Body Dysmorphic Disorder (BDD) is more than just a concern about appearance – it can be a serious and debilitating mental illness.1 According to the NHS, BDD is "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." The World Health Organization (WHO) further characterises BDD as a "persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others".
The prevalence of BDD itself varies from one study to another. It is believed that Body Dysmorphic Disorder currently affects 1.7% to 2.9% of the general population, but there is a consensus that patients with the disorder may be more likely to present themselves at aesthetic practices.
Research has shown that patients who present for cosmetic surgery treatment are affected by BDD at rates markedly higher than in the general population, ranging from 3%-53%.
One study suggested that up to 70% of individuals with BDD have sought cosmetic procedures, with half having undergone such interventions. While another suggested that as many as 76% had sought treatment.
Mental health nurse and director and lead nurse at Soft Touches Aesthetics, Claire Newman, speaker on the topic of identifying and supporting patients with BDD at The Aesthetics Business Conference on 8 October 2024, comments, “Many people with BDD are drawn to aesthetic interventions. They're more likely to see someone like us rather than seek help from their GP for mental health services. This is partly because they might not realise it's a mental health issue, or they might understand but still believe it's a cosmetic problem that needs fixing.”
According to the Body Dysmorphic Disorder Foundation
Statistics are likely underreported, as many individuals with BDD may feel too ashamed of their appearance to disclose their symptoms or seek help.
“A 2023 audit in my clinic found that less than 1% of patients had BDD, but a significant portion of patients had diagnoses of depression and anxiety, which can be linked to dissatisfaction with appearance”, says Newman. “It's important to note that people don't always self-report these issues.”
It is not surprising that high rates of BDD are found among people seeking aesthetic interventions. BDD sufferers obsessively fixate on their perceived physical flaws. These flaws, though largely unnoticeable to others, become the focus of the individual's life, often resulting in severe anxiety, depression, and even suicidal thoughts.
While BDD is primarily a mental health problem, patients tend to consult aesthetic practitioners in the belief that their issues are physical in nature. After all, to the individual affected by BDD, seeking an intervention to fix ‘defects’ in their appearance seems like a perfectly viable solution.
However, this belief is a dangerous misconception. While patients may see cosmetic procedures as a viable solution, these treatments often fail to address the underlying psychological problems.1
This makes it crucial for practitioners to understand the mental health aspect of BDD, as treating the physical symptoms alone can exacerbate the patient's condition.
Newman comments, “Many people with mental health issues are attracted to cosmetic procedures. In audits I've conducted over the past two years, I've found that a significant number of patients in clinics suffer from depression and anxiety. Understanding the broader context of mental illness is important, as our mental state can influence how we perceive ourselves. For example, if we're feeling down, we may view ourselves more negatively, which can sometimes be confused with BDD. It's vital to understand patients' motivations, not just their physical history but their mental health history as well, to grasp what it means for them and how it will impact them.”
For the aesthetic practitioner, identifying a patient who may be suffering from BDD is important because there is evidence to show that cosmetic interventions may actually make the condition worse, causing patients to focus on new perceived flaws or deepening their existing dissatisfaction. This is why thorough psychological assessments and understanding patient motivations are essential before proceeding with any cosmetic treatments.
Cosmetic interventions cannot solve the underlying psychological issues that BDD patients face. In fact, these procedures often leave patients feeling worse, as they overwhelmingly see the results as unsatisfactory, regardless of the practitioner's skill or the outcome of the procedure. This can lead to repeated requests for more treatments, further complicating the patient-practitioner relationship and increasing the risk of severe outcomes, including violence towards practitioners.
For example, a report in The International Journal of Women’s Dermatology showed 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 another 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.
Newman comments, “Treatments can sometimes worsen a patient's perception of their flaws or shift their focus to other areas of concern. It's important to manage expectations and make sure that both the practitioner and patient are on the same page. I’m very open and honest with my patients, and if I have concerns that a treatment might make them feel worse, I will refuse to perform it, but I would explain why and discuss options/further support. This may include signposting/contacting relevant healthcare agencies if necessary. It's crucial to understand the patient's goals and motivations. If there's no genuine need for treatment, it’s better to refrain from treatment, as it could make the patient feel worse about themselves.”
Read our article on How to say no to patients here.
For the safety of both patients and practitioners, it is crucial to identify BDD early.
Routine use of screening questionnaires, such as the Body Dysmorphic Disorder Questionnaire (BDDQ) and the NICE guidelines, can improve patient care.
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.
However, these tools should not be used in isolation. The practitioner’s skill in building a therapeutic relationship and understanding the patient’s mental health history is equally important.1-2
Newman comments, “I’m not a huge fan of using tools in isolation. They can be helpful in guiding consultations, but they shouldn't be relied upon solely. People can easily manipulate their answers, and you might not get an accurate picture. BDD is an anxiety disorder that varies in severity; if a patient is having a good day, they might answer more positively than they would on a bad day. So, while these tools can be a guideline for follow-up questions, they aren't a true representation of the patient's condition. It's easy to lie and say anything, so it's essential to understand the patient's reasons for seeking treatment and to build a strong therapeutic relationship to get a complete picture.”
As highlighted in the Aesthetics Journal, there are a number of existing screening questionnaires that practitioners can incorporate into their initial patient consultation:
The journal also suggests the following questions as a quick and helpful starting point to help practitioners gauge whether a patient may be suffering from BDD:
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.
If a practitioner suspects a patient may have BDD, it is essential to consider whether the patient has the capacity to give truly informed consent for cosmetic procedures.
“Capacity to consent is crucial and should be assessed thoroughly prior to every treatment and not just at the initial consultation, especially if a patient’s mental state fluctuates”, says Newman. “It’s important to assess whether a patient can recall and retain the information about the treatment, especially if they have conditions like BDD that can cause anxiety.”
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 the progress of the condition and improve the quality of life for the patient.
“Practitioners may not be trained to diagnose BDD, but if they have concerns, they should address them with the patient, ideally after establishing a good rapport”, says Newman. “It’s important to have an open and honest conversation about the concerns, but in a way that doesn’t make the patient feel worse about themselves.”
It is possible of course, that the patient may be resistant to engaging 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 from BDD, not only to conserve their own reputation but also for the wellbeing of the patient.
Newman comments, “I always stress the importance of managing expectations and understanding the bigger picture. If a patient has unrealistic expectations that treatment will drastically change their life, it's crucial to discuss this openly and honestly. Sometimes, it’s better to refuse treatment if you believe it won't meet the patient’s expectations or if it might make them feel worse. If a practitioner decides not to proceed with treatment, they should explain their reasoning carefully, perhaps suggesting that the patient seek mental health support if appropriate.”
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’.
Practitioners in the aesthetics field must be vigilant in recognising the signs of BDD and other mental health conditions that may present in their patients. Understanding the psychological motivations behind seeking cosmetic procedures, conducting thorough assessments, and knowing when to say no to a patient are all crucial components of responsible aesthetic practice. By prioritising mental health, practitioners can make sure they are not only improving their patients' appearance but also safeguarding their overall well-being.
Read our interview, ‘Identifying and supporting patients with body dysmorphic disorder (BDD): A conversation with Claire Newman’, for more insights from Claire.
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