Understanding the psychology of the cosmetic patients

Transcription

1 Dermatologic Therapy, Vol. 21, 2008, Printed in the United States All rights reserved Blackwell Publishing Inc Copyright Blackwell Publishing, Inc., 2008 DERMATOLOGIC THERAPY ISSN Understanding the psychology of the cosmetic patients FARAH MALICK*, JOSIE HOWARD & JOHN KOO *Department of Dermatology, Wayne State University, Detroit, Michigan, Departments of Dermatology and Psychiatry, University of California, San Francisco and Private Practice, San Francisco, California and Department of Dermatology, University of California, San Francisco, California ABSTRACT: Patients seeking cosmetic surgery commonly present with psychiatric disorders including body dysmorphic disorder, narcissistic personality disorder, and histrionic personality disorder. A basic understanding of the characteristic features of these conditions and the importance of specialized screening questionnaires and preoperative interview questions are valuable to dermatologic surgeons as the information extracted can help provide clinicians with the most appropriate management including referral for psychiatric intervention. KEYWORDS: body dysmorphic disorder, cosmetic surgery, dermatology, histrionic personality disorder, narcissistic personality disorder, questionnaire, screening tool Introduction Consideration of psychological issues is important when evaluating patients for cosmetic surgery. Up to 47.7% of patient consultations for cosmetic procedures meet criteria for a mental disorder (1). In particular, body dysmorphic disorder, narcissistic personality disorder, and histrionic personality disorder (2) are common psychiatric conditions seen in patients seeking cosmetic surgery. It is essential for clinicians to screen for psychopathology preoperatively, and if psychopathology is suspected, referral to a mental health specialist is necessary as cosmetic surgery patients with psychiatric issues are more likely to pursue additional surgery as opposed to accepting psychiatric referral (3,4). To facilitate psychiatric consultation when warranted, this review article begins with a discussion of common psychiatric conditions in cosmetic surgery patients and ends with preoperative screening methods and recommendations which is perhaps Address correspondence and reprint requests to: Farah Malick, MD, Department of Dermatology, Wayne State University, Oakwood Dearborn Medical Park, Oakwood Blvd. Suite 300, Dearborn, MI 48124, or fmalick@med.wayne.edu. the most critical step in avoiding psychological difficulties in cosmetic patients. Somatoform disorders As defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR ), the common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder (e.g., panic disorder) (5). In addition, the physical symptoms are not intentional (5), which differentiates it from factitious disorders and malingering. Body dysmorphic disorder Body dysmorphic disorder (historically known as dysmorphophobia) is defined in the DSM-IV- TR as the preoccupation with an imagined or exaggerated defect in physical appearance (5). Table 1 lists the criteria in the DSM-IV-TR for the diagnosis of body dysmorphic disorder (5). Body dysmorphic disorder is observed in 5% to 15% of cosmetic surgery patients (6,7). It can begin 47

2 Malick et al. Table 1. Diagnostic criteria for body dysmorphic disorder Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person s concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). (Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) (5). Table 2. Common presenting symptoms in patients with body dysmorphic disorder (13 15) Facial complaints Hair complaints Nose Other Acne Altered hair growth Blackheads Abdomen Altered skin color/texture Altered hair texture Contour bumpy nose Breasts Dry lips Hair thinning Relation to forehead Buttocks Excessive facial hair Impending baldness Shape crooked nose Chin Facial asymmetry Scalp complaints Size Ears Paleness/redness Too much hair Texture Eyelids Scars Eyes Spots Genitals Swelling Jaw Telengiectasias Mouth Vascular markings Teeth Wrinkles (Adapted from Wilson et al.) (6). as early as childhood but usually begins during adolescence and is equally common in men and women in outpatient mental health settings (5). Women and men with body dysmorphic disorder share similar features such as age of onset, course of the disease, symptom severity, and impairment of functioning (8,9). Any area of the body may be the focus of concern; however, the most common areas are the skin (e.g., minimal acne, scarring), hair (e.g., thinning), and nose (10 12). Women are more likely to compulsively pick their skin, are more concerned with waist and hip size, and hair abnormalities (8), whereas men are more concerned with hair thinness