GUIDELINES & RESOURCES

FOR PRACTITIONERS

When dealing with patients who may suffer from Body Dysmorphic Disorder (BDD), it’s crucial to communicate with care, empathy, and understanding. Certain comments or approaches can inadvertently harm or trigger a patient with BDD, potentially exacerbating their condition.

WHY IS PRE-TREATMENT SCREENING SO IMPORTANT?

By using reliable standardised mental health screening methods prior to cosmetic treatments, aesthetic practitioners can safeguard their patients' overall well-being-- but also protect their own reputation and themselves. This approach fosters a more ethical and safe practice environment for both patients and practitioners.

Protecting your patients' overall wellbeing

Many patients seeking cosmetic procedures may have underlying mental health conditions. Proper screening can identify at-risk individuals, preventing potential harm and ensuring their safety.

Over 20% of patients seeking cosmetic procedures suffer from BDD (D Sarwer et al., 2012).
44.1% of patients seeking elective plastic surgery have a history of psychiatric disorders— significantly higher rate than the general population (26.2% according to Kessler et al., 2005). Common mental health issues include:
- Major Depressive Disorder (50.6%) and Generalised Anxiety Disorder (32.9%) (Jang et al., 2019)

Rates of psychiatric disorders are higher among cosmetic surgery patientsBDD is associated with high levels of distress:
- 4 out of 5 BDD sufferers have suicidal thoughts.
- 1 in 4 BDD sufferers attempts suicide (KA Phillips , 2007).

Better Outcomes & Patient Satisfaction

Patients with BDD often struggle with distorted self-perception and unrealistic expectations regarding the outcomes of cosmetic procedures. This can lead to significant dissatisfaction with surgical results.

Patients with BDD generally have poor outcomes after surgery due to unrealistic expectations (Phillips et al., 2001).
- Over 98% of BDD patients remain dissatisfied after cosmetic procedures; only 1% report satisfaction (Veale et al., 1996).
Patients maintaining or achieving high levels of positive mental health are over 27 times more likely to recover well after surgery when compared to those who maintained the lowest level of positive mental health (Iasiello et al., 2019).
82% of surgeons believe BDD patients have poor postoperative outcomes (Sarwer et al., 2002).

Effective, Reliable Identification Of At-risk Patients

While most surgeons are aware of BDD among their patients, they tend to severely underestimate its prevalence. Standardised psychological pre-screening tools offer a more reliable method for identifying BDD, improving patient care and reducing risks.

84% of plastic surgeons have reported unknowingly operating on patients who turned out to suffer from BDD (Higgins et al., 2017).
Surgeons are generally poor at screening for BDD compared to standardised tools:
- Surgeon intuition has a sensitivity of 4.7% (Joseph et al., 2016), compared to:
  - BDDQ has 100% sensitivity and 89% specificity (Joseph et al., 2016; Ziglinas et al., 2014).
  - BDDQ-DV has 100% sensitivity and 94.7% specificity (Ziglinas et al., 2014).

Legal & Physical Protection for Practitioners

Failing to identify BDD before a procedure can expose practitioners to significant legal and physical risks. Patients with BDD may be unable to provide informed consent and can become dissatisfied, leading to legal disputes or, in extreme cases, violence.

There have been legal cases where a BDD diagnosis brought the patient’s ability to consent into question (Sweis et al., 2017).
BDD patients dissatisfied with surgery may retaliate against practitioners in several ways:
- 2% of plastic surgeons have been physically threatened by a patient with BDD.
- 10% have received threats of violence and legal action (Sweis et al., 2017; Wang et al., 2016).
- 40% have been threatened by a patient with BDD (Ziglinas et al., 2014).
- Since 1991, three plastic surgeons have been murdered by patients with BDD who were unhappy with their results (Sweis et al., 2017).

THINGS TO
AVOID

Certain phrases, even when well-intentioned, can inadvertently reinforce a patient's obsession with their appearance if they suffer from Body Dysmorphic Disorder (BDD). Avoiding the phrases and approaches outlined below can help create a supportive environment where patients feel understood and cared for. By prioritising empathetic communication, you can help guide patients towards appropriate treatment options and support their journey towards better mental health.

