Body Dysmorphic Disorder and Treatment Considerations In Aesthetic Medicine

Upholding patient trust and reputability are equally as important as retaining returning clients. Practitioners have a duty of care to their patients, including refusal of unnecessary treatment in some cases. Most patients seek out aesthetic treatments to enhance and balance their features, yet individuals struggling with Body Dysmorphic Disorder or BDD can perceive these treatments be a solution to an insecurity or underlying psychological issue. BDD can be difficult to diagnose without formal psychological training and even more difficult for practitioners to discuss with a patient. But when is it best to say no and how should you approach those conversations?

Clients are increasingly knowledgeable about aesthetic treatments, thanks to internet research and the prevalence of social media, yet these platforms can also be problematic when it comes to the motivations behind seeking out non-surgical procedures. Nurse Michelle Bolton told Fox: ‘I personally feel social media has a significant role in driving demand for aesthetic treatment. People see others posed in certain lights, filters and this makes them feel inadequate. They often come into clinic with unrealistic expectations or asking to look like a filter. I do believe filters have a huge detrimental impact to mental health and body image.’ Nurse Billie Jae Darragh agreed, ‘The use of filters and constant exposure to over-edited pictures have a harmful impact on self-esteem and self-perception, resulting in patients seeking out certain treatments. I’ve often been asked to make a patient’s lip look like a certain Instagram filter!’

Practitioners need to be able to identify when patients are struggling with their body image and where perceptions of their appearance are not marrying reality. Social media has a huge role to play in this issue, distorting patient’s perceptions of the possibilities that aesthetic medicine can offer. Patients must understand that aesthetic treatments can only enhance the natural features and cannot replicate virtual reality, thus a certain level of self-acceptance must be established pre-treatment, to ensure that the patient is psychologically healthy and fully capacitated to consent.

What Are The Symptoms of Body Dysmorphic Disorder?

Body dysmorphic disorder is a psychiatric disorder characterised by preoccupation with an imagined defect in physical appearance or a distorted perception of one’s body image (Alavi et al., 2011, Franca et al., 2017, Ribeiro, 2017).

• Being repulsed by or an aversion to one’s own reflection
• Need for reassurance with regard to perceived flaws
• Seeking unnecessary cosmetic procedures
• Referential thinking: thinking that others are equally preoccupied or disturbed with their perceived defects
• Camouflaging behaviour
• Abnormal or demanding behaviour toward surgeons or staff
• Frequent mirror checking or an avoidance of mirrors

The Importance of In-Depth Consultations

During consultation, it’s important to establish the patient’s motivations behind seeking out a treatment, alongside their desired outcomes. Some patients may be aware that they look unnatural, but this is their preferred style, allowing them to fit in with a trend or to stand out from the crowd. These patients must be differentiated from those with body dysmorphic disorder. These initial conversations can paint a picture of the individual’s state of mind and are key to identifying the warning signs of body dysmorphic disorder.

It is vital that patients do not feel pressured into treatments during consultation. Finances play a key part in this situation: patients may feel guilty and uncomfortable if a practitioner has already opened or prepared products, or the patient may be unwilling to sacrifice their deposit. Michelle Bolton asserted, ‘If in the consultation I feel that they’re not 100% sure on treatment, or I feel that they’re not really going to get the results that they want, or if I’m concerned about body dysmorphia, then I will actually refuse treatment or book for the patient to come back at another time to then have the treatment. It’s important not to pressurise clients into having consultations and treatments at the same time.’ Providing a ‘cooling-off period’ helps to ensure full treatment consent, giving patients the time and space to fully consider the benefits, risks, outcomes and motivations for their elected treatment.

Whilst some practitioners may suggest additional treatments during consultation, such as jaw filler alongside chin filler, for individuals with BDD this can ignite a new fixation and amplify existing insecurities. Practitioners should avoid highlighting further potential augmentations, unless specifically asked to do so by the patient, to ensure that they are not acting in a way that could be deemed as predatory.

The BDD Foundation is advancing a case for mandatory psychological assessment prior to cosmetic treatments, while working to de-bunk the misconception that body dysmorphic disorder will be ‘cured’ by undertaking a number of aesthetic procedures. The evidence is contrary, reporting that appearance dissatisfaction will remain, if not intensify, after aesthetic interventions (BDD Foundation, 2021.)  Alongside going against medical and ethical guidance, agreeing to perform a procedure that will incur an unnatural result is unlikely to satisfy the patient in the long-term, potentially breeding further insecurity, whilst putting the practitioner’s credibility at risk.

Consultation Forms

Busy schedules and time constraints can make it difficult to ensure that enough time is spent with each client, prior to treatment. Currently, there is no standardised consultation form for aesthetics clinics that incorporates the psychological assessment needed to account for total consent and understanding. Nurse Michelle Bolton argued, ‘I think many consultation and consent forms are not up to standard… I chat to each client; it’s about forming strong relationships and understanding why they want their treatments. It’s so important to say no and be honest about expectations.’ The Joint Council for Cosmetic Practitioners (JCCP) recommended the inclusion of a psychological assessment in all consultations to ensure safe patient selection and distinguish treatment pathways.

