While body image dissatisfaction may motivate the pursuit of cosmetic medical treatments, psychiatric disorders may be relatively common among patients seen in dermatologic settings.
Clinicians who acquire a basic understanding of common psychiatric conditions can properly screen their patients.
Body dysmorphic disorder (BDD) patients seek out cosmetic medical treatments with great frequency. It is therefore important for dermatologists to be educated in BDD and be able to recognize it before unnecessary procedures are performed.
The dermatologist should be wary of the patient that has come severely depressed or on an impulse for they may have mood disorders that mainly encompasses two categories: unipolar depression and bipolar disorder.
Personality disorders may cause difficulties in maintaining a healthy doctor-patient relationship due to poor compliance, communication skills and trust issues.
Anxiety disorders may cause concerns for a dermatologist, especially since they can commonly occur along with other mental illnesses.
Evaluating a patient’s psychological condition is essential since every patient is not an appropriate candidate for cosmetic procedures.
The exam should also include a thorough review of the patient’s family and medical histories, as well as past treatments, outcomes and complications.
Patients should be able to express how they feel about their appearance and why they are considering the procedure.
Laser therapy is very effective when treating children and teens, but the laser team must be prepared to deal with psychological issues of both the patient and parents.
Body image dissatisfaction may motivate the pursuit of cosmetic medical treatments. psychiatric disorders characterized by body image disturbances, such as BDD, mood, anxiety, and personality disorders, are relatively common among these patients. Understanding of psychiatric issues in laser surgery becomes important and may prevent potential problems. Embarrassment and shame often prevent sufferers from revealing their true degree of distress, not only to their family and peers, but to healthcare professionals as well. |
Introduction
Cosmetic treatments have become increasingly popular over the past decade with the advent of new techniques and devices, such as lasers. According to recent statistics released by the American Society for Aesthetic Plastic Surgery (ASAPS), there were nearly 11.5 million surgical and nonsurgical cosmetic procedures performed in the United States in 2006. The majority were nonsurgical with over 2.2 million laser procedures performed for hair removal, skin resurfacing and treatment of leg veins. Approximately 93% of laser skin resurfacing procedures were performed with non ablative techniques.1
The increase in popularity may be attributed to several factors including the perception that a better appearance will lead to happiness and success, the greater availability of safer, minimally invasive procedures, and amplified mass media attention.2
The media has showered the American public with shows and information that glamorizes cosmetic enhancement. The constant exposure to images of what culture claims to be ideal may drive individuals to achieve unrealistic appearance standards. Physical attractiveness is often attributed with a sense of confidence and better self-esteem. A person whose appearance falls below the contemporary aesthetic standards runs the risk of being the target for prejudice and discrimination.
Health professionals have long been interested in understanding the motivations for seeking a change in physical appearance as well as the psychological outcomes of these treatments.2 The earliest documented studies of the psychological characteristics of cosmetic surgery patients occurred during the 1950s and 1960s. They reported high rates of psychopathology, up to 70%, among cosmetic surgery patients.3
Additionally, available data suggests that psychological complications occur at higher rates than do physical complications in plastic surgical practices. Though surgical site pain and sleep disturbance were frequent physical complaints, depression and anxiety were the most prevalent post surgical complications. Patients with pre-existing psychological conditions were even at greater risk for such outcomes. This leads to delayed recuperative time, poor patient compliance, anxiety, dissatisfaction of the procedure, and hostility toward the clinician.4
Although laser surgery can be used for medical purposes such as port wine stains and hemangiomas, many laser procedures are performed for aesthetic enhancements. The focus of this chapter will be on the psychological issues associated with the latter. To date, there is minimal data published on the psychological aspects of laser surgery specifically, but there is a growing interest in psychiatric issues surrounding the practice of cosmetic procedures.
While body image dissatisfaction may motivate the pursuit of cosmetic medical treatments, psychiatric disorders characterized by body image disturbances, such as BDD, mood, anxiety, and personality disorders, may be relatively common among these patients. Therefore an understanding of psychiatric issues in laser surgery becomes important and may prevent potential problems.
Evaluation of the Patient
Evaluating a patient’s psychological condition is essential. Some patients may have significant emotional and psychological instability and therefore are not suitable candidates for cosmetic laser treatment. Using a consistent screening method may help identify appropriate and inappropriate patients for such procedures (see Table 1).
