INTRODUCTION
The search for beauty or attractive appearance to others seems to be the object
of fascination for humanity. Although it involves stereotypes that vary
according to cultural standards, the notion of beauty, a dynamic concept of
quest for perfection, may at some point, approach what has been termed psychic
disorder, as already described by studies conducted in the area of
psychiatry.
When we made a historical incursion, we realized that while endemic diseases and
pests decimated a large number of people, obesity prevailed, as a synonym for
health and well-being. Currently, we are observing a movement contrary to this
perception, whose presuppositions show the supremacy of slenderness, i.e., being
slim is considered beautiful. In this new context, delimiting the thin line
between personal desire for aesthetic improvement and body dysmorphia can be a
difficult task1.
In the literature, dysmorphophobia was first described by Morsellini in 18862. However, in Pitanguy et al.3 referred to this term in 1976 in Brazilian
literature. Dysmorphophobia is also known as the eponym of the Quasimodo
Complex4 and more recently as body
dysmorphic disorder (BDD); dysmorphophobia was established as a disease in
Volume III of the Diagnostic and Statistical Manual of Mental
Disorders of 1987 (DSM-III-R) and is reported as “Body
Dysmorphic Disorder” in the current DSM V, published in 20135.
In clinical practice, we observed that the patients affected by BDD present
extreme dissatisfaction with their appearance, which translates into intense
suffering. We also found reports of functional impairments in social and work
life, high levels of stress and comorbidities. These factors contribute to the
constant search for aesthetic procedures, culminating in mostly poor
results4,6,7.
We understand that when performing physical examination, specialists often notice
minimal or nonexistent changes. From this viewpoint, it is up to the surgeon to
identify the patient’s type of disorder and to refer him, if necessary, to the
psychiatrist. We emphasize, however, that in most cases this type of
psychopathology may go unnoticed, and the professional should, therefore, try to
protect himself against possible legal disputes8. This is the reason of this study.
Thus, on the basis of extensive research and clinical experience, we will try to
develop the ideas presented here, with the intention of collaborating with the
mosaic of studies carried out in the plastic surgery research field.
OBJECTIVE
In this study, we intend to demonstrate the relevance of BDD relevance in
patients seeking plastic surgery services and to focus the attention of the
physician on this condition, that is often forgotten. We also seek to reiterate
the importance of correct screening so that the team can refer patients for the
appropriate treatment, thus, avoiding unnecessary aesthetic procedures. We also
propose, in the case of BDD diagnostic uncertainty, to suggest possible ways for
the surgeon to protect himself against the possibility of future legal
problems.
METHODS
We conducted qualitative and quantitative research, wherein we searched for
articles, dissertations, book chapters and theses that focus on BDD,
dysmorphophobia and Quasimodo syndrome. To broaden our theoretical scope, in
what concerns specifically databases, we emphasize PubMed, SciELO, Lilacs and
Bireme.
DISCUSSION
Starting from the current expansion of aesthetic surgical procedures, which
exceeded 10 million in 2005, according to Crerand et al.9, and reached 629 thousand in Brazil alone in 200910, the exaggerated worship of physical
form is evident. Among the factors that motivate the requirement for such
aesthetic surgical procedures is the common notion that a sculptural body is
necessary to achieve professional and personal success. Similarly, an
increasingly precocious aesthetic concern among young people, the endless quest
for perfection (facilitated by the vast tools of Plastic Surgery), constant
discussions about diet, exercise, and fashion, which corroborate certain
patterns of beauty, can feed among other factors, the experience lived in BDD.
Such lifestyle conditions provide an environment conducive to the development of
this condition, thus, making it more evident.
Bellino et al.11 reported that 0.7% of the
general population experiences the disease, while Macley reported an incidence
of 1% to 2%12. Aouizerate et al. reported
that 9.1% of the population may seek cosmetic surgery13. Although there are several social factors involved, the
etiology is not fully understood to date. It is believed that the etiology may
be associated with the patients’ own psychological status regarding their image,
as built from childhood and influenced by the external environment during
development14,15. In addition, the patients who present
an exaggerated self-criticism of their aesthetic appearance may be more likely
to progress to this pathological condition16.
