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Original Article

Prevalence of body dysmorphic disorder among Saudis

seeking facial plastic surgery
Zainab Salman Al Shuhayb
Medical Intern, King Faisal University, College of Medicine, Al Ahsa, Saudi Arabia

Abstract Importance: Nonpsychiatric physicians often encounter body dysmorphic disorder (BDD) which is a common
psychiatric disorder. In the general population, BDD is estimated to affect 1%–2%. In esthetic specialties,
however, rates are markedly higher.
Objective: This study aims to quantify the prevalence of BDD among people seeking facial plastic surgeries
in Saudi Arabia because the literature is sparse in this field.
Design: This is a cross‑sectional study, conducted in 2018 (October–December).
Setting: A self‑administered web‑based questionnaire was administered on 453 individuals, aged 18 years
and older, of Saudi residence.
Participants: A total of 453 individuals, aged 18 years and older, of Saudi residence, were enrolled in the study.
Main Outcome(s) and Measure(s): The study has three main measures which are: (1) sociodemographic
data, (2) previous and future plastic surgeries, and (3) the Body Dysmorphic Disorder Questionnaire.
Results: A total of 453 individuals were enrolled in this study. Of the total sample, 34.2% reported their
desire to go for a facioplastic surgery in future, of which 14.19% fulfilled the criteria of BDD. Twenty‑two
individuals who fulfilled the criteria were all females (100%). All were relatively young, with 54.5% aging
between 18 and 24 years of age, followed by 45.5% aging between 25 and 34 years of age. The majority were
married 54.5%, with the rest being single. The majority of individuals (59.1%) live in cities, followed by 36.4%
living in villages and 4.5% living in outskirts. Nearly 68.2% hold a college degree, followed by 27.3% holding
a high school degree. The vast majority reported the desire to undergo a rhinoplasty (54.5%), followed by
facial implants (9.1%), facelift (4.5%), eyebrow lift (4.5%), and cheek/jaw contouring (4.5%).
Conclusion: We report a prevalence of 14.19% among people seeking facial plastic surgery. This prevalence
is warring, requiring special attention by facioplastic surgeons, plastic surgeons, and dermatologists, when
dealing with patients. We recommend the screening of all patients to be a standard practice to ensure the
best outcome possible.

Keywords: Body, disorder, dysmorphic, facial, surgery

Address for correspondence: Dr. Zainab Salman Al Shuhayb, King Faisal University, Al Ahsa, Saudi Arabia.
E‑mail: [email protected]

INTRODUCTION The Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, defines BDD as a preoccupation with
Nonpsychiatric physicians often encounter body dysmorphic an imagined defect in appearance, with marked excessive
disorder (BDD) which is a common psychiatric disorder.[1,2]
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DOI: How to cite this article: Al Shuhayb ZS. Prevalence of body dysmorphic
10.4103/ssj.ssj_11_19 disorder among Saudis seeking facial plastic surgery. Saudi Surg J
2019;7:83-6.

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Al Shuhayb: Body dysmorphic disorder in plastic surgery seekers

concern toward slight physical anomalies. To fit the criteria, Data collection
the preoccupation must cause clinically significant distress Data were collected using a self‑administered web‑based
in social, occupational, or other areas of functioning.[3] questionnaire.