Table 1
General psychiatric features to asses during initial evaluation
Considerations | Possible causes | |
|---|---|---|
General appearance | Is the patient’s dress provocative and alluring? | PD or mania |
Mood/affect | Is there a flat affect? Are they overly emotional? Are they paranoid or suspicious of you? Do they avoid eye contact? Are they cooperative or oppositional? Are they overly anxious? | Depression, PD, or mania BDD, PD, or depression |
Speech | Is the voice monotone or easily excitable? Is there pressured speech? Is there latency of response? | PD or mood disorder Mania depression |
Thought process | Is there tangibility or flight of ideas? | Psychosis or mania |
Cognition | Can they make rational decisions independently? What are their expectations of the outcome of procedure? Are they insightful? |
Consider the patient’s general appearance, demeanor and behavior, is there intense sadness or despair, inappropriate seductiveness? Are symptoms of rapid speech and euphoria present? Are they extremely critical of their self-image, despite the fact there may be no noticeable disfigurement or defect? Deciding to pursue a cosmetic procedure on a whim may denote a manic impulse, or an excessive need for approval may indicate a BDD patient. Subtle signs like these may suggest the patient’s true motives and conditions. There may be baseline patient anxiety on any initial cosmetic consultation but spending time and communicating with the patient should ease such apprehension.
The psychological assessment should also include a thorough review of the patient’s family, medical, and surgical histories. Some psychological disabilities tend to run in families and evidence of multiple cosmetic enhancements may insinuate a patient suffering from BDD. Reviewing their medication list may allude to various medical conditions.
It is crucial that a thorough history also include all past consultations, treatments, outcomes and complications. A history of multiple physicians treating the same problem, or patients who claim they usually suffer from multiple complications or prolonged postoperative course should alert the practitioner that this patient may be challenging to satisfy. Indeed, many patients with psychiatric illness are still well suited for cosmetic measures and benefit from it, but it is important to recognize those patients that have unrealistic expectations of what cosmetic procedures can achieve.
Factors to Consider
A patient who speaks poorly of previous physicians will often be disappointed with all of their subsequent treatments and physicians. Anticipating potential troubles should help minimize or avoid prospective dilemmas and anxiety in one’s practice.
It is advantageous for the physician to listen to the concerns of nursing staff who take care the patient. The patient may be very unreasonable or unruly with the staff but appear very well-mannered and respectful in front of the physician. In such instances, it is important to re-evaluate the patient before proceeding with cosmetic procedures because such finicky behavior can be very detrimental to the doctor-patient relationship and to the doctor-staff dynamics in the future.
Furthermore, it is vital that there is a clear understanding of exactly what the patient expects of the procedure and a detailed discussion on the fine points of a procedure, such as its risks and possible outcomes. Patients who continue to ask, “But I will get results, won’t I?” or “But I won’t have any complications, right?” will maintain their unrealistic expectations, and in such cases a consultation with another physician may be preferred.
Be aware of patients who are unable to verbalize their cosmetic issue or those that say “I just want to look younger,” or “I just want to look better.” They may be difficult patients to achieve good satisfaction since they frequently will be discontent with the results and even declare that the procedure made them look worse. Similarly, the patient who tries to isolate the smallest little scar or wrinkle that is so vague and challenging to find will usually be dissatisfied with the treatment. Occasionally, a patient may demand one particular treatment and be unwilling to consider other options suggested by the physician. This may give rise to unhappy outcomes or unforeseen complications that could have been avoided.
The physician should recognize one’s own personality, strengths, and style. Some patients are excellent candidates for cosmetic treatments but may simply fare better with a different physician. Suggesting that a patient get a second consultation with a colleague for another opinion may be beneficial in such circumstances. Patients will usually respect your honesty and the fact that you truly value their welfare.
First impressions often prove useful for gauging the suitability of a cosmetic procedure, but cannot guarantee proper patient selection. Therefore, a thorough medical history, including a psychological assessment should help the physician recognize appropriate patients and avoid certain predicaments. In certain circumstances, a referral to a mental health professional may be warranted if a psychological comorbidity is noted that fosters an unhealthy communication and relationship between the patient and treating physician.
The following is a central description of select psychiatric disorders that may be encountered during an initial consultation for laser cosmetic surgery. Recognizing the presence of such conditions will allow for appropriate treatment.
