Pathway for BDD

Dr Rishi Mandavia talks through the new pathway he has helped develop for Body Dysmorphic Disorder

Speaking to colleagues in non-surgical and surgical aesthetics, it became really apparent that patients with Body Dysmorphic Disorder (BDD) frequently seek non-surgical and surgical aesthetic treatments.

If you treat patients with BDD aesthetically, there is a lot of research and evidence showing that it can worsen their perception of how they look. It has also been shown that treating them tends to worsen their mental health. You make them less happy with how they look, and you make them more mentally unwell, so it’s a double whammy.

With aesthetic treatments, you’re never going to get perfect symmetry or perfect skin. The idea is to make it better, but, post treatment, patients with BDD tend to focus on the area more, feeding into their anxiety and causing their mental health to become worse, and, for a condition that has a high suicide rate, we must be very careful that we appropriately screen these patients.

I led the largest ever study on rhinoplasty, across 33 countries. Out of the 41,250 rhinoplasties on which we collected data, only three percent of patients were screened for BDD. So, it’s quite apparent that pre-procedural screening for BDD is insufficient, with higher levels needed to avoid unsuccessful outcomes.

While screening tools exist, there is no evidence-based pathway for BDD, which can result in failure to identify patients, leading to unsuitable treatments and poor outcomes.

WHICH SCREENING TOOL?

Firstly, which screening tool should you use? There are over 25, so why would you use one screening tool over another one and how do you implement it in your practice? If the patient is at risk of BDD, what are you going to do thereafter to make sure they are safe?

There were two main aims to the paper we recently published in the Journal of Facial Plastic Surgery. The first aim was to conduct a systematic review, which is the most robust review, of the available literature looking at screening tools and pathways for BDD.

There are different kinds of reviews. In some cases, the reviewer cherry picks certain papers, but a systematic review adheres to something called PRISMA guidelines. It is the most robust way of ensuring you’ve reviewed all the relevant scientific articles on the topic, and extracted relevant data to address your aims.

We searched medical databases for all the papers that were published before October 2023 that discussed patient pathways and screening for BDD.

We screened titles and abstracts to see what’s relevant and then, we read the full papers. After we read the full papers, we extracted data that was relevant to our research question and synthesised the data to make an evidence based pathway.

We found 28 screening tools; we extracted information on each screening tool, including strengths and weaknesses, with the aim that a clinician can look at data, and assess which is the best screening tool for their practice. For example, some questionnaires take around 20 minutes to complete. which may be too long for some.

CONSTRUCT A PATHWAY

The second aim of the paper was to construct a practical pathway that could easily be embedded into clinical practice in an aesthetic clinic. Thirty one articles discussed pathways for BDD and they recommended a multidisciplinary approach, consisting of aesthetic clinicians and mental health professionals working closely with patients.

For patients, assessment for BDD should take place before performing any facial aesthetic treatment. The assessment should be carried out by a mental health professional, or, alternatively, patients should be asked to complete a scientifically validated BDD screening tool as part of their aesthetic consultation. It is also crucial that aesthetic clinicians are trained on BDD awareness as well as on the selected screening tool, its application and interpretation. In the event of suspected BDD, the aesthetic procedure should not be performed. Rather, the patient should be referred for mental health assessment and potential treatment. After this, a multidisciplinary approach should be adopted between the aesthetic clinician and mental health professional to assess whether or not the benefits of the aesthetic procedure outweigh the risks. We’ve embedded this pathway and are auditing its use in our clinic.

POSITIVE FEEDBACK

One interesting thing is the positive feedback we’ve received from patients. It’s a tricky conversation to have, right? We’re saying no to what they view as help and referring them to a mental health professional instead. I thought some patients would get upset about that, but it’s been quite the opposite. They are grateful that we have an ethical approach that prioritises their mental health. I also feel more comfortable treating them, knowing that we have a robust pathway for patients with potential BDD.

We started implementing the pathway in our clinic around October last year. We’ve audited our results for the past four months and we found 16 patients who screened positive for being at risk of BDD. All of them were sent for psychiatric input, of which three were treated.

I don’t like to mandate things but I recommend that all clinicians should follow a robust pathway for BDD.

I don’t think the pathway is difficult to implement. The important thing is to train your clinicians on BDD. There are courses available for this; we use Blue Stream Academy, which I would recommend. The screening test we use has a high accuracy of diagnosing BDD and there are only nine questions, so it doesn’t take long. I think the rest of the pathway is quite easy to embed. I also recommend that clinicians identify a psychiatrist nearby that they trust and have a good relationship with. The rest of our policy is that, if someone is at risk of BDD, if the patient consents, we let their GP know as well, just to make sure that there is comprehensive communication.

Read the full paper here: https://pubmed.ncbi.nlm.nih. gov/38216141/