Regular Article Demographic features of patients seeking cosmetic surgery

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1 Psychiatry and Clinical Neurosciences (1998), 52, 283±287 Regular Article Demographic features of patients seeking cosmetic surgery JUN ISHIGOOKA, MD, PhD, 1 MITSUHIRO IWAO, MD, 1 MAKIHIKO SUZUKI, PhD, 1 YOSHITSUNA FUKUYAMA, BA, 2 MITSUKUNI MURASAKI, MD, PhD, 1 AND SADANORI MIURA, MD, PhD 3 1 Department of Psychiatry, Kitasato University School of Medicine, 2 General Consulting Division, Kitasato University East Hospital and 3 Kitasato University School of Allied Health Sciences, Sagamihara, Japan Abstract Key words The demographic features of 415 patients seeking cosmetic surgery were investigated from a psychiatric point of view. Of the 415 patients, 198 (47.7%) were found to have mental disorders according to ICD-10 including: 17 with schizophrenia, 20 with other persistent delusional disorders, 33 with depressive episode, 47 with neurotic disorders, 42 with hypochondriacal disorder, ve with paranoid personality disorder and 14 with histrionic personality disorder. The rate of subjects with poor social adjustment was 56.0%. It was noteworthy that such a considerable number of patients with mental disorders or with poor social adjustment had sought cosmetic surgery. Distinct gender differences were found: male subjects were characterized to have a greater number of mental disorders, especially dysmorphophobia (other persistent delusional disorders plus hypochondriacal disorder) and showed the narrow age range between teenage and young adult age when they were preoccupied with their `deformity', and poor social function. A history of frequent operations was not considered to be an indicator for mental abnormality. The diagnostic issue in dysmorphophobia is brie y described. cosmetic surgery, demography, dysmorphophobia, gender difference, mental disorders. INTRODUCTION The nature of body dysmorphic disorder (dysmorphophobia) is disputable, particularly the validity of diagnosis. Andreasen and Bardach 1 have argued as to whether dysymorphophobia is a symptom or a disease. Other investigators have also taken the diagnostic issues of this disorder, 2±7 including the relation to other disorders and the issue of comorbidity. 8,9 Indeed, there appears to be some confusion in DSM-IV criteria 10 of dysmorphophobia, which is classi ed into hypochondriasis based on an absence of delusion in `ugliness'. However, it is dif cult to separate a delusion from simple preoccupation in such a monosymptomatic disorder. Moreover, dysmorphophobia, has been traditionally understood as a subtype of `Taijinkyofusho' (anthrophobia), a related concept of social phobia, in Japan. This understanding has been widely accepted in Japan, but still remains controversial in Western countries. The confusion seems to occur, at least in part, because there is no psychiatric view regarding people who are preoccupied with their appearance. Most patients who are distressed about their appearance would not visit a psychiatrist. Such distress would be often missed by doctors, particularly cosmetic surgeons. Accordingly, a psychiatric investigation of patients who visit cosmetic surgeons may contribute to revealing the `real' features of Correspondence address: Jun Ishigooka, MD, PhD, Department of Psychiatry, Kitasato University School of Medicine, Asamizodai, Sagamihara, Kanagawa 228±8520, Japan. Received 7 November 1997; revised 24 December 1997; accepted 30 December somatoform disorders and related conditions. It has been noticed by surgeons and dermatologists 11±22 that patients with a `deformity' may show mental or behavioural disorders. Reports from psychiatrists 23±30 have not been satisfactory in terms of subject size and were undertaken before the introduction of the operational diagnosis for mental disorders. It is important therefore that patients visiting cosmetic surgeons are investigated by psychiatrists. The present study was carried out to describe demographic features of a large population of patients seeking cosmetic surgery from a psychiatric point of view. SUBJECTS AND METHODS The subjects included in this study were 415 patients (male 130; female 285) who visited the Department of Plastic