Through the Looking Glass: Strategies for Managing Patients Who Have Red Flags for Body Dysmorphic Disorder

Laura M. Cascella, MA, CPHRM

Healthcare providers who offer cosmetic and aesthetic services often take satisfaction in knowing that they are helping patients address physical issues that might impede their body image, emotional well-being, and psychosocial functioning. Surgeries or procedures that correct or improve these issues can ultimately enhance patients’ quality of life and address lingering insecurities. Yet, for some patients, seeking out cosmetic and aesthetic services is symptomatic of a more complex issue, which ultimately can lead to negative consequences for both the patient and the healthcare provider.

People who have body dysmorphic disorder (BDD) represent only a small portion of the overall population, but their prevalence increases in healthcare settings that provide cosmetic services, such as dermatology practices, plastic and cosmetic surgery practices, and dental and oral surgery practices.¹ Physicians, dentists, and other healthcare professionals in these settings should possess knowledge about BDD and be attuned to potential red flags for the disorder. Further, as part of patient selection criteria, providers should consider a protocol for managing patients who might potentially have BDD.

About Body Dysmorphic Disorder

BDD is a mental health disorder that is characterized by a persistent preoccupation or fixation with nonexistent or minor flaws in physical appearance. This preoccupation is notably disproportionate in relation to the actual defect (if any exists), and can cause an individual significant emotional distress and an inability to function in work and social settings.

BDD was initially introduced in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. In the 5th Edition of the DSM, released in 2013, BDD was reclassified from a somatoform disorder to an obsessive compulsive disorder.² People who have BDD often engage in repetitive behaviors (compulsions) as a result of their preoccupation (obsession) with perceived physical flaws. Compulsive behaviors may include:

• Excessive mirror checking and grooming
• Skin picking
• Camouflaging behavior (e.g., repeatedly applying makeup, adjusting clothing, or covering a body part)
• Constant comparison with others
• Reassurance seeking (which often does little to assuage their concerns)
• Referential thinking (e.g., misinterpreting other people’s behaviors or actions as a negative response to the perceived physical flaws of the person with BDD)

How BDD develops is not entirely understood, although research suggests biological and environmental factors may play a role, including genetics, brain function, family dysfunction, abuse and neglect, bullying, and media influence. People who have BDD commonly have other psychiatric conditions, such as mood, anxiety, and personality disorders.³

BDD often begins during adolescence, although it may go undiagnosed for years. The disorder affects men and women about equally, although some research indicates that physical areas of fixation may differ between the sexes. Men might be more apt to focus on perceived flaws associated with the genitals, height, excess body hair, thinning hair, body build, and muscle size. Women tend to focus on their breasts, hips, legs, body weight, and skin.⁴ The Body Dysmorphic Disorder Foundation notes that “Most people with BDD are preoccupied with some aspect of their face and many believe they have multiple defects.”⁵

Legal and Ethical Implications

The fixation on physical flaws and the perceived negative consequences of having these flaws often drive individuals who suffer from BDD to seek cosmetic or aesthetic services. Further, as cosmetic procedures and treatments continue to expand, so too does the opportunity for individuals who have BDD to address a range of perceived body image issues. Unfortunately, for these patients, cosmetic treatment often is a paradox because their expectations often do not align with reality, which can lead to a toxic cycle of dissatisfaction and increased preoccupation with alleged physical shortcomings.

These characteristics of BDD trigger questions about the legal and ethical implications of performing cosmetic procedures on patients with known or suspected BDD. Issues have been raised about whether these patients can legally consent to treatment due to the nature of their disorder.⁷ Although informed consent is a complex issue that isn’t universally defined, the right to consent to healthcare treatment generally applies to competent adults. Whether BDD erodes a person’s competency to the point that it precludes them from providing consent is still debated.

Beyond the informed consent issue, questions have arisen about whether it is ethical for providers to perform cosmetic procedures on these patients knowing that BDD is a mental health disorder, not a physical condition — and treating these patients often is futile.

Studies have shown that patients with BDD who have cosmetic treatments often are dissatisfied with the results, and this dissatisfaction can create different types of risk for the treating healthcare provider. Malpractice lawsuits are an obvious risk in these situations, but patients also might respond in other ways, such as verbally criticizing the provider, writing negative online reviews, and making complaints to the state medical board or dental board. In some severe instances, patients with BDD have retaliated with aggression, violence, and even murder.⁹

Additionally, both healthcare providers and patients may suffer financial consequences as a result of patients’ dissatisfaction with cosmetic procedures. For providers, increased costs might occur if patients request refunds, or if providers feel compelled to redo services in an attempt to appease patients. Patients might suffer financially if they continue to seek cosmetic services to have the perceived physical flaws remedied or if they transfer their preoccupation to other body parts.

