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Body Image

Should Patients With Body Dysmorphia Have Cosmetic Surgery?

Body dysmorphia can lead to unrealistic expectations about cosmetic procedures.

Key points

  • Body dysmorphia is often revealed through behaviors like frequent mirror checking and excessive grooming.
  • This history can be traced back to the term imagined ugliness syndrome.
  • Cosmetic interventions may exacerbate psychological distress in some cases.
Source: Freepik on Freepik
Source: Freepik on Freepik

Body dysmorphic disorder, BDD, a psychiatric condition marked by excessive concern over imagined or minor defects in appearance, is intricately linked to the prevailing cultural ideals of beauty. Research suggests these standards of attractiveness, heavily influenced by societal norms, play a significant role in the development of BDD, contributing to a distorted self-image and body dissatisfaction.

Origins and Evolution of BDD

BDD’s history can be traced back to when it was termed imagined ugliness syndrome. Recognized formally in psychiatric literature with the advent of the DSM-III, BDD has since evolved in its diagnostic criteria. The DSM-V categorizes BDD under obsessive-compulsive and related disorders, emphasizing its compulsive nature and the significant distress or impairment it causes in one’s life.

Identifying BDD

BDD is often revealed through behaviors like frequent mirror checking, excessive grooming, or seeking reassurance about one’s looks. The relentless belief that one is unattractive or repulsive dominates the patient’s thoughts, overshadowing any reassurance they might receive. This disorder can lead individuals to pursue unnecessary dermatological treatments or cosmetic surgeries, often with the unrealistic expectation that these procedures will fix their perceived flaws and, by extension, their life problems.

Demographics and Prevalence

BDD typically emerges in adolescence, with a significant number of cases reported before the age of 18, although it can also appear later in life. Estimates suggest that up to 1 percent of the U.S. population may suffer from BDD, with higher prevalence noted in aesthetic medical settings, such as dermatology and plastic surgery practices.

Etiology of BDD

The causes of BDD are multifaceted, involving psychological and physiological factors. Experiences such as childhood teasing, bullying, and abuse can contribute to the condition, as can complex psychological processes like the displacement of emotions. The proliferation of social media has introduced another layer, providing a platform for comparison and cyberbullying that can aggravate BDD symptoms.

Cosmetic Procedures: A Growing Trend

There has been a notable rise in individuals seeking cosmetic procedures, with millions undergoing surgeries worldwide. This increase has led to more frequent encounters between medical professionals and patients with BDD. Historically, BDD has been considered a contraindication to cosmetic surgery. Patients with BDD often harbor unrealistic expectations and are typically dissatisfied with surgical outcomes, which do not align with their distorted self-perception. This dissatisfaction can lead to severe repercussions for both the patient and the surgeon, including legal actions and, in extreme cases, acts of violence. For instance, one study found that 2 percent of plastic surgeons had been physically threatened by a patient with BDD.

Assessment and Treatment: A Multi-Dimensional Approach

A more nuanced approach to understanding BDD suggests differentiating between mild and severe cases. Patients with less severe symptoms who do not exhibit significant life impairment may benefit from cosmetic procedures if their expectations are managed appropriately. Treating patients with mild BDD symptoms requires careful screening and collaboration with mental health professionals to ensure the best outcome.

Screening for body dysmorphic disorder is an essential step in the diagnostic process, particularly for professionals in the fields of dermatology, cosmetic surgery, and mental health care. Using validated screening tools can help clinicians determine the presence and severity of BDD symptoms and make informed decisions about the appropriateness of cosmetic interventions. There are two widely used questionnaires for BDD screening.

The BDD Questionnaire-Dermatology Version (BDDQ-DV)

The BDDQ-DV is a specific form of the Body Dysmorphic Disorder Questionnaire, adapted for use in dermatology settings. It’s designed to be a self-administered screening tool. Patients can fill it out while waiting for their consultation, which can then inform the clinician’s assessment and subsequent discussions about treatment options. The BDDQ-DV consists of questions that gauge the patient’s preoccupation with their appearance, the extent of their concern, behaviors they may engage in because of their appearance concerns, such as checking mirrors or seeking reassurance, and the impact of these concerns on their daily life. If the responses indicate a possible case of BDD, the clinician can pursue further evaluation, possibly involving a mental health professional.

The Dysmorphic Concern Questionnaire (DCQ)

The Dysmorphic Concern Questionnaire is another screening tool for BDD, though it is more complex and comprehensive. It includes questions that are not exclusively about BDD symptoms, which can help to identify broader concerns that may require attention, including other mental health issues. For instance, the DCQ asks about worries over body odor, sweating, and general appearance and assigns points to responses. A cumulative score can indicate the likelihood of BDD, with a higher score suggesting greater concern and possible BDD diagnosis. This tool is beneficial for identifying individuals who may be at risk for BDD but may not be aware that their concerns are disproportionate or indicative of a deeper psychological issue.

Both the BDDQ-DV and the DCQ have been validated, meaning they have been tested for their effectiveness in accurately identifying BDD in patients. Validation gives clinicians confidence in using these tools as part of their practice. Moreover, these tools can facilitate communication between the patient and the clinician, providing a structured way to discuss concerns that might otherwise be difficult to articulate. When BDD is identified, treatment can focus on psychological interventions, which are the first line of treatment for BDD, rather than cosmetic procedures, which may not address the underlying disorder.

In summary, screening tools for BDD should be an integral part of the assessment process for individuals considering cosmetic procedures. These tools provide a standardized way to identify symptoms of BDD, ensure that patients receive appropriate care, and prevent procedures that may not be beneficial. Clinicians are encouraged to incorporate these validated questionnaires into their practice to support the well-being of their patients.

Concluding Thoughts

As cosmetic procedures become increasingly common, both cosmetic professionals and mental health practitioners must recognize and understand the implications of BDD. Using a multidisciplinary approach, including careful patient screening, can aid in distinguishing those who might benefit from cosmetic procedures from those for whom such interventions may exacerbate their psychological distress. Further research is needed to refine treatment strategies for BDD, aiming to enhance the psychological well-being of those struggling with this often debilitating disorder.


Dufresne RG, Phillips KA, Vittorio CC, et al.. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27: 457-62.

Higgins S, Wysong A. Cosmetic Surgery and Body Dysmorphic Disorder - An Update. Int J Womens Dermatol. 2017 Nov 20;4(1):43-48. doi: 10.1016/j.ijwd.2017.09.007. PMID: 29872676; PMCID: PMC5986110.

Mancuso SG, Knoesen NP, Castle DJ. The Dysmorphic Concern Questionnaire: A screening measure for body dysmorphic disorder. Aust N Z J Psychiatry. 2010 Jun;44(6):535-42. doi: 10.3109/00048671003596055. PMID: 20397781.

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