Obsession With Perfection
Plastic surgeons call them “red flag” clients: the struggling actor who’s sure his eyes are a millimeter too close together, or his chin a shade too weak; the college student who swears her mouth is slightly off center, her complexion uneven. They fret compulsively over physical flaws that others barely notice.
“These people imagine themselves to be ugly, and no matter what you do to help them they are unsatisfied,” said Dr. Barry Weintraub, a Beverly Hills plastic surgeon.
Since the first aesthetic procedures were performed centuries ago, cosmetic surgeons have attracted people in pursuit of various physical ideals. While most are willing to accept improvement, some insist on perfection. In recent years, many surgeons have begun to tag the most extreme perfectionists with the label “body dysmorphic disorder,” or BDD, which is defined as a disabling preoccupation with minor or imagined physical imperfections. Now a handful of doctors throughout the country have begun giving psychological tests to potential clients who they believe may be chronically unhappy about their appearance.
Dr. Stephen Pincus, a surgeon who performs cosmetic procedures in Marina del Rey, gives prospective patients a verbal screening test, asking, for example, how many hours a day they spend thinking about a perceived deformity.
Weintraub said he administers a questionnaire to about one in 10 clients who come for a consultation. “Once I hear someone start using the phrase ‘absolutely perfect,’ as in ‘I want an absolutely perfect nose,’ I get nervous,” he said.
Weintraub’s form includes these questions: Are you very concerned about the appearance of some part of your body that you consider especially unattractive? Is your main concern with your appearance that you aren’t thin enough or that you might become too fat? What effect has your preoccupation with your appearance had on your life? How much time do you spend thinking about your defect per day on average: less than an hour; between one and three hours; or more than three hours?
Some doctors doubt whether this sort of appearance obsession is a stand-alone psychological disorder; the preoccupation is often accompanied by clinical depression and social phobias, mental health researchers said, and it’s hard to say which problems came first. At the same time, there clearly exists a small group of plastic surgery clients who are never happy with their surgical outcomes, said Dr. Katharine Phillips, a psychiatrist at the Brown University School of Medicine who studies body image.
In a new study of 289 people being treated for image disorders, Phillips found that about 80% of those who’d had cosmetic surgery were unhappy with the results. “The research is somewhat limited in this area,” she said, “but everything we know tells us that this is a group of people that generally does not do well with plastic surgery, they don’t worry any less about their appearance after the work, and sometimes the outcome is disastrous; they get violent or sue their doctors.”
Phillips estimates that about 1% to 2% of the population suffers from a significantly distorted body image; and between 7% and 15% of those seeking cosmetic operations do. Doctors who study patients obsessed with their physical appearance are sought-after speakers at plastic surgery meetings, and there are good reasons beyond concern for patients for the profession to pay attention.
* Between 30% and 60% of patient lawsuits against plastic surgeons now stem primarily from dissatisfaction with the work, rather than strict questions of competence, experts estimate. “Conservatively, I would say that 50% of the suits are avoidable,” by screening patients for mental fitness, said Dr. Mark Gorney, medical director of the Doctors Company, a medical liability firm in Napa, Calif.
* In June, a state appeals court in New York dismissed a case in which a patient sued her plastic surgeon for failing to diagnose her with BDD. The patient had visited various surgeons dozens of times and argued that her use of antidepressants and history of “unnecessary” surgeries should have tipped the doctor. The court dismissed the case. Gorney has been urging colleagues to screen for such patients and has developed his own rough diagram to help identify them. On one end are people with clearly noticeable deformities that do not become an object of obsession.
“Think of Quasimodo in Notre Dame,” he said. “He says, ‘Gee, doctor, I got this hump. I’d love it if you could do something about it.’ That’s going to be a satisfied patient, no matter what you do.” At the other end are those who are beside themselves over a little bump or scar that’s barely visible. Yet competition among plastic surgeons, in a slumping economy, has meant that most surgeons are not yet screening for those patients, Gorney said.
As a rule, experts say, successful surgeons with their choice of patients have the incentive and means to do psychological testing; but the majority pull on their surgical gloves after only a perfunctory consultation. In the end, those who want a procedure done almost always find some doctor to perform it. “If I won’t do it,” Pincus said, “they’ll find someone who will.” Plastic surgeons who do administer tests say there are a few hallmark signs of an abnormal physical fixation, or BDD. These clients often pick their faces, sometimes doing damage with their nails. Frequently they wear hats or scarves to camouflage their perceived imperfections. Often they’ve had multiple surgeries.
