Body Image and Aesthetic Treatments: What Is Body Dysmorphic Disorder, and When Should You Seek Support?

What is body dysmorphic disorder?

Body dysmorphic disorder is a condition in which a person sees one or more features of their appearance as a flaw and spends a great deal of time preoccupied with it. The feature in question is mostly so minor that others do not notice it or attach no importance to it. The UK National Health Service (NHS) defines this condition as a mental health problem and states clearly: having it does not mean that a person is vain or self-obsessed; it can be very upsetting and can affect daily life.

The worry most often concerns the face: the skin, nose, lips, hair, jawline. However, any area of the body can become the focus of the worry. It can be seen at any age; it most often begins in adolescence and young adulthood, and it affects both women and men. Its cause is not fully known; it is said that it may be associated with a similar condition, obsessive-compulsive disorder or depression in the family, and with being teased or bullied in childhood.

There is an important distinction here. Being bothered by your appearance from time to time, wanting to change a feature or considering an aesthetic procedure does not mean having this disorder. The difference lies in the intensity of the worry, the time it takes up and the extent to which it restricts life.

Which signs stand out?

The following are behaviours and thoughts commonly seen in this condition. Taken one by one, many of them are things everyone does from time to time; what is significant is that they are constant and cause distress.

• Intense and persistent worry about a particular area of the body, especially the face
• Frequently comparing your appearance with that of others
• Looking in the mirror very often or, on the contrary, avoiding mirrors and photographs altogether
• Spending a long time on make-up, hair, clothing or posture in order to hide the feature seen as a flaw
• Squeezing, picking or fiddling with the skin in order to make it smooth
• Repeatedly asking those close to you for reassurance ('I don't look bad, do I?') and not being able to feel relieved by the answer
• Staying away from work, school, meeting friends or being photographed because of your appearance

When this condition is not treated, it can affect working life, social life and relationships; it can lead to depression, self-harm and thoughts of suicide. The NHS stresses that the symptoms are unlikely to go away on their own without treatment and may get worse over time, and that there is nothing to be ashamed of in asking for help.

How common is it among people seeking aesthetic procedures?

A systematic review that brought together studies carried out in different settings calculated the prevalence of body dysmorphic disorder in adults in the general population at about 2 per cent. In the same review this figure was about 13 per cent among people presenting for general cosmetic surgery, about 9 per cent in cosmetic dermatology outpatient clinics and about 20 per cent among those presenting for nose reshaping surgery.

Another meta-analysis, focusing on cosmetic surgery and dermatology patients, paints a similar picture: an average of 15 per cent in cosmetic surgery patients and an average of 13 per cent in dermatology patients. However, the most important finding of this study is not the averages but the ranges: in individual studies the figures varied between 2 per cent and 57 per cent.

Read these numbers with caution. The studies were carried out in different countries, with different screening questionnaires and mostly in surgery or dermatology patients; data specific to those presenting for non-surgical procedures such as fillers and botulinum toxin are scarcer. What can safely be said is this: the condition is markedly more common among people seeking aesthetic procedures than in the general population, and it mostly goes unrecognised.

This does not mean that everyone who wants an aesthetic procedure has a mental health problem. The great majority of those who present do not have this disorder. The numbers only show why it is necessary for the physician to keep this possibility in mind during the consultation.

Does an aesthetic procedure relieve this worry?

Mostly it does not. In a study of 200 people diagnosed with body dysmorphic disorder, about two thirds of the participants had received a non-psychiatric treatment such as dermatological treatment or surgery; these treatments rarely improved the symptoms of the disorder. An earlier study of 289 people by the same research group gave a similar result.

A review that examined the subject critically states that the available publications indicate a poor outcome after aesthetic interventions in most of these people. The same review also adds an honest caveat: prospective, well-designed studies are few, and the possibility that some people with mild symptoms, whose worry is limited to a single area, may benefit from a procedure cannot be ruled out completely. For this reason the decision is made not by generalisation but by the physicians who assess the individual's situation.

Why the result is so often not enough has to do with where the problem lies. In this condition the source of the distress is less the shape of the tissue than how that area is perceived. Even if the procedure is technically successful, the person may find the result inadequate, the worry may shift to another area, or a search for a new procedure on the same area may begin. Because every procedure has its own risk, this cycle accumulates risk without providing benefit. We cover the subject of repeated requests for procedures separately in our article “Rumour: Botulinum toxin (commonly called botox) and fillers are addictive; once you start, you cannot stop — What does the science say?”.

Questions I can ask myself

The questions below have been adapted from the screening questions recommended to clinicians by NICE, the body that produces health guidelines in England. Clinicians use them to understand how much the worry affects daily life.

