Body dysmorphic disorder (BDD) is a mental health condition characterized by an obsessive focus on perceived physical flaws.1 These “flaws,” which are minor or nonexistent, cause significant distress and impairment in daily life. Individuals with BDD may seek cosmetic treatment, such as orthodontics, in the hope of fixing their perceived defects and improving their self-esteem, but such interventions rarely address the underlying issue, instead leading to a cycle of treatment-seeking and dissatisfaction.
The condition was first described in 1891 by Enrico Morselli (1852-1929), an Italian psychiatrist and neurologist who coined the term “dysmorphophobia,” or “fear of deformity,” to describe a preoccupation with imagined physical defects. The American Psychiatric Association formally recognized BDD as a psychiatric disorder in 1987, yet it remains underdiagnosed in many patients seeking cosmetic treatment.
The disorder affects approximately 3% of the general U.S. population, and a London study found it in 8% of orthodontic patients.1 Frequently presenting between the ages of 12 and 24, BDD affects both genders, though women are diagnosed more than twice as often as men. The disorder is also more prevalent among Caucasians and Asians.
For a diagnosis of BDD, three criteria must be met: a preoccupation with a perceived defect in appearance that is either imagined or exaggerated; significant distress caused by this preoccupation; and the absence of another mental disorder (such as anorexia nervosa) that could explain the condition.1 That said, individuals with BDD frequently suffer from co-occurring mental disorders, such as depression, social anxiety disorder, obsessive-compulsive disorder, and eating disorders.
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Since BDD is a psychiatric disorder, only 2% to 20% of patients are satisfied with the results of cosmetic treatment, regardless of any improvements as measured by conventional standards. Instead, the patient’s fixation generally persists or shifts to another area of the body. Alarmingly, about 40% of patients with BDD may consider or pursue legal action against their providers.1 “Don’t worry, Dr. Kravitz,” a patient with BDD once joked to me. “It’s not like I’m going to sue you.” I didn’t find that remark amusing.
In fact, every BDD patient I’ve treated has been challenging, due not to their malocclusion but to their persistent dissatisfaction. If you suspect BDD during a consultation, be cautious about recommending treatment. These patients often already have a pleasing smile, and no fee can justify the stress they bring to your practice. For practitioners currently treating patients with BDD, I have two recommendations: First, consider switching them to Invisalign at no additional charge so that they can take responsibility for the success of their own treatment. Second, focus on building rapport with them over perfecting their teeth—you have effectively become their substitute psychiatrist.
Recognizing the signs of BDD will help you manage patients’ expectations and avoid prescribing unnecessary treatment. It’s essential to understand that the patient’s perception, however distorted, is their reality, so attempting to address their concerns through physical changes alone will prove ineffective, frustrating, and unprofitable while bringing them little to no relief. Worst of all, their distress may end up affecting you. Keep this rule in mind: if a patient is unhappy when they enter your office, they will likely be unhappy when they leave.
NDK
REFERENCES
- 1. Polo, M.: Body dysmorphic disorder: A screening guide for orthodontists, Am. J. Orthod. 139:170-173, 2011.
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