Why Should Body Dysmorphic Disorder Not Be Overlooked in Patients Seeking Aesthetic Procedures?


As aesthetic procedures have become more widespread in society in recent years, the prevalence of psychiatric problems in individuals seeking cosmetic dermatology clinics has also increased. Body Dysmorphic Disorder (BDD), in particular, is characterized by obsessive concerns about appearance and often poses serious risks to both the patient and the practitioner. Unfortunately, BDD remains underrecognized in cosmetic dermatology. However, if not diagnosed promptly, it can lead to serious psychological and physical problems.

In this article, we explore why BDD should be carefully evaluated in cosmetic dermatology, its clinical features, patient behaviors, and treatment approaches, based on scientific data.

What is BDD and who experiences it?
Body Dysmorphic Disorder is a psychiatric disorder characterized by an excessive focus on a flaw in one's appearance that is actually minimal or non-existent. These individuals often perceive themselves as ugly, disfigured, or unacceptable. The perceived "flaw" often focuses on the skin (acne, scarring, discoloration) or hair (hair loss, frizziness, asymmetry).

Patients with BDD may:

Focus on this flaw for 3 to 8 hours a day,

Obsessively look at or avoid mirrors,

Use excessive makeup or accessories to conceal their appearance,

Avoid social situations, experience functional impairment at work and school,

In severe cases, become housebound and may attempt suicide.

Can compulsive skin picking and hair pulling be a symptom of BDD?

Yes. Skin picking (dermatillomania) and hair pulling (trichotillomania) are frequently observed in individuals with BDD. For example, these individuals may spend hours fiddling with their skin or hair to "smooth" or "even out" their skin. Sometimes these behaviors are performed with sharp objects such as needles, tweezers, or knives and can lead to deep scarring. These individuals do not intend to harm themselves; their goal is simply to "correct the defect."

Why do patients with BDD seek treatment at dermatology clinics?
Individuals with BDD often consider their problems an aesthetic issue. Therefore, they tend to seek cosmetic dermatology rather than psychiatry. This makes dermatologists the first point of contact for these patients.

BDD patients may persistently request procedures such as isotretinoin, dermabrasion, hair transplantation, or laser surgery. However, even if the procedures are objectively successful, these patients have a low satisfaction rate. Many patients continue to experience anxiety after the procedure, discover new flaws, and are dissatisfied with the results.

What risks arise in patients without a diagnosis of BDD?

Conflict with the doctor: Dissatisfaction may lead to complaints, insults, or even physical attacks against the doctor.

Legal action: A patient who is dissatisfied with the procedure may file a lawsuit against the doctor.

Patient health: A patient with an unrecognized BDD may be at increased risk of suicide due to increasing anxiety.

Treatment failure: Procedures may worsen symptoms rather than improve them.

Research, particularly in the US and UK, has shown that approximately one-quarter of patients with BDD have attempted suicide at least once in their lives. This rate is 6 to 23 times higher than the general population.

How can BDD be screened in the dermatology setting?
Dermatologists can assess the frequency, intensity, and functional impairment of patients' appearance concerns with simple questions. For example:

“What aspect of your appearance bothers you most?”

“Does this concern prevent you from socializing or working?”

“How much time do these thoughts take up during the day?”

These questions are the first step in assessing whether a patient is at risk for BDD.

In addition, confidential screening protocols have been developed that can be used in many clinics. These protocols allow patients to be screened without their knowledge, and individuals at risk can be identified early.

How should BDD be treated?
The effectiveness of aesthetic procedures in the treatment of BDD is limited. In some cases, they can even worsen symptoms. Therefore, psychiatric support should be the first step. Among the most effective treatments:

Serotonin reuptake inhibitors (SSRIs): Positive responses can be achieved with medications such as fluoxetine and sertraline.

Cognitive behavioral therapy: Helps restructure the thought patterns that cause BDD.

If the patient refuses referral, the dermatologist can collaborate with the psychiatrist to develop a treatment plan or, in certain cases, begin treatment with SSRIs.

What should dermatologists consider when approaching patients with BDD?

Instead of saying, "Your problem is BDD," the focus should be on understanding their concerns.

The phrase "Your problem is BDD" should be explained in a supportive, non-judgmental manner.

If cosmetic procedures are planned, realistic expectations should be established.

The patient should be provided with detailed information before each procedure.