Body Dysmorphic Disorder in practitioners

Many aesthetic practitioners have a heightened awareness – perhaps more so than any other group of medical professionals bar psychotherapists – of body dysmorphic disorder (BDD).

BDD is a serious mental health disorder where patients become obsessed with minor or non-existent physical flaws to the extent that they become severely depressed and suicidal.

Statistics on the proportion of the UK population with BDD vary – from five out of every 1000 people1 to one to two out of every 100 2 – but there seems to be an agreement across the board that the disorder disproportionately affects people who have sought or continue to seek medical aesthetic treatments. It is estimated that 9-15% of aesthetic dermatology patients and up to half of those seeking surgical rhinoplasties suffer from BDD.3

Every aesthetic practitioner and cosmetic surgeon will likely have encountered or treated patients with either suspected or diagnosed BDD and will be familiar with the delicate and cyclical nature of the disorder, whereby most tend to be dissatisfied with the results from treatment and experience a worsening of their BDD symptoms, leading them to seek more treatment, and so on.

While patient-centred aesthetic practitioners will know how to recognise the signs of BDD in patients and be familiar with clinical management pathways and referral processes for such patients, what happens when it’s not the patient suffering from BDD, but the practitioner themselves?

Under the radar

Dr Steven Harris and Dr Neetu Johnson conducted the first known research into BDD among aesthetic practitioners via a small survey study in 2017. Writing in the November 2017 issue of Aesthetic Medicine, Dr Harris presented the findings, in which he and Dr Johnson concluded that, notwithstanding limitations, “…the results of this survey found that the prevalence rate of BDD among practitioners is higher than that found among aesthetic patients (16% versus 9-15%).” After analysing the responses from 51 surveys distributed at two medical aesthetic conferences, they found that BDD was most common among aesthetic nurses at 50%, followed by aesthetic doctors at 16%, while the prevalence of BDD symptoms was lowest within the dental profession.

Six years on from the study, Dr Michael Prager spoke to BBC News in July of this year about the subject, commenting that he found a lot of his industry peers to be “unrecognisable” after repeated aesthetic treatment and that patients could end up looking “rather weird” if treated by a practitioner with BDD. But is it the case that more practitioners have BDD than their patients, and how big is the risk to the people they treat?

“I believe there is only one such study — or at least I am not aware of any other study like this — it was done on a very small number of aesthetic practitioners, so further research is necessary to establish the findings of this survey,” points out Dr Bhavjit Kaur. She also notes that any BDD diagnosis is quite subjective, and therefore there isn’t a pre-determined way to say for certain that someone is suffering from the disorder. “The diagnosis is based on various versions of questionnaires, not objective investigations and findings, and there is not enough research [or] money for research for BDD,” she says. While she agrees that “some aesthetic practitioners are very particular about their looks and may appear ‘overdone’,” Dr Kaur is careful to make the distinction between other factors that could cause someone to be preoccupied with their appearance, aesthetic practitioner or otherwise.

“Is it BDD, body dissatisfaction, vanity, peer pressure… we can’t be sure as BDD is a mental health condition where a person spends a lot of time worrying about flaws in their appearance. These flaws are often either not noticeable or only slightly visible to others. The obsession is severe enough to cause clinically significant distress or impairment in social, academic, occupational or other areas of functioning. The Diagnostic and Statistical Manual of Mental Disorders (5th edition) classifies BDD in the chapter on Obsessive-compulsive and related disorders, along with obsessive-compulsive disorder (OCD) and several other disorders. “To meet diagnostic criteria (by using BDD questionnaire/s) the person at some point during the illness must engage in repetitive behaviours, like excessive mirror checking, camouflaging, skin picking and excessive grooming, etc.”

