Recognizing Body Dysmorphic Disorder in Aesthetic Patients: Ethical Considerations and Best Practices

Understanding Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder (BDD) is a severe mental health condition characterized by an obsessive focus on perceived flaws or defects in one’s appearance. These perceived imperfections often lead to significant anxiety, depression, self-harm, and even suicidal thoughts. BDD affects both men and women and is more than just vanity; it’s a debilitating disorder that impacts one’s daily life and mental well-being.

Identifying Signs of BDD

Recognizing BDD in patients seeking aesthetic treatments is crucial for practitioners. Key indicators include:

– Excessive Concern with Appearance: Patients may obsess over their face or a specific body part.

– Comparative Behavior: They often compare their looks with others.

– Mirror Checking or Avoidance: Frequent checking in mirrors or complete avoidance of reflections.

– Concealment Efforts: Using makeup or clothing to hide perceived flaws.

– Skin Picking: Engaging in behaviors to make the skin appear “smooth.”

– Desire for Unnecessary Procedures: An intense need for cosmetic surgeries or tweakments.

– Emotional Distress: Feelings of shame, guilt, and isolation.

– Compulsive Behaviors: Engaging in rituals as coping mechanisms.

– Makeup and Tanning: Overuse of makeup and excessive tanning.

Additional signs from mental health resources include the belief that their body lacks proportion or symmetry, worry that others think they are vain, and isolation due to their perceived flaws.

Causes of BDD

The exact cause of BDD is not fully understood, but it is believed to be linked to genetic factors, past trauma (especially appearance-related teasing or bullying), and possible chemical imbalances in the brain. Individuals with BDD often have other mental health issues, such as obsessive-compulsive disorder (OCD), eating disorders, or generalized anxiety disorder.

 Impact of Social Media and Technology

The increase in screen time and the use of social media platforms has amplified self-consciousness about appearance. Filters and editing apps can enhance insecurities by presenting unrealistic standards of beauty. This phenomenon is contributing to a rise in self-esteem issues and, potentially, BDD. With the widespread use of platforms that allow for easy alteration of images, individuals are more frequently comparing themselves to edited versions of peers and celebrities, leading to heightened dissatisfaction with their natural appearance.

 Ethical Considerations for Aesthetic Practitioners

Aesthetic practitioners must be cautious when dealing with patients who may have BDD. It’s generally advised to avoid treating individuals with suspected BDD, particularly with injectables or non-essential cosmetic procedures. The heightened self-focus during and post-lockdown has made this even more critical.

Emergency Situations

In urgent cases, such as when a patient with BDD has attempted self-injection, practitioners should consider the best course of action, possibly involving the patient’s general practitioner or mental health provider. Emergency care should be handled with an understanding of the patient’s mental state and potential risks.

Diagnostic Approach

When diagnosing potential BDD, practitioners should look for:

1. Warning Signs: Red flags include a belief that surgery will solve all problems, dissatisfaction with previous procedures, and a history of psychiatric treatment.

2. Structured Interview: Conduct a brief but thorough interview to evaluate emotional distress and the impact on the patient’s quality of life.

3. Questionnaires: Utilize BDD-specific questionnaires, which are quick to complete and can provide significant insight.

Building a Trustworthy Practice

Refusing treatment to a patient with suspected BDD is an ethical obligation for practitioners. Clearly communicate your decision and provide reasoning and consider directing them to mental health resources or professionals. Building relationships with counselors or psychotherapists for referrals can be beneficial. This approach helps in maintaining a practice that is centered on patient well-being rather than profit.

 Prevalence of BDD in Dermatology Patients

BDD is particularly common among patients seeking cosmetic procedures. Studies indicate that the prevalence of BDD in dermatology ranges from 8.5% to 15%, but it is likely higher among cosmetic surgery patients, with rates between 6% and 20%. Given these statistics, dermatologists and aesthetic practitioners are likely to encounter BDD frequently and should be prepared to manage such cases appropriately.

Recognizing and Managing BDD

Distress and functional impairment are common among BDD patients. Emotional distress is often apparent during initial consultations. Practitioners should evaluate the patient’s psychosocial issues and quality of life to understand how much the perceived flaw affects their daily functioning. Lack of insight into their condition often correlates with the severity of BDD, making these patients challenging to manage.


Dealing with patients with suspected BDD requires a sensitive and ethical approach. By prioritizing patient welfare over profit, practitioners can maintain their integrity and ultimately attract a high-quality clientele. Recognizing the signs of BDD, understanding its impacts, and knowing when and how to refuse treatment are essential skills for any ethical aesthetic practitioner. Through careful assessment, ethical decision-making, and appropriate referrals, practitioners can ensure they are providing the best possible care for their patients.

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