Psychopathology symptoms in a sample of female cosmetic surgery patients

https://doi.org/10.1016/j.bjps.2011.09.038Get rights and content

Summary

Objective

During the past decades, cosmetic surgery has become increasingly popular. People with certain psychopathology disorders, for example, body dysmorphic disorder (BDD), are dissatisfied with their physical appearance, and a significant number try to receive cosmetic medical treatment for their complaints. It seems relatively easy for them to receive this type of surgery, despite the fact that it has no or even adverse effects on the symptoms. The present study aimed to investigate the psychological condition and especially the presence of psychopathological symptoms such as BDD in cosmetic surgery patients.

Methods

Questionnaires about body image dissatisfaction, symptoms of BDD and psychopathology in general and satisfaction about surgery were sent to patients who had been treated in a large cosmetic surgery clinic.

Results

Of the patients who replied, 86% were pleased with the outcome of the cosmetic procedure. Further, 21–59% of these former patients scored higher on questionnaires of body image dissatisfaction and psychopathological symptoms than a norm group from the general population. When differentiating the group on the basis of BDD symptomatology, it appeared that the high BDD symptomatic group displayed significantly worse outcome on all measurements. That is, high BDD symptomatic patients were more dissatisfied about the result of surgery, exhibited higher levels of psychopathology, and had lower self-esteem than the low symptomatic BDD patients.

Conclusion

These findings clearly suggest that the evaluation of the psychological condition and motivation of the candidate patient might be a valuable addition to the standard procedure in cosmetic medical treatment settings.

Introduction

Cosmetic surgery has become increasingly popular. In 2009, 12.5 million procedures were carried out in the United States.1 This number includes both classical surgical methods (such as liposuction and rhinoplasty), making up about 1.5 million procedures, as well as new, non-surgical cosmetic procedures, good for nearly 11 million procedures.2 Between 2000 and 2009, cosmetic procedures have increased with nearly 70%,1 which is largely accounted for by these new techniques.

From the patients’ point of view, the most important reason for undergoing cosmetic surgery is body dissatisfaction, their bodily appearance constituting an important component of their self-esteem.3 Body image refers to the way people perceive their bodily appearance4, 5 and is composed of several components, of which actual physical appearance is an important one.5 Sarwer et al.6 introduced a theoretical model of the relationship between body image and cosmetic surgery in which two basic elements – body image valence and body image value – play a central role.7 Body image valence refers to the importance of body image to one’s self-esteem, whereas body image value entails the degree to which one is (dis)satisfied with one’s appearance. According to this model, people whose self-esteem highly depends on their appearance (high body image valence) and who have a significant body dissatisfaction (low body image value) will consider cosmetic surgery.6

People with body dysmorphic disorder (BDD) are extremely dissatisfied with their physical appearance. According to the Diagnostic and Statistical Manual of Mental Disorders,8 BDD is defined as a preoccupation with an imagined defect in one’s appearance. Furthermore, the preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Any part of the body may be the focus of BDD,9 but the preoccupations mostly relate to one or more aspects of the face or body such as skin, hair and nose.10 Since patients with BDD are more or less convinced that the solution for their problem lies in changing their appearance, they may often be encountered in medical treatment settings. An investigation by Veale et al.11 indicated that 26% of 50 patients with BDD had undergone cosmetic surgery, whereas Hollander, Cohen and Simeon12 even reported a higher rate (40%). Another study13 assessed medical treatment-seeking behavior in 250 adults with BDD. It appeared that 76.4% had sought and 66% indeed received some type of medical (e.g., dermatological, surgical and dental) treatment. Crerand, Phillips, Menard and Fay14 studied 200 patients with BDD and discovered that 71% had sought and 64% indeed received cosmetic medical treatment. Dermatological treatment was most often sought and received. Nevertheless, those treatments rarely led to the improvement of BDD symptoms. A French prospective study15 included 30 patients with minimal defect in appearance (of whom 12 had BDD), requesting cosmetic surgery. They found that five years after the surgery request, six out of the seven operated BDD patients still had BDD and that three non-BDD patients had developed BDD at follow-up.

