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Section 26
Special Risks in BDD Clients Undergoing Plastic Surgery

Question 26 | Test | Table of Contents

Last year, 291,000 American women had bags implanted in their breasts, 324,000 Americans had fat vacuumed out of their bodies, and 231,000 had fat, skin and muscle cut from around their eyes. Add less common operations such as buttock lifts, pectoral implants and vaginal rejuvenations, as well as "minimally invasive" procedures such as Botox injections, and the American Society of Plastic Surgeons estimates that Americans underwent at least 10.2 million cosmetic surgery procedures last year. Cosmetic surgery has gone mainstream.

Like any other surgical procedure, cosmetic operations can never be completely free of risk. Although anyone contemplating cosmetic surgery is likely to have talked over with their surgeon the risks to their physical health, there are some forms of ill health associated with the procedures that are far less likely to be mentioned. In particular, people who go under the knife in the quest for a more attractive body or face are more likely than the average person to be suffering from psychiatric problems. There is mounting evidence that those who choose to undergo cosmetic surgery are more likely to commit suicide. What isn't known is just how much people's mental health is being placed at risk by the burgeoning nip and tuck culture. A related question is whether cosmetic surgery brings any long-term mental health benefits. After all, implicit in the advertisements and promotional TV shows is the promise not merely of bigger breasts or flatter stomachs, but also the idea of a psychological lift. "We have to believe that cosmetic surgery will improve our self-esteem and body image, and make us feel better about ourselves. If not, we're wasting an awful lot of time, effort and money," says David Sarwer of the Center for Human Appearance and the University of Pennsylvania School of Medicine in Philadelphia. Yet while cosmetic surgery is booming, research into the mental well-being of recipients has not kept pace, says Katharine Phillips, a psychiatrist at Brown Medical School in Providence, Rhode Island.  The results of the few quality studies that have been done are equivocal. Perhaps unsurprisingly, cosmetic surgery patients are more likely than average to have a poor body image. More striking is Sarwer's finding that 18 per cent of a sample of patients having cosmetic surgery were taking drugs to treat a psychiatric condition, typically an antidepressant (Plastic and Reconstructive Surgery, vol 114, p 1927). Only 5 per cent of patients undergoing non-cosmetic plastic surgery were taking similar drugs.
That in itself doesn't mean cosmetic surgery is a bad idea, says Sarwer. These patients also invest more than others in their appearance, fitness and health, and the greater use of psychiatric medicines may be a sign that they pay equal attention to their mental health.

Short-term satisfaction
Numerous studies have found that most patients seem satisfied with their procedures, at least in the short term, and surgery might even improve body image. A 2002 study led by Thomas Cash of Old Dominion University in Norfolk, Virginia, found a woman's perception of her body image improves for at least two years after she has had breast implants, while a 2005 study of general cosmetic procedures by Sarwer's team found it improves for at least one year (Aesthetic Surgery Journal, vol 25, p 263). Whether such improvements in body image last longer than a few years is not known, and studies of patients' self esteem, depression rates and perceived quality of life are inconclusive.

However, findings from epidemiological studies of a link between cosmetic surgery and suicide are firmer and more disturbing. Five recent studies, including a US study of over 13,000 women who received breast implants and another from Canada of 24,000 (American Journal of Epidemiology, vol 164, p 334), set out to investigate the alleged link between silicone breast implants and cancers, autoimmune diseases and other disorders. Though they failed to confirm any such connection, another striking link did emerge: women who have received breast implants are two to three times as likely to kill themselves as those who have not. "The only consistent finding from all the studies has been the unexpected one of suicide," says Joseph K. McLaughlin, director of the International Epidemiology Institute in Rockville, Maryland, who ran some of the studies.

The suicide risk revealed by these studies could turn out to be an underestimate, as deaths due to suicides are frequently attributed to other causes. For example, an update to the US study this year found that women with breast implants also have a higher risk of suffering a fatal road accident and some of those deaths could be suicides, suggests study leader Louise Brinton of the National Cancer Institute in Bethesda, Maryland (Epidemiology, vol 17, p 162). Meanwhile, McLaughlin has been re-examining death notices of Swedish women with implants. He says that early indications suggest that suicide may turn out to be even more common than reported in these women (BMJ, vol 326, p 527).

