Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures

Development of a Preoperative Psychological Screening Tool: Piloting the Cosmetic Readiness Questionnaire (Pilot-CRQ)

BACKGROUND

Patients with psychological risk factors such as body dysmorphic disorder (BDD) and unmanaged mental health concerns are considered at higher risk for dissatisfaction with aesthetic procedures. Identifying these risks before a procedure may decrease the chance of adverse outcomes for patients and practitioners.

OBJECTIVES

In this study we aimed to develop a comprehensive psychological screening tool to assess patient's psychological suitability for surgical and nonsurgical aesthetic procedures.

METHODS

Items for the Pilot Cosmetic Readiness Questionnaire (CRQ) were developed by psychologists (n = 3) and then reviewed by plastic surgeons (n = 2) and nonsurgical cosmetic doctors (n = 3). Patient interviews (n = 15) and piloting of the questionnaire (n = 69) provided data regarding the scale's initial psychometric properties.

RESULTS

Results supported the reliability and validity of the Pilot-CRQ's subscales of Body Dysmorphia, Psychological Distress, Self-Criticism, Perfectionism, and Lack of Openness. Lack of Openness was a validity scale that examined the degree that respondents might be underreporting symptoms. The CRQ predicted individuals with a BDD diagnosis, as rated by a blinded expert clinical psychologist, with high sensitivity and specificity.

CONCLUSIONS

These results provide support for the Pilot-CRQ identifying people with BDD and psychological factors related to aesthetic treatment outcomes and provide a strong basis for employing the CRQ in clinical contexts and in future research.

LEVEL OF EVIDENCE: 2 (DIAGNOSTIC)

The Cosmetic Readiness Questionnaire (CRQ): Validation of a Preoperative Psychological Screening Tool for Aesthetic Procedures

BACKGROUND

Several psychological risk factors are associated with patient dissatisfaction with aesthetic procedures, such as body dysmorphic disorder (BDD), unmanaged mental health concerns, and unrealistic expectations. Identifying these risks by preoperative screening may protect patients from adverse psychological outcomes and provide reputational or legal protection for practitioners.

OBJECTIVES

In this study we aimed to further develop and validate the Cosmetic Readiness Questionnaire (CRQ), a comprehensive psychological screening tool to assess patient suitability for surgical and nonsurgical aesthetic procedures.

METHODS

The CRQ was validated across 2 studies in clinical contexts, examining structural and construct validity in a sample of 8031 individuals who completed the CRQ as part of routine clinical care. In a further sample (n = 574), criterion validity was explored through the relationship between the CRQ and dissatisfaction with past aesthetic treatments. Risk category cutoff scores were developed.

RESULTS

Results supported the reliability and validity of a 5-factor CRQ that measured body dysmorphia, psychological distress, self-criticism, unrealistic expectations, and lack of openness. High scorers on the CRQ were 78% more likely to report dissatisfaction with a past cosmetic procedure than low scorers.

CONCLUSIONS

The CRQ is a comprehensive and valid screening measure for identifying patients who may require further psychological assessment or additional support before aesthetic treatment. Instructions are provided on how to implement the CRQ in clinical practice.

LEVEL OF EVIDENCE: 3 (DIAGNOSTIC)

An Evidence-based Pathway for Body Dysmorphic Disorder in Facial Aesthetics

Aesthetic procedures should be avoided in patients with body dysmorphic disorder (BDD) since they can negatively impact mental health and lead to further aesthetic dissatisfaction. There are no evidence-based patient pathways for BDD in facial aesthetics which can result in the failure to identify patients with BDD, leading to unsuitable treatments and suboptimal patient care. We aim to construct the first evidence-based patient pathway for BDD in surgical and nonsurgical facial aesthetics. A systematic review was performed and articles that discussed screening or patient pathways for BDD in field of facial aesthetics were included. We extracted relevant information from each article on screening tools and pathways for BDD. Data were synthesized by summarizing the data under column headings into a structured narrative and into new tables. Based on this synthesis, a practical pathway for BDD was constructed. Forty articles fulfilled the criteria for inclusion. Twenty-eight BDD screening tools were discussed in the included articles, and we provide an overview of these tools. Thirty-one articles discussed patient pathways for BDD, and we synthesized this information into a structured narrative. Combining these findings, we present an evidence-based patient pathway for BDD for patients presenting for facial aesthetic treatments. This systematic review has resulted in the first, evidence-based, patient pathway for BDD in surgical and nonsurgical facial aesthetics. This practical pathway can be used by aesthetic clinicians to identify patients with potential BDD and provide clear guidance for managing cases where BDD is suspected. It will help reduce the number of facial aesthetic procedures performed on patients with BDD, safeguard patient mental well-being, and prevent further aesthetic dissatisfaction.

