Body Dysmorphic Disorder  and OCD in Aesthetics

Body Dysmorphic Disorder is a mental health condition that affects up to 2.9% of the population; this disorder can go undiagnosed thus the actual figures of this Body Dysmorphic Disorder can be higher (Schulte et al. 2020 and Krebs, Fernandez and Mataiz-Col, 2017). According to Arora (2019), Body Dysmorphic Disorder prevalence within a cosmetic clinic can be as high as 5- 15% of the population. It is often difficult to diagnose which has led to surgeons unknowingly carrying out procedures On Body Dysmorphic Disorder sufferers. Body Dysmorphic Disorder is an extensive somatoform disorder in which an individual preoccupies themselves with perceived flaws relating to their appearance (Philips, 2014). Body Dysmorphic Disorder is often presented with another comorbidity which usually includes OCD, self-esteem, anxiety and depression (Singh and Veele, 2015).  

Body Dysmorphic Disorder sufferers spend a lot of time trying to hide or improve their bodies which they perceive as severely impaired. Body Dysmorphic Disorder sufferers become fixated on fixing their flaws; however, these flaws are not seen by anyone else but themselves. Arora (2019) states that Body Dysmorphic Disorder symptoms are categorised into two groups common obsessive concerns which include negative thoughts about body image, and common compulsive behaviour which includes mirror checking compulsively (Chee et al. 2020 and Arora, 2019). Body Dysmorphic Disorder symptoms include but are not limited to, comparing their own body to others, excessive self-grooming, skin picking to make it perfect and concealing their flaws through expensive makeup or clothing (NHS, 2020). 

Body Dysmorphic Disorder often leads to individuals wanting to obtain perfection of their bodies, this can cause immense stress, cause anxiety and eating disorders (Sarwer and Spitzer, 2012).  Body Dysmorphic Disorder sufferers usually focus on their hair, skin, chest, nose, eyes and stomach (Perkins, 2019). The size, shape and symmetry often cause immense distress to Body Dysmorphic Disorder sufferers. Body Dysmorphic Disorder can be categorised into delusional and non-delusional, with delusional Body Dysmorphic Disorder individuals suffering from hallucinations of the perceived flaws which appear grossly significant (Soler et al. 2018). Delusional Body Dysmorphic Disorder has a higher severity than non-delusional Body Dysmorphic Disorder as the client only visualises the little imperfections of perceived flaws without hallucinations (Soler et al. 2018).

Body Dysmorphic Disorder is a comorbidity of OCD; it is reported that the prevalence of OCD is up to 2.3% of the adult population; however, this can account for up to 5% of the population as some assessments give sub-optimal results or borderline results (Lack, 2012).  Body Dysmorphic Disorder and OCD are both mental health illnesses and the symptoms are cross-linked(Kohler, Coetzee and Lochner, 2018). OCD, like Body Dysmorphic Disorder, has two main categories as intrusive negative thoughts and ritualistic behaviours. Intrusive negative thoughts include contamination fears, the need for perfection, organisation and worries about self-harm to themselves or others (Fontenelle, 2010). Ritualistic behaviours known as common compulsions include the need to wash things several times, checking certain things before leaving the house and continually seeking reassurance (Lack, 2012 Malcolm et al. 2018). According to Lank (2012), 75% of people suffering from OCD have another comorbid disorder: anxiety, depression, self-esteem, and Body Dysmorphic Disorder. OCD has been ranked as one of the top ten most disabling diseases worldwide and is also considered the fourth most common mental health illness within Western Society (Yang et al. 2018).

OCD symptoms usually start gradually but differ in severity from person to person; however, OCD causes lifelong effects and symptoms progress with stress-related life events (Pietrabissa et al. 2016). Research conducted by Ruscioet al. (2010) suggests that from the onset of OCD, it usually lasts up to 8 years and 9 months on average when seeking help. OCD has a negative impact on work-life, social life and family relationships, OCD can also cause severe anxiety and depression, leading to suicidal tendencies or suicide (Pietrabissa et al. 2016). These suicidal tendencies are related to OCD, as the sufferer cannot mentally cope with intrusive thoughts in their mind. OCD suffers may strive for perfection in daily tasks that are timely and impact their quality of life (Yang et al. 2018). Studies have shown OCD sufferers have a low quality of life with 73% of people having impaired family relationships due to OCD, 58% suffering from low academic results, and 48% were chronically unemployed due to OCD (Srivastava et al. 2011). 