or balding, small body habitus, and genital size insufficiency (8). Some common presenting symptoms in patients with body dysmorphic disorder are listed in Table 2 (13 15). The quality of life in patients with body dysmorphic disorder is poorer compared to patients suffering from recent myocardial infarction, Type 2 diabetes, obsessive compulsive disorder, bipolar disorder, and schizophrenia (16,17). Disorders that may accompany body dysmorphic disorder include major depression, avoidant personality disorder, social phobia, obsessive-compulsive disorder, delusional disorder (somatic type), anorexia nervosa, and gender identity disorder (11,12,15,18). Phillips et al. (8) report that approximately 25% of body dysmorphic disorder patients will have attempted suicide. Body dysmorphic disorder may be difficult to diagnose in cosmetic surgery patients (19,20). Diagnostic questions for body dysmorphic disorder are listed in Table 3 (16). Patients with body dysmorphic disorder look to dermatologists or plastic surgeons for treatment rather than psychiatrists (21). Phillips et al. (8) studied 188 patients with body dysmorphic disorder evaluated in a psychiatric setting and found that 46% looked to dermatologists for treatment and 38% received dermatologic treatment (8). Psychiatrists use the Body Dysmorphic Disorder Questionnaire (BDDQ) as a screening tool for body dysmorphic disorder (22). The BDDQ has been shown to have 100% sensitivity and 89% specificity in a psychiatry setting (22). Another instrument is the Body Dysmorphic Disorder Examination Self- Report (BDDE-SR), which is a more specific diagnostic tool which measures body image dissatisfaction and the symptoms of body dysmorphic disorder (23). Using the BDDQ to detect disease, Phillips et al. (24) conducted a study of 268 patients seeking 48

3 Psychology of cosmetic patients Table 3. Diagnostic questions for body dysmorphic disorder** Have you ever been very worried about your appearance in any way? * If yes: What was your concern? Did you think (body part) was especially unattractive? * If yes: What about the appearance of your face, skin, hair, nose, or the shape or size or other aspect of any other part of your body? Did this concern preoccupy you? That is, did you think about it a lot and wish you could worry about it less? What effect did this concern have on your life? Did it cause you a lot distress or interfere with your functioning in any way? ** These questions are a guide to diagnosing body dysmorphic disorder. Body dysmorphic disorder is diagnosed if the criteria presented in Table 1 are met. In addition, for body dysmorphic disorder to be diagnosed, the appearance concerns should not be better accounted for by an eating disorder. (Adapted from Phillips et al.) (16). dermatologic treatment in a community and university setting and found that 11.9% of these patients screened positive for body dysmorphic disorder. In addition, in patients with nonexistent or minimal defects, 15.2% screened positive for body dysmorphic disorder (24). Only 13% of patients described improvement in their body dysmorphic disorder symptoms from dermatologic treatment (24). Dufresne et al. (25) slightly modified the BDDQ and investigated it as a screening tool for body dysmorphic disorder in a dermatology setting (Body Dysmorphic Disorder Questionnaire-Dermatology Version (Appendix 1)). The modification involved substituting a Likert scale from 1 to 5 indicating a range of severity for yes/no responses (25). In this study, 15% of 46 patients in a cosmetic dermatologic setting were found to have body dysmorphic disorder (25). The BDDQ-Dermatology Version was shown to have 100% sensitivity and 92.3% specificity when compared with semistructured clinician interview (25) thus demonstrating its effectiveness as a useful screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Body dysmorphic disorder is underrecognized in dermatologic practices (21,26 28) and it is important for dermatologic surgeons to recognize this disorder in a cosmetic surgery setting for several reasons. For example, these patients can be difficult to treat (28 30) but it is a treatable condition. Most patients with body dysmorphic disorder were not satisfied with their cosmetic procedure (31,32). Some patients seek legal action or become violent towards their treating physician (33). Approximately 25% of body dysmorphic disorder patients will have attempted suicide according to Phillips et al. (8) A study of dermatology patients who committed suicide reported that most had acne or body dysmorphic disorder (34). Personality disorders As defined in the DSM-IV-TR, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (5). Personality disorders are categorized into three clusters (clusters A, B, and C). Individuals with