Exploring body dysmorphia and facial aesthetics

Zainab Al-Mukhtar discusses an important ethical dimension of facial aesthetic treatments, and how to manage body dysmorphia in patients.

Zainab Al-Mukhtar discusses an important ethical dimension of facial aesthetic treatments and how to manage body dysmorphia in patients.

Body dysmorphic disorder (BDD) is defined by the World Health Organization (WHO) as a ‘persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others’.

It is a disabling psychological disorder characterised by excessive preoccupation with one’s perceived defect or flaw in physical appearance, when the appearance is actually normal.

Many patients with BDD actively seek out aesthetic treatments to correct imagined defective bodily or facial features. This makes it exceptionally important for all aesthetic practitioners to have a strong awareness and understanding of the condition.

With the distortion in self-image often leading to extreme feelings of self-consciousness, people with BDD are likely to repetitively and compulsively check the appearance of their perceived flaw and/or avoid social situations that may increase their concern about it.

The distress associated with this negative self-perception can be severe enough to be all-consuming for patients, potentially affecting daily function, education, work, quality of life and interpersonal relationships. While the primary BBD can co-occur with depression and anxiety, the loneliness and isolation itself can contribute to a further decline in mental health.

BDD is most common in adolescents and young adults but can affect people at any age. Patients with a history of eating disorders or obsessive-compulsive disorders are often at higher risk of BDD.

My observations throughout 11 years in facial aesthetics suggest that peer pressure, childhood or teenage bullying and social media can have profound psychological impacts that may lead to or contribute to BDD.

Social media posts, videos and comments can also influence many assumptions around beauty and thereby breed unrealistic expectations of individuals to confirm to certain perceived ideals.

Evaluating BDD

Without appropriate assessment or early evaluation of suspected BDD in patients seeking aesthetic procedures, they can face continuous dissatisfaction around their cosmetic results.

Failure to detect potential BDD before proceeding with aesthetic treatment is likely to result in dissatisfaction, heightened distress and/or compulsive obsessive requests for either reversal or additional unnecessary treatments.

This can be detrimental to the patient’s mental wellbeing and potentially a very challenging situation for the clinician. However, distinguishing BDD-related expectations from normal and realistic expectations is important for clinicians to do.

One must note that there are varying motivations, cultural influences and personal preferences that play a role in the perception of beauty among different individuals. As such, a personalised approach should be taken with every patient.

Though a patient’s individual taste may not align with the aesthetic ideals or perception of beauty of the practitioner, this does not necessarily indicate a potential diagnosis of BDD, especially if there are no other specific signs or symptoms.

Assessment

Assessment tools exist to support practitioners in identifying potential BDD. These should only be used by suitably qualified practitioners, but they should not be depended upon alone. They should be used alongside a thorough patient consultation with the view of building rapport and understanding between patient and practitioner.

During the consultation, it is important to take a detailed aesthetic history and ask certain questions that bring to light a patient’s motivation to seek treatment. However, one must be mindful that patients may not always feel comfortable revealing the depth of their concerns, and therefore may withhold honest answers. This is more likely to be the case for patients who have previously been denied treatment by other practitioners.

Additionally, the mood of the patient can influence their answers, and therefore their answers may be inconsistent between appointments and present a confusing picture to the practitioner. With severe BDD, in which there is usually more impaired functioning and depression, cosmetic treatment should be avoided before psychological therapy.

In cases of milder BDD, in which patients seem to have more localised concerns around a certain feature and more realistic expectations around treatment results, some clinicians believe that these patients may actually benefit from cosmetic treatment.

After a systematic review on this subject by Mandavia and colleagues (2024), which stated that ‘aesthetic procedures should be avoided in patients with BDD since they can negatively impact mental health and lead to further aesthetic dissatisfaction’, an outline of suggestions was made for screening and a practical pathway for BDD in the field of facial aesthetics was published.

This was to be used to help identify and provide clear guidance on the appropriate management of patients with suspected BDD, thereby ‘helping to reduce the number of facial aesthetic procedures performed on patients with BDD, safeguard patient mental wellbeing and prevent further aesthetic dissatisfaction’.

Best practice

The review suggested that completion of a validated screening tool as a mandatory step in an aesthetic consultation could be completed with the patient before any aesthetic procedure. It was suggested that the cosmetic procedure screening questionnaire was one of the suitable assessments of choice.

