Broken Mirror, Reflection

Body Dysmorphic Disorder: What You Need to Know as a Bariatric Patient

April 19, 2017

Body Dysmorphic Disorder (BDD) or Body Dysmorphia is a topic many people wonder about in the WLS community. There are some common misconceptions and mystery as to what it is, so gaining clarity on the matter will help you in understanding BDD. Even more so, what you can do about it should you have this condition.

What Body Dysmorphic Disorder Is

BDD is a DSM-5 diagnosis, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), that involves distress due to a perceived physical anomaly, such as a scar, the shape or size of a body part, or some other personal feature. It is more than just having doubts or dissatisfaction with one’s appearance. People with BDD experience persistent, intrusive thoughts about the imagined defect to the degree it impairs their interaction with others. Though others are not concerned with or aware of the anomaly, the person with the imagined flaw will have great concern over where, when or who they interact with because of it.

BDD has been experienced around the globe for more than 100 years. It is relatively common in the general population with estimates being anywhere from 2 – 13%, depending on the study.

Unfortunately, BDD often goes unrecognized, undiagnosed, and untreated.

Some common features of BDD include someone repeatedly seeking reassurance about their imagined flaw, compulsively comparing themselves to others, excessive checking of the flaw in mirrors, skin picking, and being distracted by the obsessions to the point of neglect in an area of their life. Though the perceived flaw is minimal or even nonexistent to others, the person with BDD will often engage in self-deprecating or self-critical talk, “I’m ugly, and look disgusting.”

Knowing The Difference

In the WLS community, body image issues are common. The majority of people tend to be dissatisfied with their bodies and outward appearance more than their “normal weight” peers. But being dissatisfied with one’s appearance is more often indicative of having a distorted body image versus having BDD.

Having a distorted body image can be differentiated from BDD in that it involves a preoccupation with overall body mass, whereas BDD involves focusing on a specific part or feature.

The psychosocial functioning and quality of life with BDD is usually markedly poor. For example, occupational, social and other areas of functioning are really impaired.

Most of the people whom I have interviewed admit to having body image issues before surgery, and, after surgery.  However, they quickly point out that the issues are just “different.” Before surgery, it may be a general dissatisfaction with one’s body or appearance, after surgery it may become more specific. The most common preoccupation post-op seems to be…drum roll, please…excess skin! To no one’s surprise, this is the number one complaint of many WLS patients after surgery. And the degree to which this issue affects people is relative to the amount of weight loss, genetics, elasticity, etc. Some people have the means and resources to have this taken care of after WLS, but some people don’t.

What Does This Mean For WLS Patients?

The good news is that body image can improve with even a modest reduction in weight. It can also affect romantic and sexual relationships. In the social realm, relational dynamics can change as well. Many people who lose weight after having surgery often receive compliments on their progress and appearance from people who are close to them and people who are more in the acquaintance category.

Losing a significant amount of weight can bring about a great sense of accomplishment, but some will experience distress, as living in a thinner form sometimes comes with unwarranted attention. Imagine describing oneself, like many of my patients, as being “invisible” prior to having surgery to being in the spotlight to those around you afterward. The statement I hear on a regular basis, “Now my weight is everybody’s business,” can bring about resentment and feelings of vulnerability. Because, as in many cases, it’s implied that one’s worth is tied to body shape or weight.

A lot of the time there is an identity shift taking place after surgery because thinness is new and unfamiliar. This can become uncomfortable and unsettling for some.

People who struggle with this aspect have admitted to me, “I wish I was big again because I knew what to do with it.” This mindset is potentially scary in that it is a precursor for self-sabotage.

What You Need To Know

It takes a while for your brain to catch up with your body’s metamorphosis after WLS. It will take you experiencing various situations numerous times to help your brain adapt and adopt your new frame.

There is a disconnect between your brain and your body when it comes to self-perception. I have patients who have maintained a 100-pound weight loss for a decade, yet continue to have difficulty seeing themselves as they are. Seeing and believing aren’t always in sync.

One of the most interesting phenomenon for me in working with WLS patients is how they perceive themselves. It is common for those who have had surgery to be told by friends that their clothes are too big for them. To their surprise, they will actually fit in a size smaller (or two) garment than they thought was possible.

What your brain sees in your mirror and what you see in an old photo can be two completely different things. This isn’t BDD, and it probably isn’t body image distortion; however, it is more likely body image adjustment. Your brain and eyes, in a sense, have to recalibrate to the reality of the new image. The image has to become ingrained in your brain over time through seeing yourself in your new form time and time again.

Remember, having body image concerns is normal. The struggle in this area is more common than what you may realize. Though body image concerns often begin in adolescence, they play out in adulthood. No matter where you are in the WLS journey, it is up to you to take care of yourself including your body image and self-image.


It is important for anyone struggling with body image issues to seek help as soon as they can. Whether it’s BDD, body image distortion, or body image adjustment, getting help will allow the sufferer to not feel alone in their struggle. The following are suggestions and tips going forward:

  • See a professional to assess where you are on the body image spectrum. Don’t self-diagnose.
  • Seeking professional help to minimize self-sabotage behavior is a must. A clinician with experience in bariatrics and cognitive-behavioral therapy can be a tremendous ally.
  • Be aware of conditional value; “As long as I look a certain way, I am worthy of other people’s love and acceptance.”
  • In therapy, work on learning to accept compliments and handling comments from others.
  • Anyone who has a history of weight-related mistreatment and abuse are more likely to have body image concerns.
  • Monitor your own tendency to obsess or be preoccupied with anything related to your body image. You need to be kind to your body.
  • Monitor any self-critical behavior. The best anti-bully campaign you can be a part of is giving yourself positive words that are like nutrition for your soul.
  • Attaining and maintaining self-acceptance at all stages of the weight loss journey is key. Without self-acceptance, sabotage will result.
  • If you don’t reinforce you’re worth it, you’re not going to sustain it (your health).


Dr. Steven Reyes offers expertise on the psychological adjustments associated with weight loss surgery. Dr. Reyes is best known for his compassionate coaching and therapeutic approach in helping others with their psychological and physical well-being. Dr. Reyes' research includes a phenomenological study of the post-surgical adjustment issues with weight loss surgery patients between 1 and 2 years post-op.

Read more articles from Steven Reyes!