Fantastic or drastic? Can plastic surgery be addictive?

“Plastic surgery addiction may sound like a joke but it is actually a serious problem that more and more people are suffering from in modern times” (http://plasticsurgeryaddiction.net/)

In many circumstances, the use of using plastic surgery to help correct a facial or body deformity, whether congenital or caused by an accident of some description, is clearly a helpful and beneficial treatment to individuals. However, in the world of celebrity media, ‘plastic surgery addiction’ is up there with alcohol and drug addictions as one of the addictions that those in the public eye are most likely to succumb to. We can all think of celebrities that are known to have repeatedly gone under the surgeon’s knife (Michael Jackson, Cher, David Gest, Micky Rourke). There are understandable reasons as to why celebrities are a higher risk group for seeking out cosmetic surgery. Firstly, there is an almost obsessive need in the ‘showbiz’ world to look as (aesthetically) good as possible. Secondly, they have the money and can afford to do it repeatedly. As long as the person has the money to pay for the surgery and the doctor is willing to perform it, there are no guidelines as to when to stop (unlike the regulation of prescription drugs, and other medical and/or surgical procedures).

As I noted in a previous blog, I am unconvinced that any of these high profile celebrity cases are “addicted” to plastic surgery but like ‘tanorexia’ there is certainly the desire to look good as a way of feeling good about themselves. However, there are certainly cases of individuals who seek out constant plastic surgery because they suffer from Body Dysmorphic Disorder (BDD). As I noted in a previous blog on BDD, it typically manifests itself as a preoccupation with an imagined physical defect or an exaggerated concern about a minimal defect. Furthermore, the perceived flaw or defect may not even be noticeable to other people. This leads the BDD sufferer to want cosmetic surgery in an attempt to try to change or eliminate the perceived defect. Even people who are outwardly (and objectively) very attractive can perceive themselves to be very unattractive.

Empirical research carried out among patients undergoing plastic surgery, have typically reported that between 5% and 15% of the sample have BDD. Even if the constant seeking out of cosmetic surgery is not a genuine addiction, BDD sufferers appear to have a higher risk of developing addictions to alcohol and illegal drugs as they are often used to cope with and/or forget about the symptoms and consequences of the disorder. They also engage in more ‘safety behaviours’ (such as staying indoors and avoiding social contact) that in some cases develops into social phobias. This can then result in relationship and/or family discord, and affect education and/or work (depending upon age and life circumstances of the sufferer).

The British psychiatrist Dr David Veale (The Priory Hospital North London) and his colleagues have published a number of studies on BDD with specific reference to those seeking plastic surgery. In one of his team’s first studies, a quarter of 50 BDD patients attending a British psychiatric clinic were reported to have been successful in obtaining at least one cosmetic surgical procedure. In another study, Dr Veale reported that 25 of his BDD patients had received a total of 46 cosmetic surgery operations.

Dr Katharine Phillips (Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, USA), and arguably the world’s leading authority on BDD, has also examined the relationship between BDD and cosmetic surgery. In one of her team’s studies of 58 BDD sufferers who had undergone cosmetic surgery, they reported that the vast majority of the patients (83%) felt no better or were worse after their cosmetic operation(s). Veale has also reported similar findings (i.e., that BDD sufferers experience increasing dissatisfaction following surgery).

However, Dr Veale also reports that there are some cosmetic procedures where BDD patients tend to experience increased (rather than decreased) satisfaction. For instance, operations involving the pinning back of protruding ears (pinnaplasty), and breast augmentation or breast reduction (mammaplasty), tend to show higher satisfaction ratings among BDD sufferers than those undergoing cosmetic nose surgery (rhinoplasty). However, over 50% of BDD patients often have more than one concern about their bodily appearance so even if one surgical procedure produces short-term satisfaction, this may be replaced with anxiety about another body part (resulting in a desire for further cosmetic surgery).

Dr Veale also notes that some BDD patients are very distinct from others (for instance, those with BDD seeking reconstructive nose surgery appear to be distinct from other types of BDD sufferer). Prior to seeking medical help, BDD sufferers wanting rhinoplasty often attempt ‘do-it-yourself’ surgery to correct their perceived defects and flaws. Examples of ‘‘DIY’’ surgery among this type of BDD patient include (i) using a pair of pliers in an attempt to make the nose thinner, (ii) using sticky tape to flatten the nose, and (iii) placing tissue in the nostrils to try to make the nose look more curved. Compared to patients with other body image disorders, those who have attempted DIY surgery appear to have high rates of both depression and attempted suicide.

