Identifying and supporting patients with Body Dysmorphic Disorder (BDD): A conversation with Claire Newman

In her talk at The Aesthetics Business Conference on 8 October, mental health nurse and director and lead nurse at Soft Touches Aesthetics, Claire Newman will highlight the positive impacts of aesthetic procedures on mental health and wellbeing while also addressing the potential risks, particularly the development of body dysmorphic disorder (BDD). We caught up with her to find out more.

Hamilton Fraser: Can you give us an overview of what you'll be discussing at the Aesthetic Business Conference in October?

Claire Newman: I'll be talking about identifying and supporting patients with Body Dysmorphic Disorder (BDD). It's crucial because many people with BDD are drawn to aesthetic interventions. They're more likely to see someone like us rather than seek help from their GP for mental health services. This is partly because they might not realise it's a mental health issue, or they might understand but still believe it's a cosmetic problem that needs fixing.

When I discuss BDD and mental health, I tend to address mental health as a whole. I touched on it in an article I wrote for the Aesthetics Journal recently. Many people with mental health issues are attracted to cosmetic procedures. In audits I've conducted over the past two years, I've found that a significant number of patients in clinics suffer from depression and anxiety. Understanding the broader context of mental illness is important, as our mental state can influence how we perceive ourselves. For example, if we're feeling down, we may view ourselves more negatively, which can sometimes be confused with BDD. It's vital to understand patients' motivations, not just their physical history but their mental health history as well, to grasp what it means for them and how it will impact them.

Hamilton Fraser: How common is BDD, and how do you differentiate between someone with BDD and someone who's simply concerned about their appearance?

Claire: I've been in aesthetics for 10 years, and I'd say BDD isn't that common. In my audits, less than 1% of patients might have BDD, and that's based on my observations rather than self-reporting. It's important to note that people don't always self-report these issues, so it's just my observation. I do treat patients with mild BDD, but I manage them very carefully and strictly. I discuss my concerns with them, and we proceed with caution.

I suspect that you might encounter more people with BDD in training settings where screening isn't as stringent as it would be in a clinic where practitioners develop a deeper relationship with patients. When someone comes to me from another clinic, I always ask, "Why have you come to me now?" I’m very thorough in my consultations, trying to get a sense of what's going on with the patient. It's challenging because sometimes anxiety or depression can be mistaken for BDD. On the other hand, in online forums, there's a tendency to jump to conclusions and diagnose BDD prematurely when someone presents with minor concerns. It's important to understand how these concerns impact the patient before making any assumptions.

Hamilton Fraser: Are there any tools or questionnaires you'd recommend for helping practitioners identify BDD?

Claire: I’m not a huge fan of using tools in isolation. They can be helpful in guiding consultations, but they shouldn't be relied upon solely. People can easily manipulate their answers, and you might not get an accurate picture. BDD is an anxiety disorder that varies in severity; if a patient is having a good day, they might answer more positively than they would on a bad day. So, while these tools can be a guideline for follow-up questions, they aren't a true representation of the patient's condition. It's easy to lie and say anything so it's essential to understand the patient's reasons for seeking treatment and to build a strong therapeutic relationship to get a complete picture.

Hamilton Fraser: How does BDD relate to other issues like eating disorders? Is there a connection?

Claire: There can be a connection. BDD often coexists with other conditions like depression, anxiety, eating disorders, self-harm, and even substance abuse. Understanding these comorbidities is key. However, there's still a lot of stigma surrounding mental health, especially with more severe conditions like schizophrenia or bipolar disorder. This stigma can make patients reluctant to fully disclose their mental health history. Some patients might not have full insight into their condition, especially if their mental state fluctuates.

I’ve had patients open up about their struggles, like one woman who was having significant work-related stress and contemplated suicide. We had a conversation, and although I did perform her treatment because she felt it would help her cope, I also signposted her to relevant support services. So, it's not just about performing the treatment; it's also about providing support and understanding the broader context of the patient's mental health.

Hamilton Fraser: Aesthetic treatments can improve self-esteem and mental health, but can they also exacerbate BDD?

Claire: Yes, treatments can sometimes worsen a patient's perception of their flaws or shift their focus to other areas of concern. It's important to manage expectations and ensure that both the practitioner and patient are on the same page. I’m very open and honest with my patients, and if I have concerns that a treatment might make them feel worse, I will refuse to perform it, but I would explain why and discuss options/further support⁣.  This may include signposting/contacting relevant healthcare agencies if necessary.

For example, I had a patient with severe BDD who had undergone several surgical procedures that left her feeling worse because the surgeons didn’t handle her condition well. It's crucial to understand the patient's goals and motivations. If there's no genuine need for treatment, it’s better to refrain from treatment, as it could make the patient feel worse about themselves.

Read our article on How to say no to patients here.

Hamilton Fraser: What should a practitioner do if they suspect a patient has BDD but aren’t confident in handling it?

Claire: Practitioners may not be trained to diagnose BDD, but if they have concerns, they should address them with the patient, ideally after establishing a good rapport. It’s important to have an open and honest conversation about the concerns, but in a way that doesn’t make the patient feel worse about themselves. If a practitioner decides not to proceed with treatment, they should explain their reasoning carefully, perhaps suggesting that the patient seek mental health support if appropriate.

For example, I once treated a patient who had BDD and was preoccupied with her skin. She was very anxious about the potential swelling after a lip treatment. She had booked herself into a hotel for a night so no one could see the swelling, as she knew it would make her feel worse. Although she was ultimately fine, it made me more cautious about managing expectations. In some cases, if a patient's concerns are unfounded, I will refuse treatment and explain why. However, every patient is different, and it's important to approach each situation individually.

Hamilton Fraser: How does capacity to consent come into play, especially if a patient's mental state is fluctuating?

Claire: Capacity to consent is crucial and should be assessed thoroughly prior to every treatment and not just at the initial consultation, especially if a patient’s mental state fluctuates. For example, I once had a patient whose anxiety was exacerbated by a urinary infection. I advised her to go to her GP, and when she came back, it was like talking to a different woman. Her mental state had improved, so we proceeded with treatment. It’s important to assess whether a patient can recall and retain the information about the treatment, especially if they have conditions like BDD that can cause anxiety.

Hamilton Fraser: If a patient undergoes treatment in a compromised state, how likely is it to lead to complaints?

Claire: Most complaints stem from dissatisfaction rather than complications. Taking thorough before-and-after photos is crucial, as aesthetics is subjective, and perceptions of beauty vary. It’s also important not to project our own values onto patients. Understanding what their appearance means to them and how the change will impact them is key. For example, people who pursue extreme looks, like the real-life "Barbie" or "Ken," might be motivated by business opportunities rather than BDD.

Hamilton Fraser: How do you approach patients with unrealistic expectations?

Claire: I always stress the importance of managing expectations and understanding the bigger picture. If a patient has unrealistic expectations that treatment will drastically change their life, it's crucial to discuss this openly and honestly. Sometimes, it’s better to refuse treatment if you believe it won't meet the patient’s expectations or if it might make them feel worse.

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