I recall reading an article in one of New York City's leading Daily News papers. The article reported on the final divorce settlement between one of New York's most well known art dealers and his wife. The headline read, "She wins $2M-but not a penny more for plastic surgery." It seems the wife had a habit of spending huge sums of money having cosmetic surgery and wanted her husband to go on paying the bill. The Supreme Court Justice, stated in her ruling that the husband would not be required to spend another penny on his wife's cosmetic procedures. The Judge, further, declared in the decision that "the wife fails to establish that the sums spent on such procedures comport with standards of either reasonable needs or necessity."

While most readers were caught-up in the glaring lights of the divorce proceedings leading to the multi-million dollar settlement, I was drawn to the words of the Supreme Court Judge "reasonable needs or necessity."

From a legal point of view, I certainly agree with the Judge's conclusion. Why would a reasonable person repeatedly submit to painful, and often, life-threatening surgical procedures in the absence of medical needs or necessity? Is she crazy? The answer, obviously, is no. From a psychological point of view, a different conclusion can be reached. As a psychotherapist, I asked myself; is it possible that this woman is just one of hundreds of Americans, mostly women, suffering in secret and shame from a psychological disorder commonly known as Body Dysmorphic Disorder (BDD)?

BDD is a relatively common disorder that is often mis-diagnosed or under-diagnosed by mental health professionals. BDD is a mental disorder defined as a preoccupation with a perceived defect in one's appearance. If a slight defect is present, which others rarely notice, the concern by the individual is markedly excessive. BDD is well known and appropriately diagnosed in Europe, but has been largely neglected in the United States.

Body dysmorphic disorder is a new label for an old package. BDD has been described in European, Russian, and Japanese literature under several names; most commonly "dysmorphophobia." An Italian doctor, Morselli, first coined the term in 1886 from the Greek word meaning "misshapen." The word dysmorphophobia has been used in many ways, it is generally understood as a subjective feeling of ugliness or defect that the individual thinks is noticeable to others; despite a normal appearance, if a slight defect is present it is grossly exaggerated.

For example, the individual may complain of devious-looking eyebrows, an excessively large nose or large head, small breasts, or small genitals; these defects are felt by the individual as unbearably ugly. Too often, this preoccupation with physical appearance is persistent and pervasive; resulting in social withdrawal and repeated visit to dermatologists and plastic surgeons in an effort to correct the imagined defect. Freud once treated a patient whom he called the "Wolfman" who exhibited classical symptoms of BDD. The "Wolfman" believed that his nose was so ugly he avoided all public life and work.

Dr. Katharine Phillips, Director of the Body Dysmorphic Disorder Program, Butler Hospital, in Rhode Island, and the author of "The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder," stated that many patients who seek outpatient medical and psychiatric treatment are often experiencing symptoms related to BDD...yet the BDD diagnosis is missed by the clinician. The question, than, is why? The short answer is that BDD often not recognized and not diagnosed for the following reasons. For the patient, BDD is a secret disorder that the individual is ashamed of and the symptoms are not revealed to the clinician. It is not infrequent for a client to be in therapy with a therapist and never discuss their BDD symptoms. BDD is like sexual abuse if the concern is not asked about; often it is not revealed. Great courage is required of the client to bring up the subject of BDD for open discussion.

Another reason for the wide under-diagnosis of BDD is the poverty of knowledge of many mental health professionals who are not aware that BDD is a recognized and treatable mental disorder. Even though BDD has a long history, it is still among the lesser known mental disorders. And, the symptoms of BDD is often trivialized. One regularly hear statements such as, what is the big problem about a few blemishes? She is such a beautiful woman, and why this overwhelming concern about her face. Also, because in today's society out attitude about physical appearance plays an important part in the widespread trivialization of BDD.

Furthermore, BDD is often mis-diagnosed because this mental disorder is often accompanied by other more common symptoms such as depression, social anxiety and eating disorders that are much easier to discuss; and are more acceptable by society at large. Therefore, the diagnosis that the client is most likely to be given is depression or social phobia, not BDD. What is even more frustrating, should the client reveal their BDD symptoms they may be told that their symptoms are not the "problem" the real problem that should be addressed is low self-esteem, relationship problem and other related issues. True, these problems may co-exist with BDD, nevertheless, BDD should be diagnosed and treated if it is present.

For example, in my practice, I have had the opportunity to work with several clients with presenting problems relating to their perceived "ugliness." Case in point, Joan (not her real name) 28 years old is a very attractive woman of Jamaican ancestry. Joan always wore a baseball cap to conceal what she believed was a grossly protruding forehead that caused her facial feature to appear "ape-like." According to Joan, she never let anyone sees her without having her forehead covered; sometime this includes her husband when the anxiety is intense. Joan explained that she rarely entertains at home for this reason. When I am in an environment where wearing baseball cap is inappropriate I will arrange my hair to conceal my forehead.

Since no one at work has ever seen me without my cap on; they were naturally curious and often made smart remarks which I often ignored. Then one day a co-worker came up from behind me and removed my cap. This seemingly innocent act infuriated me, "I wanted to kill her, I was so angry." I felt so ashamed and embarrassed. Joan further explained, now everyone knew my secret and how ugly I was. I ran all the way home crying and could not return to work for a week.

In reality, Joan is a very beautiful woman with smooth cocoa-like skin tone; with no facial defects or abnormal forehead. Joan was in therapy for six months before she developed the courage to remove her cap during sessions.

Body dysmorphic disorder, or the preoccupation with an imagined defect in physical appearance, is usually not associated with eating disorder. However, it does pertain to a different kind of profound disturbance in body image.

It is often difficult to convince individuals with BDD to seek therapy. This avoidance of therapy is regrettable; because the feeling that one is deformed often leads to social isolation. Like an eating disorder, BDD is kept secret because the individual feels humiliated and embarrassed by the obsession with ugliness.

Often, clinical protocol precludes diagnosis of anorexia nervosa and bulimia at the same time, but both have been noted in the same individual at different points in time. Both reflect a profound psychological disturbance. However, eating disorders involves negative feelings about the whole body; whereas body dysmorphic disorder concerns isolated body parts.