Fun house mirrors are a midway mainstay. Everyone loves the cheap thrill of stepping in front of one mirror and seeing enormous hips. Try another and your nose looks gigantic. Most of us find these distortions amusing because we don't take them seriously. But if you're among the one per cent of North Americans who suffers from Body Dysmorphic Disorder (BDD), that fun house mirror is an apt metaphor for what's going on inside your head: you see a minor flaw as a huge disfiguration. A tiny scar as a deep crevasse. You're constantly tormented by a defect that doesn't exist.

Montreal psychiatrist Dr. Luis Vacaflor says BDD is a catchall phrase for patients who have distorted impressions and ideas about their own bodies. "It's actually a spectrum of psychiatric illnesses that are linked to each other, and they differ, in part, according to the degree of severity." A patient could be a diagnosed psychotic, who displays a profound inability to reason, a neurotic with obsessive-compulsive tendencies, or someone who is very depressed.

Dr. Vacaflor says BDD is really caused by a constellation of factors, and he describes the obsession with the so-called defect as "a visible island in a sea of discontent." For example, a small scar could become the focal point of the many things troubling a patient; she might also be convinced that other people are pointing it out, and laughing at her. "Since we discover the world through our bodies, body dysmorphia is a primitive way of expressing anxiety," says Vacaflor. "When your body becomes the enemy, it's always a problem that psychiatrists take very seriously." An equal percentage of men and women are affected by BDD, though it's most common in teens or twenty-somethings. According to Vacaflor, the problem is often triggered by stress.

Because of all the media speculation about Michael Jackson and BDD, we think of body dysmorphia as a modern phenomenon - but it's not. An Italian physician first profiled the disorder in 1886. And just before the First World War, Sigmund Freud treated a male patient he called the "Wolf Man," who was so obsessed with his "ugly" nose that he was unable to make friends or to hold a job. What's different about today, of course, is that esthetic surgery is now widely available, and patients with BDD may view this option as a solution to all their problems.

Toronto cosmetic facial surgeon Dr. Peter Adamson estimates that four to five per cent of the patients who come to him for a consultation have a concern that's out of proportion for a minor defect. "Another one per cent have what I would call true body dysmorphia. These patients are obsessed with a physical flaw that has no basis in reality." And Dr. Adamson is among many surgeons who refuse to do cosmetic work on patients with BDD.

"It's actually a disservice to them because they are never going to be happy with the results," explains Montreal plastic surgeon Dr. Gaston Schwarz. "In some cases, patients with body dysmorphia can become violent towards their surgeon after having a procedure." Another plastic surgeon, Vancouver-based Dr. Nicholas Carr, also points out that when a patient with BDD does manage to be satisfied with cosmetic surgery, it's highly likely that their fixation will simply switch to another physical feature.

"The face tends to be the biggest area of concern," says Carr. "Because men shave and women put on makeup, they're getting continual feedback from their mirror. It can also be linked to race in some cases. Asian patients with body dysmorphia are often obsessed with their eyelids or nose." Adamson has noticed in his practice that men with BDD tend to fixate on their nose, while women are more likely to focus on their skin. "They may even pick away at an imagined defect and create chronic inflammation," he says. And Schwarz has had female patients without any localized fat deposits who kept insisting they needed liposuction. "I have to be honest with them," he says.

While body dysmorphia is rare, Schwarz says surgeons have to be on the lookout, or a patient may fly under the radar. "You have to listen to your patients, ask the right questions and observe their behaviour." In addition to an intense preoccupation with a physical flaw, Schwarz notes that patients with BDD often keep repeating information. "They're obsessed with documenting it too. Doing research and having a list of questions is normal, but when they have pages and pages of detailed questions, it raises a red flag." Another habit BDD patients tend to share is bringing in dozens of drawings and photos to a consultation. "The sketches are usually badly done and have no resemblance to reality, but the patient will still insist something is wrong," says Carr.

Adamson is always on the alert when a patient says their life is impacted to the point where they won't have social relationships, or they're afraid to go to their jobs or leave the house. "Patients like this are convinced that no one likes them because of the way they look."

Multiple surgeries and consultations can be a tip-off too. "I had someone come for a consultation once who'd had seventeen eyelid surgeries," remarks Carr. "When a patient has a distorted area of what they really look like, it's obvious they need a psychiatrist, not a surgeon."

But surgeons face an uphill battle when they recommend counseling. "It is very difficult to tell patients there is something wrong with them, and that they need psychiatric help," reveals Schwarz. "Some are insulted, and tell me they're not crazy, but the problem is - they don't have any insight into what is really wrong. Because Body Dysmorphic Disorder takes different forms, it's one of the most challenging aspects in plastic surgery."

Adamson estimates that he asks 12 to 15 patients a year to go for counseling. "If I think something can be done for them cosmetically, I may suggest they get psychiatric help and come back for reassessment in a year. If they're obsessed with an imaginary defect, however, it's an unequivocal no. The problem is, the people who need help most, are the least likely to think they need it."

Vacaflor says that BDD is very difficult to treat. If a patient is psychotic, drugs may reduce the intensity of the symptoms, but the fixation itself usually remains firmly entrenched. Anti-depressants or anti-anxiety drugs - in combination with talk therapy - sometimes work with milder forms of BDD. Schwarz recalls a young woman who was obsessed with the size of her breasts. After counseling, she had an augmentation, and has remained happy with the results, and with herself. However, Schwarz says a patient like this is always an exception, never the rule.

"You could say that cosmetic surgery patients are more finicky than normal because they are taking steps to correct a feature they're unhappy with," observes Carr. "Fortunately for us, the average patient has a secure, healthy psyche. For instance, a woman with small breasts might think: 'I'll have a consultation and see if implants would be the right thing for me.' But there's a big difference between a patient who takes a proactive approach towards improving her appearance, and one who wants me to correct a physical flaw that simply isn't there."