Keep it in mind

The medical aesthetics specialism is gaining new ground in publicising the safety and protective measures in place for patients.1 It is routine practice for consultations to be documented, structured and detailed, with sufficient time allocated to ensure a medical history is taken, there has been a clinical assessment, the patient has been consented and that any questions have been answered.

The role of a mental health assessment is rarely included in the training syllabuses of aesthetic foundation and advanced training courses. This is despite the fact that the General Medical Council (GMC) guidelines stress the importance of the role of the psychological assessment, and most aesthetics clinicians do recognise the need for mental health skills in clinical practice.

It’s an apt time for professionals to be considering which frameworks for mental health assessment work well in aesthetic practice

It’s an apt time for professionals to be considering which frameworks for mental health assessment work well in aesthetic practice and which mental health diagnoses are most prevalent in aesthetic practice. A broad range of symptoms can be determined from a mental health assessment. Such symptoms can be atributed to common mental health disorders, such as anxiety and depression, and also severe and enduring mental health conditions. Established aesthetic professionals appear to be familiar with screening tools for Body Dysmorphic Disorder (BDD) and oten have pathways for such a patient group, particularly for surgical patients.3

In this article, I would like to share with you:

•Which mental health conditions are likely to be present in your patient group

•How patients can benefit from your awareness and management of these conditions

•The risks of not being aware of a patient’s mental health needs.

DEPRESSION AND ANXIETY

In 2014, 19.7% of people in the UK aged 16 and above showed symptoms of anxiety or depression. This percentage was higher among females (22.5%) than males (16.8%).4 Evidence suggests a clear link between depression and lowself esteem.5 For many patients, the decision to have a nonsurgical treatment is a solution to boost self-confidence. However, symptoms of depression can impact on a person’s ability to understand, reason and appreciate and express a choice.6 By screening for the absence of active symptoms of depression, aesthetic clinicians would be able to evidence a robust consent for treatment.

Anxiety may form part of a greater underlying picture of mental health disorders (such as Generalised Anxiety Disorder) or it can be situational and normal as a result of stress. Due to this common presentation, aesthetic clinicians are likely to already have well-developed skills in managing anxious patients.7 Clinicians may wish to reflect on ways to share essential aftercare information in a manner that does not trigger further stress. Further consideration may also need to be given as regards appropriate channels for the patient to access aftercare services, how the clinic will respond and the method of review offered to the anxious patient

POST-TRAUMATIC STRESS DISORDER (PTSD)

About 7-8% of the population will have PTSD at some point in their life.8 The disorder is likely to occur greater a traumatic event such as an accident, physical assault, disaster or to witness death or injury. Symptoms of PTSD are very distressing and can include extreme physical symptoms, flashbacks where it feels like the trauma is happening again, nightmares and feeling emotionally numb. Although a trigger to this disorder is usually related to the sights, sounds and smells of the original trauma, a person will be hypersensitive to stress and touch (including facial touch), even in situations completely unlike the original trauma. For this reason alone, it is good practice to screen for this diagnosis and/or the progress of the treatment of PTSD so that the patient and clinician can be pre-warned of a relapse of the condition due to the potential stress caused by an aesthetic treatment.

PERSONALITY DISORDER

There is much stigma regarding this diagnosis, and it is ventured that in the UK there could be as many as one in 20 of the population experiencing an undiagnosed personality disorder.9 UK psychiatrists understand there to be 10 different type of personality disorder,10 making it a complex disorder to diagnose. A person with a personality disorder is likely to have difficulty with relationships, their management of emotions and controlling their behaviours. People with personality disorders may also experience decompensation when stressed or having difficulty adapting. Aesthetic procedures, their expected complications and a disappointment in treatment outcomes may all trigger decompensation and therefore patients with a personality disorder diagnosis (under the care of a mental health team) must be made aware of this risk to their psychological health.

BODY DYSMORPHIC DISORDER (BDD)

BDD often occurs in people with other mental health disorders, such as major depression and anxiety.11 Other factors that might influence the development of the disorder is experience of traumatic events or emotional conflict during childhood. Patients with BDD are at risk of seeking a cosmetic treatment for a perceived law and are unlikely to be satisfied that the outcome improves their psychological preoccupation of the issue. While there is some evidence to support consideration of treatment in mild to moderate cases,12 it is broadly recognised that clinicians are at risk of retaliation by a patient who thinks that the intervention has worsened their appearance.

IN CONCLUSION

This article seeks to expand on awareness regarding some of the mental health disorders likely to present in cosmetic medicine. Diagnosing and managing such conditions in aesthetic practice is complex and requires more than a paper-based approach. It is good practice for clinicians to consider the appearance and behaviours of the person presenting alongside the information elicited via their medical history and any appropriate screens.

Such processes, alongside any additional mental health training, are reasonable steps for professionals to take in order that a more holistic approach to patient safety is taken. Clinicians are advised to consider

•Have I assessed mental health needs?

•Is there a risk the patient cannot consent to treatment and/or is inappropriate for treatment?

•Are there drug interactions from psychotropic medication?

•Has the patient been made aware of the psychological risks of treatment and/or likelihood of dissatisfaction?

•Is a mental health referral required for further assessment or case management support?

•What support is required for pre-care and post-care information to be retained and understood.What plans for support during treatment are required? AM

REFERENCES

1.nhs.uk/conditions/cosmetic-procedures/before-you-have-a-cosmetic-

procedure/

2. gmc-uk.org/-/media/documents/Guidance_for_doctors_who_offer_cosmetic_interventions_210316.pdf_65254111.pdf

3.ncbi.nlm.nih.gov/pmc/articles/PMC5986110/

4.digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014

5. Manna G, Falgares G, Ingoglia S, Como MR, De Santis S. The Relationship between Self-Esteem, Depression and Anxiety: Comparing Vulnerability and Scar Model in the Italian Context. Mediterranean Journal of Clinical Psychology MJCP VOL 4 N.3 (2016)

6. bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-14-54

7. bmj.com/content/325/7357/207

8. Mental health statistics for England: prevalence, services and funding. Number 6988, 25 April 2018.

9. mentalhealth.org.uk/a-to-z/p/personality-disorders

10.medical.cfoapublications.co.uk/12581

11.adaa.org/understanding-anxiety/related-illnesses/other-related- conditions/body-dysmorphic-disorder-bdd

12.ncbi.nlm.nih.gov/pmc/articles/PMC5986110/#bb0210

Nofie Johnston is a registered mental health nurse. She has practiced in cosmetic medicine since 2014 and is the director/lead clinician at Juno Aesthetics. Nofie has an interest in identifying and managing mental health conditions within aesthetic practice and is keen for other aesthetic health professionals to embrace this holistic approach.