Identifying Body Dysmorphic Disorder

The rise of social media, reality TV programmes and influencer culture has changed the way people across the world relate to and seek to perfect their physical appearance. With the constant pressure to always look your best comes the rise of body dysmorphic disorder (BDD), a mental health condition where a person consistently worries about perceived defects or flaws in their appearance.¹

BDD is most prevalent in adolescents and teens, as shown in the NHS Mental Health in Young People survey, which found that in 2017, more than one in 20 (5.6%) 17- to 19-year-old girls in the UK experienced BDD.² While BDD is not covered in the recent Mental Health of Children and Young People in England 2022 report, a rise in eating problems was seen in 17-to-19-year-olds from 44.6% in 2017 to 58.2% in 2021, which could indicate a possible rise in BDD as well.³ As more of these individuals become of an age to present at clinic for aesthetic procedures, this increase in young people’s vulnerability is something aesthetic practitioners must bear in mind.

Those who are struggling with BDD have a distorted view of how they look, which is often focused on one part of their body.⁴ Research suggests that one in 50 people in the UK (2% of the population) will struggle with BDD, but between 5% and 15% of patients who present for aesthetic procedures meet the diagnostic criteria for the condition, showing a higher proportion of your patients are likely to have BDD in comparison with the general population.^5,6

Whilst the exact cause of BDD is unknown, it has previously been linked to genes, chemical changes in the brain and even traumatic past experiences.⁷ When a person has BDD, they often intensely focus on their appearance, repeatedly checking the mirror, grooming or seeking reassurance, sometimes for many hours each day.^8,9 Their perceived flaws, and these repetitive behaviours surrounding them, may cause them significant distress and impact their ability to function in daily life. Some people living with BDD commonly seek out aesthetic treatments and plastic surgery in the hope of improving their self-esteem, correcting a perceived physical defect, pleasing a partner or overcoming past emotional trauma, among other things.⁴ It is crucial that aesthetic practitioners are aware and mindful of this propensity for their patients to have BDD, as it is essential that they are treated responsibly or referred on to a qualified clinician to receive additional help for their condition.

The dangers of BDD in aesthetics

If BDD is left untreated or unaddressed, it can trigger severe impairment to overall quality of life, and may lead to serious consequences including suicidal ideation and attempts, increased anxiety, depression and eating disorders. A survey by the Body Dysmorphic Disorder Foundation found that about 0.3% of all people with BDD take their own life every year.¹⁰

While cases you see in clinic may not be this severe, many people going through cosmetic treatments have unrealistic expectations that they will come out on the other side feeling differently about themselves, as if one procedure will cure all their insecurities and even additional mental health problems. It is this excessive optimism going into the aesthetic clinic which can subsequently cause disappointment if perfection is not attained, sometimes leading to renewed anxiety and a resumed search for other ways to ‘fix’ their perceived flaw. This underlines the importance of a screening process prior to procedures so practitioners can avoid patients’ disappointment negatively impacting your clinic’s reputation.

Thankfully, recognition of the prevalence and severity of BDD is growing. The Health and Social Care Committee’s recent Parliamentary report on the impact of body image on mental and physical health has a section emphasising the detrimental impact of BDD. It also contains recommendations for a governmental strategy that brings together the Department of Health and Social Care, the Department for Digital, Culture, Media and Sport and the Department for Education to tackle the growing problem of body dissatisfaction and its related health, educational and social consequences.¹¹ Research from the BDD Foundation included in the report found that 85% of people with BDD do not receive an accurate diagnosis, due to stigma around the condition and a lack of knowledge among healthcare professionals.¹¹ This is something the Committee, and I, want to see change.

Red flags to consider

Medical practitioners who offer cosmetic and aesthetic services often take satisfaction in knowing that they are helping patients address physical issues that might impede their body image. However, it is important that they possess adequate knowledge about BDD and are attuned to potential red flags for the disorder, as offering treatment to vulnerable patients should be avoided.

The common symptoms of BDD include:¹

• Constantly checking one’s appearance in the mirror, or avoiding mirrors altogether
• Trying to hide body parts under a hat, scarf or makeup
• Obsessively comparing themselves with others (this may present as a patient requesting to receive treatments to look like a particular individual or celebrity)
• Always asking other people whether they look okay
• Believing that others notice their perceived flaw in a negative way

Some other less common signs may include:¹²

• Making multiple visits to medical practitioners, especially to dermatologists
• Compulsive skin picking in an attempt to remove unwanted hair or blemishes
• Changing clothes frequently and excessively
• Constantly exercising or grooming
• Keeping obsessions and compulsions secret in fear of social alienation

Vulnerable patients might present to clinic with one or more of these symptoms, or a variation of them, so practitioners should be aware of what to look out for. If aesthetic practitioners are in doubt about whether a prospective patient is vulnerable due to this condition, a BDD screening may be a good option if conducted by those who are competent, trained and insured to deliver such a service. This often takes the form of a series of questions posed to the patient to help determine whether they need psychological treatment before aesthetic procedures should be offered, or indeed whether they should be carried out at all.

Some practitioners may formulate these questions based on their insights or experience with their patients, or collaborate with external psychological expertise on this. Alternatively, questions such as these are generally accepted as best practice for screening prospective patients:¹³

1. Do you worry a lot about your appearance and wish you dwelled on it less?
2. What are your specific concerns regarding your appearance?
3. On a typical day, how many hours do you spend thinking about your appearance? (More than one hour is considered excessive)
4. What effect does this have on your life?
5. Does this make it hard to work or socialise?

Referring patients

Practitioners should refer a patient to a mental health expert when they are contemplating whether the psychological status of the patient may affect their satisfaction with the outcome of treatment. This could be because the expectations of the procedure’s outcomes are unrealistic cosmetic procedures, or their mental health history reveals co-existing psychological disturbances.

If practitioners are concerned about an individual’s mental health following their consultation or a BDD questionnaire, they should not continue with treatment. Instead, patients can be directed to complete a self-referral to an NHS or private GP who can assist them with accessing the relevant talking therapy to help them through their difficulties.¹⁴ The BDD Foundation is also a great avenue, which can provide further help and support.¹⁵ Alternatively, practitioners may choose to refer directly to a specialist therapist or clinic, or a psychological provider such as Onebright.¹⁶ The benefit of this is that once the patient is referred, they will go through a psychological assessment process and the specialist can provide insights which can help practitioners in further understanding patients’ wellbeing and suitability for aesthetic treatment. Referrals for further psychological will imply that commencement of treatment should be paused, deferred or refused altogether dependent on the individual’s circumstance.

Industry best practice

Referring suspected BDD sufferers to a mental health professional before offering treatment should be best practice across the industry in order to ensure vulnerable patients are looked after. Healthcare professionals can do this through setting up a screening/ questionnaire process for patients and having networks in place through which to seek external support. 

It is important for healthcare professionals to realise that it is not their responsibility to diagnose patients, but they must accept the cruciality of their observations during consultations in the process of getting patients the help they need. As well as potentially placing mentally unwell patients at risk by providing them with care or advice without adequate training, trying to help vulnerable patients yourself can lead to significant stress for you which is not conducive to best practice. 

It is of vital importance that aesthetic practitioners raise awareness of BDD by sharing scientific literature on the topic with both their clinic teams and patients, and signposting patients to specialist psychological providers who are trained to both screen and provide full psychological assessments and treatment if needed to ensure patient safety before any treatment is offered or performed.