Plastic surgeons may be missing signs of mental illness in most of their patients who have diagnosable body image issues.

Researchers screened almost 600 patients seeking cosmetic or reconstructive surgery for body dysmorphic disorder and then had plastic surgeons independently evaluate those patients. They found a disparity in the number of diagnoses between the two groups, according to a study published in JAMA Facial Plastic Surgery. While the researchers marked off almost 10 percent of the patients screened as having the mental illness, which could drive a person to seek plastic surgery, the surgeons only identified a fraction of that group in their own evaluations — less than 5 percent of those affected.

Read: Surgeon Leaves Scissors in Patient

Body dysmorphic disorder is “characterized by persistent and intrusive preoccupations with an imagined or slight defect in one's appearance,” the Anxiety and Depression Association of America explains. Although many people have a physical feature they don’t like, that dislike in a person with BDD will interfere with their life because they cannot control their obsession, and “think about their real or perceived flaws for hours each day.”

“They may even undergo unnecessary plastic surgeries to correct perceived imperfections, never finding satisfaction with the results,” the association says, estimating that about 1 percent of Americans have the disorder.

Some other signs of the mental illness include exercising excessively; constantly comparing themselves to others; camouflaging their appearance with makeup, hats or body positioning; constantly checking themselves in a mirror or avoiding mirrors all together; and picking at the skin.

According to the study, there is not a lot of documentation on how many people with BDD get plastic surgery and the doctors do not commonly screen for the mental illness in a formal manner. “Routine use of validated BDD screening tools may improve patient care.”

One of the study authors, Johns Hopkins University School of Medicine otolaryngology professor Dr. Lisa Ishii, said in a story on CBS News that it was a surprise how many patients had body dysmorphic disorder and how often surgeons missed it, and she’s concerned “we are inherently biased” in a belief they can help patients get better.

But Dr. Rodney Rohrich, editor-in-chief of the journal Plastic and Reconstructive Surgery, told CBS that people with BDD are looking to deceive plastic surgeons and would be unlikely to fill out a questionnaire about the mental illness, instead trying another surgeon. “They do eventually find a surgeon who will operate on them again,” he said.

Although Ishii suggested referring people suspected of having BDD to a psychiatrist, Rohrich instead turns them away because he finds confronting them about their condition doesn’t work. “I try to let them down softly. I try saying, ‘I don’t see what you see.’ Sometimes I just tell them, ‘I’m not good enough to give you the result you want.’”

Source: Ishii M, Joseph AW, Ishii L, et al. Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics. JAMA Facial Plastic Surgery. 2016.

See also:

Natural Childbirth After Fibroid Surgery

Toddler Gets Tongue Reduction Surgery