Possible motivations

Dr Harris also believes that it is important to make the distinction between BDD and other possible motivations for why practitioners and patients alike “distort themselves”. He is one of the authors of a paper published in The Aesthetic Surgery Journal this year that explored the motivations of 24 women for seeking lip-filler injections. One participant in the study had a formal diagnosis of BDD, but many others “described a spectrum of preoccupation and distress with appearance and associated checking behaviours,” reads the paper. The majority of subjects identified social media as the main factor for them seeking the procedure, describing the phenomenon as “impacting perceived aesthetic norms.” The authors go on to explain that “a process of perceptual drift occurs whereby mental schema encoding expectations of ‘natural’ facial anatomy can adapt through repeated exposure to enhanced images.”

BEYOND THE OBVIOUS

So, much like with patients, various factors could motivate an aesthetic practitioner to seek treatment themselves, aside from BDD. However, this isn’t to say that the subject doesn’t deserve attention or further research. Kimberley Cairns, integrative psychologist and advisor to the JCCP says that it’s far too soon to conclude that the prevalence of BDD is higher in practitioners than in their patients, but she does agree that “sector taboos” like this need further investigation.

“Through my work and experience, I have certainly observed heightened arousal in practitioners regarding their appearance. This can be an incredibly sensitive and demanding state for the practitioner which can be all-consuming and affect how they conduct themselves professionally and personally, and can lead to burnout,” she says.

Interestingly though, she notes that people who are more at risk of developing BBD or having undiagnosed symptoms exasperated could find themselves working in fields like aesthetic medicine. “It may be that people susceptible to BDD may be drawn to professions that help soothe or ease associated symptoms through access to technologies and interventions. This presents a higher risk of under-representation, misdiagnosis or under-diagnosis in the workforce,” she says. Cairns highlights that common practices like performing complementary treatments on each other or acting as treatment-training models could be making things even worse. “This brings further and relevant debate to training standards and the appropriate use of staff as models. This widespread practice may be harmful if not correctly safeguarded,” she adds.

SAFETY FIRST

It’s important to keep in mind that a practitioner with diagnosed (or undiagnosed) BDD doesn’t automatically pose a potential risk to patients. Indeed, Dr Kaur reminds us that there is no evidence to support this. “It is difficult to diagnose BDD and there are no studies on the risk of an aesthetic practitioner with BDD on patient welfare,” she says. “BDD is a mental illness that impacts how people perceive their own body, not other people’s.” However, “there is a variant of BDD called BDD By Proxy (BDDBP), which is characterised by a preoccupation with perceived defects or flaws in another person’s appearance. The person of concern may be a family member, partner, friend, or stranger. This preoccupation causes ‘clinically’ significant distress and often interferes with day-to-day functioning4,” explains Kaur. “If that is present, then the aesthetic practitioner with this variant of BDD may focus on one aspect of the person rather than the whole face as holistic treatment. But again, there are no studies on this.”

Similarly, and echoing her comments on the unique circumstances of working in the aesthetic medicine sector, Cairns presents an example of how BDD may present and be undiagnosed in a practitioner, as opposed to a member of the general public. “It can be rooted in the worry and sometimes fear of negative appearance-based judgments from patients, colleagues, family and friends. These can exist when a practitioner may ruminate on the notion that they must conform to the implied sector standards of beauty and ultimately ‘keep up appearances”. This can involve an extraordinary investment of time, thought and money where a practitioner is compelled to ensure they are presenting themselves by sector norms to be regarded as credible and successful. These attributions of internal worth based on external appearance are of particular sensitivity when the practitioner is the marketing or branding influence to promote both patient selection and retention. This uncovers a unique, complex and dynamic transaction or transference of the patient-practitioner, a practitioner-patient relationship which is seldom discussed.”

The issue of potential undiagnosed and diagnosed BBD among aesthetic practitioners warrants much more investigation, both from a patient-safety and practitioner-wellbeing perspective. Hopefully, there’s enough concern among influential practitioners and industry thought-leaders to move the conversation — and, ultimately, the clinical pathways – along.