COMMENT ▼
Body dysmorphic disorder
and aesthetic procedures
Aesthetic practitioners treat all kinds of people, and each one is motivated to seek treatment for different
reasons. In some cases, patients may have underlying issues that encourage them to seek aesthetic
procedures. In this comment piece, Eda Gorbis explores the issue of body dysmorphic disorder in aesthetic
patients, and provides recommendations on how to identify and treat this psychiatric disorder
T
here can be multiple reasons why a patient is
seeking aesthetic procedures. A recent study,
published in JAMA Dermatology, found that
patient motivations consisted of seeking im-
provements in the following: aesthetic appearance
(e.g. looking younger), physical health (e.g. preventing
worsening of physical conditions), and psychosocial
wellbeing (e.g. feeling more confident about onesself)
(Maisel et al, 2018). However, in some cases, a seri-
ous psychological disorder, body dysmorphic disorder
(BDD), may be the primary reason why a patient is
seeking aesthetic treatment. Dey et al (2015) showed
that around 13.1% of patients seeking cosmetic surgery
had BDD. Due to this prevalence and the potential
negative effects of aesthetic treatment on patients
with BDD, practitioners must be able to catch this dis-
order and refer patients to mental health professionals
for proper diagnosis.
Body dysmorphic disorder: the
disease of self-perceived ugliness
BDD, or the disease of self-perceived ugliness, is a
psychiatric disorder in which afflicted individuals have
a pervasive distortion of their self-image, usually by
having persistent preoccupations, or obsessions, with
a particular part of their body (American Psychiatric
Association (APA), 2013). Common obsessions of
appearance include the nose, mouth, eyelids, muscles,
breasts, and penile size in males. Research has suggested
that compared to individuals without BDD, individuals
with BDD show abnormal brain activity when
processing visual information, and this suggests that
EDA GORBIS
Founder and Executive Director, Westwood Institute for Anxiety Disorders,
Los Angeles
Clinical Assistant Professor of Psychiatry and Behavioral Sciences, USC Keck
School of Medicine, California
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these individuals have a distorted self-image in their
minds (Feusner et al., 2010). The greatest challenge for
BDD patients is to learn to accept that their physical
defect does not exist, or if it does, to accept it without
the all-consuming desire to change it.
BDD is also characterised by compulsions, or
repetitive behaviours and mental acts, to alleviate the
anxiety they feel from their self-perception of their
appearance (APA, 2013). Some common compulsions
found in individuals with BDD include seeking
reassurance, comparing and contrasting their looks
with others, mirror checking, mirror avoiding, and
masking and camouflaging their perceived flaws.
BDD patients must be helped to realise that these
compulsive behaviours not only fail to reduce their
anxiety, but indeed cause and stimulate it.
These obsessions and compulsions are time-
consuming and can significantly interfere with
an individual’s daily functioning (APA, 2013). For
example, the author previously encountered a patient
who showed up to the location of her birthday party
32 hours late because she was absorbed in perfecting
her face with make-up and facial wraps. Additionally,
individuals with BDD often change their social and
professional lifestyles to avoid appearing in public.
They may also withdraw from society, which could
cause them to lose their job, fall behind in school, or
have failing relationships with other people.
By its nature, BDD is highly comorbid with other psy-
chopathologies, such as obsessive compulsive disorder
(OCD), excoriation disorder (skin picking), trichotillo-
mania, major depression, social phobia, and substance
abuse. High delusionality and suicidality are associated
characteristics that make BDD a very dangerous
disorder. Therefore, designing a treatment plan for
patients with BDD must focus on the individual as a
whole and target their specific symptomatology. Since
BDD is a psychiatric disorder, it requires psychiatric
© 2019 MA Healthcare Ltd
treatment rather than aesthetic treatment, which rarely
leads to successful outcomes in patients with BDD.
Proper treatment for BDD can include medication (e.g.
selective serotonin reuptake inhibitors (SSRI’s)), cogni-
Journal of AESTHETIC NURSING ► March 2019 ► Volume 8 Issue 2

Questionnaires should be given to potential patients and should include questions inquiring about procedure history and satisfaction
tive-behavioural therapy (CBT), exposure and response
prevention (ERP), psychoeducation, and family support
led by an expert in BDD.
Impacts of aesthetic treatment
on individuals with body
dysmorphic disorder
Not only are aesthetic procedures performed on
individuals usually unsuccessful in achieving patient
satisfaction, they often have a negative impact on the
patient’s overall wellbeing. Plastic surgery or aesthetic
procedures usually prove no benefit in patients with
BDD, because no matter how good the results are,
they are never good enough, and the obsession is still
present. Although an aesthetic procedure can physically
correct a flaw, patient satisfaction is only temporary,
as BDD obsessions can shift to other body parts and
symptoms can worsen (Phillips, 2005). This creates
a snowball effect of a continuous cycle of obsessions,
anxiety, compulsions, and relief.
A patient will obsess over a flaw, get anxiety from
the obsession, compulsively seek out an aesthetic
procedure to relieve the anxiety, find temporary relief,
then obsess over another flaw, get anxiety from that
obsession, compulsively seek out another aesthetic
procedure, find temporary relief, and then find another
perceived flaw to obsess over. This cycle will continue
on and on, worsening the BDD and the severity of the
© 2019 MA Healthcare Ltd
obsessions and compulsions. If the cycle is not stopped,
these patients may repeatedly seek surgery and show
signs of addiction to cosmetic surgery due to the
impulsive nature of BDD itself.
