Psychological Screening Measures for Cosmetic Plastic Surgery Patients: A Systematic Review

Transcription

1 INTERNATIONAL CONTRIBUTION Special Topic Review Article Psychological Screening Measures for Cosmetic Plastic Surgery Patients: A Systematic Review Aesthetic Surgery Journal 33(1) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Petra Wildgoose, MD; Amie Scott, MS; Andrea L. Pusic, MD, MHS, FRCSC; Stefan Cano, DPhil; and Anne F. Klassen, DPhil Abstract With the increasing popularity of cosmetic surgery procedures, preoperative psychological assessment of cosmetic surgery patients may improve outcomes by highlighting patient expectations and motivations, as well as by identifying those who may require psychological referral. In this article, the authors describe a systematic literature review to identify and evaluate current self-report tools used in the psychological screening of cosmetic surgery patients prior to surgery. Articles related to the preoperative mental health assessment of cosmetic surgery patients were identified by searching MEDLINE, EMBASE, HAPI, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials through November The full text of potentially relevant articles was examined by 2 reviewers, and articles that met the inclusion criteria were reported. Close reading of 100 full-text articles showed that although a variety of instruments are currently being used as preoperative assessment tools, there are limitations to their validity and usefulness in the screening of cosmetic surgery patients. To properly assess cosmetic surgery patients, a scientifically sound and clinically useful instrument is needed. Keywords cosmetic surgery, screening, questionnaire, psychological Accepted for publication June 7, The popularity of both surgical and nonsurgical cosmetic procedures is growing. According to the American Society for Aesthetic Plastic Surgery (ASAPS), more than 9 million surgical and nonsurgical cosmetic procedures were performed in the United States in 2011, a 197% increase since Factors that have contributed to this increase in popularity include social acceptance of plastic surgery procedures and media coverage that shows firsthand results to the public. 2 Individual motivations to pursue aesthetic plastic surgery procedures and improve appearance include the desire to improve self-confidence, self-esteem, and social interactions. With a clinically satisfactory outcome, research shows that most patients are satisfied following cosmetic surgery; there is, however, a small subgroup of patients who are not. 3-5 Discontentment despite a clinically satisfactory outcome can occur as a result of a preexisting psychiatric condition. 6 Research suggests that many patients who seek consultation for a cosmetic procedure meet the criteria for a psychiatric disorder such as body dysmorphic disorder, narcissistic personality disorder, or histrionic personality disorder. 7 Those who undergo a cosmetic procedure and remain dissatisfied despite a clinically satisfactory outcome may pursue additional aesthetic procedures and are at risk of experiencing further psychiatric symptoms, including depression, anxiety, social isolation, and selfdestructive behavior. 6,8 By treating these patients, the Dr Wildgoose is a medical graduate at McMaster University, Hamilton, Ontario, Canada. Ms Scott is Research Project Manager and Dr Pusic is Associate Professor in the Department of Plastic and Reconstructive Surgery at Memorial Sloan-Kettering Cancer Center, New York, New York. Dr Cano is Professor in the Department of Neurology at Peninsula College of Medicine and Dentistry, Tamar Science Park, Plymouth, Devon, United Kingdom. Dr Klassen is Professor in the Department of Pediatrics at McMaster University, Hamilton, Ontario, Canada. Corresponding Author: Dr Anne F. Klassen, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada, L8S 4L8. aklass@mcmaster.ca

2 Wildgoose et al 153 Table 1. Search Terms Used in the Electronic Bibliographic Search Facial cosmetic procedures Elective procedures Psychology screening scales cosmetic surgeon is at risk of negatively affecting the patient. In addition, the surgeon assumes the risk of possible legal action because of a miscommunication regarding expectations for the outcome. 9 The use of a preoperative assessment tool to identify patients with underlying psychiatric issues, inappropriate motivations, or unrealistic expectations, as well as to provide reason for psychological referral, may be helpful to avoid such situations. Such a tool would not replace formal in-depth assessment but would alert the medical team of the need for further evaluation and possible psychological consultation. We conducted a systematic literature review to identify and evaluate the content of self-report questionnaires used to screen cosmetic surgery patients for psychological issues or inappropriate expectations and/or motivations prior to surgery, with the goal of determining the need for the development of new, clinically relevant screening measures. Methods Rhinoplast-, blepharoplast-, rhytidectom-, rhytidoplast-, face lift, facelift, facial surg-, skin