The most common ‘complication’ in aesthetic medicine is unlikely to be a vascular occlusion. More frequently it is a dissatisfied patient. The impact of aesthetics treatments on self-image is purely in the eye of the beholder. This leads to a broad spectrum of responses; some will be genuinely happy with their treatment outcomes while others 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 per cent 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 pre-treatment 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. It also advises deciding whether referral to another experienced professional colleague is appropriate. The GMC affirms the identification of red flags which lead to referral and diagnosis are crucial to achieving positive outcomes.
Here are some tips on elevating your screening for mental health issues during aesthetic consultations…
Use your gut instinct as a medical professional – if 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; they may underplay their psychiatric history and be quite forceful in their desire for treatments. 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 in the form of tools to assess patients. But one-to-one live human interaction, active listening and two-way communication is equally powerful. It is a great tool for alerting you to areas of concern which may, or may not, be alluded to with formal screening questionnaires.
Allocate sufficient time for consultation of the patient to adequately explore psychological drivers for treatment and context
So much information needs to be accrued during the aesthetic consultation. As such, time is of vital importance to openly explore patient ideas, concerns and expectations. Delving into a patient’s psychiatric history will provide clues as to red flags for drivers for treatment. Aspects of social history and personality will also give useful cues. Overall, rapport can only be 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. Provide an objective patient assessment from your independent standing. This distance from friends and family can build a safe, confidential space for patients to discuss their true concerns.
Get familiar with the art of gracefully declining aesthetic treatment and persuading patients to engage in and facilitate their psychological care
There is still a long way to go with regards to managing societal stigmas 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. Sharing insights into their situation can aid discussions as to further plans to manage the real concern and driver for procedures. When 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 that aesthetic treatments delivered in high street stores, which 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 an 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, improve quality of life for the patient and their family – it may even help to save the life of the patient. 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 an 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.