Surgery of Kitasato University Hospital, Japan from January 1980 to June 1997 to seek cosmetic surgery. The `deformity' for which they consulted the plastic surgeon was not deemed to be unusual. All patients were referred regardless of the presence or absence of mental manifestations at the time of their rst visit. The patients underwent a psychiatric interview and were diagnosed using ICD-10 criteria 31 while being assessed in terms of their backgrounds, deformities complained of, and the types of operation desired. The diagnosis was made according to the major diagnostic categories in ICD-10, however, focusing on dysmorphophobia, it was determined whether it should be diagnosed as other persistent delusional disorders (F22.8) or hypochondriacal disorder (F45.2). For the purpose of the study, these two disorders were conveniently separated based on the degree of preoccu-

2 284 J. Ishigooka et al. pation in subjects despite the diagnostic issue of dysmorphophobia. Subjects whose concern with `deformity' was not obstinate were diagnosed into other categories than the two disorders. The social adjustment of subjects was assessed with the dichotomy of `good' or `not good'. Subjects who met at least one of the following criteria were estimated as `not good': (i) sensitiveness to interpersonal relationships; (ii) excessive avoidance of interpersonal relationships due to `ugliness'; (iii) no work or school activities without a speci c reason for at least half of days spent at work or school. The assessment was made at the rst interview because most of the patients visited only once. Patients who presented before the introduction of ICD-10 were re-diagnosed according to their medical histories. For categorical data producing a R C cross-tabulation, the Chi-squared test was used to test the independence of variables and adjusted standardized residual was computed. Adjusted standardized residual above +2.0 or below )2.0 means that the observed frequency was a departure from the expected results, with a statistical signi cance. For a 2 2 table, odds ratio (OR) and its 95% con dence interval (CI) were calculated. A Mann±Whiteney U-test was conducted for the intergroup comparison. All statistical procedures were carried out with SPSS statistical software (version 7.5 for Windows). RESULTS Age at rst visit The mean SD of age at the rst visit was subjects were signi cantly younger than female ( and , respectively, P < 0.001). Figure 1 shows the distribution of subjects by gender. The age distribution in male subjects peaked at 20±24 years, and 80% of the subjects were included between ages of 15 and 29. The female distribution had two peaks; the rst at the ages between 25 and 29 years and the second small peak was between the ages of 40 and 44 years. History of subjects Regions of the body concerned The incidence of regions of the body concerned is shown in Table 1. Because a patient could seek an operation of two or more regions, the total incidence was 581. Three hundred and seventy-six subjects (90.6%) desired operations to be performed on the face, including 39 subjects who could not specify the region of face and 15 patients who desired operations on both face and other body regions. In male subjects, the rst three ranked order of regions in face desired to be operated was: (i) nose; (ii) eye lid(s); and (iii) mandibular angle plus chin, while, in female subjects, the third ranked regions was the area of the cheeks. Age of onset The age distribution when subjects were preoccupied with their `deformity' is shown in Fig. 2. Almost all of the male subjects (82.3%) began to be preoccupied between teenage years and early adult life. In contrast, female subjects were widely distributed across all age groups, although a peak of the distribution was found in the late teenage years. Consequently, age of onset in male subjects was signi cantly lower than that of female subjects (P < 0.001). Number of operations Some of the subjects reported that they had previously undergone cosmetic operations before their rst visit during the study period. There was no signi cant association between gender and frequency of surgery (Table 2). Sixty subjects had been operated three times or more before visiting us, however, there