Flawed Reflections: Understanding BDD

3 min readJun 9, 2023

Body Dysmorphic Disorder (BDD) is a health condition where a person obsesses over one or more perceived flaws in their appearance. AHPRA, our governing body, has recently put new regulations in place for practitioners who perform cosmetic medicine. Starting July 1st, practitioners must follow specific guidelines for patient care, including referrals, consent, social media use, and more. While we’re happy about these improved standards, there are some areas that need clarification. That’s why we spoke with Dr. Toni Pikoos.

Toni is a therapist and psychologist who specialises in BDD and body image. We met at an Aesthetic Medicine conference in Melbourne last year, where I discussed ethical patient treatment and Toni talked about BDD. Toni was on AHPRA’s advisory panel for these new regulations, and she shares her insights on how clinicians can meet the new regulations, how patients can stay safe and seek mental health treatment if necessary, and interesting information for all our listeners with an interest in psychology.

Screening tools. The BDDQ — DV screening tool currently in use is good but has its limitations. If you answer “NO” to question 1, “Are you worried about how you look?” the following questions are irrelevant and don’t need an answer. Toni agrees that this questionnaire might miss subtle nuances in a patient’s behaviour.

I use Leslie Fletcher’s questionnaire with good effect in my clinical practice. It’s called “Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology” and it allows a grading system of assessment. While Toni endorses this tool, she’s also creating her own and it will be available on her website https://www.readymind.com.au/ before July 1st.
Referrals and Waitlists. Psychologists who are qualified in body image and associated disorders are aware of the new regulations and therefore prepared for our referrals. As with all referrals, communication ensures the practitioner and mental health expert are aware of the patient’s progressions. Although long waitlists exist for mental health assessments, Toni and her colleagues understand patients and practitioners don’t want to wait in limbo for an appointment so have put in place measures to ensure a timely turn around.

A cure for BDD? Practitioners have patients who present more obsessively at some appointments than others. Toni clarified that how a person presents can depend on what’s happening in their life. For example, influence from another can make a person feel they are aesthetically inferior, leading to BDD behaviour manifestation. A life event or period of time where a person feels a lack of control can also contribute to BDD. With the correct help, a person can move on from these challenging contributions and develop a healthy sense of self.

The Future. Thankfully, those of us who have always done the right thing won’t be changing much of our practice. But as with all things, the naughty 5% of practitioners who have always done the wrong thing will no doubt continue to flout the system. They won’t provide adequate BDD assessment for patients who clearly struggle with an obsessive preoccupation of their appearance. They won’t refuse treatment to patients who it’s unsafe to treat. They’ll keep taking money from vulnerable people because these practitioners don’t care. They won’t refer patients to a psychologist for help, as the AHPRA guidelines request. These practitioners will likely drive elements of the cosmetic medicine profession even more underground and create a black market. But those of us who genuinely care about our patients can stand up tall knowing we do all we can to protect them and uphold high standards of care. That’s how we keep our daughters safe in this wild world of beauty — and for that, I thank you.

Links

Cosmetic practitioners — https://www.readymind.com.au/

All listeners interested in Toni’s excellent body image empowerment content on Instagram — https://www.instagram.com/thebddtherapist/

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