Schwartz, who treats plastic surgery patients with body dysmorphic disorder, says that to put it simply, "BDD is not being able to see how you look in reality."
Anorexia and bulimia are the most well-known incarnations of this type of skewed body image, but an "addiction" to perfecting the body through cosmetic surgery can be another way of playing out the same body-image issues.
"It starts as an insecurity, but then [some part of them] thinks that fixing the things on the outside will fix problems inside," Schwartz says.
It's rare that someone will actually become "addicted" to plastic surgery, says Dr. Julius Few, a Chicago-based plastic surgeon, but for in some cases, that "really good feeling" gained post-op becomes a substitute for other things that are missing in the patient's life.
And when patients use the physical changes of cosmetic surgery to fulfill psychological needs, it raises a red flag for plastic surgeons, Few says. "Plastic surgery should not be used to offset something totally unrelated that is going bad in their life."
Dr. Henry Kawamoto, a clinical professor of plastic surgery at the University of California, Los Angeles, says he's had patients with body dysmorphic disorder and says that you get a feel for what the red flags are when a patient comes in.
If they have a long history of multiple procedures, that's a clue, he says. Or if they "talk about flaws that we can't see or that can't be improved with an operation, that's another flag."
Few and Roth say that all board-certified plastic surgeons are trained to gauge when it will be psychologically, as well as physically, healthy for a patient to undergo a procedure, but when in doubt, they refer their patients to counseling.
"Many times there are patients who are already a 10," Roth says, and it seems like they may be having psychological issues that make them think they need to change. In this case, "serious consideration should be given to psychiatric counseling prior to a trip to the operating room," he says, "and I often will suggest that."
Kawamoto says that he will tell them, "'You've maxed out; I can't improve on what you already have.' But unfortunately, they will always find somebody to do it for them."
Schwartz says our society is in part to blame because "in our world of beautiful people, people want to look like those beautiful people they see, to look like a model, and people have gotten carried away."