Imagined Ugliness: Can an Orthodontist Figure it out?

Introduction

“Beauty is in the eyes of the beholder” they say. But what if the beholder has a twisted image of themselves in their mind? Perceptions of beauty changes with culture & time, there is no specific mathematical equation for beauty. While all beauty is not universal, the human face in particular can be shown to universally appear more "beautiful" based on geometric comparisons [1]. If the face were a song, one could think of the front view as the melody and the side view as the harmony or overtones. The frontal view of the face is the most important view because we generally perceive each other (particularly when we interact socially) from the front not from the side. Our evaluation of how another face appears occurs from the frontal view. Therefore this view is MOST critical for our evaluation of another individual. The human face conforms most closely to phi proportions when we smile. You’ll be perceived as more beautiful with a warm smile than with a cold-hearted look of anger, arrogance or contempt. Even with a perfectly proportioned face though, there are endless variations in coloring and the shapes of each facial feature (eyes, eyebrows, lips, nose, etc.) that gives rise to the distinctive appearance of each race and provide for endless variations in beauty that are as unique as each individual. Interestingly, symmetry in face does not necessarily equate to beauty. Many, if not most, faces that are perceived as beautiful are usually not even close to being perfect in symmetry of the left and right sides. Our human brains are complex structures that are geniuses in themselves. It can give one person the ability to capture the world whereas sometimes it can lock the mind in its own cage of self doubts. We all have that one imperfection we wish we could change – a crooked tooth, a large nose, acne-prone skin, eyes that are too narrow, a flabby stomach, and the list goes on. However, we accept it and carry on with our daily lives – it’s more of an annoyance than a debilitating thought. People suffering Body Dysmorphic Disorder (BDD), become fixated on that imperfection-in fact obsessed, until it becomes the only thing they see when they look in a mirror. These obsessive and controlling thoughts can lead them to spend exorbitant amounts of time & money trying to cover or conceal the flaw, to seek verbal approval of their looks, even though they are not likely to believe what people tell them, to socially withdraw, and to have thoughts of suicide. BDD is described as a distressing pre-occupation with perceived defects in appearance or excessive concern over minimal defects which cannot be better accounted for other mental disorders such as anorexia nervosa, gender identity disorder, major depressive disorder, avoidant personality disorder or social phobia. Approximately 1.7% to 2.4% of the U.S population are reportedly known to be affected, with roughly equal distribution among men and women. Though the percentile seems small it’s mainly due to the fact that majority of such patients go unnoticed & don’t seek proper medical help. BDD is a poorly studied condition among Asian populations. The disorder usually first surfaces in adolescence and is characterized not only by obsessive thinking about a flaw that is usually imagined or if present, hardly noticeable to the general population, but also characterized by compulsive checking of the perceived flaw (for example, spending lots of time in front of the mirror), engaging in behaviours to minimize the appearance of the perceived flaw and hiding the disorder from others due to fear of social stigma. In most patients the concerns about appearance focus on the head and face. As the patients lack insight to the true nature of the problem they usually seek non psychiatric and cosmetic treatments. Even to an extent of undergoing drastic cosmetic surgeries to “fix” the flaw. Most frequently requested treatments by the BDD patients are dermatological, surgical (rhinoplasty, liposuction and breast augmentation) and dental (tooth whitening, jaw surgery and orthodontic) treatments [2]. BDD has been recently added to the somatoform disorders category (DSM IV). Clinical knowledge of the disorder particularly among general practioners is not wide spread & a dentist not having knowledge of BDD might land up in legal redress. Though there are people suffering from this disorder general awareness is still lacking. Celebrities going under the knife just to enhance their beauty, has given shelter to this disorder in the form of “trends”. Plus in the race to “we can fix everything” mentality it often goes undiagnosed.

BDD in Existing Literatures

It was first described by Enrico Morselli as dysmorphophobia in 1866 [3]. Freud’s famous “Wolf Man”, a case of a patient’s delusions about his nose, might have been a case of BDD. High profile celebrities are even known to have this disorder the most famous example of this generation being Marilyn Monroe, Michael Jackson, the one which hits close to home is actress Ileana D’Cruz. It’s time to understand the monster lurking in the shadows & address the problem as a clinician. Because of the distorted body image caused by the disorder the person tends to believe that he or she is horribly ugly or disfigured. Dentists & orthodontists are more likely to encounter these kind of patients as the concern of such patients involve non-existent minor flaws for Eg- odd smile, shape of lips, profiles etc. Therefore it’s necessary to identify such patients in order to avoid unnecessary treatment & distress to both patient & the clinicians.

