The 'ugly truth' about Body Dysmorphic Disorder
It is often dismissed as a "first world" problem and a "bad case of vanity" caused by today's obsession with appearance and celebrity.
But, writes Susanna Jolly, Body Dysmorphic Disorder (BDD) affects up to one in 50 people and many with the condition "self-medicate" by undergoing frequent and repeated plastic surgery procedures.
Former glamour model Alicia Douvall famously spent over £1m on over 300 procedures - but two years ago she spoke about her addiction to surgery was driven by her undiagnosed battle with BDD.
The condition is a disabling preoccupation with an imagined, or slight, flaw in appearance.
Symptoms often start in adolescence.
Minnie Wright, 47, has suffered from BDD for most of her life.
"The symptoms started when I was 11 after being bullied at school.
"A lot focused on the size of my nose."
Minnie says she would apply "shading" make-up and hold her head in a particular way to avoid showing her nose in profile.
Vanity? Not fair
People with BDD delay seeking help for fear of being dismissed as vain.
Dr David Veale, one of the foremost BDD experts, specialised in this area 20 years ago following the suicide of a BDD patient under his care.
He says: "Ideally, we want to try and diagnose people with BDD early, as treating them is easier than once the thoughts and anxieties have really become entrenched.
"The most important message is that BDD is a treatable illness."
BDD treatment is typically a combination of an anti-depressant medication and cognitive behavioural therapy - but the wait for diagnosis and treatment can be lengthy.
Plastic not 'fantastic'
During these delays, BDD sufferers may try to "cure" their perceived imperfections with plastic surgery.
Minnie explains, "I wanted something done, but was still a child. I had a nose job done privately on my 18th birthday.
"Initially, I did feel better, but ultimately I was unhappy.
"It was a bit like moving the furniture around - the underlying problem was still there, it just all looked a bit different".
Later in life Minnie's focus shifted to unhappiness with her hair and the symptoms were so "immobilising" she contemplated suicide.
Studies have suggested people with the condition have a much higher suicide rate than the general population. Minnie herself has known four people who have committed suicide while they had BDD.
Dr Veale, who also works with the Body Dysmorphic Disorder Foundation, acknowledges this higher risk: and reports that a third of his patients have had at least one cosmetic procedure.
Crucially, fewer than 10% of BDD patients will be satisfied with the results.
Their anxieties are often transferred to another aspect of their appearance, sometimes leading to multiple procedures.
Around 15% of people seeking plastic surgery are thought to have BDD.
Mr Simon Withey, a consultant plastic surgeon, said: "BDD is extremely complicated and surgeons will never be experts.
"However, you get a sixth sense that something is not right if you ask the right questions. For me, one of the signs is if the patient is 'over-prepared'.
"If I sense something is not right, I won't operate".
Psychiatrists have a number of assessment tools they use to identify BDD, but these are too long to be useful in a surgeon's clinic.
Dr Alex Clarke studies the psychological aspects of plastic surgery. Her team has been developing a more accessible BDD screening questionnaire.
She said: "Primarily surgeons want to operate. Their concern is that if they say no, the patient will walk out the door and go and see someone else a few doors down".
The questionnaire identifies the presence of classic BDD symptoms and explores the patient's expectations. Both surgeons and patients have been accepting of this new tool in current trials.
"Over the past 15 years we've seen surgeons go from being quite resistant to recognising that these are part of delivering a gold standard service," says Dr Clarke.
But the question is how to reach those unscrupulous individuals who will do anything for the right price?
Mr Marc Pacifico, a consultant plastic surgeon and spokesman for the British Association of Aesthetic and Plastic Surgeons (BAAPS) said: "It's a wild west out there.
"It is a sad fact that if you look hard enough, you will find someone who will do whatever surgery you want. Anyone can call themselves a "cosmetic surgeon" and set up a practice.
"People can easily be fooled by a flashy website or renowned address."
BAAPS recommend for looking for "badges" of credibility such as Fellowship of the Royal College of Surgeons (FRCSPlast) and the surgeon being a BAAPS member.
Poor practice includes being seen initially by a salesperson, rather than a surgeon, and surgery offered at a low price, or part of a time-limited deal.
The comments that follow any online article about BDD often dismiss it as a "first-world problem".
But there is evidence that is not the case. Prof Leo Fontanelle is a BDD specialist from Rio de Janeiro. Brazil has the second highest rate of plastic surgical procedures performed in the world.
He says: "We have seen patients from across the socio-economic classes. We don't yet have the data to tell us how many of our patients have surgery prior to being diagnosed and treated.
"However, it remains important for our plastic surgeons to be aware and refer patients to the appropriate services".
Is the selfie to blame?
Media images have long been cited as one potential factor in leading people to develop poor body image, and recent years have also seen the rise of the selfie.
A recent survey showed that 16-25 year olds spend on average 16 minutes and seven attempts to take the perfect selfie.
So is this pressure to look perfect affecting people's mental state?
Dr Veale says not. "It is difficult to draw the line where body dissatisfaction stops and BDD starts.
But he says it is actually earlier life events such as poor child-mother attachment and bullying that are more significant.
"The media pressures are out there, but they are only a small part of the story".
Dr Clarke wants education and awareness in schools needs to improve.
"Children need to be taught some 'media literacy' to understand that all the airbrushed images they see aren't real.
"It is too easy to become a victim of this pressure if you are not socially robust enough."