Phillips et al.13 found that cosmetic treatments rarely improved BDD symptoms. The most frequent treatment outcome in their study was ‘no change in overall BDD severity’ (72%). Overall BDD severity worsened in 16.3%, whereas it improved in 11.7% of the individuals. Only 7.3% of all treatments led to both a decrease in concern about the treated body part and overall improvement in BDD. Generally, patients worried more about another body area, developed new appearance concerns, became more concerned about minor imperfections in the treated area or worried that an improved body part would become ugly again. Still, BDD patients’ satisfaction rating of the surgery itself was quite high, which might explain surgeons’ positive decisions to operate on these patients.

The estimated prevalence of BDD patients within cosmetic medical settings varies from 5% to 15% in the United States.16, 3, 9 A Brazilian study17 reports a prevalence of 14% in a cosmetic dermatology setting compared with 6.7% in a general dermatology setting. The first European study reported a prevalence rate of 9.1% in a cosmetic surgery setting.18 A Dutch study in the dermatology and plastic surgery clinics of an academic hospital detected 3–8% BDD patients.19 A Dutch pilot study among nine dissatisfied cosmetic surgery patients20 found that the majority displayed clearly heightened scores on psychopathology questionnaires, including BDD. None of them had undergone a preoperative psychological screening. Taken together, a significant number of BDD patients try to receive cosmetic medical treatment and they often appear to slip through preoperative screenings, obtaining the desired surgery. Yet, these types of treatments fall short of expectations in BDD patients.

The present study sought to investigate the presence of psychopathological symptoms, especially BDD symptoms, in a sample of cosmetic surgery patients. We also wondered whether increased scores on BDD questionnaires were associated with less satisfaction about surgery, more body dissatisfaction and higher rates of psychopathology. To our knowledge, the different forms of psychopathology and their association with treatment (dis)satisfaction have been hardly investigated within cosmetic surgery patients. Research into these factors is important as it is essential to detect crucial psychological problems before surgery. To this end, we asked patients who had been treated by cosmetic surgery clinics in the Netherlands to fill out questionnaires about body image, BDD, psychopathology in general and satisfaction about surgery

Section snippets

Participants

Questionnaires were randomly sent to 1000 clients who had surgery in the past 5 years in one of the four Velthuis Clinics in the Netherlands and who had given consent for future approach. One-hundred and thirty-five individuals (127 females) returned the questionnaires. As there were only eight male responders, the main analyses will be carried out among only the female participants. Mean age was 45.4 years (SD = 11.8; range 21–79). Mean time since their most recent surgery was 2.4 years (SD = 1.6,

Results

First, we examined the percentage of individuals who were dissatisfied about the cosmetic surgery. It appeared that 86% of our total sample were happy with the result at the time of the surgery, 9% was unhappy, while 5% did not answer this question. With regard to current satisfaction with the result of the surgery, 79.3% were still happy, whereas 12.6% were currently unhappy and 8.1% did not answer this question. Only 6.7% of our sample reported that they had ever been refused for cosmetic

Discussion

The present study explored the psychological condition of cosmetic surgery patients and especially the presence of psychopathologies such as BDD. We also wondered whether high BDD symptomatic individuals differ from low symptomatic individuals with regard to surgery satisfaction, and overall psychological functioning. In general, 86% of the participants reported to be pleased with the direct outcome of the cosmetic procedure and 79.3% were still satisfied, which is a satisfactory percentage for

Conflict of interest

There are no conflicts of interest reported for this study.

Funding

The departments of Clinical Psychological Science, Maastricht University and Clinical Psychology, Erasmus University Rotterdam, are thanked for their financial contribution to the study. These contributions covered the postal expenses for sending questionnaires to 1000 participants and for the free-of-charge return envelopes.

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