Risk Strategies

The inherent risks in treating patients who potentially have BDD indicate that healthcare providers should determine how best to identify and manage these patients. Providers who offer cosmetic and aesthetic services should consider the following strategies as part of a prudent risk management approach:¹⁰

• Be aware of common signs of BDD, and listen carefully to how patients describe their physical problems and their impression of the consequences of those problems. Consider whether patients’ responses are proportional and whether their expectations of treatment are realistic.
• Ensure that you have a comfortable, private space for patient assessment, discussions about treatment and expectations, and disclosure of sensitive information. Reassure patients about your commitment to privacy and confidentiality.
• Limit interruptions and the number of people present while assessing patients, but have a witness or chaperone in the room when talking to patients about concerns related to BDD. Give patients ample time to discuss their situations, expectations, and concerns.
• Consider using an evidence-based questionnaire or assessment tool to screen patients for signs and symptoms of BDD. Research shows that these tools are more reliable for identifying potential BDD than clinicians’ judgment alone.¹¹
• Develop a clinical workflow that incorporates aspects related to identifying, managing, and referring patients for psychiatric or psychologic assessment if you suspect they potentially have BDD. Establish working relationships with trusted mental health providers to facilitate the referral process.
• When proceeding with treatment, discuss realistic expectations of treatment outcomes with patients, and engage them in thorough informed consent processes that disclose potential risks, benefits, and alternative treatment options. Document the informed consent process and the provision of any patient education in each patient’s health record.
• Be cognizant of how marketing and advertising strategies for cosmetic and aesthetic services might influence patients’ expectations. Carefully review promotional materials to ensure they do not make unrealistic guarantees, promise idealized outcomes, or establish an unattainable standard of care.

Resources

For more information about BDD and managing patients who may potentially have the disorder, see the following resources:

• Body Dysmorphic Disorder Foundation: Resources
• International OCD Foundation: BDD for Professionals
• MedPro Group: Risks Associated With Cosmetic Dental Procedures
• MedPro Group: Risks Associated With Cosmetic Medical Procedures
• Medscape: Informed Consent in Body Dysmorphic Disorder
• National Institute for Health and Care Excellence: Obsessive-Compulsive Disorder and Body Dysmorphic Disorder: Treatment

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¹ Higgins, S., & Wysong, A. (2017). Cosmetic surgery and body dysmorphic disorder — an update. International Journal of Women's Dermatology, 4(1), 43–48. https://doi.org/10.1016/j.ijwd.2017.09.007; Day, B. (2020, January 30). Examining body dysmorphic disorder in dental patients. Dental Tribune. Retrieved from www.dental-tribune.com/news/examining-body-dysmorphic-disorder-in-dental-patients/

² Higgins, et al., Cosmetic surgery and body dysmorphic disorder — an update; Substance Abuse and Mental Health Services Administration. (2016). DSM-5 changes: Implications for child serious emotional disturbance [Internet]. Table 23, DSM-IV to DSM-5 body dysmorphic disorder comparison. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t19/

³ Body Dysmorphic Disorder Foundation. (n.d.). What is body dysmorphic disorder: Related conditions. Retrieved from https://bddfoundation.org/information/bdd-related-conditions/; Anxiety and Depression Association of America. (2021, March 7). Body dysmorphic disorder. Retrieved from https://adaa.org/understanding-anxiety/body-dysmorphic-disorder; Higgins, et al., Cosmetic surgery and body dysmorphic disorder — an update; Joseph, A. W., Ishii, L., Joseph, S. S., Smith, J. I., Su, P., Bater, K., Byrne, P. . . . Ishii, M. (2017). Prevalence of body dysmorphic disorder and surgeon diagnostic accuracy in facial plastic and oculoplastic surgery clinics. JAMA Facial Plastic Surgery, 19(4), 269–274. https://doi.org/10.1001/jamafacial.2016.1535; Scott, S., & Newton, J. T. (2011, March). Body dysmorphic disorder and aesthetic dentistry. Dental Update, 38(2), 112-114, 117-118. doi: 10.12968/denu.2011.38.2.112

⁴ Scott, et al., Body dysmorphic disorder and aesthetic dentistry; Higgins, et al., Cosmetic surgery and body dysmorphic disorder — an update.

⁵ Body Dysmorphic Disorder Foundation. (n.d.). What is body dysmorphic disorder? Retrieved from https://bddfoundation.org/information/what-is-bdd/

⁶ Higgins, et al., Cosmetic surgery and body dysmorphic disorder — an update.

⁷ Ibid; Francis, T.E. (2012, February 2). Informed consent in body dysmorphic disorder. Medscape. Retrieved from www.medscape.com/viewarticle/758800_4

⁸ Higgins, et al., Cosmetic surgery and body dysmorphic disorder — an update.

⁹ Ibid.

¹⁰ Scott, et al., Body dysmorphic disorder and aesthetic dentistry; Cagnassola, M. E. (2017, September 21). Recognizing body dysmorphic disorder in cosmetic dentistry. Dental Products Report. Retrieved from www.dentalproductsreport.com/view/recognizing-body-dysmorphic-disorder-in-cosmetic-dentistry; Higgins, et al., Cosmetic surgery and body dysmorphic disorder — an update.

¹¹ James, M., Clarke, P., & Darcey, R. (2019). Body dysmorphic disorder and facial aesthetic treatments in dental practice. British Dental Journal, 227, 929–933. https://doi.org/10.1038/s41415-019-0901-7; Joseph, et al.,
Prevalence of body dysmorphic disorder and surgeon diagnostic accuracy in facial plastic and oculoplastic surgery clinics.

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