Introduction
In recent years, cosmetic surgery has become one of the most frequently performed procedures globally, mirroring evolving beauty ideals and broader socio-cultural changes. Initially more common among women, cosmetic enhancement has increasingly been embraced by men over the past two decades. A major driver of this trend is the influence of social media, which propagates idealized and often unrealistic standards of physical appearance. As a result, many individuals dissatisfied with aspects of their looks turn to cosmetic procedures in hopes of improving self-esteem, gaining social acceptance, and alleviating psychological distress. Within this context, body dysmorphic disorder (BDD) has emerged as a significant psychological factor associated with the demand for cosmetic surgery. BDD involves excessive and persistent concern with imagined or minor flaws in physical appearance, often unnoticeable to others. Notably, those with BDD frequently remain dissatisfied even after undergoing surgery, with symptoms sometimes worsening. This highlights the importance of pre-surgical psychological evaluation to avoid unnecessary or potentially harmful procedures. An important clinical observation is the strong relationship between BDD and borderline personality disorder (BPD). Individuals with BPD often present with emotional instability, identity confusion, and heightened sensitivity to rejection—features that may amplify concerns over body image. Moreover, they frequently experience social anxiety and feelings of inferiority, which can intensify their preoccupation with physical imperfections. As such, individuals with BPD traits may represent a particularly vulnerable subgroup in cosmetic surgery contexts.
Method
The present study aimed to explore the psychological predictors of BDD in individuals with BPD symptoms seeking cosmetic procedures. Specifically, the research proposed and tested a model in which social anxiety predicts BDD symptoms, with feelings of inferiority acting as a mediating variable. The core hypothesis suggested that higher levels of social anxiety would be associated with more severe BDD symptoms, and that this relationship would be partially explained by feelings of inferiority. This applied research employed a descriptive-correlational design and utilized structural equation modeling (SEM) to examine the proposed model. The study population consisted of adults with BPD symptoms who attended cosmetic clinics in Tabriz between 2024 and 2025. From an initial convenience sample of 400 individuals, 250 participants (232 females, 18 males) were retained after removing incomplete responses and confirming BPD traits using the Borderline Personality Disorder Questionnaire (Gashtasbi Asl et al., 2017).

Participants completed several validated self-report questionnaires:

Body Dysmorphic Disorder Metacognition Scale (Rabiei et al., 2014)

Social Anxiety Scale (Jerebark, 1996)

Feelings of Inferiority Questionnaire (Yao et al., 1997)

Borderline Personality Disorder Questionnaire (Gashtasbi Asl et al., 2017)

All instruments demonstrated acceptable psychometric properties in prior Iranian research. Data were analyzed using SPSS-27 and Smart PLS-3. Descriptive statistics summarized the sample, and SEM was used to test the hypothesized pathways.
Results
The results supported the proposed model, revealing that social anxiety significantly predicted BDD symptoms, and this relationship was partially mediated by feelings of inferiority. These findings suggest that individuals with elevated social anxiety are more likely to develop BDD, partly due to underlying self-perceptions of inadequacy. From a clinical perspective, these results underscore the importance of addressing inferiority beliefs in therapeutic interventions for individuals with BPD traits seeking cosmetic surgery. Cognitive-behavioral strategies aimed at enhancing self-worth and challenging maladaptive self-schemas may reduce the likelihood of distorted body image and unnecessary surgical pursuits.
Discussion
Furthermore, the findings highlight the need to implement psychological screening protocols in cosmetic surgery settings. Identifying individuals at psychological risk—particularly those exhibiting high social anxiety, BPD traits, and feelings of inferiority—can support timely referrals to mental health professionals, promoting safer and more ethical surgical practices. Future research is encouraged to investigate longitudinal outcomes of psychological interventions in this population and explore integrated care models that link cosmetic and psychological services.