After performing cosmetic surgeries for nearly a decade, Dr. Beverly Fischer, head surgeon at the Advanced Center for Plastic Surgery in Maryland, encountered a patient who would haunt her for years.

A young woman in her 20s, who had recently lost weight, was seeking nasal reconstruction surgery. “She told me, ‘I don’t want a cute turned-up nose, I just want it slightly smaller,'” said Dr. Fischer. “Everything she asked for sounded realistic. I operated on her and when she first came back she was like, ‘I don’t know if it’s small enough. I don’t know if I see much of a difference.’ I told her that it takes close to a year for the swelling to go away and that she had to be patient.”

This dissatisfaction with her surgery resulted in multiple visits to Dr. Fischer’s office. The patient would come in, appointment or no appointment, requesting more surgeries, expressing dissatisfaction about teasing from family and friends, and worrying that she couldn’t go out at night because she thought she looked like a trauma patient. “She was coming in every week complaining about something,” said Dr. Fischer. “She was almost incapacitated to the point where she couldn’t go out of her house anymore.”

After Dr. Fischer suggested she see a psychiatrist, the patient, who felt offended by her comment, continued to harass Fischer and her staff, even bringing in her husband to chastise the doctor on her medical advice. “It got to be a nightmare,” admits Fischer. “I just gave her back their money and told her that I couldn’t communicate with her anymore, and that it was best if she left the practice.”What Dr. Fischer didn’t know at the time was that her patient was suffering from body dysmorphic disorder (BDD), a body image disorder characterized by an obsessive preoccupation with some perceived defect in appearance. BDD causes those who suffer from it significant distress, and it’s a difficult disorder to treat. Oftentimes, it is categorized as an obsessive-compulsive disorder, but while both conditions might share the same OCD-spectrum, researchers have found a significant difference between OCD and BDD: People with BDD tend to have poorer insight than OCD patients, and they tend to be more delusional.