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Practice Points
15 (
3
); 330-331
doi:
10.4103/JCAS.JCAS_195_20

Role of Psychological Assessment in Aesthetic Procedures

Department of Dermatology, Apollo Clinic Newtown, Kolkata, West Bengal
Department of Dermatology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India

Address for correspondence: Dr. Nidhi Jindal, Department of Dermatology, Apollo Clinic Newtown, Tower 1, 16 B, Rosedale Garden, Newtown, Kolkata 700156, West Bengal, India. E-mail: skinspeaks1@gmail.com

Licence

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Disclaimer:
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The psychology behind an aesthetic procedure needs to be understood and assessed by the attending cosmetologist for the satisfactory outcome of the procedure. Being alert about certain psychiatric conditions can help in deferring certain procedures, which prevent us from correcting something that is actually not required and will protect us from future trouble. The incorporation of the user-friendly body dysmorphic disorder (BDD) screening questionnaire in preaesthetic procedure workup as a routine can help in excluding psychologically unstable patients, who can be a contraindication for conducting the procedure per se.

Keywords

Aesthetic procedure
body dysmorphic disorder
clinical red flag signs
psychological assessment

A global survey conducted by the International Society of Aesthetic Plastic Surgery (ISAPS) in December 2019 clearly states that cosmetic procedures are on the rise globally.[1] India ranks fourth after the United States, Brazil, and Mexico in performing cosmetic surgeries and sixth with regard to performing nonsurgical cosmetic procedures. People aspiring for drive through Botulinum toxin injections during COVID 19 in Miami[2] clearly highlight the importance of aesthetic procedures in the present world.

Various studies have shown the prevalence of BDD to be 1–3% in the general population against 7–15% among people seeking cosmetic surgeries,[3] which emphasizes the need of preprocedural psychological assessment for ideal patient selection. Unfortunately, I could not find similar statistical studies from India, despite India being among the top countries conducting these procedures. Psychological assessment will rule out BDD or other psychological conditions that might be a contraindication to aesthetic procedures. Patients seeking aesthetic treatments commonly present with psychiatric disorders, including BDD, narcissistic personality disorder (NPD), and histrionic personality disorder (HPD). NPD comprises a pervasive pattern of grandiosity (in behavior or fantasy), a constant need for admiration, lack of empathy beginning by early adulthood and present in a variety of situations such as relationships, school, work, or financial affairs. HPD is a psychiatric disorder that is distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. BDD is the condition that a cosmetologist should be aware of and will be discussed here.

BDD is an often under-recognized psychiatric disorder that is characterized by over concern with physical appearance, such that an ideal appearance becomes the overwhelming and all-pervasive concern. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) classifies BDD as an obsessive-compulsive-related disorder (OCRD) with a common age of onset between 15 and 30 years.[4] Patients with BDD visit cosmetic and plastic surgery clinics more often than psychiatrists. It is of utmost importance to assess and interpret the motive and emotional drive behind patients seeking cosmetic procedures. Cosmetologists should have an insight about the entity, as people with BDD often see their problem as cosmetic rather than psychological or psychiatric. The most common areas of preoccupations are the skin, hair, nose, eyes, eyelids, mouth, lips, jaw, and chin.

A simple psychological screening questionnaire preprocedure will help in filtering BDD among aspirants of aesthetic procedures. The BDD screening tools that have been validated to be used specifically in dermatology settings are the Body Dysmorphic Disorder Questionnaire (BDDQ), Body Dysmorphic Disorder Symptom Scale (BDD-SS),[5] Dysmorphic Concern Questions (DCQ),[5] and Body Dysmorphic Disorder Questionnaire - Dermatology version (BDDQ-DV).[5] However, the BDDQ-DV questionnaire is used most frequently among all three.[5] These tools can be used to exclude and assess BDD among aesthetic procedure aspirants. We found self-reported BDDQ an easy tool to incorporate in routine practice. Screening forms are provided by either the doctor or the counselor along with other required forms before aesthetic consultation. Form filling takes about 5–10 minutes, which includes the time required to explain the importance of the form to subjects. Close observation for clinically evident red flag signs [Table 1] can further help clinicians in diagnosing BDD among their patients.

Table 1 Clinical red flag signs of BDD
A. Related to their appearance concern
1. The cosmetic ‘defect’ is either objectively nonexistent or very minor
2. The distress and disability shown by the individual is out of proportion to the cosmetic problem in and of itself
3. The expectations of the patient toward the cosmetic procedure outcome are highly unrealistic (they have a strong belief that the cosmetic procedure will drastically change their life, such as getting a new job or partner etc)
4. The patient gives typical history of numerous cosmetic procedures done in the past with which they had not been happy and are constantly seeking revisions and/ or other procedures
5. Camouflaging perceived flaws, such as using heavy makeup, scarves, or gestures that cover their body, and having poor eye contact
6. Evidence of skin picking or other injuries from attempts to self-correct perceived flaws
7. They are always emphasizing their desire to make them like a specific person, generally a celebrity
B. Related to general behavior in clinic
1. These patients have unexpectedly demanding, aggressive, and angry behavior
2. They repeatedly seek reassurance about their looks from the clinicians and the staff
3. They ask for appointments at odd times, usually when it is dark outside
4. They always suspect others of staring, laughing at, or mocking them for their appearance

CONCLUSION

The aim of psychological assessment is to increase positive outcomes among cosmetic procedures and prevent performing such procedures in those who actually need different intervention (psychotherapy or pharmacotherapy). Screening for BDD should be considered essential before patients undergo aesthetic procedures. A positive screening does not indicate avoidance from the provider’s side but demands a proper referral to a psychiatrist if necessary. Being alert about specific psychiatric conditions can help in deferring the procedure, which can be later troublesome to both the physician and the patient. Appropriate knowledge in experienced hands can bring quintessential results only with ideal patient selection.

Learning bullets

  1. Over concern about physical concerns that are otherwise not perceived by others should raise suspicion for BDD

  2. Aesthetic aspirants should be screened for BDD

  3. Clinical red flag signs for BDD

  4. BDD screening questionnaire should be incorporated in routine aesthetic practice

  5. Positive screening needs referral

Authorship

All the authors listed have contributed substantially toward the concept, writing, and editing of the article. All authors have put in equal efforts to the literature search of the related articles and the interpretation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

  1. International Society of Aesthetic Plastic Surgery (ISAPS) . International survey on aesthetic/cosmetic procedures. Available from: www.isaps.org
    [Google Scholar]
  2. , . Florida Offers Drive-Through Botox to Quarantined Residents. Medscape. Reuters Health Information © 2020; .
  3. , , . Body dysmorphic disorder and the liposuction patient. Dermatol Surg. 2005;31:559--60; discussion 561.
    [Google Scholar]
  4. . Personality Disorders. Diagnostic and Statistical Manual of Mental Disorders (5th ed). Washington, DC: American Psychiatric Publishing Inc.; .
  5. , , , , , . Body dysmorphic disorder screening tools for the dermatologist: A systematic review. Pract Dermatol. 2015;2:44--9.
    [Google Scholar]
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