narcissistic and histrionic personality disorders fall into cluster B and exhibit dramatic, emotional, or erratic (5) characteristics. Narcissistic personality disorder As defined in the DSM-IV-TR, narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy (5). Table 4 lists the criteria in the DSM-IV-TR for the diagnosis of narcissistic personality disorder (5). Fifty to seventy-five percent of those diagnosed with narcissistic personality disorder are men (5). The prevalence ranges from 2% to 16% in the clinical population and less than 1% in the general population (5). Narcissistic personality disorder is observed in 25% of cosmetic surgery patients (35). Patients with this personality disorder tend to feel that they were their most attractive when they were younger and so they may be trying to recreate that younger image (35). In addition, these patients continue to return to your practice despite being unhappy with the treatment results (2). Histrionic personality disorder As defined in the DSM-IV-TR, histrionic personality disorder is a pattern of excessive emotionality and attention seeking (5). Table 5 lists the criteria 49

4 Malick et al. Table 4. Diagnostic criteria for narcissistic personality disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) requires excessive admiration has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends lacks empathy: is unwilling to recognize or identify with the feelings and needs of others is often envious of others or believes that others are envious of him or her shows arrogant, haughty behaviors or attitudes (Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) (5). Table 5. Diagnostic criteria for histrionic personality disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: is uncomfortable in situations in which he or she is not the center of attention interaction with others is often characterized by inappropriate sexually seductive or provocative behavior displays rapidly shifting and shallow expression of emotions consistently uses physical appearance to draw attention to self has a style of speech that is excessively impressionistic and lacking in detail shows self-dramatization, theatricality, and exaggerated expression of emotion is suggestible, i.e., easily influenced by others or circumstances considers relationships to be more intimate than they actually are (Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) (5). in the DSM-IV-TR for the diagnosis of histrionic personality disorder (5). In clinical settings, histrionic personality disorder has been diagnosed more in women, and limited data from general population studies show a prevalence rate of 2 3% (5). Histrionic personality disorder is observed in 9.7% of cosmetic surgery patients (35). These patients tend to have unrealistic expectations when it comes to themselves and results of cosmetic procedures (2). It is important to document these patients reactions as they may never be satisfied with treatment results (2). Interviewing techniques and screening for psychological issues There are several methods to help detect potential psychological issues in cosmetic surgery seeking patients. For example, Edgerton and McClary (36) recommended that a highly professionally defined physician patient relationship is important. It is best for the physician to let the patient speak and convey their reasons for wanting cosmetic surgery (37). When interviewing patients seeking cosmetic surgery, keep in mind that psychiatric patients often elicit strong emotional responses from their health care providers (2). A thorough medical and social history (2) including psychiatric history and current mental state should be obtained (38). Pertinent questions and important signs when interviewing cosmetic surgery seeking patients include a history of numerous procedures performed by many clinicians, particularly those who were unsatisfied with the results or a history of lawsuits or violence toward previous physicians (38). Ritvo et al. (2) goes on to mention Do they have a history of noncompliance with previous treatment plans? 50

