As Practitioners, we have a duty of care to our patients, including refusing 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 we know when is it best to say no!
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.
Charlotte Benson said 'I feel social media has a significant role in driving demand for aesthetic treatment. People see others posed in certain lights, and filters which makes them feel inadequate. They often come into the clinic with unrealistic expectations or ask to look like a filter. I do believe filters have a huge detrimental impact on mental health and body image. The use of filters and constant exposure to over-edited pictures hurt 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!’
We 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 reflection
Need for reassurance about 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 avoidance of mirrors
The Importance of In-Depth Consultations
During the consultation, we need 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 our 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. Charlotte Benson asserted, ‘If in the consultation I feel that they’re not 100% sure on treatment, or I feel that they’re not going to get the results that they want, or if I’m concerned about body dysmorphia, then I will 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, We highly recommend this is not done as for some individuals with BDD this can ignite a new fixation and amplify existing insecurities. We believe we 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.
Consultation
We chat with each client; it’s about forming strong relationships and understanding why they want their treatments. It’s so important we say no and are honest about expectations. In all consultations ensure safe patient selection and distinguish treatment pathways.
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.’
We believe every individual treatment must be carried out with the patient’s best interests in mind and the intention of improving their confidence. We should refuse treatment if we 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. We stress the need for an industry-wide standard of care, ‘if we all said ‘No’ when we should do, these vulnerable patients would not be able to practitioner-hop to satisfy their addictions.’
Keep The Conversation Patient-Centric
Effective communication is key to protecting our clients. Patients must 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 argues 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
We believe that showing before and after photos during consultation provides a visible, evidence-based comparison as a reason 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.