ORIGINAL ARTICLE
Evaluation of Relationship Between Body Dysmorphic
Disorder and Self-Esteem in Rhinoplasty Candidates
Bahadir Baykal, MD,
Ibrahim Erdim, MD,
Isa Ozbay, MD,y Fatih Oghan, MD,y
Fatih Oncu, MD,z Zeynep Erdogdu, MD, and Fatma Tulin Kayhan, MD

Aim: To investigate the relationship between body dysmorphic
syndrome and self-esteem in rhinoplasty candidates.
Results: A negative statistical correlation was evident between
Rosenberg Self-Esteem Scale (RSES) and Body Dysmorphic
Disorder Examination-Self Report (BDDE-SR) scores. In terms of
responses to the first Body Dysmorphic Disorder Questionnaire
(BDDQ) question, which focuses on general attitude toward body
dysmorphic syndrome, the average RSES YES score was signi- or disadvantaged at work, socially isolated, and at high risk of suicide
ficantly less than the NO score. No significant differences appeared especially when all hope of altering their appearance is lost.2,3
between RSES scores and scores for the 4th subgroup of BDDQ
questions (subgroups A, B, and C; these questions explore how much
time is spent daily on maintenance of bodily appearance). However,
significant differences appeared between scores for the 4th subgroup of
BDDQ questions and BDDE-SR scores. The average BDD-SR score of
subgroup A (less than 1 hour spent on bodily maintenance) was
significantly lower than those of group B (13 hours) and group C
(more than 3 hours). However, no significant differences appeared in
average BDD-SR scores between subgroups B and C.
Materials and Methods: In this prospective study, 56 patients
(31 females and 25 males) were evaluated preoperatively using
the BDDQ, the BDDE-SR, and the RSES. Patients younger than 15
years and those with deformities caused by trauma were excluded.
Conclusions: Rhinoplasty candidates had higher levels of body
dysmorphic disorder (BDD). Although patients with low RSES
scores were more likely to have BDD, rhinoplasty candidates were
not notably deficient in self-esteem. However, in rhinoplasty candi-
dates with low RSES scores, the frequency of BDD was elevated.
Therefore, the authors suggest that rhinoplasty candidates with low
RSES scores should be investigated carefully in terms of BDD.
From the
Department of Otolaryngology, Bakirkoy Sadi Konuk
Education and Research Hospital, Istanbul; yDepartment of Otolaryn-
gology, Faculty of Medicine, Dumlupinar University, Kutahya; zDepart-
ment of Psychiatry, Bakirkoy Psychiatry Neurology Research Hospital,;
Humanite Psychiatry Central, Istanbul, Turkey.; yDepartment of ORL,
Faculty of Medicine, Dumlupinar University, Kutahya; zDepartment of
Psychiatry, Bakirkoy Psychiatry Neurology Research Hospital,; and


