This guidance document proposes actions that JCCP registrants might seek to undertake to assure themselves that someone is not experiencing Body Dysmorphic Disorder (BDD) before they undertake treatment. The JCCP recognises that BDD forms a discreet aspect of the psychological wellness and morbidity spectrum, and practitioners should review this paper in that context. However, the JCCP's increasing understanding of the vulnerable nature of many individuals seeking cosmetic procedures necessitates a renewed focus on this specific area of concern.
Background
BDD is characterised by a preoccupation with an imagined defect in one's appearance, or in the case of a slight physical anomaly, the person's concern is markedly excessive. BDD is characterised by time-consuming behaviours such as mirror gazing, comparing particular features to those of others, excessive camouflaging tactics to hide the defect, skin picking and reassurance seeking. Experience in the cosmetic sector shows that individuals with possible BDD may be less risk-averse, being prepared to accept a level of procedural risk that is disproportionate to the concern at hand when viewed objectively. They are more likely to be ‘cosmetic shoppers’ with a history of seeking interventions from a range of practices or training organisations locally or nationally. The effort expended by such users of cosmetic services is typically characterised by diminishing satisfaction in how they look. These are ‘red flag’ features that can be readily identified through the provision of sufficient questioning of the person's medical and cosmetic history.
It is thought that 0.5% to 0.7% of the population have BDD with an increased prevalence rate in the aesthetic consumer and practitioner population. The emotional aspects of aesthetic consumers reveal a complex picture. Psychological vulnerabilities are significantly higher in patients seeking aesthetic treatments.
For people known to be at higher risk of BDD (such as individuals with symptoms of depression, social phobia, alcohol or substance misuse, Obsessive Compulsive Disorder (OCD) or an eating disorder), or for people with mild disfigurements or blemishes who are seeking a cosmetic or dermatological procedure, healthcare professionals should routinely consider and explore the possibility of BDD.
» Many cases of BDD remain unrecognised, sometimes for many years. Relatively few health professionals actually possess expertise in the recognition, assessment, diagnosis and treatment of the less common presenting features BDD «
Pre-consultation
Advertising and social media standards should always be truthful, honest and legal; it should direct a prospective patient towards a consultation, not a treatment in the first instance.
The consultation
Patient selection processes are complex and should be treated as such. The JCCP reiterates that a consultation (regardless of device, injectable or intervention) should consist of the following:
- Informed consent (reference should be made in this regard to the regulated professionals published guidance on decision-making and consent to illustrate the considerations/steps to take to achieve informed consent).
- Basic patient demographic data
- Medical / healthcare history including past and current illnesses, allergies, medication history, family history, psycho-social and emotional history, cosmetic history, socio-economic factors, cultural and well-being determinants
- Exploration and assessment of reasons / expectations for the patient undertaking an aesthetic procedure and the provision of informed consent. As part of informed consent, sufficient time (at least 48 hours) should be provided to enable the patient to reflect on the information provided and discussed, which will vary for each individual patient and proposed procedure
- Physical assessment of the patient, in particular the skin and structures relevant to the procedure
- Psychological or emotional health assessment
- Description and agreement of benefits and risks associated with the proposed treatment plan with the inclusion of no intervention. Outline the risks and benefits of a particular intervention as part of the consultation and to share such information with their patients prior to the commencement of any treatment episode
- Determination of post-treatment / outcome expectations and timescale for evaluation of the same and the provision of suitable arrangements to be put in place for any follow-up care required outside of the planned evaluation appointment in the event that an adverse reaction or emergency occurs
» The National Institute of Clinical Excellence (NICE) guidance promotes that healthcare professionals should routinely consider and explore the possibility of comorbid OCD by asking direct questions about possible symptoms «
Psychological and psychosocial assessment
All patients must be carefully assessed prior to the provision of any aesthetic / cosmetic treatment to identify emotional or psychological disorders or vulnerabilities that promote inappropriate motivations, or coercive pressure and / or unrealistic expectations. This can include offering psychoeducation regarding the way in which individuals seek to adjust their appearance to align with norms of members of their elected social group (divergence in appearance norms), and perhaps even challenging patients' beliefs about the role of appearance and self-worth where safe to do so.
