Phillips  N = 453/290
Crerand  N = 419
Appearance of treated body part
Overall BDD symptoms
Crerand subsequently reported in greater detail on the same cohort of patients . The authors specifically investigated the possibility of outcome differences between surgical, minimally invasive (MI), and “other” procedures. There were too few MI procedures to perform a three-way comparison; the authors therefore performed two separate statistical analyses, one in which surgical and MI procedures were pooled (surgical/MI) and compared to “other” procedures, and a second in which surgical procedures were compared to MI and “other” (MI/other) procedures. Despite the somewhat arbitrary distinction between MI and “other” procedures, the authors found a statistically significant difference between the surgical/MI group and the “other” group in improvement in preoccupation with the treated body part (25.3 % versus 15.6 %, p = 0.04). There was no significant difference in perceived improvement in appearance of the treated body part (33.3 % versus 24.8 %, p = 0.11) or in improvement of overall BDD symptoms (2.3 % versus 4.0 %, p = 0.75). In the surgical versus MI/other comparison, surgical interventions were more likely to result in improvement in preoccupation with the treated body part (27.9 % for surgical versus 15.9 % for MI/other, p = 0.023) and trended toward greater improvement in perceived appearance of the treated body part (36.1 % versus 24.9 %, p = 0.069). There was no difference in overall BDD symptom severity (1.6 % versus 4.0 %, p = 0.368). While the authors found some differences in outcome depending on the type of procedure that was performed, the outcomes were nonetheless poor across all types of procedures.
Veale et al.  described patients who had been referred to them by consultant psychiatrists, dermatologists, and cosmetic surgeons, or who had self-referred. Of those who were assessed over a period of 9 months and who met criteria for BDD, 48 % had seen either a cosmetic surgeon or dermatologist at least once, and 26 % had undergone one or more operations on their perceived defect. About 81 % rated themselves as dissatisfied with the outcome of the consultation or operation.
Veale  subsequently reported on 25 patients with BDD who at the time of psychiatric assessment had reported that they had previously had cosmetic surgery. The patients had undergone a total of 46 operations. Several patients reported performing their own cosmetic surgery because they had been turned down by a physician or because they could not afford it. Satisfaction after a first cosmetic procedure was an average of 3.9 on a scale of 0–10, and this decreased to 2.8 after a second and third procedure. Three patients claimed that they were not preoccupied by their appearance prior to surgery, and their symptoms of BDD developed only after a procedure that they believed to have been performed poorly.
Even when patients have been satisfied with the results of cosmetic procedures, preoccupation can transfer to a different body part. In Veale’s  study, four of the six patients who rated themselves satisfied went on to have additional procedures or were dissatisfied with another area of their body. In a separate study, Tignol et al.  noted that five of seven patients who had undergone cosmetic surgery were preoccupied with a new body site at 5-year follow-up.
Suicide attempts have also been reported in association with BDD, although there is little to suggest that these were consequences of or even temporally related to cosmetic treatment of perceived deformity. Cotterill and Cunliffe reviewed a series of 16 patients who committed suicide at some time after presenting with dermatological problems to their dermatologic clinic. Of these, three had been diagnosed with BDD at initial presentation . In Veale et al.’s  cohort of 50 patients, 24 % reported prior suicide attempts. One patient who had been referred with suspected BDD committed suicide prior to evaluation and was therefore not included in the cohort. Phillips et al.  reported an annual suicidal ideation rate among patients with BDD of 57.8 % and a mean annual suicide attempt rate of 2.6 %.
Additional Implications for Dermatologist
BDD patients often engage in compulsive behaviors such as skin picking, hair plucking, scratching, application of harsh chemicals, and at-home procedures to cope with, or attempt to correct, their perceived physical defects . In one extreme example, a patient’s preoccupation and picking of a skin defect on her neck was so extreme that she exposed her carotid artery through extensive manipulation . These behaviors may be the presenting sign of BDD, and dermatologists should be aware of this and be prepared to work with or refer to a psychiatrist for treatment of the underlying condition. In addition, dermatologists should be prepared to treat the sequelae of these behaviors, including bleeding, scarring, and infection.
The best interest of the patient is always of greatest concern to the treating physician. The discussion above has focused on outcomes of cosmetic treatments from the perspective of the patient with BDD. However, there are potential consequences to the treating physician as well. These include threats of litigation and, even, violence.
In one survey of cosmetic surgeons, 40 % of respondents indicated that a patient with BDD had threatened them legally (29 %), physically (2 %), or both legally and physically (10 %) . Lawsuits have been executed by patients who have alleged substandard surgical technique. Additionally, in one case (although subsequently dismissed), a patient filed suit, claiming that informed consent had not been obtained because such consent is not possible in the setting of BDD . In interviews of 58 consecutive patients with BDD, Perugi et al. found that 30 % reported to be more aggressive and violent toward their relatives and friends . In an assessment of 33 child and adolescent patients with BDD, 38 % reported having committed violent acts associated with their BDD toward themselves or others .