Psychological Screening for Cosmetic Procedures
Should a psychological assessment always be carried out before a cosmetic procedure? Find out from David Sarwer, a leading expert in the psychological aspects of surgery.
Training in health psychology and/or behavioral medicine is a good foundation for doing this work. Experience in working effectively with surgeons and multidisciplinary medical teams is also useful. Much of my advanced training has been in cognitive-behavioral approaches, which I believe provided me with a framework and language to communicate psychological constructs effectively to patients and medical providers. Others who work in this space also have established expertise in areas such as eating disorders, anxiety disorders, body dysmorphic disorder, and body image more generally. The book, Presurgical Psychological Screening, that I co-edited with Dr. Andrew Block also includes a discussion of these issues.
The basic elements of an initial psychological assessment are a good place to start. After that, a deeper dive into the patient’s motivation for body contouring procedures, as well as their postoperative expectations about how the procedure will (and will not) impact daily life, is important. Ideally, the patient should be weight stable for a period of time, eating the recommended postoperative diet without signs of malnutrition, and engaged in an appropriate level of physical activity. As rates of psychopathology are higher among bariatric surgery patients than the general population, the presence of relevant disorders and symptoms should be the focus of the evaluation as well.
While the majority of bariatric surgery patients are interested in body contouring procedures, only a fraction of them undergo these procedures. They are rarely covered by insurance and are expensive. The procedures can have a positive impact on body image and quality of life for many patients. As a result, some members of the bariatric surgery community advocate that body contouring procedures should be the accepted standard of care for patients who undergo bariatric surgery.
This article provides a relatively contemporary review of the literature in this area: https://pubmed.ncbi.nlm.nih.gov/26395601/
As millions of individuals undergo cosmetic procedures each year, it is likely that all of the psychiatric diagnoses are represented in the patient population. My colleagues and I have previously suggested that body dysmorphic disorder, eating disorders, and mood disorders (in part because of the increased rate of suicide among women who undergo cosmetic breast augmentation) are the disorders likely seen with greatest frequency.
This article reviews the psychological aspects of cosmetic surgery: https://www.sciencedirect.com/science/article/abs/pii/S1740144518305552
There is a chapter in Presurgical Psychological Screening that discusses how to evaluate for these and other disorders in this patient population:
While many people assume that individuals who present for cosmetic surgery have low self-esteem, that has not been supported in empirical studies. Certainly some patients have low self-esteem, whereas others have a healthy amount of self-esteem and are looking to improve their dissatisfaction with their appearance. Some studies have shown that self-esteem improves after a procedure; others have found no statistically significant change.
In the work my colleagues and I have done in this area, we have focused more on body image dissatisfaction than self-esteem. Studies from around the world have repeatedly shown that patients report increased dissatisfaction with the feature of their appearance that they want to improve with a procedure. This dissatisfaction likely motivates the interest in the first place. Other studies have found that cosmetic procedures are associated with improvements in these concerns postoperatively, which is encouraging.
This article provides a more detailed discussion of these issues: https://www.sciencedirect.com/science/article/abs/pii/S1740144518305552
Individuals who undergo minimally-invasive, as well as traditional cosmetic surgical procedures, are rated by others as being more physically attractive postoperatively. Further, cosmetic procedures have been associated with improvements in body image, self-esteem, and quality of life. However, there is no evidence that these procedures impact the social relationships of these individuals. I often tell patients who are undergoing cosmetic procedures that they likely will feel better about their appearance, but that the quantity and quality of their interpersonal relationships may not necessarily change. Patients who are motivated to undergo a cosmetic procedure to in order to save a failing romantic relationship, or enter into a new one, may have unrealistic expectations about these procedures.
The most psychologically appropriate patients for cosmetic procedures are internally motivated; they are interested in improving their appearance to enhance their body image and self-esteem, rather than to please others. Appropriate patients also have relatively discrete concerns about their appearance that are readily seen by the treating physician. When asked what they don’t like about their looks, they are more likely to say “I don’t like this bump on my nose. It makes me self-conscious when someone looks at my profile.” This is in contrast to patients who say to the treating physician, “I’m ugly. You are the beauty expert. Tell me what to do.” Finally, the most appropriate patients have realistic expectations about the impact of the procedure on their lives. They are not expecting a dramatic change in how they look and how others will treat them.
A number of studies have found that women who receive breast implants, whether for cosmetic or reconstructive purposes, report improvements in their body image, self-esteem, and quality of life. Many women also report greater confidence in their appearance in general and during sex. Some studies also have found that women report greater sexual satisfaction and improvements in sexual functioning. However, there is more work to be done in this area.
This article provides a more detailed discussion of these issues and also discusses the interesting relationship between cosmetic breast augmentation and suicide. https://www.sciencedirect.com/science/article/abs/pii/S1740144518305552
A small number of studies have investigated adverse childhood experiences in persons who are interested in cosmetic procedures. Unfortunately, these studies have suffered from a number of methodological limitations, including small sample sizes, failure to include a comparison group, and use of non-validated measures. This is another area where more research is needed. In the absence of that work, it may be premature to recommend that physicians offering these procedures assess adverse childhood experiences. Mental health professionals working with patients interested in cosmetic procedures are likely better trained and positioned to discuss these sensitive issues with patients appropriately.
