Empathize with the patient. Statements such as “sorry for the suffering,” “I understand that you are experiencing much anxiety,” or “I think that there is a way for you to feel better” may be helpful, while also not acknowledging the actual appearance complaint.

Approach the patient in a calm and nonjudgmental way. Many are ashamed and feel misunderstood. Do not compare those with body dysmorphic disorder (BDD) to other people in terms of appearance or functioning as this may make them feel worse.

Do not argue with patients about how they look, discuss appearance at length, or try to talk persons out of their faulty beliefs [1]. Comments such as “you look fine,” “did not notice it,” and “not that bad” do not work. Although certain individuals, typically those with some insight, may benefit from the occasional reminder that their view is wrong and due to a mental disorder, the majority will not believe your comments to be true. Even if a response does temporarily improve symptoms, this short-lived relief fuels more attempts to again obtain this reassurance. Therefore, the main objective is to not comment on the appearance.

Do not offer cosmetic treatments. If you have already provided treatment, be willing to stop and avoid being defensive. If a patient is suspected but unknown to have BDD, avoid all invasive procedures; however, it may be acceptable to provide a minimally invasive procedure that is relatively inexpensive and not permanent, and reevaluate on follow-up. Although the vast majority should be excluded from surgery, a group of authors describe a subset of patients with the “Thersites complex,” who may be candidates for cosmetic correction after careful selection [2]. The authors describe those with this complex as having excessive preoccupation with an actual but minor bodily defect or anomaly. Relative indications include a minimal real deformity (Thersites complex) with excessive concern, realistic expectations, acceptable surgical risks, and operative feasibility. Of note, many contraindications are discussed including multiple previous surgical operations, aggressive behavior, unacceptable surgical risk, and psychoses.

Always ask about suicidal ideation. Immediate treatment is needed for any patient with suicidal thought. Rates of attempted and completed suicide are surprisingly very high in those with BDD, possibly higher than any other mental illness [3–6].

Familiarize yourself with those in your community who can offer help, support, and treatment for your patients. See the below list of national and international resources.

Refer the patient to a mental health expert in your area. Once suspected, it is imperative that a patient receive appropriate psychiatric treatment from a mental health expert familiar with BDD. When making the referral, remain calm, nonjudgmental, matter-of-fact, and empathetic. If a patient is hesitant or refuses to get mental health treatment, try changing the focus on the suffering he or she is experiencing and the effect of this on his or her quality of life and everyday functioning. Focus on the time spent on every day worry, the stress on his or her mind and body because of intrusive thoughts, and the inability to live a normal life. Discuss his or her lack of control and how the thoughts and obsessions are, in fact, controlling his or her life [1]. Encourage a trial of treatment, and discuss that he or she does not necessarily have to be on it for his or her entire life. If mild and with some insight, refer the patient to a mental health expert with experience in cognitive-behavioral therapy (CBT) and BDD. If moderate, the patient can be started on a selective serotonin reuptake inhibitor (SSRI) or referred to a CBT specialist, or both. If severe, the patient needs to be on an SSRI and referred to a mental health expert. BDD can be life-threatening so always inquire into suicidal thoughts.

Recognize that patients may not accept the referral. If a patient is insistent upon cosmetic care and has poor to absent insight, one can try referral to psychiatry as a standard protocol.

Decide your comfort level with starting SSRIs. If patients are delusional, suggest trying an SSRI to help other symptoms that have become associated, that is, depressed mood. Alternatively, suggest trying an SSRI as an experiment to see how it will affect mood and symptoms. After patients’ symptoms improve, they may be more amenable to referral to a trained expert.

The initial consultation is the first means in establishing a physician–patient relationship. This consultation can incorporate simple screening questions for the practitioner to better understand patient motivations and concerns. If suspected, simple screening questionnaires can be administered. The Body Dysmorphic Disorder Questionnaire and Body Dysmorphic Disorder Questionnaire—Dermatology Version are both simple, short questionnaires that can be administered in the waiting room as an effective way to identify those who may have symptoms of BDD. See Chap. 11.

Look for red flags that may be indicators of underlying pathology. Red flags include doctor shopping with dissatisfaction of results; checking appearance in mirrors excessively; seeking reassurance; using makeup and clothing to cover up defects; making statements indicating impairment in work, school, or social realms; and spending substantial amounts of time thinking about or trying to camouflage the defect.