How to diagnose: body dysmorphia versus body modification

Every now and then an extreme case of cosmetic intervention hits social media and becomes a viral talking point. Such cases, including that of 22-year-old Andrea Emilova Ivanova from Bulgaria who claimed to have quadrupled the size of her lips with a total of 25mls of dermal filler seeking the accolade of the largest lips in the world, raise the question of body dysmorphia. But it is just body modification?

In this blog, Dr Tim Pearce discusses how to spot body dysmorphia, how it differs from body modification, and the ethics surrounding treating or ultimately refusing those patients who request extreme procedures.

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What is body dysmorphia?

Diagnosing body dysmorphia is complex and cannot be done from a picture alone. During Dr Tim’s medical training, he carried out a six-month rotation in psychiatry where you spend a long time analysing and working out exactly how people fit into the different official diagnosis frameworks for mental health disorders. This requires engagement, so although we can tell a lot about someone from a photograph, their extreme appearance cannot give a correct diagnosis alone.

There are many reasons why people have extreme treatments, it could be because they have body dysmorphia which means they are obsessively seeing themselves in a negative frame of light, constantly ruminating over a particular problem (that others likely cannot see) and trying to make an adjustment in the hope that it will make them happier. They fail at this and repeat the cycle, which becomes a futile cycle of trying to make themselves feel certain about their appearance, achieving nothing, but not stopping in their pursuit because they feel dissatisfaction with the outcome again and again.

Individuals who practice and enjoy body modification, however, are not necessarily dysmorphic. The two things can be very separate and there is a clear distinction.

How to spot the signs and diagnose body dysmorphia?

Many people would be forgiven for quickly diagnosing someone as body dysmorphic just by looking at them and making assumptions based on their appearance. Dr Tim points out that we cannot make such quick judgements and take what we see on face value.

To illustrate he uses examples such as tattoos or circumcision – these are things that people do to their bodies that have no physical benefit, they do not necessarily make them better looking, but they make the choice as individuals that it is something that they want to do in their lives. It may be to help them in some way, to allow them to feel different, or to mark an occasion; whatever the reason, it can seem odd or out of place to other external eyes.

Another example is African tribes who place ever larger plates in their lower lip. In the context of their environment, if you do not have a plate in your lip or someone else has a larger one, you are at a disadvantage. Thus, the plates are culturally required to survive, but for us in Western nations we see it as mutilation. There are lots of examples across cultures where if you are not part of the culture, it does not make any sense why someone would want to do something like that to their body.

As a healthcare professional, Dr Tim notes that his purpose is to improve someone’s health and well-being. If a patient wants to have fillers to have enormous lips, as in the case of Ms. Ivanova, it is possible to want that without obsessively thinking that you are ugly, or without always looking in the mirror having a sense of dread and self-loathing. Some people modify their bodies for other reasons not related to body dysmorphia, although as healthcare professionals we must to talk to them in detail before we can make or disregard a diagnosis of true body dysmorphia. Of course, this also does not mean that what they are thinking of doing is going to make them happier or healthy, and this is where your judgement as a clinician comes into play, a responsibility that must be taken seriously.

How do you make the judgement call to treat a patient who asks for an extreme treatment?

As an aesthetic clinician, Dr Tim says he can only make the decision to treat from his perspective and if he is confident that a treatment is going to make someone happier and healthier. There is an argument for carrying out certain treatments that may seem unnecessary, but have a cultural fit, but this is a judgement call. For example, if a patient has a weak chin and you restore the shape of the chin, you are doing it to make them fit in with what is socially perceived to be more normal and help them in their day-to-day life.

Therefore, if a patient is striving to reach a more common appearance within their culture, as a clinician you can make a stronger argument that it is valid to treat them, even though you may only be doing so for the sake of culture. This is your decision.

Dr Tim’s aim is to create natural, healthy-looking faces when he performs aesthetic treatments, stating that his role is not to help a patient fit in with their culture or follow a trend or fashion. In the case of a request for very large lips, he would advise the patient that although this look might be relevant and accepted amongst their circle of friends and peer group, it would be regarded as strange within wider society, as it does not conform to the known ratios of the natural shape and form of the lips. He would decline to treat as requested, instead favouring offering them a natural look.

When assessing a patient and determining whether to treat, you must try and look at their environment through their eyes, but on top of that, you must also try and see how they are perceived by everyone else. This can be where you might find it difficult not to be paternal or maternal, especially towards a younger patient because we are trying to project how society is going to interact with them, but we as clinicians are also just another member of that society.

The key consideration is how far away from average would you be taking their face by carrying out the treatment, because if you are taking a face a long way away from the average face, you will effectively be excluding that person from society in terms of functioning healthily. The further away you get from normal, the more likely they are going to be rejected by the herd and as healthcare practitioners, we must take that into account.

If you are a tattoo artist, for example, and a client requests a facial tattoo, you do not have to think about this because often the whole point of having the tattoo or body modification is to differentiate oneself. All you need is consent, there is no requirement to make a judgement on whether the tattoo is going to be in their best interests or help them function healthily. Healthcare professionals are bound to attempt to decide on whether treatment is healthy for the patient in terms of how they will function and fit into society after the procedure.

How do you decline to treat a patient?

It can be difficult to reject a patient who has come to ask for your help, but you do not want to carry out the procedure because it does not fit in with your ethos. Initially, you might try to explain that you are not the right practitioner for them, but this seldom elicits agreement and a patient who gets up to leave. It usually results in an argument and assertions about being able to pay and whether their money is good enough for you. There are ways to learn how to say “no” to an aesthetic patient without making them angry.

You must pivot and develop ways to explain your ethos whilst avoiding being judgemental, giving only objective reasons for rejecting them rather than subjective ones. For example, explaining that you cannot treat them because you do not believe they would be better off in terms of their health or improvement to their well-being, and not because you think their lips would look stupid. The degree of that improvement must offset the risk of the procedure for you to feel comfortable doing it, concluding that ethically it is better for you to do nothing and not treat them. This tends to be accepted more readily when declining to treat an individual.

As healthcare professionals we have a responsibility to guide our patients towards treatments, or away from having treatments, if we think it is not in their best interest. Learn how to tell a patient that they are overdone.

What can we learn from extreme cosmetic interventions?

Dr Tim concludes that the most interesting thing for him when analysing extreme cases of cosmetic intervention is that aesthetic practitioners need to separate body dysmorphia from body modification. There is a difference, and an individual does not need to be body dysmorphic to have or want extreme treatments. You will encounter patients asking for treatments that you do not believe in, but they are not unhappy with themselves. Once you understand, you will be better able to explain to them why you cannot be involved because you are not in the field of body modification, you are a healthcare professional who wants to improve well-being, and for that reason, you cannot carry out such treatments.

If you are concerned about patients who may be asking for treatment for the wrong reasons and are looking for more help with diagnosing body dysmorphia or an unhealthy obsession with body modification, Dr Tim has created a downloadable body dysmorphia and body modification checklist to help you understand the difference between the two and understand your patients better.

Dr Tim loves to hear from his followers, so why not drop him a comment on social media if you have anything to add to the discussion on body dysmorphia; you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

Body Dysmorphia vs Body Modification: Diagnosis

Dr Tim tackled the thorny topic of body dysmorphia in his popular Aesthetics Mastery Show. Discussions included whether clinicians should agree to give big lips – are they imposing their beauty values if they don’t? When and how to reject a patient wanting big lips and how to identify dysmorphia.

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Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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