News Special: Recognising Body Dysmorphic Disorder

By Holly Carver / 02 Aug 2021

Aesthetics looks into the importance of being able to identify when a patient might be suffering from BDD

Body dysmorphic disorder (BDD) is a psychological condition continually gaining more recognition in the aesthetics specialty. It’s been estimated that around one in eight patients who present to facial plastic and reconstructive surgery settings suffer from the disorder, although it’s likely to be underreported.1 In terms of the general population, it is thought to affect 0.5% of people in the UK.2 Recently, reality star Katie Price stated that BDD could be the reason behind her latest round of plastic surgery, having already undergone around 20 surgical procedures as well as numerous non-invasive treatments.3

Obsession with both invasive and non-invasive aesthetic procedures and increased insecurity isn’t an unusual occurrence, and has led to patients putting themselves in danger. One extreme example includes former model Hang Mioku, who injected herself with cooking oil after practitioners refused her any further procedures.4 Therefore, it’s not only important for practitioners to be able to identify the condition, but also to be aware of how to get the patient correct support.

The British Association of Aesthetic Plastic Surgeons (BAAPS) recently highlighted the importance of practitioner knowledge and skills in this area by launching a new psychology course for its members, aiming to equip surgeons with the necessary skills to respond to psychological factors in patient consultations.

Plastic, cosmetic and reconstructive surgeon and BAAPS board member, Miss Caroline Payne commented, “BAAPS has run psychology courses before, but we have changed the emphasis in this new course to enhance the psychological skills of the surgeon in helping patients. BDD is a spectrum of symptoms and can be very mild to quite unsettling for the patient, so for those that work in the aesthetics industry, knowing how to unpack a patient’s needs and desires and isolate targeted goals can help us decide whether a patient has actual symptoms of BDD.”

Identifying possible BDD

Aesthetic practitioner Dr Reena Jasani recommends that practitioners implement routine screening during all initial consultations. She says, “Questions that practitioners can ask would include: which area(s) would you like treating and why? How frequently do you check or look at that area of your body? Have you had any previous cosmetic treatment and how satisfied are you with your previous treatment?” Miss Payne also suggests asking whether the treatment will increase the patient’s self-confidence and self-esteem.

If there are concerns that the patient may have symptoms relating to BDD, Dr Jasani then recommends specific screening tools and questionnaires, such as the BDD Questionnaire-Dermatology Version (BDDQ-DV). “By completing these questionnaires and having a consultation with the patient, the aesthetic practitioner will have a better idea of patient concerns, motivations and expectations. If BDD is suspected, a referral for psychological assessment would be an appropriate step to take for formal diagnosis,” she adds.

"We must be there to help patients in the understanding of their expectations and whether they can be realistically achieved"

Miss Caroline Payne

Dr Jasani also emphasises that BDD should not be confused for insecurity, and vice versa, for which aesthetic procedures can be hugely beneficial. “From my own experience, the level of insecurity can range from someone being mildly self-conscious about the part of their body to being severely impacted by it (but still may not have BDD),” she says, adding, “Their level of insecurity depends on multiple factors such as their overall confidence in themselves, any recent significant life events (such as a breakup or divorce), whether their flaw/concern is also noticed by others – amongst other considerations. In the majority of these cases, I find patients often feel empowered after undergoing cosmetic treatment. They feel better in themselves, have increased self-esteem and confidence, and the results are satisfactory to both the practitioner and patient.”

Potential impact on practitioners

One study of the literature indicated that having a mental illness is often linked to dissatisfaction following cosmetic procedures.5 This is a main focus of the BAAPS course, and Miss Payne notes that a lot of the content will be aimed at how to manage patient expectations. She comments, “There is the patient who will go from practitioner to practitioner until they eventually see someone who will operate and then consequently you end up with an unhappy patient. We have to get the message across to practitioners that not all patients are suitable for surgery or other cosmetic procedures. If a patient comes to you after seeing multiple surgeons/practitioners, you should recognise that it’s highly likely that whatever you say will still not be acceptable to them in the long run. It is actually a lot harder to say no to patients than it is to say yes, so this is a skill that people need to equip themselves with.”

Dr Jasani adds that where a patient feels that their cosmetic defect has not been addressed it can have a negative impact on the practitioner, as the patient may put pressure on them for further treatment, submit a negative review, raise a complaint, or in some cases, even seek litigation, making recognition at the initial stages important. She notes that she once had a patient attend for dermal filler treatment and then return a week or two later requesting further injections elsewhere on the face. This continued for a few weeks, with the patient pointing out a variety of perceived flaws which distressed her greatly. Dr Jasani explains, “I didn’t realise it at the time, but the patient was presenting with typical signs of BDD. She focused on a perceived flaw, sought treatment for this area and due to the nature of the condition, these compulsions continued as she moved onto other perceived flaws. Now, with my continued experience combined with the use of the screening questionnaire, I am now able to have a better understanding of patient motivations, which enable me to either treat them or refer them to the appropriate care pathway.”

Creating awareness

Dr Jasani believes that aesthetic training providers should focus on incorporating mental health into their courses. She says, “I believe that it would be beneficial for BDD to be highlighted more in aesthetic training courses, so practitioners are better prepared when they see BDD patients. Aesthetic practitioners also have the responsibility to do further learning by reading informational websites and articles to increase their awareness of the condition, so a greater understanding can be created. This will allow us to support our patients in the best way possible.”

Miss Payne agrees, adding that the role of a practitioner should be about more than just treating the patient based on what they ask for. She comments, “We must be there to help patients in the understanding of their expectations and whether they can be realistically achieved. We must not be there to simply get a consent, operate and leave the patient in psychological distress. After this last year in particular, it is not just the physiological wellbeing of patients, it is also the psychological wellbeing that we should be looking after.”

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