Understanding Body Dysmorphic Disorder in Medical Aesthetics

The true measure of a practitoners expertise is not perfecting a client’s appearance, but recognizing when a request stems from deeper psychological issues, such as Body Dysmorphic Disorder (BDD), and declining to perform the procedure.

Five experts featured in the Tatler Address Book explain how they navigate the difficult balance between client requests and ethical responsibility, stressing that sometimes, no treatment at all is the correct option.

Spotting Concerns Deeper Than the Surface

The first challenge is screening clients whose requests for “perfection” mask complex mental health issues or past trauma.

• Proactive Screening: Dr. Aggie Zatonska of Atelier Clinic uses detailed questionnaires, which include adapted BDD tools, even before a consultation. She combines these responses with clinical observation of a patient’s language and emotional state to determine if the concern is proportionate or if it indicates an underlying mental health issue.
• Recognizing Trauma: Consultant Plastic Surgeon Lydia Badia notes that patients with requests tied to past trauma (like childhood abuse or neglect) often believe surgery will “fix” their life. They typically express anxiety or depression and struggle to maintain relationships.
• Reading the Signs: Other experts rely on experience. Consultant Plastic Surgeon Mark Solomos says he acts as a “part-time psychologist,” using his experience to spot cases that mask deeper issues, referring them for psychological assessment before considering surgery.
• Common Warning Signals: Dr. Bibi Maryam Ghalaie and Oculoplastic Surgeon Daniel Ezra both highlight key red flags: repeated dissatisfaction, unrealistic expectations, and a disproportionate concern over a minor flaw. Ezra notes that BDD patients “massively magnify certain issues,” creating a mismatch between the complaint and its actual impact on their quality of life.

The Art of the Refusal

Recognizing a problem is only the first step; declining a client—especially an ultra-high-net-worth individual unaccustomed to refusal—requires tact and excellent bedside manner.

• Prioritizing Health: Dr. Badia views underlying psychological distress like any other chronic condition that must be stabilized before surgery. She explains that without this, the patient will remain dissatisfied because the surgery cannot resolve “internal trauma.”
• Maintaining Professional Boundaries: Dr. Zatonska stresses maintaining a doctor-patient dynamic over a client-provider relationship. She avoids blunt refusals, instead explaining her rationale and offering alternatives to ensure the treatment is “safe and appropriate.”
• Direct Honesty: Dr. Solomos is direct, explaining that surgery cannot resolve psychological issues. Similarly, Dr. Ezra finds that frankness often brings relief. He tells patients that their “mind is playing tricks on them” and that they are focusing on areas “nobody else can see,” which often results in a positive response.
• Framing as Care: Dr. Ghalaie often suggests a pause, saying, “Perhaps today is not appropriate for us to proceed… may I suggest you take some time to think over the options.” She frames the refusal as a measure of care and support.

Introducing Psychological Support

The refusal to treat is often a crucial pivot point, opening the door to mental health support, which can be sensitive to suggest to high-profile clients.

• Honesty and Empowerment: Dr. Ezra finds it best to be honest and ask the client directly if they feel they would benefit from support.
• Normalizing Referral: Dr. Badia normalizes the suggestion by linking their body image concerns to past life experiences, then suggesting a referral to a specialist in body image. Dr. Zatonska frames the referral as an extension of care for overall well-being, not a rejection.
• Ensuring Independence: Dr. Solomos only refers patients to psychologists who are completely separate from his practice. This separation is crucial to ensure the psychologists are not pressured to approve surgery, thereby protecting the clinic’s reputation for long-term patient satisfaction.
• Urgency and Continuity: Dr. Ghalaie often routes referrals through the patient’s GP for continuity of care. She stresses the need for urgency if there is a high risk of harm, escalating to a crisis mental health team or emergency services if necessary.

Ultimately, for these leading practitioners, the willingness to withhold a procedure is often the most important, and most ethical, service they can provide.