are seeking looks cartoonish and unreal,” Byrne said. 

Byrne said he often is left having a tough conversation about what's possible, including some eye widening options, plumper lips and so on. 

Snap, the parent company of Snapchat, didn't have a formal statement replying to the JAMA opinion piece but did say helping users express themselves in a fun way is a priority for the company. 

Bringing altered images to the plastic surgeon isn't new. 

Alan Matarasso, clinical professor of surgery at Northwell Health System/Hofstra University and president-elect of the American Society of Plastic Surgeons, said his clients have been bringing him photo-edited images for years – just years ago these images were airbrushed magazine photos of celebrities. 

More: As stigma lifts, more men opt for plastic surgery — from 'torso tucks' to Botox

More: Carrie Underwood shuts down plastic surgery rumors following accident: 'It's a little sad'

He told USA TODAY the technology is “good and bad.” In some ways, a face filter could give someone a clearer idea of what their face might look with, for example, plumper lips. On the other hand, Matarasso said “it can make people obsess over minor irregularities.” 

“The reality is that no body looks perfect, and no one can look perfect,” Matarasso said. 

Matarasso's most common facial surgery requests are nose procedures, followed by (in no particular order) chin enlargements and eye and eyebrow procedures. 

“Keep it in perspective,” he said, encouraging clients to be open to the reality of plastic surgery. 

Follow Ashley May on : @AshleyMayTweets

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Body Dysmorphic Disorder

Body Dysmorphic Disorder | Johns Hopkins Medicine

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Body dysmorphic disorder (BDD) is a mental health problem. If you have BDD, you may be so upset about the appearance of your body that it gets in the way of your ability to live normally. Many of us have what we think are flaws in our appearance. But if you have BDD, your reaction to this “flaw” may become overwhelming.

You may find that negative thoughts about your body are hard to control. You may even spend hours each day worrying about how you look. Your thinking can become so negative and persistent, you may think about suicide at times.

What causes body dysmorphic disorder?

The cause of body dysmorphic disorder is thought to be a combination of environmental, psychological, and biological factors. Bullying or teasing may create or foster the feelings of inadequacy, shame, and fear of ridicule.

What are the risk factors for body dysmorphic disorder?

Nobody knows the cause of BDD. It usually begins in your adolescence or teenage years. Experts think that about one of every 100 people has BDD. Men and women are equally affected. Factors that may contribute to BDD include:

  • A family history of BDD or a similar mental disorder
  • Abnormal levels of brain chemicals
  • Personality type
  • Life experiences

What are the symptoms for body dysmorphic disorder?

You can become obsessed with any part of your body. The most common areas are your face, hair, skin, chest, and stomach.

Symptoms of BDD include:

  • Constantly checking yourself in the mirror
  • Avoiding mirrors
  • Trying to hide your body part under a hat, scarf, or makeup
  • Constantly exercising or grooming
  • Constantly comparing yourself with others
  • Always asking other people whether you look OK
  • Not believing other people when they say you look fine
  • Avoiding social activities
  • Not going the house, especially in the daytime
  • Seeing many healthcare providers about your appearance
  • Having unnecessary plastic surgeries
  • Picking at your skin with fingers or tweezers
  • Feeling anxious, depressed, and ashamed
  • Thinking of suicide

How is body dysmorphic disorder diagnosed?

A mental health professional will diagnose BDD your symptoms and how much they affect your life.

To be diagnosed with BDD:

  • You must be abnormally concerned about a small or nonexistent body flaw
  • Your thoughts about your body flaw must be severe enough that they interfere with your ability to live normally
  • Other mental health disorders must be ruled out as a cause of your symptoms

There are other mental health disorders that are common in people with BDD. They include obsessive compulsive disorder, social anxiety, depression, and eating disorders.

How is body dysmorphic disorder treated?

Specific treatment for BDD will be determined by your healthcare provider the following:

  • The extent of the problem
  • Your age, overall health, and medical history
  • Your tolerance for specific medicines, procedures, or therapies
  • Expectations for the course of the disorder
  • The opinion of the healthcare providers involved in your care
  • Your opinion and preference

Treatment for BDD may include talk therapy or medicines. The best treatment is probably a combination of the two. Cognitive behavioral therapy (CBT) is the most effective talk therapy.

In CBT, you work with a mental health professional to replace negative thoughts and thought patterns with positive thoughts.

Antidepressant medicines known as selective serotonin reuptake inhibitors usually work best for BDD.

What can I do to prevent body dysmorphic disorder?

The best way to prevent BDD from becoming a serious problem is to catch it early. BDD tends to get worse with age. Plastic surgery to correct a body flaw rarely helps.

If you have a child or teenager who seems overly worried about his or her appearance and needs constant reassurance, talk with your healthcare provider.

If you have symptoms of BDD yourself, talk with your healthcare provider or a mental health professional. 