Humanite Psychiatry Central, Istanbul, Turkey.
Received January 3, 2015.
Accepted for publication June 28, 2015.
Address correspondence and reprint requests to Dr Fatih Oghan, Evliya
Celebi Egit. Arast. Hast., Okmeydani Cd., Kulak Burun Bogaz AD,
Kutahya, Turkey; E-mail: foghan2001@yahoo.co.uk
Ethical approval: Bakrkoy Sadi Konuk Training and Research Hospital
(approval no. 2012/18/06).
The authors report no conflicts of interest.
Copyright # 2015 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002082
The Journal of Craniofacial Surgery  Volume 26, Number 8, November 2015
Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
(J Craniofac Surg 2015;26: 23392341)
B ody dysmorphic disorder (BDD) is a psychiatric disorder charac-
terized by a preoccupation with an imagined defect in physical
appearance. BDD patients focus on a particular part of the body and
spend a great deal of time in front of a mirror, checking their
appearance. BDD patients have a poor quality of life, even worse
than that of depressed patients.1 BDD patients are often unemployed
Although many individuals with BDD seek nonpsychiatric medical
and surgical treatment to improve perceived defects in physical
appearance, such treatments have received little attention.
BDD is present in approximately 5% of patients seeking cosmetic
surgery4; rhinoplasty is the most frequently sought treatment.5,6
Despite the absence of any physical indication, rhinoplasty is often
performed to improve psychosocial functioning in BDD patients.7
A correlation is evident between individual self-esteem and the
demand for cosmetic surgery,8 and poor body image is associated
with poor self-esteem.9,10 However, the literature on the link
between self-esteem and BDD is sparse, and it remains unclear
whether poor self-esteem is a cause or consequence of BDD.9
In the present study, we evaluated the relationship between BDD
and self-esteem in patients seeking cosmetic rhinoplasty.
MATERIALS AND METHODS
This prospective study included 56 patients (31 females, 25 males)
who sought rhinoplasty at the ENT Clinic of the Bakirkoy Sadi
Konuk Education and Research Hospital between January 2012 and
January 2013. All patients preoperatively completed the Body
Dysmorphic Disorder Questionnaire (BDDQ), the Body Dys-
morphic Disorder Examination-Self Report (BDDE-SR), and the
Rosenberg Self-Esteem Scale (RSES). Patients younger than 15
years or who had deformities caused by trauma were excluded.
Ethics approval was obtained from the Bakrkoy Sadi Konuk
Training and Research Hospital (number 2012/18/06). Informed
consent was obtained from each patient.
The BDDQ was developed by reference to DSM IV criteria and
was used to select patients with possible BDD. The BDDQ has
been validated in a psychiatric population; its sensitivity is 100%
and specificity is 89%.11
If a subject answers the first question NO, BDD is absent, and if
the first answer is YES, BDD is probable. The 4th question
separates patients into subgroups A, B, and C. A patient preoccupied
with his or her body for less than 1 hours daily is grouped into A, for 1
to 3 hours daily into B, and for more than 3 hours daily into C.12
The BDDE-SR explores BDD symptomatology and has 3 parts.
The 1st part assesses the body parts of greatest concern, and the 2nd
the behaviors associated with attempts to improve these body parts
(eg, cosmetic surgery). The 3rd part features 28 questions, to be
answered using a seven-point scale (06). A score of more than 38
points indicates the presence of BDD.13
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Baykal et al The Journal of Craniofacial Surgery  Volume 26, Number 8, November 2015

The RSES features 10 items, each scored on a four-point scale. A TABLE 2. RSES and BDDE-SR Values of Patients
score above 21 reflects positive self-esteem, and lower scores
Male Female Total
indicate lower self-esteem.13 Mean  SD Mean  SD P MinMax Mean  SD
All statistical analyses used Number Cruncher Statistical System
(NCSS) software, 2007 version (Statistical Software, UT). We RSES 31.32  4.69 30.81  5.7 0.718 1840 31.04  5.23
derived descriptive measures (averages, with standard deviations). BDDE-SR 37.6  27.1 53.81  41.9 0.087 0139 46.57  36.67
The independent t-test was used to compare data between groups,
the Chi-squared test to evaluate relationships between variables, and BDDE-SR, Body Dysmorphic Disorder Examination-Self Report; RSES, Rosen-
Pearson correlation test to perform multiple comparisons. Tukey berg Self-Esteem Scale; SD, standard deviation.
t-test was also used. Statistical significance was defined as P < 0.05.

