TOKYO - A woman in her 30s who sees cosmetic surgery as casually as a trip to the hairdresser is among patients highlighting the difficulty of identifying body dysmorphic disorder (BDD) in Japan.
"I'm always thinking about which part I should 'update' next," said the woman, who works in the service industry in the Kanto region.
She has undergone a string of cosmetic procedures since her 20s, including double-eyelid surgery, having artificial cartilage inserted into her nose and liposuction.
Her interest in cosmetic surgery faded for a time after she gave birth but soon returned. Seeing images of influencers on social media made her uneasy about her own appearance. She borrowed money from family members to undergo surgery in South Korea, but soon found another part of herself that bothered her.
Looking in the mirror, she thought, "I can't bear the idea of living with this face for the rest of my life."
About a year ago, she visited a psychiatric and psychosomatic clinic in Tokyo's Chuo Ward run by psychiatrist Hiroaki Harai for treatment of obsessive-compulsive disorder, or OCD, which she already had, and was also diagnosed with BDD.
The condition causes people to become so preoccupied with their appearance that it interferes with their daily lives. Some continue undergoing cosmetic surgery without ever feeling satisfied, while having little awareness that they may have a disorder.
The woman sees changing her face as a hobby and has little sense that it is an illness.
"I want my child to grow up without suffering under the pressure of lookism," she said, referring to an excessive emphasis on physical appearance.
Even so, she wants to continue having cosmetic surgery.
Another patient at the same clinic, a woman in her 20s, once became unable to attend high school because of concerns about her appearance.
After putting on makeup and getting ready to go out, she sometimes became so depressed that she could not leave home. At other times, she boarded a train but got off before reaching her destination and returned home.
When under pressure from exams or approaching assignment deadlines, her attention would shift to her face. She would pinch her nose in an attempt to make the bridge look higher and became convinced that cosmetic surgery was something she had to undergo in her lifetime.
At the urging of her parents, she began attending the clinic several years ago.
She received treatment including medication and cognitive behavioral therapy aimed at easing her distress. As part of the therapy, she practiced facing her own reflection in glass.
After treatment, she found it somewhat easier to walk through crowds.
But problems remain. During online university classes and job interviews, seeing her own face on the screen can draw her attention away from what is being said.
"I come here for treatment so I can survive in this world," she said.
Psychiatrist Hiroaki Harai, who runs the clinic and has treated many BDD patients, said the disorder is characterized by a pursuit of perfection.
"Many patients who come to see us are still searching for the goal itself -- what kind of person they want to become," he said.
Concerns vary from facial features to body hair. BDD has generally been considered more common among women, though Harai said growing numbers of men in their teens and 20s are seeking treatment.
The number of people with the disorder in Japan is unclear.
To help identify suspected cases, Harai and cosmetic surgeon Goichi Haraoka, a specially appointed associate professor at Osaka Metropolitan University, compiled a manual outlining signs such as excessive concern about appearance, depressed mood and problems with personal relationships, school, work or social activities.
Haraoka said he suspects BDD when patients have clearly undergone excessive surgery but remain dissatisfied with the medical care they receive.
He said dissatisfaction can sometimes simply reflect inadequate cosmetic treatment, but where that is not the case, doctors need to consider the possibility of BDD and connect patients with appropriate care.
But referrals from cosmetic surgery clinics to psychiatrists are not routine, while relatively few psychiatrists have experience treating the condition.
With information about beauty and appearance widespread on social media, Haraoka said it is unrealistic to expect people to live without thinking about how they look.
"We need to raise awareness of BDD in cosmetic surgery and deepen cooperation with psychiatry," Haraoka said.