March 2019 ► Volume 8 Issue 2 ► Journal of AESTHETIC NURSING
▼ COMMENT
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Patients who are dissatisfied with their aesthetic
procedures may feel guilty and/or angry with
themselves or their practitioner for not improving
their appearance. As a result, there have been reports
of individuals with BDD retaliating against their prac-
titioners via lawsuits, physical assaults, and in some
cases, even murder (Sweis et al, 2017). Not only are
aesthetic procedures on BDD patients dangerous
for the patients themselves, but they can also be
dangerous for the practitioners.
Identifying patients with
body dysmorphic disorder
The major concern is that BDD is not always recognised
by plastic surgeons, aesthetic practitioners and general
practitioners. BDD can take years to diagnose after onset,
due to the notorious secretiveness of BDD patients about
their preoccupations, likelihood to seek non-psychiatric
» To tackle this problem, practition-
ers must educate themselves on body
dysmorphic disorder, whether it be by
taking educational classes, connecting
with professionals in the field of
psychology or reading informational
websites and articles «
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COMMENT ▼
help instead of psychiatric help, and inadequate training
of aesthetic practitioners, plastic surgeons, dermatolo-
gists, and even psychologists in spotting and redirecting
a BDD patient.
To tackle this problem, practitioners must educate
themselves on BDD, whether it be by taking educational
classes, connecting with professionals in the field of
psychology, and/or reading informational websites
and articles. Since BDD can be a very sensitive topic,
practitioners must be mindful and treat each patient
with respect and in a non-judgmental manner when
addressing this issue.
BDD must be screened for prior to any aesthetic
procedures. Questionnaires should be given to all
potential patients and should include questions
enquiring about how many surgeries they have had,
what the level of satisfaction was from their previous
surgeries, if their self-image changed after the first
surgery, how upset they are with the targeted body
part, and how many hours a day they check or look
at that body part. Specific screening tools have been
developed and validated for the purpose of identifying
patients with BDD, such as the BDD Questionnaire-
Dermatology Version (BDDQ-DV) and Dysmorphic
Concern Questionnaire (DCQ) (Danesh et al, 2015).
Based on the results of these questionnaires and
general interviewing during the initial consultation,
practitioners will have a better sense of their patient’s
motivations. If BDD is suspected, it is important for
practitioners to refer these individuals to a psychologist
or psychotherapist who is an expert in BDD so that
they can give a proper diagnosis and recommend
further treatment.
Key points
►► Patients seek aesthetic treatment for many reasons. In
some patients, underlying body dysmorphic disorder
(BDD) could be motivating them to seek out
these procedures
►► BDD is a psychiatric disorder in which affected
individuals have a pervasive distortion of their
self-image. It usually involves a persistent
preoccupation or obsession with a particular part of
the body
►► Individuals with BDD do not benefit in the long-term
from aesthetic procedures, as the underlying
psychological issue needs to be treated, rather than
the aesthetic issue itself
►► It is important that aesthetic practitioners equip
themselves with the correct knowledge and tools to
be able to diagnose BDD and refer patients on to get
the help they need
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Conclusion
Ultimately, individuals with BDD will not benefit
from aesthetic procedures. The only treatment that
can help them in the long-term is a surgery of the
mind, to rewire and change their distorted body
images, rather than cosmetic surgery which acts to
physically, temporarily fix their flaws. Treating these
individuals with aesthetic procedures and without a
proper mental health referral can actually negatively
affect the lives of the patients and even the lives of
the practitioners. It should be stressed to practitioners
to determine the motivators of a patient’s request for
aesthetic treatment. With a full understanding of the
patient through screening and interviewing, practi-
tioners will be better able to make a decision that puts
their patient’s overall quality of life first.
References
American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 5th edn. American Psychiatric Association; 2013
Danesh M, Beroukhim K, Nguyen C, Levin E, Koo J. Body
dysmorphic disorder screening tools for the dermatologist: a
systematic review. Pract Dermatol. 2015;2:44-49
Dey JK, Ishii M, Phillis M et al. Body dysmorphic disorder in a facial
plastic and reconstructive surgery clinic: measuring prevalence,
assessing comorbidities, and validating a feasible screening
instrument. JAMA Facial Plast Surg. 2015; 17(2):137. https://doi.
org/10.1001/jamafacial.2014.1492
Feusner JD, Moody T, Hembacher E et al. Abnormalities of visual
processing and frontostriatal systems in body dysmorphic
disorder. Arch Gen Psychiatr. 2010; 67(2):197. https://doi.
org/10.1001/archgenpsychiatry.2009.190
Maisel A, Waldman A, Furlan K et al. Self-reported patient
motivations for seeking cosmetic procedures. JAMA
Dermatol. 2018; 154(10):1167. https://doi.org/10.1001/
jamadermatol.2018.2357
Phillips KA, Menard W, Fay C, Weisberg R. Demographic
characteristics, phenomenology, comorbidity, and family
history in 200 individuals with body dysmorphic disorder.
Psychosomatics. 2005; 46(4):317–325. https://doi.org/10.1176/
appi.psy.46.4.317
Sweis IE, Spitz J, Barry DR, Cohen M. A review of body dysmorphic
disorder in aesthetic surgery patients and the legal implications.
Aesthet Plast Surg. 2017; 41(4):949–954. https://doi.org/10.1007/
s00266-017-0819-x
CPD questions
►► Do you feel confident that you would be able to
determine whether a patient presenting to your clinic
has body dysmorphic disorder?
►► If not, what tools do you require to be able to develop
your knowledge and skillset to be able to
determine this?
© 2019 MA Healthcare Ltd
►► If you suspect that a patient has body dysmorphic
disorder, how could you act in the best interest of the
patient to ensure that they receive the care
they need?
Journal of AESTHETIC NURSING ► March 2019 ► Volume 8 Issue 2