Living with body dysmorphic disorder

It’s important to follow your healthcare provider’s recommendations for treating your BDD. Treatment for BDD can be a long-term commitment.

When should I call my healthcare provider?

If your symptoms get worse or you experience new symptoms, tell your healthcare provider.

Key points about body dysmorphic disorder

  • Body dysmorphic disorder (BDD) is a mental health disorder. If you have BDD, you may be so worried about the way your body looks that it interferes with your ability to function normally.
  • You may take extreme measures such as repeated cosmetic surgical procedures to correct the perceived flaw.
  • Treatment involves counseling and medicines to help with feelings of discomfort and anxiety.
  • The fear of being judged creates avoidance of going into public and social isolation.
  • Left untreated, BDD can lead to severe depression and suicidal thoughts and should not be ignored.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.


Social media filters mess with our perceptions so much, there’s now a name for it

Body Dysmorphic Disorder | Johns Hopkins Medicine

Social media filters are fun! You can look a puppy dog or a nerdy cat or a fairy princess, or just hot! , slightly hotter than you actually are. you, but spackled and sandblasted and shaved down until you have a chin sharper than the Matterhorn and the complexion of a cotton ball.

The problem is, when you alter a photo and the result is a you-but-better-version staring back, you may start to get it in your head that that’s what you should look .

Cosmetic doctors are noticing an uptick in people who are bringing Facetuned, filtered and otherwise altered photos into their offices, or pulling up unaltered selfies to point out what they want fixed.

They’re calling it “Snapchat dysmorphia,” and although the term has been around for a while, a recent article in the JAMA Facial Plastic Surgery brings the topic into focus.

“Overall, social media apps, such as Snapchat and Facetune, are providing a new reality of beauty for today’s society,” the article reads. “These apps allow one to alter his or her appearance in an instant and conform to an unrealistic and often unattainable standard of beauty.”

The article claims that the phenomenon can mess with our heads, fostering some unhealthy ideas about what we really see in the mirror — and on our phones.

We’re constantly in contact with our own image …

Dr. Patrick Byrne, director of the Facial Plastic and Reconstructive Department at the Johns Hopkins University School of Medicine, says the root of the problem is fairly simple: In the selfie age, people just see their faces (and bodies) more.

“The experience of younger humans in particular in this regard, how they relate to their own appearance, is so profoundly different than at any other point in time,” he said. “We used to have photographs, of course, but we gazed upon them and thought about them infrequently. Now, we’re in this world where people are exposed to their own facial image thousands of times per year.”

Not to mention, it’s not just you who sees your face every day. Social media platforms, online forums and even dating apps mean that often, the first — and sometimes only — version of ourselves other people meet is a digital image.

In a recent set of statistics from the American Academy of Facial Plastic and Reconstructive Surgery, 55% of facial plastic surgeons reported seeing patients who wanted to improve how they looked in selfies in 2017, a 13% increase over the previous year.

In the report, academy President Dr. William H. Truswell partly attributes this rise to the importance of our digital image to our social opportunities. “Consumers are only a swipe away from finding love and a new look, and this movement is only going to get stronger,” he said.

… and that starts to alter our perception

When you see your face dozens of times a day, there are plenty of opportunities to obsess over little imperfections that other people may not even notice, and that can lead to feelings of dissatisfaction and even dysmorphia.

Byrne says he sees the disconnect between reality, mirror images and photos frequently in his practice.

“I’ve always handed patients a mirror, and they’ve picked it up and pointed, and we’ve discussed what they wanted,” he said.

“Now, what happens is at least once a week, I’ll hand someone a mirror, and they’ll look at it for a moment, get frustrated and say, ‘You can’t really see it here’ and show me a picture.

And that’s amazing, because we’re looking at the same face through different media. They’re bothered by their pictures but not by their reflections.”

Another sign that selfies and photos are affecting how people see their faces is the type of procedures requested.

“Prior to the popularity of selfies, the most common complaint from those seeking rhinoplasty was the hump of the dorsum on the nose,” the JAMA article says. “Today, nasal and facial asymmetry is the more common presenting concern.”

Byrne called a pronounced hump on the nose (dorsum) one of the most understandable reasons to seek cosmetic rhinoplasty, as it is often a noticeable facial difference that may affect someone’s confidence or social interactions.

“You can find imperfections on any face,” he says. “The question is how pronounced they are and how much they actually matter to your overall appearance.”

That altered perception can cause problems …

This perception gap, combined with the natural tendency to intimately critique one’s own oft-viewed face, can cause serious psychological problems that can’t be addressed in a plastic surgeon’s office, the article says.

The JAMA article describes body dysmorphic disorder as “an excessive preoccupation with a perceived flaw in appearance, classified on the obsessive-compulsive spectrum.”

“The disorder is more than an insecurity or a lack of confidence,” it says. “Those with BDD often go to great lengths to hide their imperfections … and may visit dermatologists or plastic surgeons frequently, hoping to change their appearance.”