Body Dysmorphic Disorder
BDD is a psychological condition that involves a preoccupation with a perceived physical defect.5 Any body parts could be the focus of their obsession. most sufferers are concerned about their face and skin problem such as hair thinning, acne, wrinkles, scars, and vascular markings. They may be troubled about a lack of symmetry or disproportionate body size.6
Individuals with BDD experience anxiety, shame, and depression about their appearance and much of their self-worth is related to how they feel about their body. The preoccupations with an imaginary flaw are difficult to control. The repetitive behaviors may take many hours per day and usually provide very temporary psychological relief.6,7 Such behaviors may include frequently checking their appearance in mirrors or reflective surfaces, elaborate grooming rituals, refusing to take pictures, wearing excessive makeup or clothing to conceal the perceived flaw, comparing their appearance with that of others, and asking for reassurance from others related to the imagined defect.7
Many sufferers with BDD may pick their skin or aggressively seek unnecessary and excessive medical procedures, in an attempt to correct what they consider to be an imperfection. Such attempts usually yield dissatisfaction and may even worsen the person’s perception of the flaw, not to mention the increased risk of health complications.7
Avoiding social situations is common among individuals with BDD because they tend to feel anxious and self-conscious around others (social phobia) where their perceived flaw might be noticed. This can cause high levels of occupational and social impairment including unemployment, absenteeism, and relational or marital problems.7 In the most severe cases, BDD may keep them housebound.
Patients with BDD are more prone to major depression. Phillips et al. noted8 that in clinical settings, 60% of patients with BDD have major depression and the lifetime risk for major depression in these patients is 80%. Patients with these comorbidities are at risk for suicide. Nineteen percent of BDD sufferers reported suicidal ideation while 7% had attempted suicide according to one study.9
Patients with BDD may not respond to all treatments for depression and may instead respond preferentially to serotonin-reuptake inhibitors.8 In addition, lengthier treatment trials than those required for depression may be needed to successfully treat BDD and comorbid depression.
The cause of BDD is still unclear, but several contributing factors appear to play a role in the development of BDD, which also might vary for each individual. There may be a genetic predisposition, as it tends to run in families. Additionally, the family environment and cultural influences during early development may be important in shaping body image.7 Some evidence suggests a neurochemical deficiency of serotonin may provoke BDD, since selective serotonin reuptake inhibitors (SSRIs) improves the condition.10
The onset is usually during adolescence and may be gradual or sudden. Preliminary estimates suggest that BDD may be quite common, with a rate of 1–2% in the general population.6 It occurs as frequently, if not more, in men than women.
Embarrassment and shame often prevent sufferers from revealing their true degree of distress, not only to their family and peers, but to healthcare professionals as well. This makes BDD extremely difficult to diagnose, and even misdiagnosed as obsessive compulsive disorder and/or social anxiety disorder. It is therefore important for dermatologists to be educated in BDD and be able to recognize it before unnecessary procedures are performed. Dr. Katherine Phillips, author of The Broken Mirror 7 and expert in the field of BDD, has developed a Body Dysmorphic Disorder Questionnaire (BDDQ) that may make a rapid and useful in-office screening tool (see Table 2).
BDD questionnaire |
|---|
1. Are you very concerned about the appearance of some part(s) of your body that you consider unattractive? If you answered “YES”: Do these concerns preoccupy you? That is, do you think about them a lot and wish you could think about them less? (If you answered “NO” to the above questions, then you are finished with this questionnaire) 2. Is your main concern with your appearance that you are not thin enough or that you might become too fat? 3. What effect has your preoccupation with your appearance had on your life? A. Has your defect(s) caused you a lot of distress, torment, or pain? B. Has it significantly interfered with your social life? C. Has the defect(s) significantly interfered with your school work, your job, or your overall ability to function? D. Are there things you avoid because of your defect(s)? E. Have the lives or normal routines of your family or friends been affected by your defect(s) 4. How much time do you spend thinking about your defect(s) per day on average? A. Less than 1 h a day B. 1–3 h a day C. More than 3 h a day It is probable that you have body dysmorphic disorder if you answered “YES” to both parts of question 1, “YES” to any of the questions for question 3, and answered “B” or “C” for question 4 |
Dermatologists may often be the first physicians to see BDD patients since many of them focus on their skin, hair and body size.6 The prevalence of patients with BDD in dermatology offices ranges from 8% to 12%, and they seek out cosmetic medical treatments with great frequency.11,12 According to one study, 76% of 289 BDD patients had sought cosmetic enhancement and that 66% did receive treatment for their perceived defects.13 However, the exact frequency of sufferers with BDD seeking laser treatments is unknown.