rejuvenation, facial rejuvenation, facial resurfacing, platysmaplast-, otoplast-, septoplast-, mentoplast-, lip augmentation, lip reduction, facial implant-, injectable filler-, facial filler-, Botox, or botulinum Asthetic, aesthetic, cosmetic, or elective Psych-, screen-, scale-, questionnaire-, outcome, instrument-, survey-, or assessment- A search strategy was developed with the aid of a medical librarian to identify studies in which a self-report questionnaire was used or developed for the mental health screening of presurgical cosmetic surgery patients. Search terms are listed in Table 1. The following databases were searched from their inception date through November 2010: MEDLINE, EMBASE, HAPI, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials. Screening of abstracts and article titles was performed by 1 of the authors to identify potentially relevant articles. The full text of all potentially relevant studies was then examined independently by 2 authors using the following inclusion criteria: The study was published in English. The sample included only elective aesthetic surgery patients. The study aim was either To develop a self-report questionnaire to screen cosmetic plastic surgery patients for psychological problems. To use 1 or more validated self-report questionnaires to screen patients for underlying mental health concerns and use the results to decide whether to proceed with surgery or to refer for psychological assessment. One reviewer extracted data from publications that met the eligibility criteria, and the second reviewer confirmed the extracted information. Information extracted from each study meeting the eligibility criteria included location of the research, sample demographics, cosmetic procedures being pursued, history of prior psychiatric diagnosis, proportion of patients referred for psychological assessment, and constructs measured. From 1521 articles identified in the initial literature search, the full text of 100 potentially relevant publications was examined. Six of these publications were found to meet the inclusion criteria. These articles described either the development of a new self-report questionnaire or the use of validated self-report questionnaires to screen aesthetic surgery patients for psychological issues prior to treatment, with the aim of referring for psychological assessment, if necessary. Results Each of the 6 studies examined in the final literature review is described below. The publications by Harris and Carr (2001) and Carr (2005) describe the development and validation of a new self-report questionnaire for use as an outcomes tool with the potential for use as a screening measure. For the other 4 articles that describe the use of validated self-report questionnaires to screen aesthetic surgery patients for psychological issues prior to treatment, additional information such as patient characteristics, cosmetic procedures, constructs measured, and proportion of patients referred for psychological evaluation is provided in Tables 2 and 3. Harris and Carr (2001) 10 and Carr (2005) 11 Based on evidence suggesting higher-than-expected patient-reported distress and dysfunction following cosmetic surgery, these authors from the United Kingdom sought to address the need for a valid and reliable selfreport measure to assess emotional and behavioral problems in cosmetic surgery patients. The first study 10 described the development of the Derriford Appearance Scale 59 (DAS59), comprising a series of 59 statements and questions that measure general, social, facial, and sexual and bodily self-consciousness of appearance, as well as negative self-concept and general feelings of irritability and hostility (eg, How irritable do you feel? ). Overall, 57 of the items measured psychological distress and dysfunction, and 2 items assessed physical distress and dysfunction. Data were collected for 3 groups: 1474 preoperative and postoperative plastic surgery patients

3 154 Aesthetic Surgery Journal 33(1) Table 2. Population Characteristics and Cosmetic Procedures by Study and Instrument When Used for Screening, Where Reported Study [Instrument] Patient Characteristics Thomas et al (2001) 3 [Prime-MD] Kellett et al (2008) 13 [ Multiple Instruments a ] Hayashi et al. (2007) 14 [Hamilton Depression Scale, Anxiety and Depression Subscales] Honigman et al. (2011) 16 [PreFACE] Sample size, No Mean age, y Country United States United Kingdom Japan Australia Sex Male Female Facial cosmetic procedure Rhinoplasty Cosmetic dentistry/osteotomy Facelift Blepharoplasty Otoplasty Skin resurfacing/dermabrasion Forehead lift Cheek/chin implants Submental liposuction Injectable fillers Peels Cosmetic procedure (nonfacial) Breast reduction Breast augmentation Abdominoplasty Body contouring Foreign body removal Prior psychiatric diagnosis Major depressive disorder Dysthymia Obsessive compulsive disorder Generalized anxiety disorder Patients referred for psychological assessment, % NA Abbreviation: NA, not applicable. a Brief Symptom Inventory, Beck Depression Inventory II, Inventory of Interpersonal Problems, Body Dissatisfaction Scale, and Experience of Shame Scale.