Other surgical cosmetic procedures may also be associated with a suicide risk, although it has yet to be quantified for most of them. The largest mortality study, conducted in Canada, found the suicide risk was almost doubled for the 25,000 women who received breast implants and 16,000 women who underwent other cosmetic procedures. A Danish study also found a moderate increase in suicide risk in breast reduction patients (Archives of Internal Medicine, vol 164, p 2450).
There is also anecdotal evidence to suggest that it's not just women who are at risk. According to Leroy Young, a plastic surgeon in private practice in St Louis, Missouri, the patients most prone to violence against themselves, and their surgeons, are young, narcissistic males who have had nose or penis surgery. "There's a plastic surgery aphorism — don't operate on the male mid-line," he says.

Trying to get at the reasons behind this increased risk of suicide is difficult. Some commentators even argue that the findings so far may not be relevant to women currently considering breast implants, as most of the women in the studies got their implants decades ago. "It's a very different world now," says James Wells, a plastic surgeon in private practice in Long Beach, California. "The implants are better, how we assess the patients is better, and implant failure rate is lower." This does not reassure epidemiologists such as Brinton and McLaughlin, who have continued to search for clues to what is behind the increased risk of suicide.

One possibility — admittedly very remote, but not yet ruled out — is that leaks from implants can alter women's brain chemistry, triggering suicide in some. Another idea is that women with breast implants commit suicide more often because they are also more likely to use drugs or alcohol. The findings of the US study are consistent with that hypothesis, as it found that women who had breast implants were more likely than other women to die for reasons related to drug and alcohol use. A more plausible explanation is that women who receive implants have personality traits or psychiatric disorders that go undetected by surgeons or are ignored by them, and that these put the women at risk of suicide. This view is backed up by the Danish study, which discovered that 8 per cent of women who had breast implants had earlier been admitted to a psychiatric hospital, the most common diagnoses including "neurosis and personality disorders" and "substance or alcohol abuse". Half the women with breast implants who committed suicide had been admitted to a psychiatric hospital before their surgery. It is unclear whether these women were predisposed to suicide and were tipped over the edge by a poor response to cosmetic surgery. "There are some who contend that patients who receive implants demonstrate a host of psychological problems that put them at risk for eventual suicide," says Brinton. "Whether this is the sole explanation or whether patient dissatisfaction after the operation is also involved is not yet clarified."

Another condition that is common among people having cosmetic surgery is body dysmorphic disorder or "imagined ugliness". BDD patients obsess about barely noticeable or nonexistent flaws in their physical appearance, and the condition now turns out to affect far more people than previously suspected. A study by Sarwer found that 2.5 per cent of female American college students have BDD. And while there have been no definitive epidemiological studies for the general population in the US, the prevalence is expected to be similar to that in Germany, where a study published this year revealed that between 1 and 2 per cent of the population meet all the diagnostic criteria, and a far higher percentage experience milder versions of the disorder (Psychological Medicine, vol 36, p 877). "People seemed puzzled by suicide in women with breast implants, but I would not be surprised if BDD was behind it," Phillips says.

Around three-quarters of people with BDD seek treatments such as cosmetic surgery or dermatological procedures, and an estimated 6 to 15 per cent of cosmetic surgery patients in the US are believed to have BDD. Cosmetic treatment for these people is rarely beneficial and it often makes symptoms worse. "When they are satisfied, which doesn't happen very often, their concerns move on to another body part — this problem is on the inside, not the outside," says Sabine Wilhelm of Harvard Medical School.

The main reason to think that BDD might account for at least some of the unexpected suicides in breast implant patients is the extraordinarily high risk of self-harm among people with BDD. A preliminary study by Phillips's team found that someone with BDD is 45 times as likely as normal to commit suicide (The American Journal of Psychiatry, vol 163, p 1280). That is more than twice the rate of people with major depression and three times that of people with bipolar disorder.

To find out whether BDD or some other psychiatric disorder is behind the suicides, and whether cosmetic surgery alters the risks, would require thousands of women to undergo extensive personality testing before and after surgery, something that psychologists and epidemiologists contacted by New Scientist doubted will be done. One stumbling block is that cosmetic surgery treatments are not based on rigorous research. "It's a field of artistic endeavour and technique, not research," says McLaughlin. Cosmetic surgery patients tend to be reluctant to volunteer for trials, preferring to remain anonymous. Some women with breast implants don't even tell their husbands that they have had the procedure, says Brinton.