Byrne says it’s hard for practitioners to identify when a patient has actual dysmorphic thoughts, rather than just an unrealistic expectation of what can or should be done for them. A 2017 Johns Hopkins study of three separate clinics found that plastic surgeons were able to correctly identify only about 5% of patients who were screened positively for body dysmorphic disorder.

What these patients need isn’t a new nose or some injectables, Byrne says. They need psychological help.

“Anything you do with BDD, they will not be happy with,” he said. People with the disorder “have a habitual repetitive brain pattern. Even if you make someone look better, you’re not helping them. You may be hurting them by deepening their obsession and reinforcing its source.”

Instagram is the worst social media app for young people’s mental health

Body dysmorphic disorder is linked to eating disorders and depression. A 2015 study from the International Journal of Eating Disorders investigated the link between social media usage and body-related behaviors among girls. It found that girls who shared photos of themselves online reported higher levels of both body dissatisfaction and an overvaluation of “the thin ideal.”

Here’s where it gets interesting: It wasn’t just sharing and consuming such photos that contributed to such unhealthy patterns. How much girls actually edited their photos mattered too, along with how much they cared about or believed in the result.

“In addition, among girls who shared photos of themselves on social media, higher engagement of and investment in these photos, but not higher media exposure, were associated with greater body-related and eating concerns,” the study says.

… when, in reality, no perception gets it quite right

Want your mind blown? Allow this observation from Byrne to send you into orbit.

“The only face in the world that you can never see is your own,” he said.

Think about it. You’ve only ever seen reflections of yourself, or pictures, or possibly the sides of your nose if you close one eye. Even you don’t know exactly what you look . So when you alter photographs of yourself, you’re just creating one unreliable image on top of another and correcting imperfections that the average observer may not notice anyway.

It’s clear that “selfie dysmorphia,” as described by dermatologists and plastic surgeons, is more than just wanting to look an idealized version of yourself, so easily accessible with filters and retouching apps. It’s also about what you see in the first place that you think needs correcting, and how you compare it to other people’s photos — often as retouched as your own but presented as reality.

“I think that’s the key, more than just the morphing technology itself,” Byrne said.

So in a way, the face we see in the selfie is an accurate representation of ourselves, just not our physical selves. It’s a reflection of our ideals and aspirations and insecurities — and that can be as distorting as any photo filter.


Body Dysmorphic Disorder: Symptoms, Causes, Diagnosis, Treatments

Body Dysmorphic Disorder | Johns Hopkins Medicine

Body dysmorphic disorder (BDD) is a condition in which a person is extremely anxious about an imagined physical defect or a minor defect that others often cannot see. People with this disorder see themselves as “ugly” and often avoid being seen by others, or they have plastic surgery to try to improve their appearance.

BDD is a chronic (long-term) disorder that affects men and women equally. It usually begins during the teen years or early adulthood.

BDD is similar in some ways to eating disorders and obsessive-compulsive disorder (OCD). BDD is eating disorders in that both are concerned with body image. However, a person with an eating disorder worries about weight and the shape of the entire body, while a person with BDD is anxious about a specific body part.

OCD is an anxiety disorder of endless cycles of thoughts and behaviors. People with OCD have recurring and distressing thoughts, and fears or images (obsessions) that they cannot control. The anxiety produced by these thoughts leads to an urgent need to perform certain rituals or routines (compulsions).

In the same vein, with someone who has BDD, the person's preoccupation with the defect often leads to ritualistic behaviors, such as constantly looking in a mirror or picking at the skin. The person with BDD eventually becomes so obsessed with the defect that his or her social, work, and home functioning suffers.

The most common areas of concern for people with BDD include:

  • Skin imperfections: These include wrinkles, scars, acne, and blemishes.
  • Hair: This might include head or body hair or the absence of hair.
  • Facial features: Very often this involves the nose, but it also might include the shape and size of any part of the face.

Other areas of concern include the size of the penis, muscles, breasts, thighs, buttocks, and the presence of certain body odors.

What are the symptoms of body dysmorphic disorder?

People with BDD have inaccurate views of themselves. This can cause them to avoid others, or lead them to harmful behaviors or to repeated surgeries to correct problems they think they have.

Some of the warning signs that a person may have BDD include the following:

  • Preoccupation with one or more defects or flaws in physical appearance that cannot be seen by others, or that appear slight to others
  • Engaging in repetitive and time-consuming behaviors, such as looking in a mirror, picking at the skin, and trying to hide or cover up the defect
  • Constantly asking for reassurance that the defect is not visible or too obvious
  • Having problems at work or school or in relationships because the person cannot stop focusing on the defect
  • Feeling self-conscious and not wanting to go out in public, or feeling anxious when around other people
  • Repeatedly consulting with medical specialists, such as plastic surgeons or dermatologists, to find ways to improve his or her appearance

Last reviewed by a Cleveland Clinic medical professional on 11/28/2017.


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