4 Wildgoose et al 155 Table 3. Constructs Measured in Each Study Used for Population Screening Study [Instrument] Constructs Thomas et al. (2001) 3 [Prime-MD] Kellett et al. (2008) 13 [Multiple Instruments a ] Hayashi et al. (2007) 14 [Hamilton Depression Scale, Anxiety and Depression Subscales] Honigman et al. (2011) 16 [PreFACE] Psychiatric disturbance Anxiety Depression Self-esteem Investment in physical appearance Body image/shame Satisfaction with appearance Interpersonal difficulties a Brief Symptom Inventory, Beck Depression Inventory II, Inventory of Interpersonal Problems, Body Dissatisfaction Scale, and Experience of Shame Scale. with problems of appearance related to congenital malformations, trauma, aging, or self-assessed disproportionate features, 473 individuals recruited from the general population who were concerned about their appearance, and 528 individuals recruited from the general population who were not distressed with their physical appearance. The psychometric development study 10 showed that the DAS59 has good internal consistency and test-retest reliability. The authors suggested that their self-report measure was user friendly, simple to administer, and easy to score and would be clinically useful to identify patients who are dissatisfied despite the clinical outcomes, as well as to establish new treatment regimens such as potentially necessary psychological interventions in combination with surgery. Although not developed specifically for screening, the authors suggested that their tool could be used for that purpose. From the DAS59, the authors then developed a shorter, 24-item version called the DAS24, which measures distress in living with problems of appearance in reconstructive plastic surgery patients and in patients distressed by facial aging. 11 Thomas et al (2001) 3 Thomas et al 3 evaluated the usefulness of a standardized diagnostic psychiatric screening tool, Prime-MD, in a sample of 53 female and 22 male facial plastic surgery patients recruited from private practice and academic centers in the United States. Prime-MD is a valid and useful instrument developed for use in primary care to identify patients with psychiatric disorders. 12 On the basis of the yes/no answers given by patients, a physician can identify patients at risk for 16 possible psychiatric conditions, including mood disorders, anxiety disorders, eating disorders, somatoform disorders, and alcohol abuse/dependence. The physician then uses a clinical evaluation guide to follow up on positive answers. Thomas and colleagues evaluated the utility of Prime-MD as a tool for screening patients with psychiatric disorders seeking aesthetic procedures. Using Prime-MD, 9.3% of patients were diagnosed with a psychiatric disorder but only 42.8% of those patients received a psychiatric referral by the surgeon. The authors noted that Prime-MD was limited by the fact it only screened for a limited number of psychiatric conditions, missing some conditions that tend to be prevalent in plastic surgery patients (eg, body dysmorphic disorder). They also pointed out that many plastic surgery patients have inappropriate expectations, rather than psychiatric issues. The authors suggested that Prime-MD could be of value in a facial plastic surgery practice as a supplement to the standard physician interview. Kellett et al (2008) 13 Kellett et al 13 conducted preoperative psychological screening of cosmetic patients using clinical interviewing and validated self-report measures to identify those who require psychological therapy prior to, or instead of, surgery. This study was conducted in the United Kingdom and included 64 females: 23 seeking breast augmentation, 23 requesting breast reduction, and 18 seeking abdominoplasty. Mental health was assessed using the Brief Symptom Inventory, the Beck Depression Inventory II, and the Inventory of Interpersonal Problems. In addition, all patients completed validated measures of body image using the Body Dissatisfaction Scale, which classifies body dissatisfaction as minimal, moderate, marked, or extreme, and the Experience of Shame Scale, which measures characterological, behavioral, and bodily shame. In total, 42.3% of the 64 screened participants were recommended

5 156 Aesthetic Surgery Journal 33(1) to receive psychological therapy prior to, or instead of, cosmetic surgery. Despite the concomitant use of a clinical interview and patient observation to produce a reasonable opinion, a methodological concern of this study was the potential overreporting of the degree of psychological distress on self-report measures, since the women may have mistakenly thought this might improve their chances of receiving a cosmetic procedure. In addition, the use of these scales for psychological screening may be limited by the inefficiency of administering multiple questionnaires, the possibility of overlooking issues relevant to patients by limiting patient information to a specific number of instruments, and the costs associated with the copyrights to administer and score multiple questionnaires. Hayashi et al (2007) 14 Hayashi