Body Image Dysmorphic Disorder in Persons Who Undergo Aesthetic Medical Treatments

Abstract

This article reviews the literature on body dysmorphic disorder (BDD) in patients who seek aesthetic surgery and other appearance-enhancing medical treatments such as dermatologic treatment. It begins with a discussion of the growing popularity of aesthetic medical treatments. The literature investigating the psychological characteristics of individuals interested in these treatments is highlighted. Studies suggest that 5% to 15% of individuals who seek these aesthetic medical treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to treatment. The article ends with a discussion of the clinical management of patients with BDD who present for an aesthetic change in their appearance.

The Popularity of Aesthetic Medical Treatments

The American Society for Aesthetic Plastic Surgery reported that 9.3 million aesthetic surgical and minimally invasive treatments were performed in 2010.¹ The vast majority, more than 7.7 million, were nonsurgical (minimally invasive) procedures such as botulinum toxin injections and chemical peels. Although the number of procedures decreased by 9% in 2011 (likely secondary to the status of the American economy), the overall number of procedures has increased 228% since 1997.¹

There are a range of potential explanations for the growing popularity of aesthetic medical treatments over the past 2 decades.^2,3 Evolutionary theories of physical attractiveness, proponents of which include psychobiologists and evolutionary psychologists, would suggest that many aesthetic procedures are performed to enhance the appearance of youthfulness and/or facial symmetry—characteristics that serve as markers of both physical beauty and reproductive potential. Over the past 4 decades, a substantial body of social psychological research has repeatedly demonstrated that individuals who are more physically attractive are judged more favorably than less attractive individuals. Research also suggests that more attractive individuals receive preferential treatment in interpersonal situations across the life span.^4,5 Thus, enhancing one’s physical appearance through medicine may confer interpersonal benefits. At the same time, the mass media and entertainment industries bombard consumers with images of physical perfection while also promoting the latest advances in aesthetic medicine. Finally, the technological advances in aesthetic medicine, which have made both surgical and nonsurgical procedures safer than ever before, have undoubtedly fueled the growth as well.

Psychological Aspects of Aesthetic Surgery

Over the past half century, plastic surgeons and mental health professionals have shared an interest in the psychological aspects of aesthetic surgery. Dating back to the 1950s, case series and small observational studies have documented the psychological characteristics of individuals who have been interested in a range of aesthetic surgical procedures. Other studies have described the psychological changes—good, bad, and indifferent—that patients have experienced postoperatively. This literature has been reviewed in detail elsewhere^6-10; we provide a general overview here.

The earliest studies relied heavily on unstructured clinical interviews of prospective patients and were performed by psychoanalytically trained psychiatrists, which was the dominant school of psychiatric thought of the time. In retrospect, it is not particularly surprising that many of the patients in these early studies were characterized as suffering from significant depression, anxiety, and, in some reports, schizophrenia. Other reports described poor psychological adaptation to the change in appearance brought about by an aesthetic procedure, including an exacerbation of preexisting psychopathology or, in some cases, a loss of identity.

Starting in the mid-1970s, studies began to include valid and reliable psychometric measures of personality (such as the Minnesota Multidimensional Personality Inventory) as well as other paper-and-pencil measures of psychological symptoms. These studies reported lower rates of psychopathology among individuals interested in aesthetic surgery. Several of these studies also suggested that cosmetic surgery was associated with improvements in self-esteem, depressive symptoms, and other psychological domains.

Over the past 15 years, much of the research on the psychological aspects of aesthetic surgery has focused on the psychological construct of body image.¹¹ In its simplest terms, body image has been described as the internal representation of an individual’s external appearance.¹² Although this definition is straightforward, the construct of body image is multidimensional, consisting of perceptions, thoughts, feelings, and behaviors associated with physical appearance. At the same time, body image is influenced by countless number of historical and proximal influences, such as the messages about physical appearance received from friends, family members, romantic partners, and the mass media across the life span. Body image is believed to play an important role in an individual’s self-esteem and quality of life.

