Over the past two years, as COVID has ravaged our world’s health systems and economy, we’ve observed a surge in the prevalence of anxiety and depression across the population. COVID has impacted not only our collective experience of distress and anxiety, but interestingly enough has influenced our perceptions of body image, both through the long-term effect of the lock downs and through increased exposure to social media.
COVID has changed patients’ patterns of behavior relevant to your practice, manifesting as high-risk clinical situations. It is more important than ever that you know how to identify them and how to set your practice up for success.
Open your internet browser news feed, and you’ll certainly find articles about increased anxiety and depression in both adults and teens. From COVID, to racial tensions, to the war in the Ukraine, our news events are constantly bombarding us with negative messages, and the aftermath is a resultant escalation in the prevalence of anxiety and depression. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes generalized anxiety as severe worry about a number of topics, events or tasks – which exceeds the real impact of the expected event. This constant worry disrupts daily function, making it hard to focus on tasks. Those with anxiety experience trouble sleeping, muscle aches and tension, as well as headaches. As you read this list of symptoms, think of your own reaction to the changes in our world, as well as the reactions of your friends, colleagues and patients.
Trauma and stress disorders, including posttraumatic stress disorder (PTSD), are defined by the DSM-5 as symptom clusters which arise as a reaction to a traumatic situation. Common symptoms include fear, anxiety, forgetfulness, anger, trouble sleeping, nightmares, avoidance, withdrawal and feeling detached or distanced from others. It is hard to imagine not having at least some of these listed symptoms in reaction to our world’s events over the past two years.
COVID Impact Studies
The Centers for Disease Control and Prevention (CDC) examined the degree to which life domains (economic, health, change in routine and social isolation) were associated with anxiety in 2020. Subjects in the U.S., U.K. and Israel uniformly reported moderate levels of anxiety in all four domains, with the most severe symptoms being experienced in the economic and health categories.
Other international studies have tried to explore the impact of COVID on anxiety and depression. One study, conducted between January 2020 and March 2020 in China and Italy, surveyed over 2,000 healthcare workers, employing the psychometric instruments to assess anxiety, depression, PTSD and insomnia. Across all subjects, over 25% experienced clinically significant anxiety and depression, and over 40% experienced symptoms of PTSD. Studies such as these have revealed that the worldwide prevalence of anxiety and depression has exceeded our previously understood rate of 1 in 5.
For example, Sherman A. Lee, PhD et al., developed the Coronavirus Anxiety Scale (CAS) to quantify the psychological impact of COVID, specifically in frontline healthcare workers. The questionnaire is a five item screening instrument, and a score of greater than nine
predicts dysfunctional anxiety with 90% specificity, 85% sensitivity. Elevated scores are correlated with global impairment in function, maladaptive coping with drugs and alcohol, hopelessness, suicidal ideation, along with negative attitudes towards the former president,
as well as Chinese food and products. Symptoms specific to COVID anxiety include excessive fear, discrimination, anger, guilt, post-traumatic stress, stigmatization, insomnia and depressive symptoms. Not only can COVID anxiety lead to acute complications of underlying psychiatric symptoms, but it can aggravate pre-existing chronic diseases.
Caroline Stamu-O’Brien, MD et al., found risk factors for COVID anxiety to include female sex, lower socio-economic status, baseline interpersonal conflicts, low social supports, frequent social media use and misinformation.2 Their data mirrors studies on health anxiety, defined as excessive vigilance to perceived bodily changes, which can lead to lower immunity, increased blood glucose, impaired sleep quality and exacerbation of mental health diagnoses. Although high health anxiety leads to catastrophic misinterpretations of body sensations and dysfunctional beliefs about health, with social distancing there has been more avoidance of the doctor’s office and hospital, which can lead to increased morbidity.3
- Examples of observed maladaptive behaviors unique to the COVID pandemic include:
- Excoriation disorder triggered by excessive hand washing
- Excessive hand washing triggering irritant contact dermatitis
- Escalated symptoms of obsessive compulsive disorder marked by contamination fears
- Removal of social supports as a result of physical isolation
COVID and Body Image
Body image can be defi ned as ‘the individual’s experience of embodiment, especially selfperceptions and self-attitudes towards one’s appearance.4 In 2015, a study conducted by Meghan M. Gillen, PhD et al., demonstrated a significant association between positive body image and less risk of depression, higher selfesteem, fewer unhealthy dieting behaviors, lower drive for muscularity and greater intention to protect the skin from UV damage.5 In 2020 Rachel F. Rodgers, PhD et al., examined the impact of the COVID lockdown on body image.6 A perfect storm arose – risk factors to positive body image increased (social media exposure, daily activity disruption, social isolation, changes in patterns of physical activity and sleep, fear of contagion), and protective factors were eliminated, such as social support and access to care.
Social media is fi lled with images promoting both the thin-ideal and panning the COVID-19 ‘19’ and ‘pandemic recipes.’ The use of video conferencing increased preoccupation with appearance since we are seeing an image of ourselves while attending a meeting. Furthermore, fears of contagion have led to increases in disordered and restrictive eating.
In 2020, Viren Swami, PhD et al., specifically studied the impact of COVID stress on body image.7 Their linear regression analysis of data from 506 adults in the U.K. sought to explore the extent to which COVID related stress and anxiety is associated with body image outcomes over and above trait anxiety and generalized stress. Their assumption was that changes to daily routine can impede adaptive body image coping mechanisms and lead to a heightened concern about shape and weight as well as increase negative ruminations about body image.
In the 255 women studied, COVID anxiety was associated with body dissatisfaction as well as with a drive for thinness. In the 251 men surveyed, COVID anxiety was associated with greater body fat and dissatisfaction with muscularity. Their study confirms that COVID specific stress and anxiety are associated with negative body image well over trait anxiety alone. Their group postulated that lifestyle factors, including diminished coping skills, increased exposure to thin ideals on social media, increased screen time and decreased physical activity are all to blame. These represent opportunities for awareness and intervention in our patients.
What does this mean for your aesthetic practice? A 2021 study published in the Journal of Cosmetic Dermatology reported respondents (n=221) were more comfortable with the aesthetic procedure clinic than they were with going to the grocery store, gym, workplace or hairdresser. In addition, 82% of respondents felt trust was an extremely important factor driving their aesthetic medicine visits. When asked what factors influenced their decision to pursue cosmetic procedures in order to refresh their look, do something positive, gain confidence or address a concern, 23% of those surveyed reported that COVID specifically influenced their decision. Of those surveyed, during periods they were unable to access aesthetic care, they experienced frustration, anxiety, stress and disappointment.8
Are your patients more at risk for COVID anxiety and other mental health concerns? In 2020, Selami Akyut Temiz, MD et al., studied the difference in anxiety, depression and CAS scores amongst their cosmetic unit patients compared to controls (cosmetic unit procedures included botulinum toxin injections, laser therapy, gold needle radiofrequency, mesotherapy and platelet-rich plasma treatments). Compared to controls, the cosmetic unit patients had elevated levels of depressive and anxiety symptoms, however both groups had similar CAS scores. The authors postulate that “cosmetic patients are a special group within dermatology, and the psychosocial needs of this group may differ.”9
As previously described, risk factors for negative body image include increased exposure to social media’s thin ideal images. The relationship between social media and body image was explored by Jasmine Fardouly, PhD and Lenny R. Vartanian, PhD in 2016. Their work revealed unique features of social media: that the medium features images of the users themselves, rather than magazines and television, which feature others. In addition, social media users are compelled
to present idealized and altered images of themselves and interact with one another, specifically with appearance-related comments and content.10 They also reported on studies on pre-teen and high school age girls using Facebook who report higher drive for thinness, internalization of the thin ideal, body objectification and appearance related concerns compared to non-Facebook using peers. A separate
study of female undergraduate students demonstrated higher levels of body dissatisfaction, and the drive for thinness and dieting was associated with higher amounts of time on Facebook. Facebook was the selected medium in the 2016 studies because, at that time, an estimated 10 million photographs were uploaded each hour.
In 2019, Candice E. Walker, MSc et al. examined whether social media influences the desire to pursue cosmetic procedures. Their research created a task examining the impact of exposure to images of facial enhancement compared to the impact of control images (travel related images). Those exposed to the facial enhancement reported greater desire to pursue changes within themselves.11
Earlier social media studies focused on Facebook; however, Instagram revolves around images, not text, and a 2017 report from the Royal Society of Public Health (U.K.) states ‘Instagram is the most detrimental social media platform for young people’s mental health and wellbeing.’