et al 14 from Kitasato University School of Medicine, Kitasato, Japan, conducted a study that involved screening 140 patients (16 male and 124 female) for psychiatric symptoms prior to undergoing cosmetic surgery to prioritize preoperative psychiatric treatment. A cosmetic surgeon interviewed all patients in the presence of a psychiatrist, and patients completed 2 subscales (depression and anxiety) of the Hamilton Depression Scale. Among 140 patients, 60 (43%) were thought to be at risk of having a psychiatric disorder. Following patient interviews, 45 (32%) patients were diagnosed with a psychiatric disorder based on the fourth edition of the Diagnostic and Statistical Manual on Mental Disorders, 15 including diagnoses of body dysmorphic disorder and depression. Of those diagnosed with a psychiatric disorder, 16 still underwent surgery, whereas 9 patients (20%) chose to pursue psychiatric treatment instead. As suggested by Hayashi et al, a limitation of this study could have been psychiatrist bias in diagnosing patients with a psychiatric disorder because of their perception that many cosmetic surgery patients have specific psychiatric disorders. The authors also emphasized the need for a screening test that is easy to administer and better accepted by the patients, due to apparent patient discomfort during the interview process. Honigman et al (2011) 16 Most recently, Honigman et al 16 developed the PreFACE, a brief preoperative psychological screening measure for use by cosmetic surgeons and dentists. Eighty-four male and female patients seeking elective cosmetic facial procedures or cosmetic dentistry in Australia completed a pre- and postprocedure questionnaire composed of a subset of items from the following validated questionnaires: the General Health Questionnaire 30, Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, Dysmorphic Concerns Questionnaire, and Multidimensional Body-Self Relations Questionnaire. These measures were chosen because they evaluate many of the psychosocial characteristics of patients thought to be dissatisfied with the outcome of their cosmetic procedures. Eight items from the administered preoperative questionnaire, including items derived from the above-mentioned validated questionnaires as well as items derived from questions evaluating psychosocial characteristics thought by the authors to be associated with poor outcomes, were chosen for inclusion in the PreFACE. The ninth and final item on the PreFACE, dissatisfaction with previous cosmetic surgical procedures, was an item included on the administered postoperative questionnaire. It was not derived from a preexisting instrument, and no explanation regarding its derivation was provided. The authors therefore used data collected in their study to identify a total of 9 items for inclusion in the PreFACE. The PreFACE uses a scoring system that ranges from 0 to 28, with higher scores indicating a higher potential for postoperative dissatisfaction. The authors recommended preoperative psychological counseling for patients who scored 11 or more. Although the development process for the PreFACE was well described, the validity of summing together scores taken from measures that assess a range of different constructs is not well described in the literature; the authors themselves recommend that the PreFACE be validated using larger samples. Discussion Cosmetic procedures for the enhancement of physical appearance are becoming increasingly popular. However, as many as half of patients who seek elective cosmetic surgery may have important psychiatric health issues. To achieve the goal of cosmetic treatments, it is necessary to preidentify patients with psychological issues and those with inappropriate expectations and/or motivations for surgery, since many of these patients are at risk of experiencing increased psychological distress related to their appearance, regardless of the outcome of cosmetic procedures. In the 6 studies included in our review, a range of different questionnaires were used to measure primarily psychiatric conditions or symptoms, with the intention of referring for psychological assessment as necessary. We found 3 questionnaires developed specifically for use with plastic surgery patients. The DAS59 and its short form, the DAS24, were primarily developed for use as outcome tools; however, the authors suggested that the DAS59 could also be used to screen for patients who may require psychological intervention. In the literature, studies to date have mainly used the DAS59 to measure perioperative psychological distress with appearance, rather than for psychological screening with the intent to refer. The third measure, the PreFACE, is a composite scale that borrowed items from 5 preexisting instruments. However, this scale is limited by a lack of qualitative interviewing to ensure that the content of the scales from which the PreFACE is derived is relevant to the cosmetic surgery patient population. In addition, the psychometric properties of the resulting composite PreFACE scale were only examined in a small cosmetic surgery population.