Body image dissatisfaction is believed to be quite prevalent among women as well as men who live in Westernized countries. This dissatisfaction can be more general (“I dislike my body shape,” as often seen with persons with obesity) or specific (“I dislike the size of my nose,” as seen with persons interested in rhinoplasty). The degree of dissatisfaction, coupled with an individual’s investment in his or her appearance, is believed to motivate a range of appearance-enhancing behaviors, including weight loss, physical exercise, skin treatments, and cosmetic surgery.^6,13,14

Body image dissatisfaction is typically thought to be greatest among older adolescents and young adults, individuals who present for aesthetic procedures in smaller numbers compared with older adults.¹ However, these young adults still appear to have interest in aesthetic procedures. Among college-aged women, 5% reported that they have undergone a cosmetic procedure. However, 40% indicated that they would consider a cosmetic procedure in the near future and 48% would consider it in middle age.¹⁵ Other studies of this population assessed predictors of attitudes toward cosmetic surgery and found that higher levels of investment in appearance and greater internalization of societal beauty ideals predicted more favorable attitudes toward cosmetic surgery.^15-18

Some studies have looked at the degree of body image dissatisfaction among individuals who present for aesthetic procedures. A number of studies have found increased body image dissatisfaction among patients who present for a number of cosmetic procedures, as compared with population norms or individuals not interested in surgery.^14,19-24 In several studies, this dissatisfaction appeared to be focused on the feature for which the individual sought surgery and not on overall body image. Encouragingly, a number of studies have documented improvements in body image following aesthetic treatments.^25-30 In a recent study of the psychosocial outcomes 5 years after cosmetic surgery, van Soest and colleagues³⁰ found that patients experienced greater satisfaction with their general appearance as well as greater satisfaction with the specific body area altered by treatment. However, the investigators found only small improvements in self-esteem and no change in mental health status 5 years following surgery. This finding is consistent with other investigations that have found that improvements in appearance may not have significant, positive effects on other psychological constructs, such as quality of life.

Collectively, this research suggests that body image dissatisfaction is associated with an interest in aesthetic procedures and that individuals who present for aesthetic medical treatments report greater dissatisfaction with the feature they would like to improve compared with those who do not seek to change their appearance. At the same time, these results raise an interesting question: Can someone be too dissatisfied with his or her body image for cosmetic surgery? Body image dissatisfaction plays an important role in a number of psychiatric disorders, including eating disorders, social anxiety disorder, gender identity disorder, and the psychiatric condition believed to be most relevant to appearance-enhancing medical treatments—body dysmorphic disorder (BDD).

BDD Diagnostic and Clinical Considerations

The current version of the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision; DSM-IV-TR) describes BDD as a preoccupation with a slight or imagined defect in physical appearance. As with most psychiatric diagnoses, this preoccupation must cause significant distress or impairment in functioning and must be associated with disruption in daily functioning.³¹ Body dysmorphic disorder is currently characterized in the DSM-IV-TR as a somatoform disorder along with conditions such as hypochondriasis. However, BDD shares common features with anxiety disorders such as obsessive-compulsive disorder (OCD) and social anxiety disorder, which, along with major depression, are the most common cormorbid conditions with BDD. For example, the preoccupation with appearance seen in BDD can take the form of compulsive grooming or appearance checking, which may be accompanied by obsessive thoughts about the perceived defect. As a result, there is some consideration that BDD will be categorized as an anxiety disorder in the upcoming DSM-V.

Body dysmorphic disorder first appeared in the DSM-III-R in 1987.³² Thus, BDD is considered a relatively “new” psychiatric disorder and, as a result, does not have the history of research seen with more well-recognized conditions. Nevertheless, prior to the disorder’s inclusion in the DSM-IV-TR, case reports of individuals with features of the disorder appeared in the cosmetic surgery literature. Edgerton and colleagues³³ described patients who were preoccupied with “minimal deformity” as well as others who were “insatiable” and returned for repeated procedures.^33,34 Similar descriptions appeared in the dermatology literature years later.³⁵ Thus, it appears that physicians who offered aesthetic treatments were familiar with some of the hallmark characteristics of the disorder before it was organized as a formal diagnosis in the psychiatry literature.

