Living with your looks: Recognising Body Dysmorphic Disorder in cosmetic practice

The author of “Living With Your Looks”, Roberta Honigman  will be speaking at the upcoming National Cosmetic Medicine Summit 2017. This two day event aims to provide a unique forum within the Australian cosmetic industry specifically tailored for cosmetic doctors, cosmetic nurses, clinic owners, dermal therapists, cosmeceutical experts and others from the cosmetic industry to discuss, collaborate and further their clinical knowledge as well as hone techniques from thought leaders and peers in the industry.

At Informa Insights, we had the pleasure to interview Roberta Honigman regarding her reseach, and recent projects prior to this event.

WHAT IS YOUR BACKGROUND AND WHAT DREW YOU TO EXAMINE THE AREA OF BODY IMAGE IN COSMETIC SURGERY?

I became interested in body image disturbance in connection with patients seeking cosmetic surgery after I was asked to speak to a patient in my private counselling practice regarding her heightened anxiety following cosmetic surgery. The sessions with her opened my eyes to a fascinating area that very few researchers and clinicians had investigated. Also my prior work was mainly in the area of disability and I became interested in looking at how people functioned both physically and emotionally with differing appearance states.

I then expanded my interests in body image and began undertaking research and writing about it. Body image is the mental picture we have of ourselves in our mind’s eye and is influenced by many factors including family, friends, society and our culture.

RESEARCH AND FINDINGS

Areas of research I have undertaken have looked at the need for pre-procedure screening and counselling for patients seeking either cosmetic or dermatological procedures as well as body dysmorphic disorder. Basically, pre-procedure screening and understanding patient motivation and managing their expectations are of utmost importance for a satisfactory outcome. Screening also highlights a need for some patients to undergo further psychological assessment and treatment prior to procedures, especially for those displaying extreme body image disturbances such as BDD.

WHY IS IT IMPORTANT TO IDENTIFY BODY DYSMORPHIA AND MANAGE THAT APPROPRIATELY?

People with BDD are more likely to be seen by cosmetic practitioners  than by mental health professionals, as the majority of BDD sufferers believe that their condition is physically rather than psychologically manifested. However, clinical evidence suggests that cosmetic procedures are rarely beneficial in ameliorating symptoms of BDD and indeed usually make things worse. Some patients become more fixated on the feature that had been treated or develop new appearance preoccupations following treatment. Others seek further cosmetic procedures while most seem to suffer further significant emotional and psychological distress and have even resorted to lawyers, violence or even homicide against the treating physician. Unfortunately, despite increasing awareness of the impact of poor body image, BDD appears to go under-recognised and /or misdiagnosed.

WHAT SHOULD PRACTITIONERS DO IF SCREENING SHOWS THE PATIENT TO HAVE AN UNDERLYING PSYCHOLOGICAL ISSUE?

Screening can take various forms, from a questionnaire to a conversation about what motivates their request for surgery and their expectations. Risks of the procedure should be clearly explained.  This is just as important when a patient seeks more surgery to ‘fix’ what they see as a poor outcome especially if done by another practitioner. If a patient cannot articulate realistic  changes they desire, or what they see is not to their liking  with their physical appearance, it is important to slow the process down, offer support and counselling with a mental health professional and explain clearly why this may not be the right time or it may not be useful to undergo surgery. It is important not to just close the door on them but to offer something  to take away otherwise they will just head off to the next physician who will give them an appointment. Some patients will not benefit from surgery or other cosmetic interventions and the reasons behind this need to be carefully explained.

DOES THE COOLING OFF PERIOD AND REFERRALS FOR MENTAL ASSESSMENT IN THE NEW GUIDELINES GO SOME WAY TO ADDRESSING THESE CONCERNS?

It is important that the patient has time to consider all aspects of the surgery and not rush in because they feel under pressure from friends, peers, family or even the practitioner. Risks and benefits should be clearly explained and the patient needs to reflect on and discuss these with family and significant others. It is important that a range of options might be put to the patient, if intended surgery is not possible or appropriate. In this time, they should also review the qualifications of the practitioner they saw to ensure they are appropriately trained and registered. As cosmetic surgery is culturally driven, this may be a difficult time for those who feel under pressure to ‘feel better about themselves’ especially after a recent trauma such as relationship breakdown or bereavement and such circumstances need to be managed carefully and sensitively by practitioners and their staff. It is at this time that supportive counselling may be of most value.

WHAT EFFECT DOES SURGERY NORMALLY HAVE FOR PEOPLE WITH BODY IMAGE CONCERNS?

We assume that people undergo cosmetic procedures to enhance their appearance and feel better about themselves; to gain confidence and greater self-esteem and a more positive body image. However in reality not all people are happy with the outcomes even despite good technical results.  The challenge is to determine this before people undergo surgery as the implications of a poor perceived result for some people with significant body image concerns are considerable and can result in stress, anxiety, depression, social isolation, requests for further surgery, and sometimes even suicidal ideation.

HOW CAN PRACTITIONERS MANAGE PATIENT EXPECTATIONS EFFECTIVELY?

Elective surgery requires full disclosure of risks and benefits and careful management of information by the practitioner. This includes the scarring and healing process which the surgeon needs to explain he/she  is unable to control or promise because it is a matter of the patient’s genetics. It is important to build realistic expectations and to discourage wrongly motivated patients, especially in the young, and to ensure what the patient is seeking is physically and psychologically attainable. It is necessary to identify high risk patients for further psychological evaluation if necessary. The patient must make the final decision based on this rather than ridiculous and unrealistic promises of what might be able to be achieved.

Robert Honigman will be discussing the results of her research at the inaugural National Cosmetic Medicine Summit. For event registration and full agenda visit here.