RESULTS TABLE 3. RSES and BDDE-SR Points of Patients

The 56 patients (mean age 27.9 years) included 31 females (mean Male, % Female, % P
age 28.7 years) and 25 males (mean age 26.8 years) (Table 1). The
RSES scores of males and females did not differ significantly RSES <21 RSES 2 8.00 4 12.90 0.555
(P 0.718). Although no significant differences appeared between >21 RSES 23 92.00 27 87.10
male and female BDDE-SR scores, the female scores were some- BDDE-SR <38 BDD 12 48.00 18 58.06 0.453
what higher (P 0.087) (Table 2). A negative correlation was >38 BDD 13 52.00 13 41.94
evident between RSES and BDDE-SR scores (r 0.520
P 0.0001). Thus, when RSES scores rose, BDDE-SR scores fell; BDD, body dysmorphic disorder; BDDE-SR, Body Dysmorphic Disorder Exam-
when RSES scores fell, BDDE-SR scores rose (Table 3). In terms of ination-Self Report; RSES, Rosenberg Self-Esteem Scale.
answers to the first BDDQ question, the average RSES score of
those who responded YES was significantly less than that of
patients who answered NO (P < 0.001) (Table 4). No significant 7% had BDD, and Vargel and Ulusahin16 found that 20% had BDD.
correlation was evident between answers to the 4th BDDQ question In our present study, the percentage was 55.4% by the BDDQ and
and RSES scores (r 0.116 P 0.441). However, a significant 46.4% by the BDDE-SR, thus much higher than those of earlier
correlation was evident between answers to the 4th BDDQ question studies. One reason is that these were prediagnoses, not final
and BDDE-SR score (r 0.461 P 0.002) (Table 5). No significant diagnoses. A second reason is that ethnical and cultural differences
correlation was observed between the scores of any subgroup may be in play.
formed by the answers to the 4th BDDQ question and RSES score Phillips et al17 found that among females, 68.5% had BDD, and
(P 0.503) (Table 6). However, significant correlations were evi- Zimmerman and Mattia18 found that 75% of females had BDD. In
dent between the scores of subgroups formed by answers to the 4th the present study, 20 (64.5%) of the 31 females were BDDQ-
BDDQ question and BDDE-SR score. The average BDD-SR score positive, as were 11 (44%) of the 25 males. Thirteen (34%) females
of subgroup A was significantly lower than those of subgroups B had BDDE-SR scores of 38 or above, as did 13 (52%) males. More
and C (P 0.005 and 0.047), but no significant difference was females than males had BDD according to the BDDQ, but the
evident between subgroups B and C (P 0.933) (Table 6). reverse was true according to the BDDE-SR. The proportion of
Of the 56 patients, 54 were principally dissatisfied with their females with BDD proportion was lower than those reported in the
noses, and 2 principally dissatisfied with their backs and abdomens. literature; this difference may be attributable to social factors.
Five patients were dissatisfied with their backs and abdomens Overall, 26% of BDD patients undergo at least 1 operation.19
(31.25%), 2 with their hair (12.5%), 2 with their mouths Phillips et al17 found that 128 (64%) of 200 BDD patients under-
(12.5%), 1 with the chin (6.25%), 1 with the upper leg (6.25%), went nonpsychiatric procedures. In the present study, 18 (32%)
1 with the face (6.25%), 1 with the forehead (6.25%), 1 with the foot patients had attempted to change their bodies before applying to our
(6.25%), 1 with the hip (6.25%), and 1 with the entire body (6.25%).
Rhinoplasty candidates reported prior rhinoplasty (6 patients),
as well as the use of exercise (4), diet (2), skin creams (2), tooth TABLE 4. RSES Points for the 1st Question of BDDQ Subgroups
whitening (1), (operative) stomach reduction (1), and rounding of N RSES Total P
the beard (1), as efforts to improve body image.
BDDQ-1 YES group 31 28.87  5.70 0.0001
DISCUSSION NO group 25 33.72  2.99

The nose is centrally located on the face, so perception of it can

affect psychological status. The psychological, cultural, and sexual
significance of the nose has been explored for more than a century.6
Andreasen et al14 found that 20% of individuals visiting plastic and
reconstructive surgery clinics had BDD, Sarwerer et al15 found that
BDDQ, Body Dysmorphic Disorder Questionnaire; RSES, Rosenberg Self-Esteem
Scale.
TABLE 5. RSES and BDDE-SR Analysis for the 4th Question of BDDQ

BDDQ-4
TABLE 1. Age Distribution of Patients

N Average SD Min Max RSES total R 0.116

P 0.441
Male 25 26.76 6.972 15 47 BDDE-SR total R 0.461
Female 31 28.77 9.763 18 48 P 0.002
Total 56 27.88 8.615 15 48
BDDE-SR, Body Dysmorphic Disorder Examination-Self Report; BDDQ, Body
SD, standard deviation. Dysmorphic Disorder Questionnaire; RSES, Rosenberg Self-Esteem Scale.