More recent studies suggest the involvement of neurobiological abnormalities. For
example, it is possible to detect neurotransmitter changes using functional
magnetic resonance. Moreover, the studies also reported abnormal activations of
specialized areas, as assessed by analytical and detailed visual processing, in
these patients; these abnormal activations were more intense in patients with
severe symptoms7.
It is also observed that the patient may identify with the image of a certain
person or character, leading him to seek ways that make him appear similar to
the figure with whom he identifies himself. This identification may be related
to what is considered an ideal of beauty and is often embodied in famous
personalities, family members, or even inanimate figures, such as dolls17.
BDD often develops in adolescence; the condition evolves gradually, with the
initial concerns that were considered “normal” degenerating to pathological,
over time (months to years). However, in some cases, BDD is suddenly triggered
by important emotional events. At this point, the degree of
insight involved, i.e., the self-perception of disease is
variable. Hence, the patient’s level of perception of his illness is minimal
compared to the discomfort generated by the defect. Therefore, in objective
terms, the sites involved in the complaints are similar to those of
non-pathological conditions. However, we note that the level of suffering
generated is intensified, which can lead to extreme stress, obsession, and
emotional torture.
In this pathological context, the presence of another comorbidity, such as social
phobia, becomes less important than it was in the past when very little was
known about the disease18.
Specialized studies indicate that a significant proportion of 12–15% of the
patients have a correlation with obsessive compulsive disorder (OCD)6, characterized by the presence of
compulsive and repetitive behavioral stereotypes, such as the act of looking at
oneself too long in the mirror or applying makeup excessively, a factor that can
lead to confusion in the distinction between BDD and OCD. Moreover, depression,
anxiety, abusive use of psychoactive substances, and even suicidal idealization
are emphasized in 22 to 28% of the cases19.
We have commonly observed that obsessive-compulsive disorder and other
psychiatric conditions are associated with eating disorders, such as anorexia
and bulimia, which are also associated with dysmorphophobia17. The degree of severity may range from almost normal to
mild to severe impairment of functionality in patients who only leave the house
at night to avoid public encounters.
In severe cases described in the available literature, there are events of
violence against the physician, including murders, fruits of achieved
“failure”6,8,13. Therefore, we should be aware of BDD in patients seeking
aesthetic care who report of various procedures performed, which were
unsatisfactory or unnecessary.
Consequently, even in those who have had little or no previous surgery, it is up
to the specialist to carry out careful anamnesis, with the purpose of eliciting
a diagnosis due to unfounded complaints of minimal or unnoticeable defects,
refined physical examination, and administration of a questionnaire20 investigating the degree of discomfort
generated by the “deformity”. If necessary, the doctor may contact surgeons who
have treated the patient previously or even seek medical history8.
We propose that treatment should be conducted mainly by the psychiatrist and the
psychologist and should involve cognitive-behavioral measures and lifestyle
changes, inclining towards a more active lifestyle. We also understand that
medication can be used, such as selective serotonin reuptake inhibitors and
tricyclic antidepressants, which can produce satisfactory results. After this
follow-up, the patient may return to the plastic surgery outpatient clinic for
reassessment21.
Based on our discussion thus far, we understand that from a legal viewpoint, the
plastic surgeon must protect himself against possible judicial litigation.
Hence, preoperative documentation is of great value in the case of BDD. We also
emphasized the use of a questionnaire, such as COPS22.
The surgeons may also protect themselves by ensuring that the patients signs a
Free and Informed Consent Term (FICT), through which the patient can authorize
that his current physician can contact other experts already consulted, thus,
valuable information may be obtained from the patient’s records that may reveal
presence of the disorder. Finally, we believe that the patient should agree that
the final surgery outcome may not be exactly as he expects, since the surgical
process is subject to biological variations and intercurrences inherent to the
surgeon8.