6 Wildgoose et al 157 Other measures, which have not specifically been designed for use with patients seeking cosmetic procedures, have been developed to assess psychological symptoms in other populations. For example, Prime-MD was developed for use in primary care to identify patients with psychiatric disorders. Although it was not developed for the cosmetic population, it was used in the study by Thomas et al 3 to screen for 16 different psychiatric illnesses in cosmetic patients. Our literature search did not reveal any studies that use other measures of depressive symptoms, such as the Beck Depression Inventory, for cosmetic patient screening purposes. Between the studies performed by Kellett et al (2008) and Honigman et al (2011), a battery of questionnaires were used to screen patients. Our team identified several limitations related to the choice and use of multiple instruments in these studies. Most of the questionnaires used to screen cosmetic surgery patients were neither developed for, nor validated within, a sample of cosmetic surgery patients. Psychometric testing to examine reliability (ie, ability to produce consistent and reproducible scores) and validity (ie, ability to measure what is intended to be measured) is needed for each application of an instrument to a new population or setting. The use of so many different instruments to screen cosmetic surgery patients suggests a lack of consensus about which instruments are most appropriate. In addition, the various instruments chosen measure different health concerns of patients (eg, anxiety, depression, self-esteem, body image, body dysmorphic disorder), but not all studies measured all of these concerns. This suggests a lack of consensus on which symptoms should be included within a cosmetic surgery screening process. Finally, the use of a battery of instruments to measure the range of symptoms considered to be important for screening patients is simply not practical in a clinical setting (eg, too costly, too time-consuming, difficult to score). A potential limitation of our review is that our search strategy may have failed to capture studies that included scales that are, in fact, used routinely as screening tools by some physicians. In addition, our search strategy excluded studies that used the same self-report questionnaires as those included in our study (as well as different questionnaires with similar content) when those questionnaires were used to measure and describe symptoms and/or traits in a sample rather than to make decisions about whether to refer research subjects for psychological assessment. Indeed, a wide variety of scales have been used in plastic surgery research to measure a range of symptoms and patient characteristics (eg, self-esteem, body image concerns, and symptoms of depression, anxiety, body dysmorphic disorder) Sarwer and colleagues have made a substantial contribution to this body of literature What our review has clarified is the lack of a purposely designed self-report questionnaire that covers the main symptoms identified as being important to preoperative screening. A scientifically sound and clinically meaningful instrument is needed to properly assess cosmetic surgery patients prior to surgery, one that can identify not only psychological distress but also inappropriate expectations and/or motivations in these patients. Such a measure should be developed from qualitative interviews with cosmetic surgery patients in addition to a literature review and expert input from health care professionals who work with this patient population. Modern psychometric methods such as Rasch analysis and item response theory should be applied to produce a valid and reliable measure with improved accuracy that can be used in both research and routine clinical practice for measuring the outcomes of individual patients. 39,40 The questionnaires we identified through our literature search were developed using traditional psychometric methods. Such measures can be used only for group-level research. We therefore do not recommend their use as clinical measurement tools for individual patients. 40 Our team has completed qualitative interviews with a large sample of facial aesthetic surgery patients and has developed items and scales for use with individual patients preoperatively. We are now field-testing these scales as part of the development of the FACE-Q, a patient-reported outcome measure for facial cosmetic surgery patients. 41 As a component of the FACE-Q, screening scales used in combination with patient outcome measures will allow physicians to elucidate the relationship between individual patients preoperative expectations and/or motivations and postoperative satisfaction and health-related quality of life. Conclusions A preoperative assessment tool designed to help plastic surgeons efficiently make sound decisions regarding patient eligibility for aesthetic procedures would benefit both physician and patient. For the patient, preoperative assessment may encourage clarification of expectations and motivations and help the patient make an informed decision. In addition, it should reduce the number of dissatisfied patients whose psychological issues only emerge or intensify following surgery. Overall, such preoperative screening may better ensure the ethics, effectiveness, and safety of the cosmetic procedures provided. 13 Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References 1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank Statistics

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