Body Dysmorphic Disorder, BDD is defined as an excessive concern about a marginal defect in appearance, psychologically affecting work, personal & social life.

1. Body Dysmorphic Disorder in
Hair loss Patients &
Benefit After Hair Transplant
Dr Rajesh Rajput aka Rajendrasingh,
M.S., M.Ch.,
Plastic Surgeon, Mumbai.
drrajeshrajput@gmail.com
www.hairlossindia.com,
+91-9821308411

2. Patient Selection
Age – 21 to 50 yrs, 100 male patients
Random volunteers – 19 refused to
enroll after reading the questionnaire
Hair loss Grade I – Grade V
Grade VI & VII were excluded
Re-evaluation for improvement
8months after Hair Transplant

3. Body Dysmorphic Disorder, BDD is defined as an excessive concern
about a marginal defect in appearance, psychologically affecting
work, personal & social life. BDD Suspects –
1. Patients who want lower hairline & more density
despite the number of sittings it may take
2.Patients wearing a hair piece at early grades of baldness
3.Patients wearing a cap continuously
4.Patients unwilling to remove cap or hair piece even
for clinical evaluation or refusing photographs
5.Patients remain isolated from family and social events
Started by recording the patient’s expectations & surgeons plans
Later found systems for evaluation of obsessive behavior, impact on
work, family, social life & personal perception of appearance
Planned this study to evaluate effects of obsessive behavior and
compare any changes or benefit after hair transplant

4. Table 1 - Patient’s Personal Evaluation of the Deformity discussed with the Surgeon’s Plan
Criteria Score 0 Score 1 Score 2 Score 3
Level of the
hairline
Good as it is Acceptable with
marginal
correction
Correction as per
doctors
Guidelines
Unusual
expectations or
own ideas
Shape of the
hairline
Good as it is Acceptable with
marginal
correction
Correction as per
doctors
Guidelines
Unusual
expectations or
own ideas
Temporal
receding
To match the
hairline
Acceptable with
marginal
correction
Correction as per
doctors
Guidelines
Unusual
expectations or
own ideas
Thinning and
Scalp show
Average
correction to
look better
Correction in
directly visible
areas
Correction as per
doctors
Guidelines
Very high Density
all over
Baldness in one
or more areas
Average
correction to
look better
Correction in
directly visible
areas
Correction as per
doctors
Guidelines
Very high Density
all over
Mild – 0 to 5, Moderate – 6 to 8, Severe – 9 to 11, Extreme – 12 to 15
Severity judged by the patient did not match clinical grade of Hair loss.
Patients perception of deformity was much higher than surgeon’s evaluation of the deformity.

5. Yale–Brown Obsessive Compulsive Scale
Identification of one or more Obsessive behaviors -
1.Looking frequently into the mirror,
2.Spending time to set the hair
3.Adjust slightest disturbance in their hair,
4.Wearing cap all the time at home & work,
5.Using hair concealers and topping up during the day,
6.Refusing dance, games etc. where hair may get undone,
7.Spending time with selected friends & family members,
8.Avoiding photographs and social events,
9.Spending time looking for newer hair loss remedies,
Scale evaluates time spent on obsession and the effect on
work, family, social and day to day life
Same scale was used to record improvement with therapy
Part of the scale for compulsive actions was not used

6. Table 2: Yale – Brown Obsessive Scale – Score of 10 & above Indicates BDD
Obsession Score 0 Score 1 Score 2 Score 3 Score 4
Time spent
on Obsession
0 hours 0 – 1 hours 1 – 3 hour 3 – 8 hours >> 8 hours
Interference
from
Obsession
None Mild Definite
manageable
Substantial
impairment
Incapacitating
Distress
from
Obsession
None Mild Moderate
manageable
Severe Constant and
Disabling
Resistance
to the
Obsession
Always
Resist
Often resists Sometimes
can resist
Only try to
resist
Cannot resist
Control over
the
Obsession
Complet
e control
Much control Little control Some control No Control
Mild – 0 to 5, Moderate – 6 to 9, Severe – 10 to 14, Extreme – 15 to 20
Score above 10 indicates BDD

7. Figure 1

8. Evaluation of Residual Traits in 16% with
Severe Score
Still wanted to look in the mirror several times a day
sometimes taking break from their work
Wanted to first go to the washroom and set hair right
before entering the party, meeting or social event
Wanted to comb the hair between a dance or after dance
Would have photographs only at a particular angle where
the hair looked the best