For the purposes of this guidance document, psychological assessment refers to the specific expert practice and theory of psychological functioning. Psychosocial assessment refers to the acknowledgement of interacting social pressures on mental health.
JCCP registrants should have acquired all of the necessary skills to enable them to make an holistic physical, psychosocial and emotional diagnostic assessment of the patient in order to determine whether a treatment episode is medical, medically related or cosmetic in nature before commencing any procedure.
JCCP registrants and all healthcare professionals are required by the JCCP/CPSA Code of Practice to recognise and to work ethically and efficiently within the expected parameters of their competence and at all times to uphold patient safety, trust and confidence.
Health Care Professionals also need to demonstrate substantive training in clinical diagnosis, taking a medical, psychological and psychosocial history and making a fully informed physical and psychological assessment of the patient.
Many cases of BDD remain undiagnosed, sometimes for many years. Relatively few health professionals actually possess expertise in the recognition, assessment, diagnosis and treatment of the less common presenting features BDD. A valid assessment tool used by a suitably equipped assessor has the scope to protect public safety and guide informed consent as an improved and meaningful process of patient selection and suitability to receive cosmetic treatments.
There are several screening tools available to Health Care Professionals to help inform whether a patient is suitable for an aesthetic procedure. Some of these are listed below:
- Appearance Anxiety Inventory (AAI)
- The Cosmetic Procedures Screening-Questionnaire (COPS) or Body Image Questionnaire
- The Body Dysmorphic Disorder Questionnaire (BDDQ)
- Body Dysmorphic Disorder Modification of the Y-BOCS (BDD-YBOCS)
- FACE-Q
For people known to be at higher risk of OCD (such as individuals who currently present with symptoms of depression, anxiety, alcohol or substance misuse, BDD or an eating disorder), or for people attending dermatology clinics, the National Institute of Clinical Excellence (NICE) guidance promotes that healthcare professionals should routinely consider and explore the possibility of comorbid OCD by asking direct questions about possible symptoms such as the following:
- Do you wash or clean a lot?
- Do you check things a lot?
- Is there any thought that keeps bothering you that you would like to get rid of but cannot?
- Do your daily activities take a long time to finish?
- Are you concerned about putting things in a special order or are you very upset by mess?
- Do these problems trouble you?
Furthermore, in the assessment of people at higher risk of BDD, NICE advises that the following 5 questions should be asked to help identify individuals with BDD:
- Do you worry a lot about the way you look and wish you could think about it less?
- What specific concerns do you have about your appearance?
- On a typical day, how many hours a day is your appearance on your mind? (more than one hour a day is considered excessive)
- What effect does it have on your life?
- Does it make it hard to do your work or be with friends?
People with suspected or diagnosed BDD seeking cosmetic surgery or dermatological/non-surgical cosmetic or aesthetic treatment should be assessed by a mental health professional with specific expertise in the management of BDD before the commencement of aesthetic treatment.
Multi and interdisciplinary approach
Many patients are motivated to seek aesthetic, cosmetic or non-surgical interventions due to emotional and or psychological factors and may therefore have inappropriate expectations that the aesthetic intervention would result in improvements in psychological or emotional health and general wellbeing.
Having access to a multidisciplinary care team for integrated care or a referral route for specialist psychological support and intervention is recommended alongside any relevant assessment to assure a JCCP registrant that a prospective patient is not experiencing Body Dysmorphic Disorder (BDD) before they undertake treatment.
Mental health BDD expertise should be considered a core feature of any aesthetic practice. It can add a valid contribution at any and every point in the patient journey e.g., patient selection, pre-treatment, post treatment, aftercare, follow up, recovery and continuous evaluation and suitability for treatment.
