Managing Anxious Patients

By Dr Jaimini Vadgama / 12 Oct 2016

Dr Jaimini Vadgama discusses the causes of anxiety in patients and effective strategies for managing this in everyday clinical aesthetic practice

Medical aesthetics and the number of surgical and non-surgical aesthetic procedures performed worldwide is growing at a rapid pace. A survey by the American Society of Plastic Surgeons indicated that the number of non-surgical procedures performed in 2015 has risen by 158% since 2000 and this reflects a worldwide trend.1

With the increase in uptake of aesthetic procedures, practitioners are also seeing an increase in the range of patients who seek these treatments. Patients who were once averse to the idea of undergoing an aesthetic procedure may now be open to learning what treatments are available and how they may benefit from them. Aesthetic procedures that were previously considered the preserve of the rich and famous have found their place in the mainstream within the last 10 years, which is likely thanks to media coverage and, more recently, as a result of increasing social media coverage.2 The social ‘stigma’ that once existed surrounding these elective aesthetic procedures now seems to be diminishing.

Although aesthetic treatments are elective in nature, this does not mean that patients who undergo these procedures are not anxious. This article will discuss some of the reasons behind these anxieties and how aesthetic practitioners can effectively manage anxious patients in their everyday practice.

What is anxiety?

Anxiety by definition is a ‘state of apprehension and fear resulting from the anticipation of an event or situation’. Common signs and symptoms of anxiety include the following:3

  • Feeling nervous, restless or tense
  • Having a sense of impending danger, panic or doom
  • Having an increased heart rate
  • Breathing rapidly (hyperventilation)
  • Sweating
  • Trembling
  • Feeling weak or tired
  • Trouble concentrating or thinking about anything other than the present worry
  • Trouble sleeping
  • Difficulty controlling worry
  • Feeling the urge to avoid things that trigger anxiety

Why might patients be anxious?

In my experience, a large percentage of patients who are anxious about undergoing aesthetic procedures will be those who have never undergone treatment before. These first-time patients are most likely anxious due to a fear of the unknown. In contrast, previous negative experiences, not limited to aesthetic treatments, can also create anxiety.4

Alongside concerns about loss of control, fear of pain and post-operative complications, aesthetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment.5 In particular, facial appearance is intimately linked to a sense of identity and patients are often apprehensive about the impact these procedures will have not only on how others may perceive them, but also on how they perceive themselves.6

As well as this, in many respects, media coverage has played a positive role in the promotion of aesthetic treatments to the public. However, the media’s tendency to sensationalise negative outcomes and ‘botched’ treatments, commonly seen with lip filler treatments, can fuel patient anxiety in relation to these treatments.

How common is anxiety in patients?

Whilst there are very few statistics to show what percentage of patients seeking aesthetic treatment are nervous about it, in my experience, I have found that a high proportion of patients are anxious in some way and it is more likely to be the case if the patient is undergoing a procedure for the first time.

Management techniques

Understanding each individual patient’s anxieties and level of anxiety is central to effective management. 

Initial consultation

Anxiety can present itself in a number of ways, some of which are not immediately apparent, so an in-depth initial consultation is the single most effective tool in order to make this assessment. Supplementing this with a specific questionnaire based on an ‘anxiety scale’ can give the practitioner an objective assessment of a patient’s anxiety level. This can be achieved with a brief three to five item questionnaire with a consistent answering scheme for each item ranging from 'not anxious' to 'extremely anxious' (Figure 1). This questionnaire can be incorporated into your clinic medical history form so that all patients are effectively ‘screened’ for anxiety at this stage.

Patients will gain further confidence and trust if you can show them a wide range of before and after photos of your own clinical work, to illustrate the variety of outcomes that can be achieved. Discussing how you managed another patient’s aesthetic concern and seeing these tangible results is a powerful tool to dampen patient anxiety based on fears of an undesirable outcome. Educating the patient about the procedure that they are considering undergoing will also work to alleviate concerns that may be fuelling their anxiety. If a particular patient’s anxiety is linked to a previous negative experience, reassure the patient by explaining how you will avoid this occurring again and describe how it will be different this time. Genuine patient testimonials in either video or written format will also give patients confidence in your clinical abilities. Having a number of patients who are happy to discuss their treatment and experience with you is also extremely valuable.

Environment

Practitioners should not view themselves in isolation and should be mindful of the impact their clinic environment and staff can have on the patient experience. A well-trained and helpful team will create a more cohesive experience for the patient, giving them further confidence in your abilities. Your clinic and support staff are a direct reflection of you as a clinician and a calm, relaxing ambiance will transfer across to your patients.

