There has been a lot of talk about the need for aesthetic practitioners to recognise the possibility that a client suffers from body dysmorphic disorder (BDD), perhaps with the aid of screening tests. However, my purpose here is to draw attention also to situations where a client may be afflicted by other serious kinds of dysmorphia, which have received much less attention than they deserve.
The word ‘dysmorphia’ is too often bandied about in social and other media in a rather casual and potentially misleading way. It is important to avoid its misuse. By itself, the word, from its ancient Greek derivation, just means dissatisfaction with bodily shape and appearance. This is not at all the same thing as BDD. Surveys show that nearly everybody is dissatisfied with some aspect of their bodily appearance and is likely to find some part or parts of their body less attractive than they would like. So, all patients seeking a procedure can be said to experience dysmorphia to some degree—something about their appearance causes them dissatisfaction.
Contrast this almost universal kind of dissatisfaction with, at the other end of the scale of severity, BDD. Let me just outline the main features of this very distressing mental health problem as it is recognised today. Certainly, a potential patient suffering from BDD presents problems for the aesthetic practitioner. Research shows that such people are, with rare exceptions, unlikely to benefit from cosmetic interventions, and there are horror stories of practitioners being subject to litigation or even (in very rare cases) violence from dissatisfied clients. It is a serious mental health disorder causing the sufferer deep distress and carrying with it a substantial risk of suicide.
What is BDD?
Recognised for over a century and given different names over the years, BDD is now defined by the American Psychiatric Association's 5th edition of it Diagnostic and statistical manual (DSM-5) (2013) as follows:
- Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable, or appear slight to others
- At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g. mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g. comparing his or her appearance with that of others) in response to the appearance concerns
- The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
The manual now places BDD among the group of obsessional disorders. Emphasis is given to the repetitive behaviours and the significant distress or impairment of functioning. Often, there is overlap or co-existence with other disorders, such as obsessional neurosis, anxiety disorders, depressive illness and eating disorders. If the patient has an unshakeable conviction that their deformity, as they see it, is recognised by other people, evoking laughter at the sufferer, or making them turn away in disgust or make rude remarks to others, such beliefs could be examples of a delusion, indicating a delusional disorder or psychosis.
Frequency of BDD
There is generally a lack of data about cosmetic treatments and the patients who seek them. BDD is thought to occur in about 2% of the general population, equally in men and women, and usually beginning in the teens. Causal factors are unclear. According to an international expert on BDD, Katherine Phillips, some 9–12% of people seeking treatment from a dermatologist and between 6% and as many as 20% of people who receive cosmetic surgery have BDD (Phillips, 2005). That is an awful lot of people.
According to the DSM-5, BDD includes preoccupation with one or more perceived defects or flaws in physical appearance that are not observable, or appear slight to others
In one study from Australia, the incidence, at 2.9%, was much lower in people seeking non-surgical cosmetic treatments, but that is still quite a lot—about one in 35.
Patient complaints
Studies show that the body areas most often causing concern are the skin, hair and nose, followed in order by stomach, weight, breast/chest, eyes, thighs, teeth, legs, body/build, ugly face, face size/shape, lips, buttocks, chin, eyebrows and hips. The complaints are very varied, including (for the skin, for example) preoccupation with wrinkles, spots, acne and large pores. Vascular markings, greasiness, scars, paleness, redness, excessive hairiness and thinning of hair are also reported as common complaints. Folliculitis and scarring may be a product of skin picking and plucking of non-existent hairs, which often just make the distress worse (Phillips, 2005).
Recognising BDD
There has been research into the use of pen-and-paper screening tests to detect the possibility of BDD, but there is little information about their actual use in clinical practice. Perhaps patients would be reluctant to answer truthfully if they fear that they may be refused treatment as a result. A broader concern is the idea that every applicant for a treatment should be regarded as potentially suffering from a serious mental disorder.
Official guidelines for practitioners
The National Institute for Health and Care Excellence (NICE) recommend that cosmetic practitioners should be aware of, and try to identify, those patients who may have BDD. NICE suggest a short list of five questions to aid detection:
- Do you worry a lot about the way you look and wish you could think about it less?
- What specific concerns do you have about your appearance?
- On a typical day, how many hours a day is your appearance on your mind? (More than one hour a day is considered excessive)
- What effect does it have on your life?
- Does it make it hard to do your work or be with friends?
A well-informed and compassionate approach is needed. The following points are also important:
- The sufferer is a deeply troubled person, not somebody who should automatically be regarded as a difficult patient who you must get rid of as quickly as possible
- The practitioner cannot be expected to make a definitive diagnosis. That is a task for other experts. Tick-box screening tests are not appropriate for use by practitioners without special training. What we are talking about is clients you may suspect are suffering from BDD and whom you want to help, if possible. Sufferers tend to be very secretive so recognition can be difficult
- BDD is a condition potentially treatable by expert medical and psychological interventions, such as antidepressant medication and cognitive behavioural therapy (CBT). If a requested procedure is bluntly refused, the patient is likely simply to seek another, perhaps less scrupulous, practitioner, thereby risking harm
- The practitioner can offer a sympathetic response by enquiring whether the client has considered seeking counselling or the possibility of referral by their GP to the local mental health services
- If the client rejects such suggestions (as is common), the practitioner would be wise just to say that they do not feel able to provide the result the patient is seeking. It would be unwise to go ahead with any procedure when there is reason to doubt whether the patient can benefit from it. Better a lost patient than a harmful outcome for both client and practitioner.
