The Red Flag Patient

By Dr Sangita Singh / 12 Jan 2017

Dr Sangita Singh explains body dysmorphic disorder and how to screen patients for the condition

With the concomitant rise in social media, in particular the ‘selfie’ and the apparently more image conscious population in the UK, cosmetic interventions seem to have become increasingly socially acceptable among consumers who are influenced by the media and celebrity culture. Additionally, non-surgical treatments are set to become more popular as people lean towards less invasive procedures that are less expensive and viewed as having fewer risks and quicker results.1

Psycho-social research demonstrates that physical appearance influences many aspects of our life, including quality of life, self-esteem, body image, interpersonal relationships, employment opportunities and financial success.2 It is therefore not surprising that many people are interested in improving their appearance in order to gain these advantages. But as we see growing numbers attending for non-surgical procedures, we will also see a greater numbers of what we may call ‘Red Flag Patients’.

Who are the Red Flag Patients?

There are several categories of Red Flag Patient; examples include the ‘perfectionist patient’, ‘litigious patient’, ‘unrealistic patient’ and the ‘indecisive patient’. However, in this article I shall be focusing on the patient with body dysmorphic disorder (BDD).4

Body dysmorphic disorder

BDD is defined as a preoccupation with a slight or imagined defect in physical appearance. This preoccupation must cause significant distress or impairment in functioning and must be associated with disruption in daily functioning.1

For patients with BDD, the face, nose, skin, and hair are the most common focus of concern;8 however, any feature or area of the body can be the focus, so the diagnosis is very pertinent to those practising aesthetic medicine.

It can be challenging applying this diagnosis to our patients as we are often treating ‘slight’ imperfections in essentially ‘normal’ features. Therefore, for our patients, it is more relevant to look at the second part of the definition regarding the disruption in daily functioning. The degree of distress, which is caused by a perceived deficit, can be very variable from one person to another.

A patient with BDD will be overly concerned and spend an excessive amount of time on behaviours such as; mirror gazing, comparing their features to others, camouflaging tactics to hide the defect and seeking reassurance.3 For example, a woman interested in aesthetic treatments who reports that she spends hours trying to conceal her defects, has stopped going out in certain situations and lost contact with many friends due to her appearance, is likely to meet the BDD criteria. However, a woman who reports being somewhat self-conscious of her ageing facial features when compared to younger work colleagues would be unlikely to meet the criteria. I shall discuss how to screen for BDD later in the article.

Prevalence of BDD

It is estimated that BDD affects between 1-3% of the general population. For patients presenting for medical aesthetic treatments, studies have consistently suggested that the rate increases to between 5-15%.6,9 There have also been some international studies that have used clinical interviews of patients reporting even higher rates of approximately 20% of patients. This suggests that a busy aesthetic practice is likely to encounter several patients with BDD every month.6

The effect of aesthetic treatments on BDD

One of the largest studies reported that less than 5% of those who had treatment had seen any improvement in their BDD symptoms, whilst 95% experienced no change, or a worsening in the condition.6 Some developed new concerns following treatment, which is seen in the normal course of the disorder. The focus of concern shifts from one feature to another.

The biggest concern though is the correlation between BDD and suicide. BDD is one of the most lethal psychiatric disorders, with a mean annual suicide attempt rate of 2.6%.6 Treating a patient with BDD is not just potentially detrimental to the patient but also to the practitioner, as around a third of aesthetic surgeons have been threatened legally and 2% threatened physically by patients with BDD.6

Given that the suicide rate in those suffering from BDD is high, it is not surprising that the growing consensus is that appearance-enhancing treatments are contraindicated in patients with BDD.

Assessing patients to screen for BDD

The most crucial step prior to any treatments being carried out is the consultation. The first consultation will lay the groundwork for everything that follows, so it is important that it isn’t rushed. The consultation is an opportunity to assess the patient’s suitability for treatment, build rapport and trust, as well as displaying our expertise. The consultation should include a psychological assessment that focuses on motivations and aims, and appearance and body image concerns.

Motivations and expectations

Patients can be internally or externally motivated.1,2 Internal motivations include: aiming to improve a certain feature in order to improve body image and self-esteem; to build confidence; look more youthful; or to increase self confidence by improving physical appearance. External motivations include: a job promotion; a new relationship; to please friends and family; or relief from emotional distress such as bereavement or divorce. Patients who are externally motivated are looking for some secondary gain. Interestingly, there have been studies suggesting that being motivated for aesthetic surgery to please a romantic partner is associated with a poor postoperative outcome.6,10 It is also important to ensure that a patient’s expectations are realistic and achievable, such as a youthful, refreshed look or improvement in a body area that they feel self-conscious about; as opposed to looking ten years younger or indeed looking like a celebrity.

Physical appearance and body image

It is always important to ask the patient what it is that concerns them about their appearance. They should be able to point to specific concerns and we should be able to visualise these readily. If the patient is overly concerned about a defect that we can’t readily identify, they may be suffering from BDD. We must also assess the degree of dissatisfaction a patient experiences. Some degree of dissatisfaction with body image is present amongst most patients. Those who spend long periods of time, during the day, dwelling on their appearance, may be suffering from BDD. Patients should also be asked how their feelings about their appearance affect their daily functioning. Those who have lost jobs or social contact, as they are not able to engage in normal daily activities could be suffering from BDD.3,6,7 There are also several scales that can be used to assess symptom severity such as: the Body Dysmorphic Disorder Questionnaire (BDDQ), BDDQ – dermatology version and the Body Image Disturbance Questionnaire.1,2,5 Practitioners may want to use these to help with the assessment of BDD.

If BDD is suspected it is important that these patients are referred for psychological assessment and not offered treatment.


The aesthetic market is growing, as is the knowledge and acceptance of the treatments we can provide. As the treatments increase in popularity and we see more patients seeking treatment, it is inevitable that we will see more unsuitable ‘Red Flag Patients’. The most important of these are the patients with BDD, as studies have consistently suggested these patients make up 5-15% of a clinic’s clinetele.6 The evidence indicates that treating these patients can lead to significant harm for both the patient and the practitioner. It is therefore extremely important that we consult thoroughly in order to screen all patients and ensure we don’t treat any we suspect may have BDD, but rather refer them for psychological evaluation. 

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