The causes of Body Dysmorphic Disorder and OCD are very similar, and individuals may present with both disorders (MIND, 2020 and Malcolm et al. 2018). The leading causes of both disorders can stem from childhood experiences such as family relationships, peer pressure, bullying and abuse. Body Dysmorphic Disorder and OCD are both psychological disorders that may have deep-rooted issues such as anxiety, trauma, low self-esteem or biological factors leading to the lack of brain chemical serotonin (Malcom et al. 2018). According to Auer (2020), there are many factors that can cause common compulsions in Body Dysmorphic Disorder and OCD, the Tripartite Influence Model (Thompson et al. 1999, cited in Auer, 2020) explores the causes of Body Dysmorphic Disorder and OCD which can include peer pressure, parental and media influence when seeking cosmetic surgery. These factors from peers, parental and media influence often lead to internalisation and social comparison, impacting body image leading to impulsive decision making on aesthetics treatments (Auer, 2020).  According to Albert et al. (2019), OCD and Body Dysmorphic Disorder have a high prevalence of suicidal ideations, and both disorders have high morbidity rates due to poor psychosocial insights and function. Other studies have found that suicidal ideations are higher in Body Dysmorphic Disorder sufferers than OCD sufferers (Eskander, Limbana and Khan, 2020). 

Social comparison theory by Festinger (1954) suggests that individuals make comparisons of themselves to others in all aspects of life. With Body Dysmorphic Disorder and OCD, these influences can be through social media and celebrity endorsements (Guyer and Vaughan-Johnston, 2018).  Comparisons are usually made in an upward comparison which leads to further body image dissatisfaction, and unrealistic expectations of cosmetic surgery for OCD And Body Dysmorphic Disorder sufferers as this unrealistic image of perfection is unobtainable(Gerber, Wheeler and Suls, 2018) With Body Dysmorphic Disorder and OCD the aim of perfection is often seen through social media where celebrities are seen as role models, these celebrities portray perfect images on social media thus the need for Body Dysmorphic Disorder and OCD sufferers wanting to pertain celebrity perfection (Brookes, 2018). 

Celebrity attachment can lead to celebrity worship and as per the Tripartite influence Model (Thompson et al. 1999, cited in Auer, 2020), media has a significant impact on an individual when seeking cosmetic surgery as a social comparison to celebrities leads to body image dissatisfaction and the common compulsive behaviours with Body Dysmorphic Disorder and OCD make the perceived flaws more noticeable to the individual (Sansone and Sansone, 2014). Celebrity attachment and celebrity worship is usually formed when individuals are unable to secure loving relationships within their home life, and they look for these relationships within celebrities (Collinson et al. 2018). Body Dysmorphic Disorder and OCD causes are often from traumatic life events such as bullying, body shaming, peer pressure, social media and family pressures (Long, 2019). There is no definite cause of Body Dysmorphic Disorder and OCD on how the onset progresses, but psychologists believe it is through a deep-rooted traumatic life event (OCD Organisation, 2020).

According to Long (2019), it can be challenging to identify clients with Body Dysmorphic Disorder and OCD within an aesthetics clinic, as stated by Egan (1994, cited in Hough, 2014) the consultation should use many skills including verbal and nonverbal. Interpersonal and intrapersonal skills are both used within the consultation process to gain a deeper level of understanding of the client’s concerns and feelings.  According to Bewley and Dimitrov (2015), psychological screening questionnaires may be useful when identifying Body Dysmorphic Disorder and OCD such as the Body Dysmorphic Disorder dermatology questionnaire and the Yale-Brown OCD assessment.

During the consultation process, listening to the client is said to be one of the most important interpersonal skills a practitioner can have. Through listening, the practitioner can gain an insight into the client, their lifestyle, concerns and psychosocial behaviour (Jahromi et al. 2016). Listening can help the practitioner achieve a deeper level of understanding. While listening, the practitioner can also see the client’s body language to gain further depth of how the concerns are impacting them. Listening is not just hearing but also uses intelligence and emotions Active listening requires listening to the content, intent and emotions of the speaker. Through active listening, the practitioner can summarise critical information and reflect it to the client, making sure that you have understood and listened to the client. 

Communication during the consultation process is vital, and correct communications skills can lead to better consultation (Smith, 2015). Communication is a way of gaining the client’s trust to delve deeper into information and find out about their concerns (Tailor, 2017 Smith, 2015). Communication can be in the form of online consultations, visual aids in the clinic and face to face consultations (Rimmer, 2016). Asking open-ended questions will allow the client to give more information than closed questions (Smith, 2015). When deciding treatment plans, this information must be given to the client and the client is given adequate time to ask any questions; this makes the consultation process more individualised to the client (Tailor, 2017).Empathy during the consultation will help the client feel more valued and understood. Empathetic words during the consultation will reassure the client that they can trust the practitioner with their concerns and personal experiences (Howeick et al. 2018). Empathy will also keep the client positive during the process and assure the client that the practitioner is non-judgemental (Derksen, Bensing and Lagro-Janssen, 2013). Several studies have shown that the empathetic approach during the consultation can reduce anxiety and relax the client (Verheul, Sanders and Bensing, 2010).