Beyond “body dysmorphic disorder”: why aesthetic medicine needs a spectrum model of body image concern

Abstract Aesthetic medicine has become a point of first clinical contact in which psychological vulnerability is frequently encountered, yet practitioners continue to rely on a binary framework of body dysmorphic disorder (BDD) or no diagnosis. This obscures a clinically consequential middle ground: patients with persistent, reassurance-resistant appearance concerns who fall short of syndromal thresholds, but shape consultation trajectories, procedural escalation, and harm. We propose the Body Image Concern Spectrum (BICS), a pragmatic clinical framework that grades appearance-related concern as mild, moderate, or severe and links each grade to a proportionate consultation pathway, from standard consent through enhanced consultation to psychological referral. BICS contextualises rather than dilutes BDD, situating it at the severe end of the spectrum, and offers aesthetic clinicians a shared language for naming graded concern, calibrating consultation intensity, and safeguarding patients without collapsing care into binary inclusion or exclusion.