This is an astute observation. I’ve often been asked by a plastic surgeon to assess a patient’s psychological appropriateness for surgery. As a consultant who may only see the patient one time, my focus in building rapport during the assessment rather than establishing rapport that will endure over time. I always inform the patient at the onset that I will be sharing my recommendation with the referring surgeon and that the patient may not like or agree with that recommendation. I also remind the patient that the recommendation includes a serious consideration of what may be best for the patient from a psychosocial perspective.
In ongoing therapeutic relationships, I think some of the same tenants apply. I agree, however, that there is a risk of an empathic break if a mental health professional shares with a patient that cosmetic surgery is not considered a good idea. I try to set the stage for situations like this at the onset of a new therapeutic relationship by informing a new patient that there may be times that I say things that are challenging or upsetting. When that happens, it is our shared responsibility to discuss those issues and remember that my comments are coming from a position of having the patient’s best interests in mind.
Over the past 20 years, studies from around the world have somewhat consistently found that 5-15% of persons presenting for cosmetic procedures have significant symptoms of or meet diagnostic criteria for body dysmorphic disorder (BDD). While this may not seem like a large percentage, in a plastic surgery or dermatology practice that focuses exclusively on cosmetic procedures, it suggests that one or two patients per week likely have the diagnosis.
The evidence suggests that greater than 90% of patients with BDD report no change or a worsening of their symptoms following a cosmetic procedure. The rate of suicidality in persons with BDD is high and a number of plastic surgeons and dermatologists have reported being threatened, either physically or legally, by patients with BDD who have been dissatisfied.
For these reasons, many mental health professionals, myself included, believe that BDD is a contraindication to cosmetic procedures. Studies show that some plastic surgeons and dermatologists agree and routinely screen for BDD and other significant mental health issues during an initial consultation. While this is recommended, it is not a recognized standard of care endorsed by the major professional societies of these providers at present.
The book Presurgical Psychological Screening provides more discussion of these issues. The review paper in Body Image details the relationship between body image dissatisfaction, BDD, and interest in cosmetic procedures.
https://www.sciencedirect.com/science/article/abs/pii/S1740144518305552
The methodologically strongest studies available suggest that approximately 5% of candidates for bariatric surgery (both the sleeve gastrectomy and Roux-en-Y gastric bypass) have a diagnosis of binge eating disorder (BED). Larger percentages of patients have symptoms of the disorder. Some studies, but not all, have found that BED is associated with smaller weight losses, greater symptoms of disordered eating, psychological distress, and gastrointestinal complications postoperatively. However, these untoward outcomes appear to occur in a relatively small percentage of patients. Many individuals with BED have very good postoperative outcomes with respect to weight loss and eating behaviour. Thus, BED is not considered an absolute contraindication to bariatric surgery.
Symptoms of disordered eating are typically assessed during the preoperative psychological evaluation required by most bariatric surgery programs in the United States as well as most third party payers. (These evaluations are not required with such regularity in other parts of the world.) Registered dietitians also may identify these behaviors as they work with patients in preparation for surgery. Patients with severe or uncontrolled symptoms will typically be recommended for additional psychological treatment prior to undergoing surgery.
There is a chapter in Presurgical Psychological Screening that describes these preoperative evaluations in more detail. The review paper from the American Psychologist provides an overview of the pre- and postoperative psychosocial issues commonly seen in persons who undergo bariatric surgery.
Sarwer DB, Heinberg LJ. A review of the psychosocial aspects of clinically severe obesity and bariatric surgery. Am Psychol. 2020 Feb-Mar;75(2):252-264. doi: 10.1037/amp0000550. PMID: 32052998; PMCID: PMC7027921.
While “Cosmetic Surgery Addiction” makes for a compelling newspaper headline or topic for a daytime talk show, I’m not a fan of talking about people being “addicted” to cosmetic surgery. I limit my use of the term to disorders that appear in the DSM.
That being said, some patients, typically those with body dysmorphic disorder (BDD) report obsessive thoughts and engage in compulsive behaviors that have similarities to other addictive conditions. As we work better understand these patients and their experiences, we likely will learn more about the similarities and differences to other disorders.
The most interesting example of the compulsive nature of these procedures is the use of minimally invasive treatments like Botox. Patients are typically informed that the benefits last approximately 6 months and then additional treatment is needed to maintain the benefit. Is there a point where a compliant patient, who comes back as recommended, becomes a compulsive patient who resembles someone with BDD? This is perhaps one of the more interesting and important questions facing the field right now.
For more discussion of these issues, please seen the invited commentary below. More discussion of BDD and cosmetic surgery is found in another question and in the links below.
David B Sarwer, PhD, Returning for Aesthetic Procedures: Compliance or Compulsion?, Aesthetic Surgery Journal, Volume 41, Issue 6, June 2021, Pages 744–745, https://doi.org/10.1093/asj/sjab157
https://www.sciencedirect.com/science/article/abs/pii/S1740144518305552
Cosmetic procedures are typically performed on persons with “normal” features who wish to enhance the appearance of them. The most popular cosmetic procedures are minimally invasive, like those you mentioned. Most, but not all, are designed to reduce or minimize the effects of aging. So, they typically are not performed on younger adults.