was no speci c correlation between frequent operations and diagnosis or social adjustment. Table 1. Body regions: desired operations n = 130 (%) n = 285 (%) n = 415 (%) Figure 1. Distribution of age at the rst visit. Skewness and kurtosis for male were 1.75 and 3.06, respectively and those for female 0.30 and )0.92. Face Nose 47 (36.2) 106 (37.2) 153 (36.9) Eye lid(s) 33 (25.4) 95 (33.3) 128 (30.8) Lip 14 (10.8) 10 (3.5) 24 (5.8) Mid face 0 (0.0) 1 (0.4) 1 (0.2) Mandibular angle, chin 23 (17.7) 17 (6.0) 40 (9.6) Ear 1 (0.8) 0 (0.0) 1 (0.2) Cheek 14 (10.8) 50 (17.5) 64 (15.4) Others 14 (10.8) 22 (7.7) 36 (8.7) Whole face 15 (11.5) 26 (9.1) 41 (9.9) Not speci ed 9 (6.9) 30 (10.5) 39 (9.4) Other than face 14 (10.8) 40 (14.0) 54 (13.0)

3 Patients seeking cosmetic surgery 285 Diagnosis One hundred and ninety-eight subjects (47.7%) were categorized as having mental disorders according to ICD-10. Eleven subjects (2.7%) could not be categorized (normal or not normal) because of inadequate information. Among male Table 3. Psychiatric classi cations of subjects* n = 130 (%) n = 285 (%) n = 415 (%) Normal 41 à (31.5) 165 (57.9) 206 (49.6) Mental disorders 85 (65.4) 113 à (39.6) 198 (47.7) Unknown 4 (3.1) 7 (2.5) 11 (2.7) *v 2 = 25.02, df = 2, P < 0.001; adjusted standardized residual was more than +2.0; à adjusted standardized residual was less than )2.0. Figure 2. Distribution of age when the subjects were preoccupied with their `deformity'. Skewness and kurtosis for male were 2.55 and 9.44, respectively and those for female 0.77 and )0.39. Table 2. surgery* Number of times the subjects had undergone cosmetic n = 130 (%) n = 285 (%) n = 415 (%) None 64 (49.2) 129 (45.3) 193 (46.5) 1 39 (30.0) 78 (27.4) 117 (28.2) 2 9 (6.9) 36 (12.6) 45 (10.8) 3 or more 18 (13.8) 42 (14.7) 60 (14.5) *v 2 = 3.25, df = 3, P = subjects, 85 (65.4%) could have had a psychiatric diagnosis, compared to 113 (39.6%) in female subjects (Table 3). The adjusted standardized residual for males with any mental disorders was 4.9. This indicates that a male seeking cosmetic surgery would be more likely to have mental disorders compared with a female. Schizophrenia (F20) was seen in 17 (4.1% of total population) and other persistent delusional disorders (dysmorphophobia, delusional; F22.8) in 20 (4.8% of total population); (Table 4). The rate of male subjects with other persistent delusional disorders (20.0%) was higher than that of female subjects (2.7%), which is statistically signi cant. All subjects classi ed into mood disorders (F3) were those with depressive episode (F32); (33 or 8.0% of total population). Bipolar affective disorder or recurrent depressive disorder was never observed. Of the female subjects with mental disorders, the percentage having depressive episode (23.0%) was higher than that for male subjects (8.2%). The most of these depressive cases seemed to have been distressed by the feeling of `failure' due to the unsatisfactory results of previous operations. Neurotic disorders (F4) excluding hypochondriacal disorder was seen in 47 (11.3%) of subjects, including 25 with anxiety disorder, unspeci ed (F41.9; mostly tentative diagnosis), seven with mixed anxiety and depressive disorder (F41.2), six with somatization disorder (F45.0) and four with an undifferentiated somatoform disorder (F45.1). Hypochondriacal disorder (dysmorphophobia, non-delusional; F45.2) was seen in 42 (10.1% of total population), out of which the number of male Table 4. Speci cation of the subjects' diagnoses* n = 85 (%) n = 113 (%) n = 198 (%) % in total subjects n = 415 Schizophrenia (F20) 6 (7.1) 11 (9.7) 17 (8.6) 4.1 Other persistent delusional disorders (F22.8) (dysmorphobia, delusional) 17 (20.0) 3 à (2.7) 20 (10.1) 4.8 Depressive episode (F32) 7 à (8.2) 26 (23.0) 33 (16.7) 8.0 Neurotic disorders (F4) 22 (25.9) 25 (22.1) 47 (23.7) 11.3 Hypochondriacal disorder (F45.2) (dysmorphobia, non-delusional) 26 (30.6) 16 à (14.2) 42 (21.2) 10.1 Paranoid personality disorder (F60.0) 1 (1.2) 4 (3.5) 5 (2.5) 1.2 Histrionic personality disorder (F60.4) 0 à (0.0) 14 (12.4) 14 (7.1) 3.4 Others 6 (7.1) 14 (12.4) 20 (10.1) 4.8 *v 2 = 40.64, df = 7, P < 0.001; adjusted standardized residual was more than +2.0; à adjusted standardized residual was less than )2.0.