Supportive language

Avoid using phrases that appear to minimise their anxiety such as, ‘there’s nothing to be afraid of’. Instead, it’s best to focus on normalising anxiety and using supportive phrases, such as, ‘many of my patients have concerns similar to yours’. Normalising anxiety shows empathy and helps the patient understand they are not alone in experiencing anxiety. Avoid the use of technical jargon and always communicate in simple, clear language.

Control

Loss of control is associated with anxiety and giving patients an element of control will aid in reducing their nerves.3 Create a signalling system whereby patients can signal to you if they feel they need a break during the procedure. Find out if the patient wishes to see what you are doing during the procedure. Some patients find it comforting to see the treatment progress gradually, in particular during dermal filler procedures where results are instantly visible.

Anxiety can present itself in a number of ways, some of which are not immediately apparent, so an in-depth initial consultation is the single most effective tool in order to make this assessment

Pain management

Fear of pain during injectable procedures is a common cause for anxiety. Use all the tools at your disposal to minimise discomfort for your patients. This can include topical anaesthetics, ice, cold devices and vibrating devices.7 Warming local anaesthetic and using the smallest needle gauge are also well described techniques to minimise injection pain.8

Distraction techniques

There are a myriad of techniques based on distraction that can help to ease patients’ nerves including the use of music, a supportive assistant, and as often found in dental surgeries, movies.9 In my clinical practice I find a combination of soothing music or music that the patient has chosen themselves, along with a supportive assistant, works best to provide a good quality distraction. This method still allows for a constant reassuring dialogue with the patient throughout the procedure.

‘Tell-show-do’ technique The ‘tell-show-do’ desensitisation technique is commonly used in clinics and involves a gradual introduction to the procedure. It should start with a verbal explanation of the procedure (tell), followed by the ‘show’ involving the demonstration of the visual and tactile aspects of the procedure (where possible), and culminate in carrying out the procedure (do). An example might be when delivering dermal filler treatment with a cannula. You can describe the sensations the patient will experience – for example, while there will be no painful sensation in the treated area, the patient may still be able to feel vibration, movement and pressure. You can then ‘show’ the patient by mimicking the feeling of pressure on the area to demonstrate to them the difference between pain and pressure, sensations that are commonly confused by patients. Finally you ‘do’ the procedure and remember to reassure the patient throughout about what they are feeling and how it is normal.

Relaxation strategies

These include breathing strategies, such as ‘boxed breathing’, and progressive muscle relaxation that can be easily employed.10 Boxed breathing, sometimes called square breathing, involves utilising diaphragmatic breathing to expand the stomach and not the chest. Have the patient count to four as they inhale, hold their breath for four seconds, exhale to a count of four, and hold their breath to a count of four. Ask the patient to try this technique for four minutes.

Progressive muscle relaxation involves helping the patient relax the entire body by tensing and relaxing muscle groups sequentially, usually tensing for 10 seconds, relaxing for 20 seconds, then moving to the next muscle group. To perform this, ask the patient to start at the top or bottom of their body. If they start at the top, ask them to tense (10 seconds), and then relax (20 seconds) their head, neck, shoulders, chest, biceps, etc. in a sequential fashion.

Cognitive behavioural therapy (CBT)

CBT is a form of talking therapy that aims to help a patient learn to change the way they think (cognitive), and act (behavioural). It can be a useful tool for patients with more severe anxiety. Working with a qualified CBT practitioner can help patients link thought patterns with emotions and behaviours. Understanding these themes then allows the patient to arrive at the underlying core issues of the anxiety and CBT focuses on the development of personal coping strategies that target changing unhelpful thought patterns. is linked to a previous negative experience, reassure the patient by explaining how you will avoid this occurring again and describe how it will be different this time. Genuine patient testimonials in either video or written format will also give patients confidence in your clinical abilities. Having a number of patients who are happy to discuss their treatment and experience with you is also extremely valuable.

Pharmacological management

For anxious patients who are keen to undergo more invasive procedures with significant associated discomfort, such as deep chemical peels, pharmacological management may be a useful aid. In these cases, oral sedation or conscious IV sedation can be useful techniques to manage not only anxiety, but also the pain and discomfort often felt during these types of more invasive procedures.

Conclusion

Establishing a good rapport and open dialogue with the patient from the outset can go a long way to greatly diminishing their anxiety. Building trust and showing the patient that you understand their anxiety and empathise with them sets the tone for your care, and emphasises that you are committed to managing their concerns. Using this approach along with a combination of the described techniques is a powerful way to manage nervous patients in everyday practice. 

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