Body dysmorphic disorder: the role of the aesthetic practitioner - Hamilton Fraser


Body Dysmorphic Disorder (BDD) is, according to the NHS, “a mental health condition where a person spends a lot of time worrying about flaws in their appearance. These flaws are often unnoticeable to others.”

What are the statistics around Body Dysmorphic Disorder in aesthetics?

The prevalence of BDD itself varies from one study to another, but there is consensus that a high percentage of patients with the disorder present themselves at aesthetic practices.  One study found up to 70% of people with BDD had sought cosmetic procedures, and half had received such interventions.

According to epidemiologic studies summarised here, 0.7% to 2.4% of the general population are affected by BDD. These studies suggest that it is more prevalent than disorders such as schizophrenia or anorexia nervosa. In addition, BDD is more commonly found in clinical settings, particularly cosmetic surgery settings where the population can reach 3% to 53%.

While the studies indicate that BDD is relatively common, it is likely that they underreport its prevalence, as many individuals with BDD feel ashamed of their appearance and may not convey their symptoms to clinicians.

Why do patients with Body Dysmorphic Disorder seek aesthetic interventions?

It is not surprising that high rates of BDD are found amongst people seeking aesthetic interventions. After all, to the individual affected by BDD, seeking an intervention to fix ‘defects’ in their appearance seems like a perfectly viable solution. The trouble is, that while the BDD sufferer obsessively fixates on their perceived physical flaws, these flaws are usually unnoticeable to others. While BDD is primarily a mental health problem, patients tend to consult aesthetic practitioners in the belief that their issues are physical in nature.

A young woman looking at her reflection in the mirror, unhappy with what she is seeing.

How can aesthetic interventions make BDD worse?

For the aesthetic practitioner, identifying a patient who may be suffering with BDD is important, because there is evidence to show that cosmetic interventions may actually make the condition worse.

Aesthetic procedures cannot solve the underlying psychological problem and tend to leave the majority of sufferers worse off – they overwhelmingly see the resulting outcome as unsatisfactory, even if the practitioner is pleased with the result. This inevitably leads to requests for more treatments, followed by increasing frustration on behalf of both the patient and the practitioner.

While this situation is obviously detrimental to the patient, it can cause a lot of stress for the practitioner too, including the potential of violent behaviour towards them. For example, according to an article in the Aesthetics Journal, 2% of BDD patients threaten their practitioners and surgeons physically and at least two cosmetic surgeons have been murdered by patients with BDD. According to one survey, 12% of plastic surgeons said that they had been threatened physically by a dissatisfied BDD patient.

It may initially seem harmless, not to mention potentially lucrative, to take on a patient with a long wish-list of treatments and interventions. But if the patient also has BDD, it is unlikely that any number of interventions are ever going to be good enough and no professional aesthetic practitioner wants dissatisfied customers.

How can aesthetic practitioners identify patients who may have Body Dysmorphic Disorder?

Clearly, for the safety of both the patient and the practitioner, it is important to recognise patients with BDD. A 2016 study published in the Journal of American Medicine found that routine use of BDD questionnaires for patients seeking cosmetic surgery could improve patient care. The study’s author, Dr Lisa Ishii, noted that she was surprised at the high prevalence of BDD among cosmetic surgery patients. “The other surprise was just how poor we were as surgeons at picking it up,” she said.

Screening questionnaires to recognise Body Dysmorphic Disorder

As highlighted in the Aesthetics Journal, there are a number of existing screening questionnaires that practitioners can incorporate into their initial patient consultation:

  • The Cosmetic Procedure Screening Questionnaire (COPS)
  • The Body Dysmorphic Disorder Questionnaire (BDDQ)
  • The Yale Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS)
  • Body Dysmorphic Disorder, NICE Guidance
  • Body Dysmorphic Disorder, Five Questions Psychiatric Evaluation for Cosmetic Procedure by Veale

The Aesthetic Journal provides  a useful summary for carrying out assessment of BDD here and suggests the following questions as a quick and helpful starting point to help practitioners gauge whether a patient may be suffering from BDD:

  1. Are you worried about how you look? (Yes/No); if you are, do you think about your appearance problems a lot and wish you could think about them less? (Yes/No)
  2. How much time per day, on average, do you spend thinking about how you look? (a) Less than 1 hour a day. (b) 1-3 hours a day. (c) More than three hours a day.
  3. Is your main concern with how you look that you aren’t thin enough or that you might become too fat? (Yes/No) How has this problem with how you look affected your life? (a) Has it often upset you a lot? (Yes/No) (b) Has it often gotten in the way of doing things with friends, your family, or dating? (Yes/No) (c) Has it caused you any problems with school or work? (Yes/No) (d)
  4. Are there things you avoid because of how you look? (Yes/No)

As practitioners, you should suspect BDD if the patient answers yes to Question 1; (b) or (c) to Question 2; yes to any part of Question 3 and yes to Question 4

Concept of body dysmorphic disorder concept, woman looking at mirror obsessively.

What should a practitioner do if they think a patient may have Body Dysmorphic Disorder?

The crucial question that practitioners need to ask of any patient is whether the individual has full capacity to give a truly informed consent for cosmetic procedures. For more guidance on consent and when it might be best to say ‘no’ to a patient, you can download our free guides, ‘Consenting principles and pitfalls – a survival guide’ and ‘How to say ‘no’ to patients’ here. The key point to remember is that if you feel nervous about treating a patient, trust your instincts and say ‘no’.

The practitioner should explain to the patient that they are not prepared to treat them as they are concerned that the patient is suffering from BDD and that cosmetic interventions may exacerbate the problem. They should of course also reassure the patient that BDD is a recognised condition and that effective treatments are available. The recommended treatment for BDD is cognitive behavioural therapy (CBT) specific to the disorder. Early recognition of BDD may also help to prevent progress of the condition and improve quality of life for the patient.

It is possible of course that the patient may be resistant to engage with mental health professionals and may instead simply consult other aesthetic practitioners in their quest to achieve physical perfection. However, the responsible practitioner would not treat a patient they suspect is suffering with BDD, not only to conserve their own reputation but also for the wellbeing of the patient.

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