Treatment of disease, disorder and injury (as defined by the Care Quality Commission, the CQC) includes mental health conditions. In the event of any doubt, it is the regulated healthcare professional's responsibility to confirm with the CQC the registration requirements for any assessment intervention.
The use of aesthetic / non-surgical cosmetic and surgical procedures for the treatment of BDD (a mental health condition) should be avoided and is not recommended by the National Institute of Clinical Excellence. It is a precarious misconception that those with BDD will be ‘cured’ by undertaking any number of aesthetic procedures. In fact, the evidence is contrary and firm that appearance dissatisfaction will remain, if not intensify, after aesthetic interventions. The inappropriate administration of cosmetic procedures to persons with BDD could be considered as an adult safeguarding issue. Safeguarding adults means protecting a person's right to live in safety, free from abuse and neglect. The Health and Care Act 2022, sets out statutory responsibility for the integration of care and support between health and local authorities.
Patient and practitioner resources
Aesthetic service providers are encouraged to clearly display simple, informative guides on all services provided, including the risks, benefits and costs of the procedures and the qualifications and insurance held by practitioners to members of the public.
The Mental Health Foundation, the British Beauty Council and the JCCP collectively engaged in June 2020 to produce and distribute a range of public and practitioner-facing toolkits relating to emotional and psychological health and wellbeing that can be accessed conveniently. Conforming with such (and other) acts of best practice and the provision of general advice and support could have a tremendous positive impact in encouraging patients to think more carefully and weigh up the potential risks and benefits of having an aesthetic procedure.
The Body Dysmorphic Foundation also offers an interactive platform where you can ask a question about Body Dysmorphic Disorder (BDD) and receive an expert answer.
The JCCP acknowledges that everyone who seeks to receive cosmetic procedures should be afforded every opportunity to be informed about what they can expect to achieve from the procedure and to be able to evaluate this against any known physical or psychological risks that might be associated with the treatment itself.
Expert comment: body dysmorphia and making decisions about how we look
Dr Antonis A. Kousoulis:
The new guidance for JCCP registrants on BDD is a critical tool for modern cosmetic practice. Whilst the general prevalence of BDD remains estimated at around 1%, according to some estimates, practitioners can expect at least 1 in 10 people seen in aesthetic, dermatology or general cosmetic surgery settings to be affected by BDD. These rates are in an upwards trend, and there are good reasons for it.
Conditions like BDD and many eating disorders have their roots in how we think and feel about our bodies, often termed ‘body image’. Our thoughts and feelings about our bodies can impact us throughout our lives, affecting, more generally, the way we feel about ourselves and our wellbeing.
The way in which our experiences and cultural context affect our body image will be different for everyone. There are, however, some broad factors that are shaping collective experiences. These include exposure to images of idealised or unrealistic bodies through media or social media, peer and commercial pressures to look a certain way or to match an ‘ideal’ body type, and marketing of cosmetic products based on a narrow beauty ideal.
Our body image is a core factor in making decisions about cosmetic operations in what is a ‘polluted’ environment. From a young age we do have a tendency to internalise messages, narratives and images about how we look. This has become more intense with the growth of social media (which has changed the very notion of the word ‘image’), and even more intense with the growth of image editing apps over the past few years and the reimagining of the celebrity culture which places celebrities as ‘people next door’ through their social media accounts. We are all now facing ever increasing scrutiny on how we look.
Thus, the ecosystem in which young people are growing up in and adults are interacting with these days is one that pushes certain narrow beauty ideals that are simply unattainable. And there are feelings of distress and shame that come with it. It is an environment that promotes body dysmorphia, instead of healthy thinking about how we actually want to look.
Being mindful of this context and building an ability to offer patients balanced views on making decisions about their appearance is a critical skill for cosmetic practitioners in the age of digital citizenship.