Considering the possibility of a legal dispute, we must mention that we were
unable to find guidelines that a plastic surgeon must follow in this respect in
the available literature. However, considering the cases already described, we
understand that these can serve as a reference for the specialist in such
situations.
In judicial dispute cases, we also noted that a patient’s lawyer could question
the validity of the signed FICT in the court, based on the presence of BDD,
which in the light of law, would compromise the judgment of his client.
Nevertheless, we believe that such an argument could be invalidated, since there
is no established diagnosis of BDD in the patient’s medical history. Thus,
although signing this document is a legal practice to ensure that the patient is
aware of all the risks involved in a surgical procedure, we defend that it is
the physician’s duty to inform the patient of the possible material risks and
complications and of clarifying that the final surgical result is influenced by
interference from factors not related to medical conduct, thus, avoiding
questioning of the document’s validity and possible allegations of
negligence8.
CONCLUSION
Considering the BDD prevalence and its relevance among patients seeking aesthetic
surgeries, we emphasize the diagnostic possibility of BDD in patients with
unfounded and distorted complaints. Due to the challenging nature of the
disease, the surgeon must be careful in his approach, including proper anamnesis
and careful observation. We believe that demonstrating receptivity and
understanding is fundamental, rather than merely referring the patient to the
psychiatrist.
We reiterate that surgery in these cases will often lead to unsatisfactory
results for both the patient and the surgeon and may even lead to judicial
outcomes.
Regarding the appropriate treatment, we suggest selective serotonin reuptake
inhibitors and cognitive behavioral therapy, according to the condition’s
severity.
With respect to other considerations, we suggest that more studies are needed
with the aim of facilitating diagnosis and standardization of conducts. In
addition, we believe that it is necessary to estimate the real prevalence of
psychopathology in the population, which could imply decreased requirement for
unnecessary surgical procedures and fewer lawsuits.
Finally, from the legal viewpoint, the physician must guard against possible
legal problems involving the surgical outcomes and the dissatisfaction of a BDD
patient. To do so, the physician must use all various resources available,
considering that there are no laws or well-defined guidelines for a legal
dispute between BDD patient and his doctor.
COLLABORATIONS
MTD
|
Analysis and/or data interpretation, conceptualization, final
manuscript approval, writing - original draft preparation, writing -
review & editing.
|
MPDC
|
Analysis and/or data interpretation, final manuscript approval,
project administration, writing - original draft preparation,
writing - review & editing.
|
LDC
|
Writing - original draft preparation, writing - review &
editing.
|
GVD
|
Writing - original draft preparation, writing - review &
editing.
|
AAS
|
Writing - original draft preparation, writing - review &
editing.
|
LVD
|
Writing - original draft preparation, writing - review &
editing.
|
LDC
|
Writing - original draft preparation, writing - review &
editing.
|
YMO
|
Writing - original draft preparation, writing - review &
editing.
|
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1. Faculdade de Medicina, Universidade Federal de
Juiz de Fora, Juiz de Fora, MG, Brazil
2. Hospital Universitário, Universidade Federal de
Juiz de Fora, Juiz de Fora, MG, Brazil
3. Faculdade de Ciências Médicas e da Saúde de
Juiz de Fora, Juiz de Fora, MG, Brazil
4. SUPREMA Hospital e Maternidade Terezinha de
Jesus, Juiz de Fora, MG, Brazil.
Corresponding author: Marilho Tadeu
Dornelas Rua Dom Viçoso, nº 20 - Alto dos Passos, Juiz de Fora, MG,
Brazil Zip Code 36026-390 E-mail:
marilho.dornelas@ufjf.edu.br
Article received: February 21, 2018.
Article accepted: February 10, 2019.
Conflicts of interest: none.