4 286 J. Ishigooka et al. subjects was 26 (30.6%) and that of female was 16 (14.2%) with signi cant difference. Two major personality disorders were found; namely, paranoid personality disorder (F60.0) and histrionic personality disorder (F60.4). The 14 subjects with histrionic personality disorder were all female. Subjects classi ed into `others' consisted of those with various personality disorders or with mental retardation. Subjects with co-morbidity were not found, although there were limitations for de nite diagnosis because of unsatisfactory interviews. Social adjustment Social adjustment could be assessed in 368 subjects, with result that 47 cases were excluded from data analysis. Two hundred and six subjects (56.0%) were assessed as `not good', which included: 88 male (72.1% of male subjects assessed) and 118 female (48.0% of female subjects assessed). The OR for male or female was 2.81 with 1.76±4.48 of 95% CI. This indicated that a male subject would be nearly three times more likely to be socially unadjusted than a female subject. This tendency was also present when the analysis was restricted to 172 normal subjects without any mental disorders. A total of 59 `not good' subjects (34.3%) were identi ed; 17 male (half of normal male subjects) and 42 female (30.4% of normal female subjects; OR ˆ 2.29, 95% CI: 1.06±4.91). However, out of the 185 subjects with mental disorders, 136 (73.5%) were assessed as `not good'. The incidence was much higher than that in normal subjects, but without gender difference (79.8% of male vs 68.3% of female; OR ˆ 1.83, 95% CI: 0.93 to 3.60). DISCUSSION In the present study, many patients seeking cosmetic surgery were considered to have mental health problems: 47.7% of the subjects had a mental disorder according to ICD-10 criteria and 56.0% of the subjects whose social adjustment could be evaluated were assessed as `not good'. Edgerton et al. 14 reported a high incidence (71%) of mentally disturbed patients among those who visited cosmetic surgeons. Connolly and Gipson 29 reported that 38/86 (44.2%) patients with any psychiatric problem sought cosmetic surgery. This study is consistent with our present results. These results suggest that at least nearly half of patients visiting cosmetic surgeons are consistently those with various types of mental disorders despite the different populations investigated. The incidence of schizophrenia in the present study was 4.1% (Table 4), which seems to be higher than that in the general population. Without respect to psychiatric diagnosis, more than half of those patients had apparent social functioning disturbance. This poor social adjustment was seen more frequently in male subjects. The gender difference was evident in mentally normal subjects rather than mentally abnormal ones. The relationship between excessive concern with physical appearance and poor social functioning remains uncertain; however, it could be imagined that the behaviour of seeking cosmetic surgery may be partly a result of an unconscious desire to resolve disturbed interpersonal relationship. The majority of subjects were preoccupied with their appearance during their adolescence or young adult life (Fig. 2), when interpersonal relationships become important to most people. It was noteworthy that a considerable number of patients with mental health problems visited a hospital to seek cosmetic surgery. Cosmetic surgery is therefore an area where psychiatrists should direct their concern. Sixty subjects had undergone cosmetic surgery previously three times or more before the study period; however, these patients were not correlated to speci c subpopulations. This result indicates that repetition of having surgery is not an indicator of mental abnormality, but is commonly seen in subjects seeking cosmetic surgery. Another characteristic nding in the present study was a distinct difference between male and female subjects. As shown in Table 3, the rate of male subjects with mental disorders was signi cantly higher than that of female subjects. Other persistent delusional disorders and hypochondriacal disorder (dysmorphophobia, either delusional or non-delusional, to our opinion) were seen more frequently in male subjects (Table 4). subjects also characterized by having narrow age range of onset between teenage and young adult life (Fig. 2), and poor social adjustment. Body image and its relation to identity has been clearly recognized in women; however, this has not been traditionally associated with men, 32 suggesting that the anxieties of interpersonal relationships in males could more easily be linked with somatic anxiety than in females. Furthermore, interpersonal relationships become particularly important in Japanese society after adolescence. Accordingly, the present results suggested that male subjects tended to seek cosmetic surgery based on their sensitiveness to interpersonal relationships and the probable failure to have successful relationships compared to female subjects. Indeed, with respect to dysmorphophobia, the ratio of women to men of reported cases in Western literature was 1.3:1; 4 however, the rate of male patients were reported to be 69% in Japan. 33 The high incidence of mental disorders in male subjects, especially of those with dysmorphophobia, seemed to be speci c to Japanese populations. It is, therefore, necessary to involve socio-cultural aspects in the diagnosis of dysmorphophobia, which are excluded in DSM-IV and ICD-10. The diagnostic issue of other persistent delusional disorders, body dysmorphic disorder and social phobia are particularly relevant. The regions of the body concerned were somewhat different between genders (Table 1), which may re ect the different perceptions of body image. REFERENCES 1. Andreasen NC, Bardach J. Dysmorphophobia: Symptom or disease? Am. J. Psychiatry 1977; 134: 673± Bishop ER. Monosymptomatic hypochondriasis. Psychosomatics 1980; 21: 731± Thomas CS. Dysmorphophobia: A question of de nition. Br. J. Psychiatry 1984; 144: 513± Phillips KA. Body dysmorphic disorder: The distress of imagined ugliness. Am. J. Psychiatry 1991; 148: 1138± Phillips KA, McElroy SL, Keck Jr PE, Pope HG, Hudson JI. Body dysmorphic disorder: 30 cases of imagined ugliness. Am. J. Psychiatry 1993; 150: 302±308.