2340 # 2015 Mutaz B. Habal, MD

Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 26, Number 8, November 2015
TABLE 6. RSES and BDDE-SR points according to fourth question of BDDQ
subgroups
N RSES Total BDDE-SR Total
BDDQ-4 A 21 29.19  6.063 49.76  30.149
B 6 29.83  2.639 99.67  19.816
C 4 25.75  7.274 92.5  49.534
P 0.503 0.002
BDDE-SR, Body Dysmorphic Disorder Examination-Self Report; BDDQ, Body
Dysmorphic Disorder Questionnaire; RSES, Rosenberg Self-Esteem Scale.
clinic for rhinoplasty: 6 had undergone prior rhinoplasties, 4 had
embarked on exercise programmes, and 3 on dietary programmes.
Notably, 6 patients who had undergone prior rhinoplasty requested
repeat rhinoplasty, demonstrating the importance they placed on the
nose in terms of appearance.
Phillips et al17 found that attempts to change the body could be
ordered as skin (80%), hair (58%), nose (39%), abdomen (32%),
tongue (30%), weight (29%), breasts (26%), bottom (22%), eyes
(22%), thighs (20%), hips (20%), face (19%), general weight loss
(18%), legs (18%), facial structure (16%), chin (15%), lips (15%),
arms (14%), cheeks (11%), and ears (11%).17 They also found that
females were more concerned than males about legs, the bottom,
hips, skin, nose, and hands. Cansever et al20 found that attempts to
change the body could be ordered as hips (50%), face (30%), teeth
(30%), eyes (30%), nose (25%), ears (25%), hair (25%), skin (10%),
and breasts (5%). In our present study, patients were dissatisfied
with (in order) their noses, waists, and abdomens. Only 1 patient
was dissatisfied with the entire body. One male patient was more
dissatisfied with his mouth than his nose, but all other regions
triggering dissatisfaction were female. Displeasure with the waist
and abdomen was more frequent among our patients than among the
subjects of previous studies, who tended to perceive more problems
with skin and hair. However, we found that females were more
dissatisfied than males with regions other than the nose, consistent
with previous research.
We found that subjects who worried a great deal about their
physical appearance had low self-esteem, consistent with the litera-
ture,4,9,21 and demonstrating the importance of self-esteem in cos-
metic surgery settings, especially among patients with BDD.
However, we found no significant relationship between low self-
esteem and a desire for rhinoplasty. However, in patients with low
RSES scores, the prevalence of BDD was higher. Self-esteem has
been reported to be significantly lower in subgroup C than A
patients.4,9,21 We found no relationship between RSES scores and
those of subgroups A, B, or C. However, the BDDE-SR score of
subgroup A was significantly lower than those of subgroups B and C.
Phillips et al22 studied 93 patients with BDD diagnosed using
DSM-IV criteria; the average RSES score was 23.8. They found that
as RSES scores fell, BDD severity, delusions, and depression all
increased. In our present study, not all subjects had BDD and the
average RSES score was not as low as that reported by Phillips et al.
However, we also found that as the RSES score fell, the BDDE-SR
score increased. Our RSES scores were comparable to those in the
literature. We found that rhinoplasty candidature did not decrease
self-esteem, but that rhinoplasty candidates with lower RSES scores
had a higher prevalence of BDD.
# 2015 Mutaz B. Habal, MD
Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
BDD and Self-Esteem in Rhinoplasty
In conclusion, many rhinoplasty candidates had BDD, the
probability of which was higher in patients with low RSES scores.
However, rhinoplasty candidature was not significantly associated
with low self-esteem. Nevertheless, rhinoplasty candidates with
lower RSES scores had a higher prevalence of BDD. Therefore,
rhinoplasty candidates with low RSES scores should be carefully
investigated in terms of BDD.
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