For persons with BDD, the face, nose, skin, and hair are the most common focus of concern; however, any feature or area of the body can be the focus.³⁶ Thus, the diagnosis likely has particular relevance to those medical professionals who offer aesthetic treatments for these features. We have previously suggested that applying the BDD diagnostic criteria to modern-day patients interested in aesthetic treatments can be difficult.^37,38 The first part of the diagnostic criteria, that an individual is preoccupied with a “slight” or “imagined” defect in appearance, could be used to describe the majority of these individuals. Many individuals seek aesthetic procedures to improve or correct slight imperfections of “normal” features. Furthermore, the classification of a feature as “normal” or a defect as “slight” is highly subjective and can be seen differently by the patient and the surgeon.

Given this issue, the second part of the diagnostic criteria—that the degree of distress impairs daily functioning—may be the more relevant aspect of the diagnostic criteria when aesthetic medical patients are considered.^{6,14,35,37-39} The degree of distress can vary greatly from patient to patient. A woman interested in an antiaging treatment who reports that her appearance has led to the loss of multiple clerical jobs over the past few years and, as a result, is now housebound likely meets criteria for BDD. In contrast, the saleswoman who is employed but reports that she is self-conscious about her aging facial appearance in comparison to the younger saleswomen in her company likely does not have BDD.

Prevalence of BDD

In the general population, BDD is estimated to affect between 1% and 3% of individuals.^40-43 Studies of college students have found the rate of BDD to be somewhat higher than the general population at approximately 5%.^15,44 However, a recent study found that the rate among college students may be as high as 10%.⁴⁵ The incidence of BDD increases among patients who present for aesthetic medical treatments. Studies that have examined BDD regardless of the type of aesthetic procedure have consistently suggested that 5% to 15% of patients have some form of the diagnosis,^46-48 although some international studies that used clinical interviews of patients reported slightly higher rates, up to approximately 20% of patients.^47,49-54

Other studies have focused on patients interested in specific procedures. Four studies have specifically assessed BDD symptomatology among rhinoplasty patients.^36,47,55-57 A recent study of 306 patients seeking cosmetic rhinoplasty found that approximately 25% of the patients in this study met DSM-IV-TR criteria for BDD. In addition, 41% of the sample met diagnostic criteria for another psychiatric condition, the most common being OCD (20%).⁵⁶ At least 2 studies have examined the rate of BDD among patients who presented for minimally invasive procedures. Among 13 patients who requested botulinum toxin injections for perceived hyperhidrosis, 23% met criteria for BDD.⁵⁸ Among 137 patients presenting for minimally invasive treatments, 2.9% met criteria for BDD.⁵⁹

A number of studies have investigated the presence of BDD in persons who sought dermatological treatment. Across these studies, the rates of BDD have been quite similar to those seen in patients interested in purely aesthetic procedures, ranging from 8.5% to 15%.^47,60-63 For example, in a study of 268 dermatology patients who sought treatment for a range of conditions (primarily acne and rosacea), 12% met criteria for BDD.⁶² There have also been reports of individuals with BDD presenting for treatment to general medical clinics,⁶⁴ plastic surgery clinics,^65,66 orthognathic surgery clinics,⁶⁷ orthodontic treatment clinics,⁶⁸ and dental practices or maxillofacial surgery clinics.^69-72 Individuals with obesity also have been found to suffer from BDD.⁷³

In addition to the skin and face, a common focus of concern for patients with BDD is a preoccupation with hair. This concern usually takes the form of fear of hair loss or thinning or hair unevenness and is especially common in men.⁷⁴ In 1 study, 56% of men and 17% of women had concerns related to hair thinning/unevenness or baldness.⁷⁴ Although the hair is commonly a focus of concern in BDD, there is a paucity of research specifically related to the topic. The data that do exist indicate that those focused on their hair commonly cover the hair with hats, scarves, and hairpieces or may use other topical treatments to combat the hair loss. In addition, some of these patients may seek hair transplantation.⁷⁵

Despite the variability across study methodologies and patient populations, it appears that 5% to 15% of patients who present for appearance-enhancing medical treatments are suffering with features of BDD. Although this may not appear to be a large percentage, we consider it to be a significant minority, particularly given that the estimated base rate in the general population is believed to be less than 2%. The rate of the disorder also suggests that an active aesthetic practice is likely to potentially encounter individuals with BDD several times each month.