It is important to understand that screening tools will provide only ‘potential BDD’ indication rather than a definitive diagnosis and do not help with assessing the severity of the potential BDD.

As Mandavia and colleagues (2024) state: ‘In the event of suspected BDD, the patient should be referred to mental health services for mental health and social assessment, patient education as well as potential mental health treatment.

Following this, the aesthetic clinician and mental health professional should work together to weigh up the risk versus benefit of the aesthetic procedure.

Ethical considerations

As dentists or medical professionals, we must always be guided by our Hippocratic oath to do no harm and to maintain our duty to safeguard our patients’ mental wellbeing to the best of our ability when under our care.

Firstly, when managing a patient with suspected BDD, consider the long-term impact of the aesthetic consultation itself. It is crucial to the wellbeing of patients that practitioners utilise emotional intelligence during all stages of a consultation with any patient, not only when listening but also, and most importantly, when relaying findings of a facial assessment, discussing diagnosis and treatment options.

It may be easy for an aesthetic practitioner to objectively approach communication with a patient, guided by a set criteria on beauty ideals relating to facial symmetry or proportions, but this can actually amplify patient insecurities if they do not fit this ideal.

To minimise the risk of triggering further distress or a deterioration in the mental wellbeing of a patient, it is important to communicate very responsibly and compassionately when outlining areas for potential treatment, with the care to ensure patients feel accepted and image-positive during any appointments.

Open communication

This is important with all groups of patients but critically so for vulnerable patients who display signs of anxiety and/or BDD. I am therefore of the opinion that training in communication should be sought by all practitioners.

Declining treatment without outlining to the patient what the concerns are and what the recommended management for the patient is may lead a vulnerable patient to consider clinic hopping in the hope that a practitioner will simply agree to treat them. They may even seek treatment by non-healthcare professionals who are likely to overlook the psychological state of the patient.

Therefore, it is upon the aesthetic practitioner to make clear to patients if a referral is advisable for psychological assessment, with an explanation that the primary goal of this is in the interest of the patient’s wellbeing, as they may then benefit from receiving the correct psychological support/therapeutic treatment before receiving aesthetic treatments.

Once BDD is suspected from a preliminary screening, clinicians should use a clear process to refer patients to either a psychologist or psychiatric professional prior to commencing cosmetic treatment.

Informed consent

As an important part of a medical consultation, patients must be fully informed of risks, benefits, potential outcomes and treatment alternatives before consent can be obtained for treatment.

For informed consent to be deemed valid, a patient must show capacity to understand risks. While there is some debate about whether BDD decreases one’s ability to make informed decisions, clinicians should assess this on an individual patient basis.

Patients with BDD are more vulnerable to the influences of social media content, which can negatively affect the mental wellbeing and self-esteem of any person, let alone someone with BDD.

Practitioners should recognise their social responsibility and be especially mindful and responsible around language when discussing case studies online so as not to imply that a feature is defective when promoting treatments as this can exploit the insecurities of vulnerable patients.

Also, cooling off periods after consultation are good practice, allowing for vulnerable patients to avoid spontaneous decisions as well as allowing an opportunity for practitioners to reflect and reassess again at a future visit.

Safeguarding patients

It is my observation that patients with undetected BDD who have been incorrectly managed have been subjected to more harm and distress because of over treatment, and these patients also suffer the psychosocial consequences of poor aesthetic outcomes.

This can contribute to heightened feelings of distress, even panic attacks and isolation. It is therefore both the professional duty and the moral obligation of practitioners to work on identification of such disorders.

I believe that all aesthetic practitioners should undergo training around mental health conditions that may be relevant in aesthetics, certainly including BDD, to mitigate the risk that patients with mental illnesses will be inappropriately managed.

More research is required into body dysmorphic disorders and how best to manage aesthetic patients with BDD. Over a decade of experience in facial aesthetics, I have honed my recognition of many potential indicators for BDD during consultations.

However, I believe that the inclusion of routine pre-treatment screening tools has made the process more reliable, creating greater effectiveness in liaison with mental health professionals, better safeguarding of patients’ mental wellbeing and more patient satisfaction.


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Read another of Dr Zainab’s articles here: Instagram takeover – Zainab Al-Mukhtar with an introduction to ultrasound in facial aesthetics

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