In the general population, BDD is estimated to affect The study has three main measures which are: (1)
1%–2%.[2] In esthetic specialties, however, rates are markedly sociodemographic data, (2) previous and future plastic
higher with a prevalence of 14.0% among cosmetic surgeries, and (3) The Body Dysmorphic Disorder
dermatology patients, 10% in the maxillofacial setting, 21% Questionnaire (BDDQ). [19] The English BDDQ
in patients seeking rhinoplasty,[4] and 13% in facial plastic was translated by a bilingual expert and tested for
surgery patients.[5,6] The reported numbers differ greatly validity which revealed acceptable internal consistency
from study to study, which can be generally attributed to (Cronbach’s α = 0.659).
the lack of a formal unified screening method used.
Statistical analysis
BDD manifests as repetitive, compulsive behaviors that can Statistics were performed using the IBM SPSS Statistics
be as mild as repetitive mirror checking, excessive grooming, version 22.0 software, IBM Corp., Armonk, NY, USA.
and camouflage with makeup or clothes to as severe as Quantitative variables were presented as mean and standard
repeatedly seeking unnecessary dermatological and plastic deviation, and qualitative variables were presented as
surgeries or even performing “do it yourself surgeries.”[7] number with percentage. For correlation with categorical
variables, Chi‑square test was used, with the results
In a study of 250 adults with BDD, 75% of patients sought presented in cross tables and clustered bar graphs, and
nonpsychiatric medical treatments. Of these, 72% of the t‑test or one‑way anova for correlation with continuous
procedures led to no change, and 16% led to a worsening variables, with the results presented in tables. P < 0.05 was
of BDD symptoms.[8] This is of no surprise because these considered statistically significant.
patients often possess unrealistic expectations about the
outcomes of these surgeries and expect it to be the solution Ethical statement
for everything there are dissatisfied with; when in reality, Ethical clearance was obtained from King Faisal University’s
these patients need psychiatric treatment and highly unlikely Research Ethics Committee. Written informed consent was
to improve solely with cosmetic procedures.[9] Because obtained as well from the participants in the introduction
of that, a diagnosis of BDD is generally considered a web page prior to involvement in the study.
contraindication to plastic surgeries by the majority of
RESULTS
surgeons. Other reasons include risk of violence against
the surgeons and malpractice lawsuits.[10‑16]
A total of 453 individuals were enrolled in this study.
In Saudi Arabia, apart from one study conducted on To quantitate the prevalence of BDD, the question of
363 patients attending a dermatology clinic in Qassim, future plastic surgery was the main outcome measure.
Saudi Arabia, in which 18.6% screened positive for BDD,[17] Any individual fit for the criteria of diagnosis followed
literature regarding BDD prevalence in cosmetic/plastic in the BDDQ was considered. The criteria are that the
clinics is sparse and nearly nonexistent. Thus, this study individual must answer yes to the two parts in the first
aims to quantify the prevalence of BDD among people question, a yes answer to any of the four parts of the
seeking facial plastic surgeries, in particular because they third question, and an answer with B or C to the fourth
are considered to be the most common cosmetic surgeries question.
sought by these patients.[18]
In our sample, 34.2% of the participants reported their
METHODS desire to go for a facioplastic surgery in future; out of
these, 14.19% fulfilled the criteria of BDD.
Study type
This cross‑sectional study was conducted in Saudi Arabia Sociodemographic descriptors
from December 1, 2018 to February 1, 2019. Twenty‑two individuals who fulfilled the criteria were all
females (100%). All were relatively young, with 54.5%
Study size and population aging between 18 and 24 years of age, followed by 45.5%
A total of 453 adult Saudis (aged 18 and older) were aging between 25 and 34 years of age. The majority were
recruited for the study. The sample size was calculated using married (54.5%), with the rest being single. The majority
Raosoft, an electronic sample size calculator. of the participants (59.1%) live in cities, followed by 36.4%
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Al Shuhayb: Body dysmorphic disorder in plastic surgery seekers

living in villages and 4.5% living in outskirts. Nearly 68.2% that young people are more heavily exposed to social media
hold a college degree, followed by 27.3% holding a high and the portrayed exaggerated, unrealistic ideas of beauty
school degree [Table 1]. and the standards of what is considered to be esthetically
appealing and what is not urge them to undergo different
Type of desired surgical procedure cosmetic procedures.
The vast majority reported the desire to undergo a
rhinoplasty (54.5%), followed by facial implants (9.1%), All the individuals who fulfilled the criteria in our study
facelift (4.5%), eyebrow lift (4.5%), and cheek/jaw were female. A number of studies have examined the
contouring (4.5%), as shown in Graph 1. gender differences among BDD patients. In general, BDD
is believed to occur approximately equal between males
DISCUSSION
and females. However, multiple studies report different
incidences among male and female individuals. In one
BDD appears to be common but appears to be
study of British patients, 76% of patients were female.[18]
underdiagnosed in noncosmetic surgery settings.[20,21] In
In contrast, a retrospective chart review study of fifty
cosmetic surgery settings, rates of 6%,[22] 7%,[23] and 15%[24]
patients revealed that 62% of the individuals in their study
have been reported. The present study reports a BDD
were male.[27]
prevalence of 14.19% in Saudis seeking facioplastic surgery.
This finding is considerably higher than the number
When the individuals were asked about which facioplastic
reported in one local study,[25] in which a prevalence of
procedure they are intending to do, the majority (54.5%)
6.63% was reported. Other studies do report a similarly
answered with “rhinoplasty.” The answer was not surprising
high prevalence. In one study, a prevalence of 31.5% was
because rhinoplasty is the most commonly preferred
reported among rhinoplasty candidates.[26]
esthetic surgery by BDD patients.[18] Prevalence among
All the individuals who fulfilled the criteria were of young rhinoplasty candidates has been reported to be 3.2% to
age (mean age: 1.45). This might be explained by the fact 16.6%.[26‑29]

CONCLUSION
Table 1: Sociodemographic descriptors
Frequency (%)
A prevalence of 14.19% among people seeking facial
Gender
Female 22 (100)
plastic surgery has been reported. This prevalence is
Age (years) warring, requiring special attention by facioplastic surgeons,
18–24 12 (54.5) plastic surgeons, and dermatologists, when dealing with
25–34 10 (45.5)
Residence
patients. We recommend the screening of all patients to
City 13 (59.1) be a standard practice to ensure the best outcome possible.
Village 8 (36.4)
Outskirts 1 (4.5) Limitations
Educational level
High school degree 6 (27.3) The scale used is a screening scale for BDD; thus, the
College degree 15 (68.2) number provided could be an overestimation of the real
Other 1 (4.5) prevalence.
Marital status
Married 12 (54.5)
Single 20 (45.5) Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.

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