Aesthetic Medical Treatments Among Persons with BDD

Body dysmorphic disorder is considered to be a rather “secretive” psychiatric condition. Patients are often reluctant to discuss their concerns with medical professionals out of fear that their concerns with their appearance will be disregarded. Patients with delusional variants of the conditions, particularly those in late adolescence or early adulthood, may be concerned that they are going “crazy.” For these and other reasons, it is not surprising that persons with BDD seek aesthetic medical treatments with great frequency and perhaps more frequently than they seek mental health treatment. Two investigations reported that 71% to 76% of patients sought and 64% to 66% received cosmetic medical treatments.^76,77 In both studies, dermatological treatments (eg, topical and oral agents for perceived acne) were the most commonly received procedures. Traditional surgical treatments (eg, rhinoplasty, liposuction, and breast augmentation) as well as minimally invasive (eg, collagen injections, microdermabrasion) and dental (eg, tooth whitening, braces) procedures also were common.^76,77

Despite interest in these treatments, evidence suggests that providers of cosmetic medical treatments refuse to perform procedures on persons with BDD with some regularity. Across these 2 studies, patients reported that 20% to 35% of their requests for treatment were not granted, most commonly because the physician deemed the treatment unnecessary or refused to provide treatment. At the same time, in a survey of aesthetic surgeons, greater than 80% reported that they had refused to operate on a patient they suspected of having BDD.⁴⁸

The Effect of Aesthetic Treatments on BDD

A handful of clinical reports and retrospective studies have described the response to aesthetic medical treatments of persons with BDD. Collectively, these studies indicate that these treatments typically do not result in any change in BDD symptoms.^76,78 In one of the largest studies, less than 5% of procedures resulted in an improvement in BDD symptoms; 95% led to no change or a worsening in the condition.⁷⁶ Some patients developed new appearance concerns following treatment, an occurrence that is not unexpected given that appearance concerns are known to shift from one feature to another over the course of the disorder. A smaller, more recent study found somewhat similar results.⁷⁹ In that study, although 33% of patients who received surgical or minimally invasive treatment reported an improvement in the appearance of the feature and 25% reported decreased preoccupation with the feature, 97.7% experienced either no change or a worsening of overall BDD symptoms, including impairment in daily functioning.⁷⁹

Of potentially greater concern is the relationship between BDD and suicide. The mean annual suicidal ideation rate among persons with BDD is 57.8%, and the mean annual suicide attempt rate is 2.6%, making BDD one of the most lethal psychiatric disorders.⁸⁰ This issue takes on greater relevance when the relationship with cosmetic breast augmentation is considered. Over the past decade, 7 large epidemiological studies designed to investigate all-mortality among women who underwent cosmetic breast augmentation have found a rate of suicide 2 to 3 times greater than expected based on estimates of the general population or comparisons to women who have undergone other plastic surgical procedures.^81-87 The reasons for this relationship are not particularly well understood; however, some evidence suggests that the relationship may be explained by the presence of preoperative psychopathology that was undetected by the plastic surgeon.⁸⁸ Although mood disorders are most commonly associated with suicide, it is quite possible that BDD could have been a contributing factor in some of these deaths.

Treating a patient with BDD also can present a challenge for the physician. Almost one-third of aesthetic surgeons have reported that they had been threatened legally by a patient with BDD.⁸⁹ Patients with BDD have described fantasies about physically harming their surgeons,⁷⁸ and 2% of aesthetic surgeons reported that had been physically threatened by a patient with BDD.⁸⁹ In addition, there are at least 4 documented cases of surgeons who have been murdered by patients who appeared to have symptoms consistent with BDD.⁹⁰ For all of these reasons, there is growing consensus that BDD contraindicates appearance-enhancing medical treatments.^{37,78,89,91-94}

Psychological Assessment of Aesthetic Surgery Patients

We believe that the relationship between aesthetic medical treatments and BDD underscores the importance of the aesthetic surgeon completing a mental health screening of all new patients. This assessment is critical for at least 2 reasons.^37,95-98 First, the screening can help determine whether patients’ preoperative motivations and postoperative expectations are realistic. Second, the screening is vital to identifying patients who have BDD or other psychiatric conditions that may contraindicate treatment.