Minimising Their Concerns

This dismisses the patient’s feelings and can make them feel misunderstood and invalidated. Patients with BDD often experience intense distress over their perceived flaws, and minimising their concerns can deepen their anxiety and frustration.

"You're worrying over nothing."

" [Feature of concern] looks fine to me."

"Everyone has something they don’t like about themselves."

Reinforcing the Obsession

Acknowledging a flaw, even in a minor way, can validate the patient's obsessive thoughts and reinforce their preoccupation with the perceived defect. This can lead to increased fixation and distress.

"I can see what you're talking about, but it's not that bad."

"You’re not alone; many people fix that."

"Do you want to try a different procedure to fix this?"

Making Comparisons

Comparing the patient to others, whether to downplay their concerns or to make them feel better, can backfire. Patients with BDD have distorted perceptions of their appearance, and comparisons can increase their feelings of inadequacy or shame.

"Most people would love to look like you"

"There are people with much worse issues."

"I’ve seen worse; yours isn’t that bad."

Offering Quick Fixes

Promising that a cosmetic procedure will solve their emotional distress can set unrealistic expectations. BDD is a mental health disorder, and while aesthetic treatments may provide temporary relief, they do not address the underlying psychological issues.

"This procedure will make you feel so much better."

"That’s an easy fix, don’t worry."

"If it bothers you that much, we should just fix it."

Directly Questioning Their Perception

Inaccurate perception is the telltale sign of BDD. While it’s important to gently challenge distorted thoughts, directly challenging them can cause the patient to feel defensive or isolated. It should be done in a sensitive and supportive way, ideally by a mental health professional.

"Are you sure it’s that bad?"

"I don’t see anything wrong- it's just in your head."

"No one else would notice that."

Comments Focused on Appearance

Focusing on appearance, even in a positive light, can reinforce the patient’s belief that their worth is tied to their looks. Patients with BDD often struggle with their self-image, and these types of comments can inadvertently emphasise the importance of appearance.

"You look fine to me"

"You’re attractive, you don’t need this."

WHAT IS BDD?

BODY DYSMORPHIC DISORDER (BDD)

is a mental health condition where a person is intensely preoccupied with perceived flaws or defects in their appearance, which are often not noticeable to others.

For patients with BDD, these concerns are not just fleeting worries; they can dominate their thoughts, causing significant emotional distress and impairing daily functioning.

What does BDD feel like to patients?

Patients with BDD often feel a persistent sense of dissatisfaction or distress about their appearance. They may fixate on specific features—such as their skin, nose, hair, or body shape—believing these are abnormal or unattractive, even when others see them as perfectly normal. This preoccupation can consume hours of their day and lead to a cycle of checking, comparing, and seeking reassurance. They might frequently check mirrors or avoid them altogether, compare themselves to others, or constantly seek validation about their appearance.

When does it become a serious issue?

Appearance-related issues become a serious problem when they start to interfere with the sufferer's daily activities. In day-to-day life, this overwhelming focus on perceived flaws can affect the their social interactions, work performance, and personal relationships. Simple activities like attending social events, going to work, or even leaving the house can become anxiety-inducing. For someone with BDD, the mirror is not just a reflection of how they look—it becomes a reflection of how they feel about themselves, which is often distorted and overly critical.

How do cosmetic procedures affect BDD?

As an aesthetic practitioner, it’s crucial to recognise that no amount of cosmetic intervention can address the underlying psychological distress of BDD. BDD patients may believe that altering a specific feature will eliminate their distress and fix deeper emotional issues. Their hope is that the procedure will provide a sense of relief or "fix" what they perceive to be the problem. However, even after undergoing a procedure, they are likely to still feel dissatisfied or find a new area to fixate on, as the root of the issue isn't the appearance itself but their perception of it.

There are 3 main Next Steps recommendations depending on your patient's results:

Remember: these are general suggestions. Each patient is different and their circumstances need to be considered on an individual basis.

Keep in mind it’s always good practice to maintain open communication, ensuring the patient has realistic expectations and understands the potential outcomes, risks, and aftercare involved in their procedure.