Despite relatively consistent findings, it should be noted that most of the studies on the relationship between BDD and cosmetic surgery comprise relatively small sample sizes so the findings suffer from issues around generalizability. Perhaps of more concern – and something that Dr Veale points out – is the fact that published studies comprise people seeking treatment in psychiatric settings so there is a high selection bias of people in favour of treatment failures (i.e., if a BDD sufferer is happy with their cosmetic surgical procedure they don’t tend to come in for further treatment as their symptoms and problems dissipate and/or disappear).

A just published study in the journal Psychological Medicine examined whether people who opt for medically unnecessary cosmetic surgery are psychologically vulnerable. A Norwegian team of researchers led by Dr Tilmann von Soest began some longitudinal research two decades ago on 12,000 school students (aged 12 to 19 years in 1992) and have been sampling them periodically over the intervening years. In 2005 there were 2,890 participants left of which 106 people (78 women and 28 men) had cosmetic surgery. Their results indicated that women with psychological problems were more likely to opt for surgery. The female participants who had cosmetic surgery were more likely to have had a history of poorer mental health (e.g., depression, anxiety, more illicit drug use, self-harm, and suicide attempts. With one exception (breast augmentation), having cosmetic surgery didn’t benefit the psychological health of the women. The researchers concluded there was “no evidence that cosmetic surgery should be used to alleviate mental health problems in women dissatisfied with their appearance”.

If plastic surgery addiction exists (and I am sceptical to say the least), it is not (as some people argue) a common side effect of cosmetic surgery (i.e., if someone is considering a cosmetic surgical procedure, they should not be concerned with fear of future reliance on – or  “addiction” to – surgery. That is not to say that repeated cosmetic surgery can’t be problematic. For instance, there are reports of individuals who have had excessive rhinoplasty that has reduced the nasal cavity so many times that they can no longer blow their nose properly. There are also countless reports involving repeated reconstructive facial surgery that has resulted in muscle tissue collapse, unsightly scarring, and permanent nerve damage (leading to permanent loss of sensation and feeling in the affected area for the rest of the patient’s life).

The good news is that most studies report that people are generally happy with the outcome of cosmetic procedures (although arguably, rigorous evaluation has not been carried out). The results of empirical research have tended to conclude that more extensive (“type change”) procedures (e.g., rhinoplasty) appear to require greater psychological adjustment by patients than “restorative” procedures (e.g., facelifts). Cosmetic surgery patients who have unrealistic expectations of the operation’s outcome are more likely to be dissatisfied with cosmetic procedures.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Castle, D.J., Roberta J Honigman, R.J. & Phillips, K.A. (2004). Does cosmetic surgery improve psychosocial wellbeing? Medical Journal of Australia, 176, 601-604.

Phillips, K.A., Grant, J., Siniscalch,i J, et al. (2001). Surgical and non psychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics, 42, 504-510.

Sarwer, D.B., Wadden, T.A., & Pertschuk, M.J., et al. (1998). Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plastic Reconstructive Surgery, 101, 1644-1649.

Suissa, A.J. (2008). Addiction to cosmetic surgery: Representations and medicalization of the body. International Journal of Mental Health and Addiction, 6, 619-630.

Veale, D., De Haro, L., & Lambrou, C. (2003). Cosmetic rhinoplasty in body dysmorphic disorder. British Journal of Plastic Surgery, 56, 546-51.

Veale, D. (2000). Outcome of cosmetic surgery and ‘‘DIY’’ surgery in patients with body dysmorphic disorder. Psychiatry Bulletin, 24, 218-21.

Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.

Veale, D., Boocock, A., Gournay, K., et al. (1996). Body dysmorphic disorder. A survey of fifty cases. British Journal of Psychiatry, 169, 196-201.

von Soest, T., Kvalem, I. & Wichstrøm, L. (2012). Predictors of cosmetic surgery and its effects on psychological factors and mental health: a population-based follow-up study among Norwegian females. Psychological Medicine, 42 , 617-626