Practitioners who are aware of local counselling options are in a better position to help patients with BDD who seek aesthetic treatments
Other serious forms of dysmorphia
I have set out quite a lot of detail about BDD to distinguish it from the other serious forms of dysmorphia that need attention.
The first of these might be called ‘pseudo’ (or false) BDD. I know of patients who have been dissatisfied by the results of their treatment and who, when they have told the practitioner of this, have been told that they must have a form of BDD—so the problem is their responsibility, not the practitioner's. This is an outrageous and wholly reprehensible attempt to blame the patient.
There is a great lack of information about clients who suffer distress about the results of their experience and the resources available to help them. The client's distress may be extreme, possibly even amounting to thoughts of suicide. They will have spent money, perhaps a great deal, on one or more procedures, which have left them feeling more dissatisfied with their appearance than they were before they embarked on seeking a remedy. Where can they turn? Already sensitive to the possibility of criticism from those close to them for their ‘vanity’ in undergoing cosmetic intervention, they may fear even greater condemnation and ridicule when their ‘deformity’ (as they may see it) and their distress about it are revealed. It may well be impossible to conceal.
In such situations, the patient's dissatisfaction may be so distressing and disabling that it amounts to a form of BDD, fulfilling the criteria listed in DSM-5, but they did not suffer from BDD before the procedure. As there is so little data available on the frequency of such a tragic outcome, its occurrence has received scant attention in the literature. I think it deserves a separate designation—perhaps post-cosmetic dysmorphic disorder. It needs to be much more widely recognised that cosmetic procedures can carry severe risks to mental health that may not be predictable. Resources are sorely needed, which can help such very troubled people.
Possible resources for the patient
Difficulties in accessing local mental health services and the scarcity of staff with special training and experience of BDD are widely recognised. Although much is heard today about the importance of mental health and the alarming frequency of problems, especially for young people, there has been little evidence of much progress in the provision and accessibility of helpful services. We know, too, that the influence of social media and other factors make concerns about bodily appearance more prevalent, yet recognition of the need for specialist mental health services alert to the significance of issues around cosmetic procedures is virtually non-existent. By contrast, in the reconstructive aesthetic sector, largely the domain of the NHS rather than the private sector, such services and recognition of the need to address psychological issues are likely to be more readily found.
My own experience as a counsellor with a special interest in cosmetic issues is that counselling can play a useful role in helping potential clients make well-informed choices when seeking treatment and in providing emotional support after a procedure. For instance, it is surprising how often prospective patients do not undertake adequate (or even any) research into the qualifications of the practitioner whose help they seek—and practitioners all too often appear unable to offer helpful referral to services if things go wrong.
The BDD Foundation (bddfoundation.org) is a UK charity with a global reach that promotes help for sufferers, their families and acquaintances in the form of self-diagnosis questionnaires, support groups and a variety of other activities designed to promote understanding, education, treatment and research. However, I believe that the need for supportive services goes much wider than just for the sufferers of BDD. Other forms of serious dysmorphic disorders are likely to be much more common. For people suffering in this way, the industry has to recognise its responsibility. We are talking about people who were not turned away as unsuitable for interventions (as is the case for sufferers with BDD), but were welcomed as patients for procedures that left them deeply traumatised.
Conclusion
BDD may be a fairly uncommon mental health problem, but its gravity and the risks it can pose for both patient and practitioner mean that every practitioner needs to be alert to the issues concerning detection, diagnosis and how to deal kindly and sympathetically with a troubled patient. Possible options for further help and treatment and available referral pathways need to be known. To the patient with BDD, it is likely to be best not to offer a procedure. However, I am concerned here particularly about those clients without pre-existing BDD who suffer severely after a procedure has failed to provide the benefit they hoped for and may have left them feeling much worse off.
All this requires that the practitioner is attentive to the psychological dimension in their practice, not just because the client might be suffering from BDD, but also because it is important for all clients. Understanding what motivates them, how well informed they may be about the procedure and its potential risks, how realistic their expectations are and what support may be available to them after the procedure are all elements that should be essential in ensuring a good relationship with the patient and a safe outcome.
For over 20 years, I have been trying to draw the cosmetic industry's attention to the importance of psychological issues in its practice. There has been some progress during that time, but not nearly enough. It seems that some people in the industry fear that attending more closely to the patient's emotional needs may somehow jeopardise the commercial success of their business by dissuading potential clients from going ahead with procedures. Such fears are entirely groundless. The aim is in no way to discourage patients, but by attending to their emotional needs (and I am talking here about all patients, not just the minority with mental health problems) to enhance the safety and success of the patient's experience of cosmetic intervention.
The need to be aware of, and prepared for, the unfortunate patient suffering from BDD or from post-cosmetic distress highlights this broader requirement.