BDD sufferers can be difficult patients for dermatologists to treat. Being sympathetic to their urges of cosmetic enhancement will not alleviate their obsession and often BDD patients insist on repeated procedures.14 Patients diagnosed with BDD should receive consultation with a psychiatrist or psychologist. Psychiatric/psychological treatment often improves BDD symptoms and the suffering it causes. The treatments that appear most effective are SSRIs, as mentioned previously, and a type of therapy known as cognitive-behavioral therapy (CBT).10 SSRIs can significantly diminish bodily preoccupation, depression and emotional distress, often improving daily functioning.8,15 They can also significantly increase control over one’s thoughts and behaviors.
When used by trained therapists, CBT substantially improves BDD symptoms in a majority of people, diminishing preoccupations with their appearance and compulsive behaviors, depressive symptoms, and anxiety, and improving body image and self-esteem. Methods include systematic desensitization, exposure techniques, self-confrontational techniques, and cognitive imagery.6,8,10
For further resources of information on BDD, see Table 3.
Table 3
Body dysmorphic disorder resources
Resources on body dysmorphic disorder |
|---|
Internet resources: http://www.bodyimageprogram.com (last accessed 11/28/07) http://www.bddcentral.com (last accessed 11/28/07) |
Books: The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Phillips KA. New York: Oxford University Press; 1996 The Adonis Complex: The Secret Crisis of Male Body Obsession. Pope HG, Phillips KA, Olivardia R. New York: The Free Press; 2000 |
Mood Disorders
Mood disorders mainly encompass two categories: unipolar depression (in this case focusing on major depression) and bipolar disorder.
Major Depression
Patients may develop exaggerated physical complaints when suffering from major depressive episodes. These can include changes sleep, interest, guilt, energy, concentration, appetite, psychomotor with suicidal ideation and overwhelming sadness. Major depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), manifests with at least five of the nine symptoms, one being a depressed mood or loss of interests/pleasure, present daily for a minimum of 2 consecutive weeks.5 (see Table 4).
Table 4
Major depression criteria5
Major depression criteria |
|---|
A. Five or more of the following symptoms have been present nearly every day for at least 2 weeks and represents a change from previous functioning (Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations) At least one symptom is: (a) Depressed mood (b) Loss of interest or pleasure in nearly all activities Other symptoms may include: (a) Significant weight loss while not dieting, weight gain, or decrease or increase in appetite (b) Insomnia or hypersomnia (c) Psychomotor agitation or retardation (d) Fatigue or loss of energy (e) Feelings of worthlessness or excessive or inappropriate guilt (f) Diminished ability to think or concentrate, or indecisiveness (g) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a mixed episode C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The symptoms are not due to the direct physiological effects of substance or a general medical condition E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation |
There are several subtypes of major depression, such as major depression with psychotic features and seasonal affective disorder (SAD). In major depression with psychosis, patients develop hallucinations, delusions and even paranoia.5 While individuals with other mental illnesses, like schizophrenia, also experience these symptoms, those with psychotic depression are usually aware that these thoughts aren’t true. They may be ashamed and try to hide them, sometimes making this variation difficult to diagnose. Risk of suicide is high among these patients. Patients with SAD have recurrent major depressive episodes in a seasonal pattern. The most common type of SAD usually begins in late fall or early winter and goes away by summer. SAD may be related to changes in the amount of daylight during different times of the year and therefore may respond to light therapy in addition to, or instead of, psychotherapy or medications.16
Patients with depression may have vague requests regarding the desired cosmetic results and request cosmetic treatment only to feel better rather than correct a physical imperfection. As mentioned previously, they also tend to have delayed recuperative time, poor patient compliance, and dissatisfaction of the procedure.4
The prevalence of major depression of those seeking cosmetic enhancement is unknown. Nonetheless, the prevalence of major depression in the general population is approximately 3–5% in males and 8–10% in females.17–19
Rates of depression are increased in patients with most major chronic medical and neurological disorders.20–23 The prognosis of depression is worsened by the presence of significant medical comorbidity.
A dermatologist should keep in mind that a patient with BDD may simply present with depression therefore concealing the underlying condition.7
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