GREEN: GOOD TO GO!

Patients in the "Green" category have shown no significant signs of Body Dysmorphic Disorder (BDD) or other mental health concerns that would suggest a risk related to cosmetic procedures. You can feel confident proceeding with their desired treatment.

Consider the following steps:

Clarify Expectations
Have a discussion about what they hope to achieve and ensure their expectations are realistic.
Check for signs of psychological distress
Review any symptoms they may have indicated and discuss their concerns in a non-judgmental way.
Consider a Referral
Suggest a brief consultation with a mental health professional, especially if any red flags arise during the conversation.

AMBER: PROCEED WITH CAUTION

Patients in the "Amber" category have shown some mild to moderate concerns that may warrant a more thorough discussion. While these patients are not necessarily unsuitable for cosmetic procedures, they may benefit from additional screening or counselling.

For these patients:

Provide Reassurance, Not Rejection
Avoid outright refusing treatment, as this can lead patients to seek out less responsible or unqualified practitioners who may not prioritise their overall wellbeing. Instead, emphasise that your goal is to provide them with the safest, most beneficial outcome, which involves understanding and addressing any underlying concerns first.
Don't Rush
It is a good practice to always encourage a "cooling off" period to allow the patient time to reflect before proceeding. PREPÆRE automatically guides patients towards the relevant resources depending on their screening results; encourage them to explore these to ensure your patients are making a well-considered decision while still feeling supported.
Start small
Where possible and reasonable, consider recommending less invasive treatment options. When it comes to injectables, encourage the patient to start with a smaller amount and build it up over time to allow you to monitor their mental health throughout the course of their treatment.
Encourage them to seek professional help
Patients who indicate serious warning signs of psychological distress are automatically provided with resources and information on consulting a qualified mental health professional. Encourage them to reach out to a trusted specialist who can provide comprehensive diagnostic assessment and therapy as needed.

RED: FURTHER EXAMINATION NEEDED

Patients in the "Red" category present significant concerns or signs suggestive of BDD or another mental health disorder that could affect their satisfaction with or suitability for cosmetic treatment.

HOW CAN I IDENTIFY PATIENTS WITH BDD?

Body Dysmorphic Disorder (BDD) can be extremely challenging to identify, especially in a cosmetic setting where concerns about appearance are expected.

Like many other mental health issues, Body Dysmorphia can be imperceptible from the outside. Patients with BDD can present as entirely "normal" in a clinical setting. They may not exhibit any obvious signs of severe distress about their appearance and may be able to articulate their desires and reasons for seeking a procedure convincingly.

USE STANDARDISED SCREENING TOOLS

Screening tools provide a clearer picture of your patient’s psychological state, helping you make more informed decisions.

If a screening indicates potential BDD or other mental health issues, you can better plan appropriate next steps—whether that means approaching with a little extra caution or a delaying the treatment, a referral to a mental health professional, or - in extreme cases - even deciding against a procedure.

MAKE YOUR PATIENTS FEEL SAFE & COMFORTABLE

Pre-treatment psychological screening not only helps identify patients who may be at risk of mental health issues but also communicates a powerful message about your practice's values.

It demonstrates that you are attuned to the complexities your patients may be facing and are committed to providing a compassionate, understanding, and supportive environment. It's a way to signal to your patients that your practice is a safe space where they are encouraged to openly share their concerns and feelings without fear of judgment, making them feel heard and respected, and ultimately leading to a stronger patient-practitioner relationship.

KNOW YOUR PATIENTS & LOOK OUT FOR WARNING SIGNS

Some patients may exhibit behaviours that could serve as red flags, but many individuals with psychological struggles may not display any outwards signs. It's important to take the time to get to know your patients on a deeper level.

Gain insight into their motivations for seeking treatment and clarify their expectations of the results. Patients with BDD often hold unrealistic expectations, believing that cosmetic procedures will completely transform their lives or "fix" all their problems.

Be mindful of unusual emotional reactions, such as intense anxiety, anger, or distress, especially when discussing their appearance or the likely outcomes of the procedure. These heightened emotional responses can be red flags indicating deeper psychological concerns.

Guidlines & Resources

PREPÆRE