Role of Psychological Assessment in Aesthetic Procedures : Journal of Cutaneous and Aesthetic Surgery

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Role of Psychological Assessment in Aesthetic Procedures

Jindal, Nidhi; Gupta, Sanjeev1

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Journal of Cutaneous and Aesthetic Surgery 15(3):p 330-331, Jul–Sep 2022. | DOI: 10.4103/JCAS.JCAS_195_20
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A global survey conducted by the International Society of Aesthetic Plastic Surgery (ISAPS) in December 2019 clearly states that cosmetic procedures are on the rise globally.[1] India ranks fourth after the United States, Brazil, and Mexico in performing cosmetic surgeries and sixth with regard to performing nonsurgical cosmetic procedures. People aspiring for drive through Botulinum toxin injections during COVID 19 in Miami[2] clearly highlight the importance of aesthetic procedures in the present world.

Various studies have shown the prevalence of BDD to be 1–3% in the general population against 7–15% among people seeking cosmetic surgeries,[3] which emphasizes the need of preprocedural psychological assessment for ideal patient selection. Unfortunately, I could not find similar statistical studies from India, despite India being among the top countries conducting these procedures. Psychological assessment will rule out BDD or other psychological conditions that might be a contraindication to aesthetic procedures. Patients seeking aesthetic treatments commonly present with psychiatric disorders, including BDD, narcissistic personality disorder (NPD), and histrionic personality disorder (HPD). NPD comprises a pervasive pattern of grandiosity (in behavior or fantasy), a constant need for admiration, lack of empathy beginning by early adulthood and present in a variety of situations such as relationships, school, work, or financial affairs. HPD is a psychiatric disorder that is distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. BDD is the condition that a cosmetologist should be aware of and will be discussed here.

BDD is an often under-recognized psychiatric disorder that is characterized by over concern with physical appearance, such that an ideal appearance becomes the overwhelming and all-pervasive concern. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) classifies BDD as an obsessive-compulsive-related disorder (OCRD) with a common age of onset between 15 and 30 years.[4] Patients with BDD visit cosmetic and plastic surgery clinics more often than psychiatrists. It is of utmost importance to assess and interpret the motive and emotional drive behind patients seeking cosmetic procedures. Cosmetologists should have an insight about the entity, as people with BDD often see their problem as cosmetic rather than psychological or psychiatric. The most common areas of preoccupations are the skin, hair, nose, eyes, eyelids, mouth, lips, jaw, and chin.

A simple psychological screening questionnaire preprocedure will help in filtering BDD among aspirants of aesthetic procedures. The BDD screening tools that have been validated to be used specifically in dermatology settings are the Body Dysmorphic Disorder Questionnaire (BDDQ), Body Dysmorphic Disorder Symptom Scale (BDD-SS),[5] Dysmorphic Concern Questions (DCQ),[5] and Body Dysmorphic Disorder Questionnaire - Dermatology version (BDDQ-DV).[5] However, the BDDQ-DV questionnaire is used most frequently among all three.[5] These tools can be used to exclude and assess BDD among aesthetic procedure aspirants. We found self-reported BDDQ an easy tool to incorporate in routine practice. Screening forms are provided by either the doctor or the counselor along with other required forms before aesthetic consultation. Form filling takes about 5–10 minutes, which includes the time required to explain the importance of the form to subjects. Close observation for clinically evident red flag signs [Table 1] can further help clinicians in diagnosing BDD among their patients.

Table 1:
Clinical red flag signs of BDD


The aim of psychological assessment is to increase positive outcomes among cosmetic procedures and prevent performing such procedures in those who actually need different intervention (psychotherapy or pharmacotherapy). Screening for BDD should be considered essential before patients undergo aesthetic procedures. A positive screening does not indicate avoidance from the provider’s side but demands a proper referral to a psychiatrist if necessary. Being alert about specific psychiatric conditions can help in deferring the procedure, which can be later troublesome to both the physician and the patient. Appropriate knowledge in experienced hands can bring quintessential results only with ideal patient selection.

Learning bullets

  1. Over concern about physical concerns that are otherwise not perceived by others should raise suspicion for BDD
  2. Aesthetic aspirants should be screened for BDD
  3. Clinical red flag signs for BDD
  4. BDD screening questionnaire should be incorporated in routine aesthetic practice
  5. Positive screening needs referral


All the authors listed have contributed substantially toward the concept, writing, and editing of the article. All authors have put in equal efforts to the literature search of the related articles and the interpretation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. International Society of Aesthetic Plastic Surgery (ISAPS). International survey on aesthetic/cosmetic procedures - 2018. Accessed on May 15, 2020.
2. Zachary Fagenson Florida Offers Drive-Through Botox to Quarantined Residents. Medscape. June 4, 2020 Reuters Health Information © 2020
3. Glaser DA, Kaminer MS. Body dysmorphic disorder and the liposuction patient Dermatol Surg. 2005;31:559-–60; discussion 561
4. American Psychiatric Association. Personality Disorders. Diagnostic and Statistical Manual of Mental Disorders. 20135th ed Washington, DC American Psychiatric Publishing Inc.
5. Danesh M, Beroukhim K, Nguyen C, Levin A, Koo J. Body dysmorphic disorder screening tools for the dermatologist: A systematic review Pract Dermatol. 2015;2:44-–9

Aesthetic procedure; body dysmorphic disorder; clinical red flag signs; psychological assessment

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