The preoperative psychological assessment should be a central part of the initial consultation. The assessment should focus on several areas: motivations and expectations, appearance and body image concerns (including an assessment of BDD symptoms), and psychiatric status and history.^37,95-98

Motivations and Expectations

A patient’s motivations for surgery should be evaluated during the initial consultation. Motivations have been categorized as internal (undergoing the surgery to improve one’s self-esteem) or external (undergoing the surgery for some secondary gain, such as obtaining a promotion or starting a new romantic relationship).^99-101 To assess the nature of patients’ motivations, it may be useful to start the initial consultation by asking why patients are interested in surgery at this time. This question may help determine if patients are interested in treatment for themselves and their own sense of self-esteem or if they are seeking treatment to please others. Although making a clear distinction between internal and external motivations is difficult, internally motivated patients are thought to be more likely to meet their goals for surgery.¹⁰² At least 3 studies have suggested that being motivated for surgery to please a romantic partner is associated with a poor postoperative outcome.^103-105

Postoperative expectations have been categorized as surgical, psychological, and social.¹⁰⁶ Surgical expectations address the specific concerns about physical appearance, both pre- and postoperative, and are discussed in detail below. Psychological expectations include the potential improvements in psychological functioning that may occur after surgery. Social expectations address the potential social benefits of cosmetic surgery.

Many individuals interested in aesthetic medical treatments believe that the procedures will make them more attractive to current or potential romantic partners. At least 2 studies have suggested that, following cosmetic facial procedures, patients are considered to be more physically attractive by others.^107-109 Nevertheless, we are not aware of any empirical evidence to suggest that patients’ social relationships improve after surgery. Thus, prospective patients should be aware that an improvement in appearance likely will not result in a change in the social responses of others.

Physical Appearance and Body Image

Given the relationship between body image and aesthetic surgery described above, the assessment of patients’ body image concerns is thought to be a central part of the evaluation.⁹⁸ Although the surgeon may know that patients are interested in specific procedures based on information in patients’ histories, it is useful to have the patients articulate, in their own words, what they dislike about their appearance. Patients should be able to describe specific concerns that are visible with little effort. Previous studies have found no relationship between degree of physical deformity and degree of emotional distress in aesthetic surgery patients.^102,110,111 Patients who are markedly distressed about slight defects that are not readily visible may be suffering from BDD.

The degree of dissatisfaction with the specific feature also should be thoroughly assessed. Although some body image dissatisfaction is typical among most patients, those who report extreme dissatisfaction may be suffering from BDD. Asking more specific questions about the extent of the dissatisfaction can indicate the degree of distress and impairment a person may be experiencing. Patients who state that they think about their appearance problem for long periods of time throughout the day may be suffering from BDD. Other patients may unintentionally reveal the extent of their preoccupation by presenting the surgeon with numerous photographs of models or celebrities who have the feature(s) they desire. Some may take photographs of themselves and, either through crude pencil drawings or elaborate computer enhancements, attempt to depict the desired changes. Although these pictures may be instructive to the surgeon in specific circumstances, such behaviors may only hint at the hours that patients likely have spent thinking about their appearance.