5 Psychology of cosmetic patients Table 6. Additional questions for exploring psychosocial issues 1. What makes now feel like the right time for surgery rather than a month or a year ago or a month or a year in the future? (Do not stop with purely practical answers like I have a vacation coming up or I just got a bonus check. Continue, OK but is there anything else? ) 2. What are three wishes about the impact on your life of a successful outcome? Please answer on a pure fantasy level don t be realistic. 3. What are three realistic expectations of the impact that successful surgery will have on your life? Can you imagine any possible disadvantages to a successful surgical outcome? 4. How do you expect key people in your life will respond differently to you after the surgery? How about strangers? 5. Does your (target body part) remind you of anyone you know? Have met? Family members? Whose eyes or whose thighs do you have? 6. Have you noticed that your readiness to have the surgery varies from day to day or week to week? Is the desire greater with certain events, moods, or reactions of others? 7. Have you noticed any unexpected emotional reactions from surgical personnel, the office, or from talking about the surgery? 8. Have you ever had any indications that others see you differently than you see yourself? 9. Do you ever have trouble following health or beauty guidelines that you agree with? 10. What percentage of peoples first impression of you do you believe your (largest body part) accounts for? What percentage after they get to know you? (Adapted from Grossbart et al.)(42). If possible, determine their use or misuse of emergency contact mechanisms with their physician, Do they have unreasonable or unreachable expectations of the proposed procedure? Do they seem responsive to education or the informed consent process? Are they spending money that is beyond their means? When interviewing patients, Wengle (39) stressed the importance of how questions are asked as opposed to the question itself. For example, How do you deal with this problem? is a better question to evaluate a patient s motives for surgery, according to Wengle (39), and is more empathetic to the patient versus Why is this feature a problem? which may suggest that the patient has underlying psychopathology (37). Furthermore, Hasan (37) suggests beginning the interview process with a statement such as the questions I am about to ask you are entirely routine, and I use them just to gain an overall sense of each patient before surgery (37) so as to put the patient at ease and not feel like they are being singled out (37). To add to this, it is also helpful to ask openended questions where the patient is given the opportunity to completely respond (40), and the physician is given the opportunity to evaluate for any underlying psychopathology that may be revealed in the patient s response (37). Another screening tool for psychopathology is the SAFE acronym (41): Self-evaluation of attractiveness (attempt to assess for a compromised self-image.) Anxiety (be conscious of possible generalized distress in the patient.) Fear (detect a patient s preoccupation with detail that may be masking underlying fears.) Expectation (determine whether the patient is expecting unrealistic social/life changes from the procedure.) Grossbart et al. (42) provided additional questions for exploring psychosocial issues which are listed in Table 6. Conclusion The ability to identify an underlying psychopathology in cosmetic surgery patients helps the practitioner with their decision making whether it be performing or refusing to perform the requested procedure to referral for psychiatric intervention (2). Improving communication skills with structured interview techniques and questions is valuable when dealing with cosmetic surgery seeking patients, especially if suspecting underlying psychiatric issues. 51

6 Malick et al. Appendix 1. Body dysmorphic disorder questionnaire-dermatology version* Are you very concerned about the appearance of some part of your body, which you consider especially unattractive? Y N If no, thank you for your time and attention. You are finished with this questionnaire If yes, do these concerns preoccupy you? That is, you think about them a lot and they re hard to stop thinking about? Y N What are these concerns? What specifically bothers you about the appearance of these body parts? What effect has your preoccupation with your appearance had on your life? Has your defect often caused you a lot of distress, torment or pain? How much? (circle best answer) No distress Mild, and not Moderate and Severe, and Extreme, and too disturbing disturbing but very disturbing disabling still manageable Has your defect caused you impairment in social, occupational, or other important areas of functioning? How much? (circle best answer) No limitation Mild interference Moderate, definite Severe, causes Extreme, but overall per interference, but substantial incapacitating formance not still manageable impairment impaired Has your defect often significantly interfered with your social life? Y N If yes, how? Has your defect often significantly interfered with your school work, your job, or your ability to function in your role? Y N Are there things you avoid because of your defect? Y N *A positive screening for body dysmorphic disorder = answering yes to the presence of a preoccupation + having at least moderate distress or impairment in functioning. (Reproduced, with permission, from Dufresne et al.) (25). References 1. Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998: 52: Ritvo EC, Melnick I, Marcus GR, Glick ID. Psychiatric conditions in cosmetic surgery patients. Facial Plastic Surg 2006: 22: Edgerton M, Langman M, Pruzinsky T. Plastic surgery and psychotherapy in treatment of 100 psychologically disturbed patients. Plast Surg Psychother 1991: 88: Wengle H. The psychology of cosmetic surgery: a critical overview of the literature part I. Ann Plast Surg 1986: 16: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, DC: American Psychiatric Association, Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detection and treatment in a surgical dermatology practice. Dermatol Surg 2004: 30: Veale D. Body dysmorphic disorder. Postgrad Med J 2004: 80: Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 1997: 185: Perugi G, Akiskal HS, Giannotti D, et al. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis 1997: 185: Phillips KA, McElroy SL, Keck PE Jr, Pope HG Jr, Hudson JI. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993: 150: Hollander E, Cohen LJ, Simeon D. Body Dysmorphic disorder. Psych Ann 1993: 23: Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder: a survey of fifty cases. Br J Psychiatry 1996: 169:

7 Psychology of cosmetic patients 13. Phillips KA. Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 1991: 148: Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. New York: Oxford University Press, Phillips K, McElroy SL, Keck PEJ, Hudson JI, Pope HG. A comparison of delusional and non-delusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull 1994: 30: Phillips KA, Dufresne RG. Body dysmorphic disorder: a guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000: 1: Phillips KA. Quality of life for patients with body dysmorphic disorder. J Nerv Ment Dis 2000: 188: Brawman-Mintzer O, Lydiard RB, Phillips KA, et al. Body dysmorphic disorder in patients with anxiety disorders and major depression: a comorbidity study. Am J Psychiatry 1995: 152: Sarwer DB. The obsessive cosmetic surgery patient: a consideration of body image dissatisfaction and body dysmorphic disorder. Plast Surg Nurs 1997: 17: Sarwer DB, Wadden TA, Pertschuk MJ, et al. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg 1998: 101: Koblenzer CS. The broken mirror: dysmorphic syndrome in the dermatologist s practice. Fitz J Clin Dermatol 1994: March April: Phillips KA, Atala KD, Pope HG. Diagnostic instruments for body dysmorphic disorder. New Research Program and Abstracts, American, Psychiatric Association 148th annual meeting. Miami: American Psychiatric Association, 1995: Rosen JC, Reiter J. Development of the body dysmorphic disorder examination. Behav Res Ther 1996: 34: Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol 2000: 42: Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic surgery practice. Dermatol Surg 2001: 27: Phillips KA, Dufresne RG. Body dysmorphic disorder: a guide for primary care physicians. Prim Care 2002: 29: Cotterill JA. Body dysmorphic disorder. Dermatol Clin 1996: 14: Hanes KR. Body dysmorphic disorder: an underestimated entity? Australas J Dermatol 1995: 36: Cotterill JA. Dermatological non-disease: a common and potentially fatal disturbance of cutaneous body image. Br J Dermatol 1981: 104: Koblenzer CS. The dysmorphic syndrome. Arch Dermatol 1985: 121: Veale D. Outcome of cosmetic surgery and DIY surgery in patients with body dysmorphic disorder. Psychiatr Bull 2000: 24: Phillips KA, Grant JD, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics 2001: 42: Phillips KA, McElroy SL, Lion JR. Body dysmorphic disorder in cosmetic surgery patients [letter]. Plast Reconstr Surg 1992: 90: Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997: 137: Napoleon A. The presentation of personalities in plastic surgery. Ann Plast Surg 1993: 31: Edgerton M, McClary A. Augmentation mammaplasty: psychiatric implications and surgical indications. Plast Reconstr Surg 1958: 21: Hasan JS. Psychological issues in cosmetic surgery: a functional overview. Ann Plast Surg 2000: 44: Castle DJ, Honigman RJ, Phillips KA. Does cosmetic surgery improve psychosocial wellbeing? Med J Aust 2002: 176: Wengle H. The psychology of cosmetic surgery: old problems in patient selection seen in a new way part II. Ann Plast Surg 1986: 16: Strauss GD. The psychiatric interview, history, and mental status examination. In: Kaplan HI, Sadock BJ, eds. Comprehensive textbook of psychiatry. Vol. 1. Baltimore: Williams & Wilkins, 1995: Lavell S, Lewis C. SAFE: a practical guide to psychological factors in selecting patients for facial cosmetic surgery. Ann Plast Surg 1984: 12: Grossbart TA, Sarwer DB. Psychosocial issues and their relevance to the cosmetic surgery patient. Semin Cutan Med Surg 2003: 22: