Stress is a natural human reaction that provides signals or cues to address the challenges and possible threats in our lives. The way in which an individual responds to stress is a significant factor to the difference in quality of life outcomes and overall well-being. The World Health Organisation (WHO) identifies stress as a top global health concern and defines it as ‘a state of worry or mental tension caused by a difficult situation’ (WHO, 2023). Stress can weaken not only the immune system but most systems in the body, including the musculoskeletal, respiratory, cardiovascular, endocrine, gastrointestinal, nervous and reproductive systems (APA, 2023).
In aesthetics, researchers have found an association between the increased likelihood of proceeding with any aesthetic procedure and a higher level of stress (Ramirez et al, 2022). This finding reiterates that caution is of paramount importance when treating patients, given the potential increased stress levels and consequent psychological vulnerability.
Hidden stressors
More generally, hidden stressors can be found in anything from smartphone dependence, unstable home environments, having unsatisfactory or poor-quality relationships, personal insecurities, a work-life imbalance, and even the possibility of misdiagnosed mental health conditions (Duchaine, 2020). Within the aesthetic consumer, financial stressors may also be concealed given the recent upsurge in requests for aesthetic finance plans. As such, both patients and practitioners may find themselves in a reactive mode to cope with these ‘hidden’ stressors.
Patient motivation and stress awareness
The ongoing inquiry into patient motivations for seeking aesthetic intervention is a growing area of research that sets the ground for a thought-provoking discussion. In a multicentre observational study in the US, Maisel et al (2018) reported that over half of the 511 participants investigated (53%) wished to undertake an aesthetic intervention to protect their health. 69.3% showed a desire to improve their sense of psychological well-being, and 56.6% wanted to increase their comfort or confidence in social situations. By understanding the clinical and motivational characteristics of patients seeking to undertake treatment, aesthetic nurses can grow to become more confident, attentive and effective when providing short- and longer-term treatment plan options for patients during the consultation process (Ramirez et al, 2021, Sobanko et al, 2015). Noticing signs of stress is therefore critical for signposting and addressing patient concerns at the best time.
The psychosocial evaluation of patients' needs is firmly fixed onto the considerations for the aesthetic licensing agenda in England (gov.uk), as perceived appearance judgements can be a source of social-evaluative stress. Several studies have explored this in depth thus far. Ramirez and colleagues, for example, found that stress may be an explanatory link in the association between appearance perceptions and depressive symptoms, and the social self-preservation theory further explains that stress is experienced when an aspect of an individual's identity has the potential to be negatively evaluated (Kemeny, 2007). In addition, Sabik et al (2019) examined the associations between self-reported appearance judgements and cortisol stress responses. Using self-reported appearance judgements and depressive symptoms via an online survey data collection, the researchers found that appearance judgement was associated with a stronger cortisol response, higher self-reported stress and greater depressive symptoms. Stress mediated all associations between appearance judgements and depressive symptoms and neither age nor gender moderated these associations. The findings suggest that appearance judgements contribute to psychological and biological stress processes.
» The psychosocial evaluation of patients' needs is firmly fixed onto the considerations for the aesthetic licensing agenda in England, as perceived appearance judgements can be a source of social-evaluative stress «
Anti-ageing and stress
Given that researchers have found cumulative stress to be linked with accelerated ageing and insulin resistance (Harvanek, et al, 2021), this brings about a curious exploration into the link between stress and ageing within the aesthetic population. Anti-ageing is a commonly used and universally accepted marketing term in the aesthetic and non-surgical cosmetic sector. Although, the term itself can be regarded as somewhat negative, harmful and prejudiced, which inadvertently places an extraordinary amount of stress upon an individual. The use of illegal advertising for anti-ageing prescription-only medicines, along with the normalisation of surgical tourism, displaces risk and profoundly promotes actual stress itself in pursuit of the anti-ageing agenda.
» The use of illegal advertising for anti-ageing prescription-only medicines, along with the normalisation of surgical tourism, displaces risk and profoundly promotes actual stress itself in pursuit of the anti-ageing agenda «
Dermatologists are remarkably aware of the significant role that psychosocial stress plays in the aggravation of skin disease, whereby the brain-skin axis makes up a complex functional interplay between the nervous/immune system and the skin (Hunter et al, 2015). There is also an evolving body of literature exploring the underlying pathophysiological mechanisms by which psychosocial stress influences skin homeostasis. The importance of individual stress perception and how this presents as conditions in the skin includes the varied roles of the major cutaneous stress response pathways. Signals that are received by the activation of these pathways affect the skin's immune system, barrier function, wound healing and susceptibility to infection. This poses interesting questions regarding the variability of patient recovery and downtime, complication management and the control of potential side effects, especially when co-occuring with other psychological conditions such as neurodivergence (Bernardes, 2018).
Lee and colleagues (2020) proposed that skin ageing can be divided according to phenotypic features. These features can be intrinsic (by the passage of time) and extrinsic (with the addition of the effects of environmental factors). Photoageing is the most typically researched factor of extrinsic ageing; however, one of the least researched extrinsic factors of skin ageing is the impact of psychological stress, yet possibly the most potent. While the authors did explain the molecular mechanisms of extrinsic skin ageing to conclude the research findings, this alone does not address individual resilience and adaptability to stress, a core feature in stress as a determinant of health. The maladaptive response of human tissues to chronic stress has an impact on gene regulation and is, in itself, nothing less than debilitating if left unchecked over time (APA, 2023). Chronic stress appears to be an important factor in determining an individual's vulnerability to ageing and age-related comorbidities as evidenced through epigenetic modifications; in particular, Zannes (2016) also further evidenced that psychological stress can accelerate epigenetic ageing.
Sleep and stress: sleep evaluation in aesthetic consultaiton clinics
Sleep is important for the growth and renewal of multiple physiological systems, thus playing a role in stress relief and even appearance. The effects of chronic poor sleep quality on human skin function and visible signs of ageing have been investigated by Oyetakin-White et al (2015). It was also found that good sleepers had significantly lower intrinsic skin ageing scores. Interestingly, after 24 hours of exposure to ultraviolet light, good sleepers had significantly better recovery from erythema. They further reported a significantly better subjective evaluation of their appearance and physical attractiveness compared with poor sleepers. It was concluded that chronic poor sleep quality is associated with increased signs of intrinsic ageing, diminished skin barrier function and lower satisfaction with appearance (O-White et al, 2015). Such findings make a case for sleep evaluation in advanced aesthetic consultation skills.
Conclusion
The branding and influence of aesthetic wellness clinics is inviting for an array of subtle or ‘hidden’ stress messages to be present in your patients. Assurance that practitioners are suitably equipped, trained and competent to assess and respond to the emotional, psychological and mental health needs of a prospective patient are fundamental to future-proof practice. In aesthetic medicine, it is crucial to develop a greater understanding of individual characteristics, socio-demographic factors, motivations, expectations and treatment readiness of patients. Having an understanding of the core determinants of stress upon the aesthetic consumer allows the influence of life's stressors and the interplay between well-being, body image and the decisions to undertake elected non-surgical aesthetic treatments. The characteristics, motivation and goals of patients seeking cosmetic procedures are likely to differ from patients in other fields of medicine, as treatments are generally perceived as ‘life-enhancing’ rather than ‘life-saving’ (Ramirez et al, 2022). It is hence incumbent upon nurses to understand the role of stress among patients seeking aesthetic treatment, and to reflect on how to address their psychological concerns to the best extent possible.
Key points
- There are multiple hidden stressors in aesthetics. Examples can include the recent upsurge in requests for aesthetic finance plans, illegal advertising for anti-ageing prescription-only medicines, and surgical tourism.
- Stress plays a key role in anti-ageing and skin-related aesthetics. The quality of sleep is also relevant to self-perceived aesthetics, thus sleep evaluation should be considered more in advanced aesthetic consultation skills.
- Nurses should seek to understand the interplay between stress and patient motivations; psychological assessments could be included more in aesthetic consulting.
CPD reflective questions
- This article has discussed several hidden stressors that may be affecting your patients. Are there any additional stressors that you observe in your practice?
- Do you think the issue of patient stress is addressed properly in your practice? If so, what advice would you provide to other aesthetic practitioners? If not, what could you do to improve your practice?
- How can you raise patients' awareness of any hidden stressors that might be driving their choices in pursuing aesthetic surgery?