Prevalence of body dysmorphic disorder, its clinical characteristics and psychiatric comorbidities in patients admitted to a plastic surgery outpatient clinic

PURPOSE

The present study aimed to determine the prevalence of body dysmorphic disorder (BDD), its clinical features, and comorbidities in patients applying for plastic and reconstructive surgery.

METHOD

Five-hundred and seventy nine participants who applied to the plastic and reconstructive surgery outpatient clinic completed a sociodemographic data form, and were subjected to the Body Perception Scale (seventy-nineBPS), Social Appearance Anxiety Scale (SAAS), TEMPS-A Temperament Scale, and Beck Depression Inventory (BDI). Participants who scored 135 or more on the BPS were included in a psychiatric interview. Next, the participants diagnosed with BDD were compared with participants with a high BPS scores but without a BDD diagnosis, along with a control group.

RESULTS

The prevalence of BDD among all patients attending the plastic surgery outpatient clinic was found to be 4.7%, whereas the prevalence was 8.6% among those specifically seeking cosmetic procedures. The mean SAAS, BDI, TEMPS-A depressive, and anxious scores were higher in the BDD group compared to the controls (p < 0.001). The difference in the mean SAAS, BDI, TEMPS-A depressive, and anxious scores of the patients with a high BPS scores and the control group was comparable to the difference observed between the BDD and control groups. A regression analysis revealed that the SAAS and depressive temperament scores have an effect on the BPS score.

CONCLUSION

The significantly high comorbidity of BDD in patients seeking plastic and reconstructive surgery underscores the importance of identifying these patients to prevent unnecessary surgical procedures.

Body Dysmorphic Disorder in Aesthetic and Reconstructive Plastic Surgery-A Systematic Review and Meta-Analysis

(1) Background: Body dysmorphic disorder (BDD) presents significant challenges in aesthetic and reconstructive plastic surgery, impacting patient outcomes and well-being. Understanding its prevalence and associated factors is crucial for effective patient care. (2) Methods: A systematic review of national and international databases on body dysmorphic disorder, plastic surgery, cosmetic surgery, reconstructive surgery, and prevalence yielded 999 studies between 1878 and April 2024. Inclusion criteria focused on studies reporting prevalence while excluding those with small sample sizes (<20 participants), unclear diagnostic criteria for BDD, and non-English accessibility. (3) Results: A meta-analysis using a random effects model was conducted on 65 studies involving 17,107 patients to estimate the prevalence of BDD. The overall estimated prevalence of BDD was 18.6%; 10,776 (62.9%) were females, with a mean age of 35.5 ± 11.7 years. Subgroup meta-analysis found significant variability in effect sizes across countries and types of specialty, of which Brazil showed the highest proportion and dermatology exhibited the smallest. Meta-regression analysis found no significant relationship between the year of publication and prevalence rates. (4) Conclusions: Our findings update the current literature on BDD prevalence in aesthetic and reconstructive plastic surgery. We emphasize the importance of proactive screening and multidisciplinary care approaches to address the complex challenges posed by patients with BDD. Further research is needed to explore evolving trends in BDD prevalence and factors influencing its expression across different cultural contexts.

Disturbed interoception in body dysmorphic disorder: A framework for future research

Body dysmorphic disorder is a severe psychiatric condition characterised by a preoccupation with a perceived appearance flaw or flaws that are typically not observable to others. Although significant advances in understanding the disorder have been made in the past decade, current explanations focus on cognitive, behavioural and visual perceptual disturbances that contribute to the disorder. Such a focus does not consider how perception of the internal body or interoception may be involved, despite (1) clinical observations of disturbed perception of the body in body dysmorphic disorder and (2) disturbed interoception being increasingly recognised as a transdiagnostic factor underlying a wide range of psychopathologies. In this paper, we use an existing model of hierarchical brain function and neural (predictive) processing to propose that body dysmorphic disorder involves defective interoception, with perceived appearance flaws being the result of 'interoceptive prediction errors' that cause body parts to be experienced as 'not just right'. We aim to provide a framework for interoceptive research into body dysmorphic disorder, and outline areas for future research.

Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences.

AIMS

To identify validated BDD screening tools and critically appraise current literature regarding its implementation and efficacy in aesthetic medicine and surgery scenarios, with the purpose of transposing the findings to the broad clinical settings in the field.

METHODS

Data was collected using advanced search from PubMed (MEDLINE). Having satisfied the search parameters, 12 studies referring BDD definition according to Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria and including a BDD screening tool in clinical aesthetic settings were selected.

RESULTS

While BDD screening enables the recognition of at-risk individuals, further work is required to uncover the best screening tool for general aesthetic clinical practice. Level III evidence favored BDD Questionnaire (BDDQ)/BDDQ-Dermatology Version (DV), and The Dysmorphic Concern Questionnaire (DCQ) among the limited available validated screening instruments to be used outside the psychiatric environment. Based on level II self-classification, one study selected BDDQ-Aesthetic Surgery (AS) version for rhinoplasty patients. The validation process of both BDDQ-AS and Cosmetic Procedure Screening Questionnaire (COPS) had limitations. For BDD screening potential in avoiding postoperative complications, the limited studies found evaluating the outcomes following aesthetic treatments using validated BDD screening measures showed a trend toward less satisfaction with aesthetic treatment outcome among positive screening population against non-BDD counterparts.

CONCLUSION

Further research is necessary to establish more effective methods to identify BDD and evaluate the impact of positive findings on aesthetic intervention outcomes. Future studies may elucidate which BDD characteristics best predict a favorable outcome and provide high-quality evidence for standardized protocols in research and clinical practice.

Understanding and treating body dysmorphic disorder

Body dysmorphic disorder (BDD) is a mental disorder that involves a distressing preoccupation with a perceived defect in physical appearance, associated with excessive or repetitive behaviours or mental acts aimed at camouflaging, checking or 'improving' the perceived area of concern. BDD is relatively common, affecting at least 2% of the population world-wide, yet is poorly understood. Professor Susan Rossell has produced a substantial body of influential research, which has improved our understanding of BDD. This includes a more comprehensive understanding of the phenomenology, neurocognition and neurobiology, as well as significant treatment advances. This work will be reviewed in this commentary.

The COVID-19 pandemic: Psychological and behavioral responses to the shutdown of the beauty industry

OBJECTIVE

During the COVID-19 pandemic, Australia implemented widespread closure of beauty and cosmetic services to control the virus spread. The effect of these restrictions is unknown, given that beauty services are widely used for stress relief or to enhance confidence. The current study explored the relationship between engagement in appearance-focused behaviors and distress regarding beauty service closure. Participants with high and low levels of dysmorphic concern were compared to determine whether COVID-19 restrictions may affect these groups differently.

METHOD

An online survey was completed by 216 participants living in Australia. Questions addressed engagement in appearance-focused behaviors during the COVID-19 pandemic and attitudes toward beauty service closure. The Dysmorphic Concern Questionnaire (DCQ) was used to group participants by low and high dysmorphic concern.

RESULTS

Appearance-focused behaviors decreased in the low DCQ group (n = 163) during the COVID-19 pandemic, while such behaviors in the high DCQ group (n = 53) remained unchanged. Individuals who were living alone, younger, reported higher dysmorphic concern and greater distress over beauty service closure engaged in more frequent appearance-focused behaviors (R² = .57, p < .001). The high DCQ group reported greater distress over beauty service closure and increased desire to obtain future beauty treatments.

DISCUSSION

While COVID-19 restrictions may have provided a break from societal appearance pressure for those with low dysmorphic concern, appearance-focused behaviors persisted in individuals with high dysmorphic concern. A greater understanding of the long-term impacts on appearance-related distress is needed to determine mental health priorities emerging from the COVID-19 pandemic.