Managing the Medicolegal Risks of Body Dysmorphic Disorder in Cosmetic Surgery

Body dysmorphic disorder (BDD) is defined as a preoccupation with a slight or imagined defect in appearance which is imperceptible to other people that cannot be better accounted for by another psychological disorder. Any body part can become the focus of BDD, but patients are most commonly concerned with skin issues, such as acne, scarring or colouration, excessive facial or bodily hair, or the size and shape of the nose. Patients with BDD spend at least one hour each day thinking about the perceived defect which causes clinically significant distress or impairment in social, occupational or other areas of functioning. BDD is classified as an obsessive-compulsive disorder (OCD), but it is distinct from eating disorders. However, in cases where the main focus is on the patient’s weight, there can be an association with conditions such as anorexia nervosa or bulimia nervosa.  

BDD is seen relatively frequently in the general population, with an estimated point prevalence of 0.7–2.4%. Thus, it is more common than conditions such as schizophrenia or anorexia nervosa, particularly as the reported figures are likely to underrepresent the true prevalence. Although the occurrence in men and women is roughly equal, age does appear to be a factor with the prevalence in adolescents being twice that in the general population. The prevalence in clinical settings is even higher, with estimates being 9–12% in dermatology patients, and up to 42% in patients with diagnosed OCD, social phobia or atypical major depressive disorder. Worryingly, some studies have reported that over half of all patients who seek cosmetic surgery have BDD. Recently, a trend linking increased social media use, particularly of applications that allow filtering of photographs, with an increasing prevalence of BDD has been reported.  

The majority of patients with BDD ultimately seek cosmetic surgery to correct their perceived appearance flaw. However, this type of treatment rarely cures them: studies estimate that only around 5% of patients report an improvement in BDD symptoms following surgery and over 80% are dissatisfied with the results achieved. Many patients become even more aware of the perceived defect, and others simply find another body area of concern. This can have serious consequences both for the patient and the surgeon. Patients can experience high levels of anxiety, depression, self-harm and even suicide. In turn, surgeons report frequent threats of both legal action and physical violence from dissatisfied BDD patients. Therefore, it appears that non-psychological interventions are unlikely to effectively treat the symptoms of what is essentially a psychological disorder.  

As a result, BDD is generally seen as a contraindication for cosmetic surgery, although some surgeons are prepared to operate on patients with mild symptoms. It is becoming more widely accepted that patients requesting cosmetic surgery should be screened for BDD, although the occurrence of this remains low. Furthermore, as there are currently no clinical guidelines outlining the correct screening procedure for BDD, identifying which patients are suffering from BDD before surgery takes place remains a challenge. Often patients are adept at hiding symptoms and many cosmetic surgeons are not sufficiently trained in psychiatric disorders to determine if the patient’s preoccupation with their appearance is disproportionate. Not surprisingly, surgeons who are more familiar with the diagnostic criteria for BDD are more likely to appropriately identify patients with the condition.  

Any pre-surgical assessment of the patient should aim to identify the critical traits of BDD, including impairment of social and daily functioning. Other key components of the consultation include personal medical history, mental health status assessment, clarification of the patient’s motivators and expectations for the proposed procedure, and a detailed explanation of treatment limitations. Factors indicative of BDD include multiple unsuccessful consultations for cosmetic surgery, motivations that are driven by external factors such as a wish to improve social life or relationships, fixation on one specific feature, presenting the surgeon with a ‘checklist’ of perceived flaws, excessively camouflaging the perceived defect, exhibiting repetitive behaviour such as constantly checking appearance in the mirror and excessively high expectations and a request for perfection.  

Although some screening tools have been developed to identify patients with BDD, none has been universally accepted. Of those currently available, the BDD Questionnaire is one, and it shows a high sensitivity and specificity, along with a high predictive value outside of clinical psychiatric practice, so appears to be a suitable for use in a cosmetic surgery setting. Several studies have shown that patients who have positive screenings for BDD with this instrument report significantly lower satisfaction levels with the results of subsequent surgery.  

BDD is relatively common, particularly in patients seeking cosmetic correction. However, in these patients, surgery rarely improves their symptoms and can lead to serious negative consequences, both for the patient and the surgeon. Recognition of patients with BDD before surgery takes place would avoid unnecessary elective procedures and the risk of subsequent litigation. Rather than surgery, patients with BDD require a multidisciplinary approach that includes referral to a mental health specialist. In this way, negative outcomes for both the patient and the surgeon can be avoided.