Screening for Body Dysmorphic Disorder and other Psychiatric Conditions in Cosmetic Settings.

Presenter: Dr Ben Buchanan

Dr Ben Buchanan is a clinical psychologist who works exclusively with people with body image and anxiety disorders, including Body Dysmorphic Disorder (BDD). He career has focussed on the intersection between BDD and cosmetic procedures, including how to predict dissatisfaction among cosmetic procedure clients. He is the co-author of the Cosmetic Readiness Questionnaire, widely used in cosmetic settings.


The following presentation was delivered in November 2023 at a dermatology conference in Australia, and is relevant for any cosmetic practitioner seeking to learn how to identify psychological risk factors for dissatisfaction. 

Dr Buchanan clarified that Body Dysmorphic Disorder (BDD) is not simply vanity or overdone cosmetic procedures; it’s an invisible disorder with deep roots in individual perceptions and experiences. He discussed how BDD affects various aspects of life and can be difficult to convince sufferers of their normal appearance. The presentation also covered the poor outcomes of cosmetic procedures in BDD patients, with about 80% reporting no change in symptoms post cosmetic procedures.

He stressed the importance of screening for BDD in cosmetic procedure candidates, outlining guidelines that include validated screening tools, documentation, and managing expectations. Buchanan highlighted psychological risk factors like OCD, depression, eating disorders, and excessive social media use, which could predict dissatisfaction with cosmetic procedures.

Buchanan introduced the Cosmetic Readiness Questionnaire, a questionnaire assessing factors like BDD, self-criticism, and perfectionism, with results indicating varying levels of risk. He noted the challenge of patients lying on questionnaires and emphasised the importance of openness in assessments. The presentation concluded with suggestions for identifying warning signs and the benefits of psychological evaluations for at-risk patients, underscoring the value of screening and referral pathways in ensuring patient well-being in cosmetic procedures.

Next, I’ll invite Dr. Ben Buchanan up to the stage. Ben is a clinical psychologist who works exclusively with people with body image and anxiety disorders, including Body Dysmorphic Disorder (BDD). Currently, he is focusing on the intersection between BDD and cosmetic procedures. Today, Ben will talk to us about screening for Body Dysmorphic Disorder and other related conditions. Thanks, Ben. 


Thank you. 


Well, it’s really great to be here. There are only a few psychologists that work in this space, and I’ve been working with BDD for over a decade now, where I did my doctoral research. We gathered a whole group of people with Body Dysmorphic Disorder and put them in an MRI scanner to study their brain. We wanted to understand why people who looked normal from the outside, and even quite attractive people, had this intense sense that they were ugly or disfigured.


Since then, there has been a wealth of research into the area. My disclosures: I’m a psychologist, the co-founder of Ready Mind (more information is on your tables), and the co-author of the Cosmetic Readiness Scale, which I’ll be talking about.


So, what is Body Dysmorphic Disorder? It’s an obsessive preoccupation with appearance, where someone looks normal or may have a slight abnormality, but their concern about it is exaggerated. BDD can significantly impact people’s lives. I’ve met people with BDD who don’t leave their homes because they’re too anxious about what others will see. I’ve also met some celebrities who appear confident on stage but deeply believe they’re ugly and hideous, causing them a lot of anxiety. BDD comes in all shapes and sizes, and people with BDD genuinely see themselves differently.


Some of the MRI research we conducted a decade ago showed there are some visual processing differences. So it’s essential to understand what BDD is not. Just because someone looks overdone or has had many procedures doesn’t necessarily mean they have BDD. BDD is invisible, and you can’t tell who has it without talking to them. BDD is not simply vanity, and it has been around for centuries; it’s not a new phenomenon. BDD is different from run-of-the-mill body image dissatisfaction. We all have some dissatisfaction with our appearance, but BDD takes it to another level, significantly impacting one’s social life, work life, or other important areas of functioning.


Some common areas that people with BDD fixate on include skin, nose, stomach, weight, chest, thighs, hair (for women), genitals, hair thinning, muscularity, height, excess body hair, and body proportions. As humans, we are intensely visual beings, and convincing someone with BDD that they look normal is incredibly challenging. People with BDD have their own backgrounds and experiences that contribute to their perception.


Visual illusions, like the famous black and blue or white and gold dress, show how our perception can be influenced by context. Similarly, people with BDD have their backgrounds and overlays that shape their perceptions.


So why are we talking about BDD? Because people with BDD often have poor outcomes with cosmetic procedures. About 80% of people with BDD report no change in their symptoms after getting a cosmetic procedure. They continue to worry about the treated area or switch to a new area of concern. Many doctors have received complaints, threats, or litigation from dissatisfied BDD patients. So, understanding and screening for BDD is essential for both patients and practitioners.


The guidelines for cosmetic procedures include using validated BDD screening tools, documenting the process, and managing patient expectations. Understanding what motivates people to get cosmetic procedures is crucial. Most people want to look better, and it’s associated with various advantages in life. However, satisfaction with one’s appearance does not have a linear relationship with how good-looking someone is.


Identifying psychological risk factors is essential. BDD is a significant predictor of dissatisfaction with procedures, and it’s closely related to conditions like OCD. Other risk factors include depression, eating disorders, personality disorders, perfectionism, unrealistic expectations, and extrinsic motivations. Excessive social media use is also a risk factor.


Assessing these risk factors can be challenging in short consultations, so using a questionnaire can help. The Cosmetic Readiness Scale is one such questionnaire that assesses various factors, including body dysmorphic disorder, self-criticism, psychological distress, perfectionism, and honesty.


There are three zones in the questionnaire results: red, yellow, and green. Red indicates a significant risk of dissatisfaction, yellow suggests some issues need addressing, and green indicates no identifiable risk.


Research shows that some people may lie on these questionnaires, which is why measuring patient openness is crucial. Openness helps identify those who may not be entirely honest in their responses. In research, most people are honest, but in clinical practice, there’s a higher proportion of lying.


When assessing patients, look for warning signs, such as strong negative language, behaviours related to mirror-checking, an extensive photo library of themselves, or excessive research about procedures. If you notice warning signs, consider referring the patient for a psychological evaluation.


Psychologists can perform psychological evaluations and provide recommendations. Most patients benefit greatly from cosmetic procedures, but some are at high risk of dissatisfaction. Screening and referral pathways can help manage these risks and ensure patients receive the best possible care.


Thank you.