Multiple studies have demonstrated that exposure to attractive peers and celebrities on Instagram negatively impacts mood, self-image and self-esteem in women.12 In addition, cosmetic procedure patients report getting their information and inspiration from social media.13
We know that body dissatisfaction – the negative feelings associated with the discrepancy between the ideal and the actual – can drive the desire to pursue aesthetic procedures. Based on the aforementioned studies, we now know that there is a strong association between social media exposure and self-image, as well as body dissatisfaction. When considering these concepts in relation to the COVID pandemic related lockdowns contributing to increased exposure to both social media and self-awareness via video conferencing, it easily explains the considerable rise in cosmetic procedures that is being reported everywhere. But what if the expectations for cosmetic procedures are unrealistic?
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) describes a preoccupation with an imagined or minimal defect in appearance, which leads to functionally impairing emotional and psychological distress. The flaws perceived by the patients with BDD are viewed as slight or non-existent by outsiders.14
Of those seeking cosmetic procedures, between 7% to 15% may have BDD. Patients with BDD often have been victims of childhood teasing, and experience low self-esteem. They may have family histories of anxiety and depression. Among the cohort of BDD patients, of the 46% who followed through with their cosmetic procedure, 76% were dissatisfied with the outcome.15 Of the plastic surgeons surveyed, 12% reported receiving physical threats from dissatisfied BDD patients post-operatively.
So, how do you identify the right candidate for a procedure? The Body Dysmorphic Disorder Questionnaire is a screening instrument examining the degree to which a patient is preoccupied with body image concerns.16 This screening tool, as well as an examination into your patient’s insight into realistic post-procedure expectations, can help screen out inappropriate candidates.
Can Cosmetic Procedures Improve Body Image
Now to the question constantly on all of our minds. Can cosmetic procedures improve body image in the non-BDD candidate cohort? According to a 2016 review of data collected between 1978-2012, Carlo M. Oranges, MD, PhD et al., demonstrated an association between body image improvement and receiving breast augmentation or reduction, abdominoplasty, cosmetic facial surgery, rhinoplasty and blepharoplasty.17 And a 2013 study by Sotonye Imadojemu, MD, MBE et al., reported a 20% improvement in body image in four out of five rhinoplasty recipient cohorts included in their review.18
Since the above-mentioned studies were retrospective analyses, Timothy P. Moss, MPH, PhD and David L. Harris strengthened the evidence through a prospective controlled outcome study of individuals seeking plastic surgery.19 They compared psychological metrics at three time points: pre-operative, three months and one year post operative in two groups: general surgery patients from an ENT clinic, and cosmetic surgery patients. Their data demonstrates
higher reported anxiety and depression pre-operatively in the cosmetic surgery patients compared to the general surgery patients; however, at both time points post-operatively, the cosmetic surgery cohort had a significant reduction in both anxiety and depression symptoms, whereas symptom levels remained the same for the general surgery cohort.
A German study conducted in 2013 by Jürgen Margraf, PhD et al. demonstrated similar findings comparing wait-listed cosmetic surgery patients to those receiving procedures. Compared to baseline, at both three months and one year, anxiety and dysmorphia were statistically significantly improved in the cosmetic surgery group compared to the control group at one year, as were quality of life measures. The authors concluded that cosmetic procedures can have a positive impact on multiple domains (psychological, feelings of well-being, feelings of attractiveness) and can decrease anxiety as well as dysmorphia.20 It should be noted that patients with BDD were excluded from this study.
In conclusion, the COVID pandemic is associated with increased prevalence of anxiety and depression. In addition, independent of this rise in anxiety and depression, body image discomfort has risen with COVID, and is signifi cantly impacted by social media exposure which also rose during COVID lockdowns. And, patients without access to their scheduled aesthetic procedures experienced worsened psychological symptoms.
Finally, while several studies conducted prepandemic clearly illustrate long lasting psychological improvement as a result of aesthetic procedures, the unique changes to our world as a result of COVID present a unique opportunity to support patients’ psychological wellness and screening out BDD will set your practice up for success.
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