• Do I worry a lot about my appearance and wish I could think about it less?
• Exactly which features of my appearance bother me?
• On an ordinary day, how many hours is my appearance on my mind? (The guideline regards more than one hour a day as excessive.)
• How does this worry affect my life?
• Does it make it hard for me to do my work or be with my friends?

With regard to aesthetic procedures, it may be useful to add the following questions: after the procedures I have had before, did I feel relieved, or did I soon begin to look for a new flaw? Have I been to more than one physician about the same complaint? When those close to me say 'I can't see anything', am I able to believe them? Do I think my life will not get better without the procedure?

This is not a test and it has no score. Answering 'yes' to the questions does not mean a diagnosis; nor does answering 'no' show that there is no problem. If your answers give you pause, that is reason enough to talk about it with a family doctor or a mental health professional.

What does it mean if the physician postpones the procedure or does not recommend it?

It can be hurtful when a physician says 'let's not do this now' or 'I do not recommend this procedure for you'. Yet most often this shows that the physician has listened to you and is thinking of you, not just of the procedure. The NICE guideline recommends that clinicians routinely keep this possibility in mind in people who ask for an aesthetic or dermatological procedure, and that people in whom the disorder is suspected be assessed by a mental health professional experienced in this area.

• If the procedure is unlikely to bring you relief, the physician is protecting you from a risk from which you would not benefit.
• Getting support for the worry itself first makes the decision that is made later a sounder one.
• Postponement is most often not a door closing but a change in the order: assessment first, decision afterwards.
• A practitioner who accepts every request without question is not safer than a physician who looks after your interests.

When a physician does not recommend a procedure, it is helpful to ask why rather than going somewhere else straight away. If you have had a similar answer from more than one physician, that is information worth dwelling on. The points to consider when choosing a physician and a facility are in our article “A 10-Point Safety Checklist for Choosing a Clinic and Physician for Medical Aesthetics”; the general framework for those considering a procedure for the first time is in our article “A Guide for First-Time Medical Aesthetic Patients”.

How much influence do social media and filters have?

Constantly looking at edited and filtered images can change the perception of what an 'ordinary' face is. In a qualitative study based on interviews with 24 women who had had lip filler to a markedly exaggerated degree, most of the participants described social media as influencing their perception of beauty; the researchers described this as perception drifting over time. This is a small, selected group; it does not show causation. Even so, it is a good reminder to make a decision about a procedure not according to a screen image but according to your face in the mirror and a physician's examination. For consultations at a young age, see our article “Medical Aesthetics for Young People”.

I am worried about someone close to me; what can I do?

• Instead of arguing about the 'flaw' they see, take the distress they are experiencing seriously: saying 'I can see how much this is wearing you down' helps more than saying 'there is nothing wrong with you'.
• Reassuring them about their appearance again and again brings short-lived relief, but is thought to feed the worry. Instead of reassurance, suggest looking for support together.
• Avoid labels such as 'vain' or 'obsessed', and avoid mockery; this condition is not a choice.
• Suggest that they see a family doctor or a mental health professional; offer to go with them to the appointment if they wish.
• Do not press for a new procedure, and do not try to forbid the procedure either; suggest that the decision be made after an assessment.
• If you notice hopelessness, remarks such as 'I don't want to live' or signs of self-harm, do not leave them alone and seek emergency help.
• Look after your own limits and health too; being close to someone in this situation can be tiring.

Are there effective treatments?

Yes. The NHS and NICE recommend two approaches to treating this condition: cognitive behavioural therapy and a group of antidepressant medicines. Cognitive behavioural therapy aims at recognising the situations that trigger the worry and changing the response to them; it mostly involves the person facing, step by step, the situations they avoid and reducing behaviours such as mirror checking. In drug treatment, antidepressants that act through serotonin are used. The mental health professional decides which approach will be used, when and for how long; when the symptoms are severe, the two may be recommended together.

It is necessary to be open about the strength of the evidence. A Cochrane review reported that at that date there were only a few, small randomised controlled trials, that these suggested that both drug treatment and cognitive behavioural therapy may be beneficial, and that the findings needed to be replicated. In other words, these treatments are the options recommended by the institutions and for which there is evidence that they work, but not everyone responds to the same degree, and recovery takes time.

For the first step you can see a psychiatrist directly or through your family doctor. Explaining your worry openly to the physician you are seeing about an aesthetic procedure is also a start; your physician can refer you to a suitable specialist. In the meantime, regular sleep, physical activity and spending time with people you love may be supportive, but they do not replace treatment.

Conclusion

If worry about appearance takes up a large part of your life, the problem most probably lies not in the mirror but in the worry itself, and effective support is available for it. In this situation aesthetic procedures mostly do not bring the expected relief. A physician who postpones or does not recommend a procedure is not against you but on your side. Asking for help is not a weakness; it is beginning to solve the problem in the right place.