Blinded by body dysmorphic disorder

A psychiatric history is not uncommon in patients presenting for aesthetic procedures.

“It is important that providers screen for signs or symptoms of body dysmorphic disorder (BDD) before proceeding with treatment,” says Elizabeth Damstetter, M.D., a dermatologist in private practice in Chicago. She recently spoke on body image dissatisfaction at the summer meeting of the American Academy of Dermatology in July.

Body image dissatisfaction is a motivator for female patients seeking aesthetic procedures. “In dermatology, we are often tasked with assisting women in improving their body image and body satisfaction,” she said.

“We need to be watchful for people that have extreme levels of dissatisfaction with their body image or whose lives are significantly impaired by their body image dissatisfaction, as these people are highly likely to have BDD,” Dr. Damstetter said.

Two other red flags for BBD are patients who complain about a flaw that is minimally or not visible to the clinician and people who make bizarre requests (such as desiring to look identical to a celebrity).

These concerns should be addressed in the preprocedure consultation. “Assessing the degree of dissatisfaction is critical in building rapport between the patient and the physician, and in optimizing a discussion on goals of treatment and realistic outcomes,” she said.

Approximately, 15% of patients presenting for procedures have body dysmorphic disorder. “For these patients, a psychiatric referral is a must and aesthetic treatment is best deferred,” Dr. Damstetter said.

Individuals with a history of psychiatric depression or anxiety are not necessarily contraindicated for aesthetic procedures. And, it is important to distinguish internal motivation from external motivation for the procedure.

“Simply put, internal motivation is the individual wishing to correct her appearance to make herself eel better and improve their own esteem. Externally motivated patients, on the other hand, want to change their appearance to achieve some secondary change, like please a romantic partner or to advance professionally. In some cases, other people may have advised the person that they need the procedure,” she said.

Internally motivated patients are far more likely to be satisfied with treatment outcomes than externally motivated patients, which should be discouraged from having the treatment, she said. “Our level of understanding that these patients should not be treated is also increasing,” she says.

“I think we have an opportunity as dermatologists to be role models for our peers and other specialties. By encouraging dialogue and strengthening patient-physician rapport by openly addressing body image dissatisfaction and patient treatment expectations, we can elevate and distinguish our specialty as the medical aesthetic experts,” Dr. Damstetter said.