5 Patients seeking cosmetic surgery McElroy SL, Phillips KA, Keck Jr PE, Hudson JI, Pope HG. Body dysmorphic disorder: Does it have a psychotic subtype? J. Clin. Psychiatry 1993; 54: 389± Hollander E, Neville D, Frenkel M, Josephson S, Liebowitz M. Body dysmorphic disorder. Diagnostic issues and related disorders. Psychosomatics 1992; 33: 156± Hollander E, Wong CM. Body dysmorphic disorder, pathological gambling and sexual compulsions. J. Clin. Psychiatry 1995; 56 (Suppl 4): 7± Brawman-Mintzer O, Lydiard B, Phillips KA et al. Body dysmorphic disorder in patients with anxiety disorders and major depression: A comorbidity study. Am. J. Psychiatry 1995; 152: 1665± American Psychiatric Association. Diagnostic Criteria from DSM-IV. First Japanese Edn. Igaku-Shoin, Tokyo, Barsky MAJ. Psychology of the patient undergoing plastic surgery. Am. J. Surg. 1944; 65: 238± Berndorfer A. Plastic surgery. Physiognomy and psychoanalysis. Plast. Reconstr. Surg. 1949; 4: 453± Jacobson WE, Edgerton MT, Meyer E, Canter A, Slaughter R. Psychiatric evaluation of male patients seeking cosmetic surgery. Plast. Reconstr. Surg. 1960; 26: 356± Edgerton MT, Jacobson WE, Meyer E. Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: Ninety-eight consecutive patients with minimal deformity. B. J. Plast. Surg. 1960; 13: 136± Clarkson P, Stafford-Clark D. Role of the plastic surgeon and psychiatrist in the surgery of appearance. BMJ. 1960; 1768± Klabunde EH, Falces E. Incidence of complications in cosmetic rhinoplasties. Plast. Reconstr. Surg. 1964; 34: 192± Webb Jr WL, Slaughter R, Meyer E, Edgerton M. Mechanisms of psychosocial adjustment in patients seeking `face-lift' operation. Psychosom. Med. 1965; 27: 183± Knorr NJ, Edgerton MT, Hoopes JE. The `insatiable' surgery patient. Plast. Reconstr. Surg. 1967; 40: 285± Reich J. The surgery of appearance: Psychological and related aspects. Med. J. Aust. 1969; 2: 5± Wright MR, Wright WK. A psychological study of patients undergoing cosmetic surgery. Arch. Otolaryngol. 1975; 101: 145± Gipson M, Chir B, Connolly FH. The incidence of schizophrenia and severe psychological disorders in patients 10 years after cosmetic rhinoplasty. Br. J. Plast. Surg. 1975; 28: 155± Cotterill JA. Dermatological non-disease: A common and potentially fatal disturbance of cutaneous body image. Br. J. Dermatol. 1981; 104: 611± Linn L, Goldman IB. Psychiatric observations concerning rhinoplasty. Psychosom. Med. 1949; 11: 307± Hill G, Silver G. Psychodynamic and esthetic motivations for plastic surgery. Psychosom. Med. 1950; 12: 345± Meyer E, Jacobson WE, Edgerton MT, Canter A. Motivational patterns in patients seeking elective plastic surgery. Psychosom. Med. 1960; 22: 193± Hay GG. Psychiatric aspects of cosmetic nasal operations. Br. J. Psychiatry 1970; 116: 85± Book HE. Psychiatric assessment for rhinoplasty. Arch. Otolaryngol. 1971; 94: 51± Druss RG, Symonds FC, Crikelair GF. The problem of somatic delusions in patients seeking cosmetic surgery. Plast. Reconstr. Surg. 1971; 48: 246± Connolly FH, Gipson M. Dysmorphophobia: A long-term study. Br. J. Psychiatry 1978; 132: 568± Beal S, Lisper H-O, Palm B. A psychological study of patients seeking augmentation mammaplasty. Br. J. Psychiatry 1980; 133± World Health Organization. Classi cation of Mental and Behavioral Disorders: Clinical descriptions and diagnostic guidelines. First Japanese edition, Igaku-Shoin Ltd, Tokyo, Fisher S. Body Consciousness: You Are What You Feel. Prentice-Hall Inc., Englewood Cliffs, Fukuda O. Statistical analysis of dysmorphophobia in out-patient clinic. Jpn. J. Plast. Reconstr. Surg. 1977; 20: 569±577 (in Japanese).