Patients also should be asked how their feelings about their appearance affect their daily functioning. These questions can indicate the degree of impairment patients may be experiencing. Those who report that their appearance concerns prevent them from maintaining employment or relationships, or prevent them from engaging in daily activities most people would do without a second thought, may have BDD. To assist further in the assessment of BDD, practitioners may wish to use one of several scales that assess symptom severity. These include the Body Dysmorphic Disorder Questionnaire (BDDQ),⁶⁴ the BDDQ–Dermatology Version,⁶¹ and the Body Image Disturbance Questionnaire.¹¹²

Psychiatric History and Status

Another important step in determining the psychological appropriateness of patients is collecting a psychiatric history. This information should be routinely collected as part of the medical history and physical exam, no differently than obtaining a general medical history. If this information is typically collected on a preprinted form completed by the patient before the consultation, these questions should be repeated during the initial face-to-face meeting with the patient. Some patients are reluctant to candidly report their mental health histories, in part out of fear that previous or ongoing psychiatric treatment will contraindicate cosmetic treatment. Approximately 20% of cosmetic surgery patients reported a mental health history, which was significantly greater than 4% of noncosmetic plastic surgery patients.¹¹³ Furthermore, 18% of cosmetic surgery patients reported using a psychiatric medication (almost exclusively antidepressant medications) at the time of their initial consultation, which was also significantly greater than 5% of noncosmetic surgery patients. Many of these patients likely received these medications from their primary care physician, not a psychiatrist. Clinical experience, as well as investigations from other surgical populations,¹¹⁴ suggests that these professionals often prescribe subtherapeutic dosages of these medications. In situations where patients are receiving these medications from nonpsychiatrists and psychopathology is suspected, a consultation with a mental health professional is recommended.^{37,95-98 ,113}

Although the current article has focused on BDD, all of the major psychiatric diagnoses can likely be found within the population of aesthetic surgery patients.^37,97,98,114 Untreated major depression and uncontrolled schizophrenia often are relatively easy to identify and contraindicate aesthetic medical treatment, just as they contraindicate several other medical treatments. The relationship between less severe psychopathology, such as mild depression or anxiety, and postoperative outcomes is less clear. In the absence of definitive prospective studies of this relationship, we believe patients who have these conditions should be evaluated on a case-by-case basis.

Mood and eating disorders may be overrepresented among patients who seek cosmetic surgery and related treatments.^115,116 Patients’ mood, affect, and overall presentation will provide important clues to the presence of a mood disorder. If one is suspected, neurovegetative symptoms, including sleep, appetite, and concentration, should be assessed. If patients report difficulties in any of these areas, they should be asked about the frequency of crying or irritability, social isolation, feelings of hopelessness, and the presence of suicidal thoughts. The relationship between cosmetic breast implants and suicide noted above also underscores the importance of screening for depression in new aesthetic surgery patients.

Eating disorders also may occur with greater frequency among women who seek procedures such as liposuction or breast augmentation.¹¹⁷ To help assess for the presence of an eating disorder, the height and weight of all patients should be obtained and used to calculate their body mass index (BMI; the patient’s weight [in kilograms] divided by height [in meters] squared). Patients with a BMI <20 kg/m² should be asked about a history of recent weight fluctuations, ongoing dieting efforts, binge eating and purging, or other compensatory behaviors. Women also should be asked about amenorrhea.

Patients with a history of psychopathology and who are not currently engaged in psychiatric treatment may warrant a preoperative psychiatric consultation to further assess their current status. Patients currently under psychiatric care should be asked whether their mental health professional is aware of their interest in surgery. Surgeons should contact these professionals to confirm that the proposed treatment is appropriate at this time. Patients who have not mentioned their interest in cosmetic surgery to their mental health provider, or refuse to allow the surgeon to contact him or her, should be viewed with caution, as it may reflect some degree of paranoid thinking suggestive of significant psychopathology. These patients warrant a psychiatric consultation. Patients who are dissatisfied with their postoperative result have used their psychiatric history as part of their legal action against the surgeon, arguing that their psychiatric condition prevented them from fully understanding the procedure and its potential outcomes. These occurrences underscore the importance of assessing and documenting the psychiatric status of all patients undergoing cosmetic surgery.

Additional Considerations

A 30- to 45-minute initial consultation is a relatively brief period of time to learn about patients’ psychiatric status. Patients typically are on their “best behavior” during their initial visit and will often expend a great deal of effort to present themselves to the surgeon as “appropriate” for surgery. They often will neglect to share information with the surgeon and his or her staff that might play an important role in evaluating their appropriateness for a procedure. Therefore, every bit of information obtained either during the consultation or observed during interactions with the nursing or office staff should be used in making a determination of appropriateness for surgery.