Etiology

Little is known about what causes BDD. There is some evidence for familial aggregation and genetic links with obsessive-compulsive disorder (OCD) [4]. Other links with OCD have been suggested through neuropsychologic and neuroimaging studies, although the literature is limited and inconsistent. A clear role for the serotonin system is evidenced by the specificity of therapeutic response to serotonergic antidepressants. Some patients report a family background that prioritized appearance, but there is little specificity. A study by Monzani, et al. [5] which examined the heritability of dysmorphic concerns in a large sample of twins found that 44% of the variation in liability to dysmorphic concerns was attributable to genetic factors, environmental factors and measurement error that account for the remaining variance. Some individuals recall their BDD having been precipitated by a particular incident such as teasing, but many patients do not report a precipitating event, and the reported events probably merely precipitated the overt manifestation of an underlying predisposition [6]. Abuse and neglect can also be contributing factors [7].

Symptoms & Behaviour

In the general population it’s difficult to ascertain BDD accurately, given the degree to which people tend to be ashamed of and hide their concerns. Also, self-reported and clinician-determined rates may differ; different rating scales may produce different results. At such times we as clinicians should be able to decipher the condition. In an article about BDD Abhimanyu, et al. has given a checklist to the symptoms & behavioural patterns in BDD [8].

The Dysmorphic Concern Questionnaire

Piet Oosthuizen, et al. [9] conducted a study for the assessment of dysmorphic concern, and to establish correlations with clinical variables [9]. The study reported that dysmorphic concern was not significantly influenced by the patient's age, sex or diagnosis. In terms of specific psychotic symptoms, there were weak positive correlations with thought interference and persecutory ideation. However, the strongest correlations were with depressed mood, according to the Beck Depression Inventory (BDI) but not the Montgomery Asberg Depression Rating Scale; the discrepancy was largely accounted for by the 'cognitive' depressive items on the BDI. In terms of objective assessment of dysmorphic features, ratings on the Waldrop scale for minor physical anomalies showed no correlation with concern expressed by the patient. These questions are designed to screen for people with certain concerns that are often difficult or embarrassing to talk about with their doctor/family/friends; and often difficult to find the right help for. The following were the questions in the questionnaire-

The two most common treatment options for body dysmorphic disorder is medication and therapy. Cognitive behavioural therapy has been found to be the most effective at treating BDD and a certain type of antidepressants have also been shown to help individuals coping with the disorder.

Surgery

It’s the last option to be considered though the surgical correction still remains controversial in such patients. But it is generally approved that surgery rarely improves the situation & can make matters even worse because the patient finds a new defect or becomes more concerned with the existing defect. Andreasen & Bardach [11], suggested that because the imagined defect is emotional rather than physical, the patient will rarely be satisfied with surgery. In the study of Phillips & Diaz [12], 109 of 131 patients who had BDD had received surgical, dermatologic, or other nonpsychiatric treatments, resulting in a worsening or at best no change in BDD symptoms in 83%.

Prognosis

Many individuals with experience of Body Dysmorphic Disorder have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction, before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the condition for most people. Some people living with Body Dysmorphic Disorder may function reasonably well for a time and then relapse. Others may remain chronically unwell. Research on outcome without therapy is not known, but it is thought that the symptoms persist for many years.

Conclusion

BDD is a psychiatric disorder in which an individual has a pre-occupation with a ‘slight’ or ‘perceived’ defect in appearance. An orthodontist needs to be vary about individuals seeking procedures for perceived defects that are not objectively evident. Other warning signs include an excessive amount of distress and disability associated with the perceived defect and unrealistic expectations for outcome either in cosmetic or psychosocial terms. Individuals who have such risk factors should be engaged in a discussion about their problem in broad terms such as ‘‘distress’’ and ‘‘disability,’’ and they should be referred to a suitable mental health professional. It won’t be a shock if such individuals go doctor shopping, as they are frequently known to go from one clinician to other until they find someone who is willing to operate on them. Sometimes they seek inappropriate or unnecessary treatment from multiple health care providers including orthodontist, and are frequently dissatisfied with the results of treatment. This could potentially increase the risk of medico-legal cases for the clinician. BDD remains an understudied psychiatric disorder. Further research is required to establish its etiopathology and neurocognitive underpinnings. Its relationship to other psychiatric disorders requires clarification. It might not be feasible to psychologically evaluate every patient but few chosen questions can be able to help identify patients who might cause problems.