The most common ‘complication’ in aesthetic medicine is unlikely to be a vascular occlusion. More frequently it is the dissatisfied patient. The impact of aesthetic treatments on self-image, is purely in the eye of the beholder. So there is a broad spectrum between those genuinely happy with their treatment outcomes and those who will be dissatisfied regardless of any physical improvement achieved.
Patients with body dysmorphic disorder (BDD) have a particularly high dissatisfaction rate with aesthetic treatments. BDD is an absolute contraindication for treatment due to the extreme psychological distress that treatment causes. It has an alarmingly high completed suicide rate and aesthetic treatments may tip the scales by causing psychological distress.
Aesthetic treatments are carried out by a diverse spectrum of practitioners with varying professional backgrounds. Many aesthetic practitioners, with their pursuit for technical prowess, may unknowingly neglect their educational development in recognising the psychological drivers that motivate their patients to seek treatments.
Aesthetic practitioners are up to 15% more likely to come into contact with patients with BDD due to the very nature of their work. With retrospective analysis, it is usual to discover psychological risk factors for dissatisfied patients that could have been be identified at the pretreatment consultation.
With referral, as well as psychological and pharmacological treatment like cognitive behaviour therapy (CBT) and antidepressant (SSRI) medication, BDD can be effectively managed. Seeking a physical solution with aesthetic treatment to this pathopsychological concern is indeed futile. The GMC (2016) Cosmetic guidance clearly states ‘to consider your patients’ psychological needs and whether referral to another experienced professional colleague is appropriate’ as identification of red flags that lead to referral and diagnosis are crucial to achieve positive outcomes.
So here are some tips on elevating your screening for mental health issues during the aesthetic consultation:
Use your gut instinct as a medical professional, and if you are in doubt, don’t treat.
Not treating is equally important compared to treating when considering aesthetic procedures. The instinctual need to care for our patients and make them (seemingly) happy in the context of private aesthetic medicine can be powerful. Patients keen for treatment can be persuasive in their manner, may underplay their psychiatric history and potentially be quite forceful in their desire for treatments. But as medical professionals, we are skilled at observing our patients and can use this expertise to develop an instinct for which patients are appropriate for these desired, rather than medically necessary, treatments.
Use of validated questionnaires or screening tools help the psychological assessment, but do not replace the need for further face to face exploration.
There are many available tools and questionnaires for psychological assessments. It may be tempting to rely on written responses within the form of tools to assess patients. But one to one live human interaction, active listening and two way communication is an equally powerful tool in alerting you to areas of concern which may, or may not, be alluded to with formal screening questionnaires.
Allocation of sufficient time is required at consultation of the patient to adequately explore the psychological drivers for treatment and context.
With a lot of information that needs to be accrued at the aesthetic consultation, time is of importance to openly explore patient ideas, concerns and expectations. Delving into the psychiatric history will give clues as to red flags for drivers for treatment. Aspects of social history and personality will also give useful cues. Overall, rapport can only developed with a patient given sufficient time for open discussion, particularly if sensitive issues are being discussed.
Approach patients from a perspective of empathy.
Many patients with BDD feel isolated, alone and unheard. An aesthetic practitioner has the unique privilege of establishing trust in a professional medical relationship. To provide an objective assessment in your standing from a position of independence from friends and family can build a safe, confidential space for a patient to discuss their true concerns.
Get familiar with the art of gracefully declining aesthetic treatment and persuading patients with variable levels of insight into their condition to engage in and facilitate their psychological care.
There is still a long way to go with regards to managing societal stigma attached to psychological diagnoses. Apart from entertaining these diagnoses, declining treatment is not expected by the patient. So discussing this patiently and sensitively sets up more patient cooperation with further plans to manage the true concern and driver for procedures. True for managing any challenging scenarios with patients, responding by understanding their perspective is more useful than being led by your own.
It has recently been suggested aesthetic treatments delivered in high street stores, that also sell cosmetics and personal care items undermine the medical nature of aesthetic procedures. After all, no one wins if treatment is undertaken for the wrong reasons.
So a holistic approach to the consultation process, paying due attention to the crucial psychological factors, is essential for patient wellbeing and satisfaction. Early recognition of BDD may help to prevent progress of the disease, to improve quality of life of the patient and of their family and may even help to save the life of the patient. And remember…apart from protecting your patients, this is equally impactful for the reputation, satisfaction levels and wellbeing of you as an aesthetic practitioner too.
Dr Kalpna Pindolia, Clinical Education Lead
An aesthetic doctor, trainer, assessor and GMC appraiser, Dr Pindolia is dedicated to a holistic approach to the individual from both medical and psychological perspectives. With a true passion for empowered education in the aesthetics sector, she is dedicated to the experience and success of our student community.