What is Total Consent?

To establish total consent, certain criteria must be met:

• Consent must be voluntary: Patients must be given the opportunity to change their minds and should not be pressured by practitioners due to time constraints or potential loss of earnings.
• Consent must be informed: Be wary of over-using medical jargon and ensure that patients fully understand the risks, treatment process and outcomes.
• Patients must have capacity to consent: The patient must be psychologically stable and able to give their full consent to not only the treatment, but to the risks involved. In cases of BDD, patients may not have the capacity to consent.

When To Say No

Patients with body dysmorphic disorder, particularly those presenting with more severe cases, may be psychologically unsuitable for treatment if their condition impairs their capacity to consent fully, or in instances where their desired treatment could further impact their mental health.

The NMC code states that aesthetic professionals must ‘act in the best interests of people at all times’ and ‘treat people in a way that does not take advantage of their vulnerability’. The code also asserts the need for ‘properly informed consent’ that adheres to ‘all relevant laws about mental capacity.’

Every individual treatment must be carried out with the patient’s best interests in mind and the intention of improving their confidence. Practitioners should refuse treatment if they feel that the patient’s desired outcome would have a negative impact on the individual physically, psychologically or socially.

Whilst many patients begin their aesthetic treatment journey requesting ‘natural’ results, over time their perception of what is ‘enough’ can become warped. Patients may request unnecessary cosmetic enhancements because they have become reliant or addicted to the self-esteem boost or perceived transformation that they feel immediately after treatment. These patients could be classed as vulnerable. Discussing the topic in the Journal of Aesthetic Nursing, Lucia Adsett stressed the need for an industry-wide standard of care, stating ‘if we all said ‘No’ when we should do, these vulnerable patients would not be able to practitioner-hop to satisfy their addictions.’

How to Say ‘No’ to a Patient

With client relations and finances potentially at risk, how should a practitioner say no, without offending their patient?

Michelle Bolton told Fox ‘If I refuse treatment, I will sit with them and have an in-depth discussion about why I am refusing treatment and what the possible implications of them having that treatment could be.’ She noted that lip filler is the most common procedure that she refuses, if clients are requesting to be overfilled, ‘I show them examples so they can understand why we’re saying no.’ After refusing treatment in a sensitive and empathetic manner, patients with BDD should be referred to a psychologist or mental health professional for continued support.

Keep The Conversation Patient-Centric

Effective communication is key to protecting client relationships. It’s important that patients understand that the refusal is in their best interest. Matching the patient’s communication style helps to establish the foundations for an empathetic and honest conversation. It is best to avoid practitioner or clinic-centric reasoning when it comes to saying ‘no.’ It’s important that the patient isn’t left feeling embarrassed, rejected or judged on their appearance. These feelings can be heightened if the practitioner’s argument is that the treatment would damage their reputation, or that they don’t want to be associated with an unnatural outcome. Instead, keep the individual patient at the centre of the conversation. Emphasise the long-term effects of over-filling such as migration and the financial implications that this may incur for the patient, such as the cost of dissolving or correction.

Before & After Photos

Showing before and after photos during consultation provides a visible, evidence-based comparison as a reasoning for refusal. This can also help patients to realise when their desired results would stray too far away from their starting point and a ‘natural looking’ middle ground. Patients with body dysmorphic disorder often struggle with a disconnect between their perceived reflection or appearance and reality. Showing photos taken in a clinical setting provides a reference point from a neutral, objective view and may help to overcome this disconnect.

The Body Dysmorphic Disorder Takeaway

Suspecting a diagnosis of BDD and raising the subject with a patient is undoubtedly an uncomfortable and sensitive situation, yet practitioners are responsible for their patients’ welfare and the effects that further cosmetic treatments will have, both physically and psychologically.

It’s important to work with patients to reach a compromise where possible, in order to provide results that you are proud of, whilst leaving the patient happy. Michelle Bolton says ‘I personally strive to make people feel beautiful. We don’t aim for ‘perfect’ while Billie Darrah argued, ‘As practitioners, we have a responsibility to share realistic results and share information responsibly.’

In-depth consultations are essential in establishing full consent, helping aesthetic professionals to avoid missing, or worsening a potential BDD diagnosis. In some cases, however, the only way to protect a patient is by refusing treatment, particularly in cases where patients have unrealistic expectations, or if they present a dissatisfaction with their appearance that does not correlate to the objective physical outcome and cannot be negated through reassurance.

Aesthetic treatments are unlikely to satiate the patient’s desire for transformation or correction. Performing treatments on these vulnerable individuals is at the very least ill-advised and at worst, could be deemed as predatory. Patients presenting with symptoms of BDD should be encouraged to consult their local GP or referred to resources that can provide psychological help such as the Body Dysmorphic Disorder Foundation or Mind UK.