Other members of the treatment team, such as nursing staff and office assistants, often witness different aspects of patients’ behavior during interactions in the office. These individuals may gather valuable insight into patients’ psychological functioning that may alert the surgeon to a potential problem. Patients who have difficulty following the office routine warrant further attention. Those who frequently cancel or change appointments, ask for appointments outside of office hours, or do not wish to talk to anyone other than the surgeon should be reconsidered for surgery. Patients who raise concerns among the staff should, at a minimum, be seen for a second preoperative consultation. If concerns persist, these patients should be referred to a psychologist or psychiatrist for an evaluation.

If the surgeon and/or staff have concerns about the psychological status of prospective patients, a referral to a mental health professional for an evaluation should be made. A psychologist or psychiatrist with interest or expertise in body image may be the ideal consultant. These mental health professionals often work with other forms of psychopathology with a body image component, such as eating disorders or BDD. Professionals who work in other areas of health psychology also may have some expertise in body image. Regardless of the expertise of the consultant, it is important that the surgeon communicate to the consultant the specific nature of the referral question. A well-qualified mental health professional with a good understanding of the psychological aspects of aesthetic medical procedures can be a valuable asset to an aesthetic surgeon’s practice.

Patients may react to mental health referrals with anger, and some may refuse to accept the referral. Patients who refuse to see the consultant are probably not good candidates for treatment. In this current competitive environment, many patients will eventually find a physician who will treat them, thereby not receiving the mental health care they need. It is hoped that some patients will hear the concerns of the initial professional and realize that cosmetic treatment is not appropriate at that time. Therefore, it is important that the surgeon treat the referral to the psychologist or psychiatrist like any other referral to a medical professional. This will often help destigmatize the mental health professional to the patient and make the referral more acceptable to him or her.

Patients also may need to be referred to a mental health professional postoperatively. On occasion, patients are dissatisfied with what the surgeon considers to be a successful procedure. In other instances, patients are experiencing an exacerbation of psychopathology (often BDD) that was not detected preoperatively. Patients in both situations warrant further assessment and, often, psychotherapeutic care.

Conclusions

The mental health issues in aesthetic medicine have long been of interest to medical and mental health professionals. In the past 2 decades, our understanding of the relationship has become more refined. Dissatisfaction with one’s appearance, rather than deep-seated and significant psychopathology, is now considered the primary motivation for an aesthetic procedure. A growing number of studies also have found that this body image dissatisfaction frequently improves following an aesthetic medical treatment.

At the same time, we have learned more about patients who report an extreme amount of dissatisfaction with their appearance that disrupts engagement in daily activity; these individuals are suffering from BDD. Although the condition is thought to affect only 1% to 2% of the general population, studies conducted throughout the world have suggested that approximately 5% to 15% of people who seek aesthetic medical treatments have some form of the condition. Unfortunately, reports also suggest that the vast majority, likely greater than 95%, report no change or a worsening in the severity of their BDD symptoms after an aesthetic treatment. For these reasons, along with the concern that these patients may engage in self-harm or direct harm toward the treating surgeon, there is growing consensus that BDD contraindicates aesthetic treatment.

Given that persons with BDD frequently seek aesthetic treatments, it is important that all new patients be assessed for the potential presence of BDD. A general psychological screening, consisting of an assessment of patient motivations and expectations, psychiatric status and history, body image concerns and BDD symptoms, and an observation of the patient’s office behavior, can identify persons for whom surgery may be inappropriate. Such a screening may include an interview with the patient and/or use of self-report assessments. Patients with suspected BDD should be referred to a mental health professional for additional evaluation prior to an aesthetic procedure.

Disclosures

Dr Sarwer’s research is supported by grants from the National Institutes of Health. He has paid consulting relationships with Allergan (Irvine, California), Baronova (Goleta, California), EnteroMedics (St. Paul, Minnesota), Ethicon Endo-Surgery (Cincinnati, Ohio), and Galderma (Ft. Worth, Texas). He also serves on the Board of Directors of the Surgical Review Corporation. Ms Spitzer has no relationships to disclose.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References