9. Evaluation of Work, College, Social and
Family Life
• Cannot concentrate due to thoughts about hair loss
• Frequent distraction or need breaks from work or studies
• Inability to complete assignments
• Hair loss is affecting friendship & acceptance by peers
• Reduced participation in social events
• Keep company of select few family members
• Do not like any talk or discussion about their hair loss

10. Table 3 Sheehan Disability Scale – for Social Life
Criteria No
Disturb
-ance
Mild - Continue
routine but
concerned
Moderate – worry
makes routine
incomplete
Severe – worry
stops or
reduces routine
activity
Extreme
– cannot
carry on
routine
life
Score
0 1 2 3 4 5 6 7 8 9 10
Work or
School
Social
Life
Family /
Home
Mild – 0 to 9, Moderate – 10 to 18, Severe – 19 to 27, Extreme – 27 to 30

11. Figure 2
88% had Improved Work,
Family, Social life but 12%
Scored Severe

12. Evaluation of Residual Traits in 12% with
Severe Score
Never make up for some opportunities that were missed
Could not get the kind of friends that others had
Brothers and sisters who are better looking enjoy more
affection among family members
Colleagues with more hair are preferred for important job
assignments
Ridiculed by bald friends for having a hair transplant done

13. Evaluation of Personal Feelings & Emotions
raised due to hair loss
Self -conscious of appearance and worried about the
reactions and comments by others
Reduced Confidence or Poor Self Esteem
Nervousness, distress, depression, irritability,
Feel rejected, hurt, misjudged, unworthy,
Unable to give the best in life, underachieved,
Lack of initiative, feeling low,
Difficult to relax, always thinking about hair loss

14. Table 4 Derriford Personal Appearance Short Scale - Modified
0 Did not apply to me at all 1 Applied to me to some
degree, or some of the time
2Applied to me to a considerable degree 3 Applied to me very much,
or most of the time
Criteria Score
0
Never
1
Sometimes
2
Considerable
3
Always
1 Feeling loss of Confidence
2 Distress at Reflection
3 Irritable at Home
4 Feel Hurt, Feel Rejected
5 Self Conscious of appearance
6 Distress at Pubs Restaurants or
Social events

15. Table 4 Derriford Personal Appearance Short Scale – Modified - Continued
Criteria Score
0
Never
1
Sometimes
2
Considerable
3
Always
7 Misjudged due to appearance
8 Feel incomplete masculine or
feminine
9 Felt I wasn't worth much as a person
10 Adjust the hair if it flies or gets
disturbed
11 Adopt Concealing Gestures
12 Difficult to work up the initiative to
do things
13 Tended to over-react getting upset
by quite trivial situations
14 Found others preferred over me for
important assignments

16. Table 4 Derriford Personal Appearance Short Scale – Modified - Continued
Criteria Score
0
Never
1
Sometimes
2
Considerable
3
Always
15 Felt sad and depressed sometimes
16 Found myself getting impatient when I
was delayed in any way
(eg, lifts, traffic lights, being kept
waiting)
17 Could have done better with proper
looks
18 Felt that I had nothing to look forward
to
19 Found it difficult to relax
20 Felt nervous in situations, with raised
heart rate sweating or shaking feet
Mild – 0 to 10, Moderate – 10 to 30, Severe – 31 to 50, Extreme – 51 to 60,

17. Figure 3

18. Evaluation of Residual Traits in 61% with
Severe to Extreme Score
Still need to use hair filler and camouflage
Will always have less hair than others around them
Others may recognize the hair transplant on close look
and form an opinion based on it
Need to use a fixed hair style, Crown looks bald
 Not enough to make you feel complete
Density is inadequate, not equal all over
More sessions required but are very expensive

19. Conclusion
We need be more sensitive to apparently minor changes in hair loss patients
Patient’s Personal perception of hair loss is more severe than the clinical
evaluation
Yale-Brown Scale, Sheehan Scale & DASS Scale can evaluate the Social,
Personal, Psychological & Emotional effects in hair loss patients
Incidence of BDD in hair loss is 28%, higher than rhinoplasty 20.7%
Patients Concern for Hair loss, Obsessive Behavior, Work, Family and Social
Life can be improved by 84% after a Hair Transplant, however,
All 100% Patients have severe to extreme concern with the Personal &
Emotional Perception of their hair loss & 61% continue to have it even after
Hair Transplant
Further evaluation and structured research on BDD in Hair loss is required