Also, a source of funds for such trials has dried up. In 1999, the US Institute of Medicine effectively cleared silicone implants of causing cancers, immune disorders and other life-threatening diseases. This meant that manufacturers lost an incentive to fund large trials. Add to that the lack of a comprehensive US registry for breast implant patients, or cosmetic surgery patients in general, and it's hard to see such studies ever taking place.

Many cosmetic surgeons do try to screen their patients for "psychological appropriateness", but even they need to be more aware of BDD and other psychiatric conditions, Wilhelm says. "I tell them to look out for what motivates the patient. Don't operate on anyone who thinks the surgery will change their life, or who has unusual or excessive requests for surgery. Focus on their suffering and seek help from a psychologist," Wilhelm says.

For surgeons who are still uncertain, Wilhelm has more advice. "Cosmetic surgery is an elective procedure. Some surgeons say: 'If a patient elects to do it shouldn't I go ahead?' My answer is: 'You as the surgeon can elect not to do it.'"

Quest for a perfect body
While it is not yet known whether women get an enduring psychological lift from breast implants (see main story), at least the idea that implants can trigger silicone-induced cancers, autoimmune disorders and other deadly diseases was laid to rest by a US Institute of Medicine Report in 1999.

Yet dangers remain. "Breast implants will not last a lifetime," warns a 2004 pamphlet on silicone and saline implants from the US Food and Drug Administration. "Either because of rupture or other complications, you will probably need to have the implants removed. Many of the changes to your breasts following implantation may be cosmetically undesirable and cannot be reversed."

Despite the graphic photos used to make this point, more than 290,000 women in the US had breast implants in 2005, up 37 per cent from 2000. "I tell these women about all these complications and more, and they still want to do it. They say they want to look better in clothes and feel more confident and less self-conscious. It's a very powerful motivator," says Leroy Young, a plastic surgeon in private practice in St Louis, Missouri.

The desire to perfect your body, even at such high potential cost, is a consequence of living in imageconscious America, says David Sarwer, a clinical psychologist and body-image researcher at the Center for Human Appearance and the University of Pennsylvania School of Medicine in Philadelphia. According to one survey, over 56 per cent of women and 43 per cent of men are dissatisfied with their appearance. "That dissatisfaction motivates a whole host of behaviours — weight loss, cosmetic and FASDhion purchases, and cosmetic surgery," Sarwer says.
- Nowak, Rachel, WHEN LOOKS CAN KILL; New Scientist, 02624079, 10/21/2006, Vol. 192, Issue 2574

Personal Reflection Exercise #8
The preceding section contained information regarding special risks in BDD clients undergoing plastic surgery.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Reliability and Validity of the Self-Report Chinese Version of the
Yale-Brown Obsessive-Compulsive Scale Modified for Body
Dysmorphic Disorder (BDD-YBOCS) in Patients Undergoing Plastic Surgery

- Chen, X., Chen, G., Wang, J., & Huang, J. (2022). Reliability and Validity of the Self-Report Chinese Version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) in Patients Undergoing Plastic Surgery. Aesthetic plastic surgery, 46(4), 2023–2030. https://doi.org/10.1007/s00266-022-02784-z


Peer-Reviewed Journal Article References:
Baker, J. H., Higgins Neyland, M. K., Thornton, L. M., Runfola, C. D., Larsson, H., Lichtenstein, P., & Bulik, C. (2019). Body dissatisfaction in adolescent boys. Developmental Psychology, 55(7), 1566–1578.

Ferguson, C. J. (2018). The devil wears stata: Thin-ideal media’s minimal contribution to our understanding of body dissatisfaction and eating disorders. Archives of Scientific Psychology, 6(1), 70–79.

Giraldo-O'Meara, M., & Belloch, A. (2019). The Appearance Intrusions Questionnaire: A self-report questionnaire to assess the universality and intrusiveness of preoccupations about appearance defects. European Journal of Psychological Assessment, 35(3), 423–435.

QUESTION 26
According to the American Journal of Psychiatry, what is the rate of suicide risk in a BDD client? To select and enter your answer go to Test.

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