The American Society of Plastic Surgeons reports a surge in interest in cosmetic plastic surgery since the COVID-19 pandemic led many people to video calls and made them hyper-aware of their own appearance.
In 2015, the Cosmetic Physicians College of Australasia found Australians were spending more than $1 billion a year on noninvasive cosmetic procedures such as Botox and fillers. This is more than 40 percent higher, per capita, than in the United States.
In the United States, where procedure statistics are reported, there was a 42 percent increase in the number of filler procedures and a 40 percent increase in Botox procedures in 2021 compared to 2020.
Rates of mental health issues in this group may be higher than in the general population, but, seemingly, not enough is being done to ensure the psychological safety of people requesting cosmetic procedures.
Body Dysmorphic Disorder
Body image concerns are generally the main motivator for seeking cosmetic procedures of all kinds. These concerns are usually focused on the body part where cosmetic intervention is sought, such as the nose for a rhinoplasty.
Severe body image concerns are a key feature of several mental health conditions. The most prevalent in people seeking cosmetic procedures is body dysmorphic disorder. In the general community, around 1 to 3 percent of people will experience body dysmorphic disorder, but in populations seeking cosmetic surgery, this rises to 16 to 23 percent.
Body dysmorphic disorder involves a preoccupation or obsession with one or more perceived flaws in physical appearance that are not visible or seem minor to other people. In response to the distress regarding the flaw, the person with body dysmorphic disorder will perform repetitive behaviors (such as excessively checking body parts in the mirror) and mental acts (such as comparing their appearance with other people).
These concerns can have a significant negative effect on the person’s daily life, with some people too distressed to leave their home or even eat dinner with family members out of fear of being seen by others.
With the distress associated with body dysmorphic disorder seemingly stemming from physical appearance issues, it makes sense that someone with body dysmorphic disorder is far more likely to turn up at a cosmetic clinic for treatment than a mental health clinic.
The problem is, cosmetic intervention usually makes the person with body dysmorphic disorder feel the same or worse after the procedure. They may become even more preoccupied with the perceived flaw and seek further cosmetic procedures.
Patients with body dysmorphic disorder are also more likely to take legal action against their treating cosmetic practitioner after believing they have not received the result they wanted.
For these reasons, body dysmorphic disorder is generally considered by health professionals to be a “red flag” or contraindication (a reason not to undergo a medical procedure) for cosmetic procedures.
However, this is not entirely clear-cut. Some studies have shown that people with body dysmorphic disorder can improve their symptoms after cosmetic intervention, but the obsession may just move to another body part and the body dysmorphic disorder diagnosis remains.
What About Other Mental Health Conditions?
Body dysmorphic disorder is by far the most well-studied disorder in this area, but is not the only mental health condition that may be associated with poorer outcomes from cosmetic procedures.
According to a recent systematic review, the rates of depression (5 to 26 percent), anxiety (11 to 22 percent) and personality disorders (up to 53 percent) in people seeking cosmetic surgery may be higher than in the general population (which are estimated to be 10 percent, 16 percent, and 12 percent, respectively).
However, these rates should be interpreted with some caution because they depend greatly on how the mental health diagnosis was made. Clinician-led interviews result in higher rates while mental health questionnaires result in lower rates. Some interview approaches can suggest higher rates of mental health issues as they may be quite unstructured and thus have questionable validity compared with highly structured questionnaires.
Besides body dysmorphic disorder, the research investigating other mental health conditions is limited. This may just be due to the fact that body image focus is at the core of body dysmorphic disorder, which makes it a logical focus for cosmetic surgery research compared with other types of psychiatric disorders.
So What Should Happen?
Ideally, all cosmetic surgeons and practitioners should receive sufficient training to enable them to conduct a brief routine assessment of all prospective patients. Those with signs indicating that they are unlikely to derive psychological benefit from the procedure should undergo a further assessment by a mental health professional before undergoing the procedure.
This could include an in-depth clinical interview about motivations for the procedure, and completing a range of standard mental health questionnaires.
If a person was found to have a mental health issue in the assessment process, it doesn’t necessarily mean the mental health professional would recommend against pursuing the procedure. They may suggest a course of psychological therapy to address the issue of concern and then undergo the cosmetic procedure.
At the moment, assessments are only recommended rather than mandated for cosmetic surgery (and not at all for injectables like Botox and fillers). The guidelines say evaluation should be undertaken if there are signs that the patient has “significant underlying psychological problems.”
This means we are relying on the cosmetic medical practitioner being capable of detecting such issues when they may have received only basic psychological training at medical school, and when their business may possibly benefit from not attending to such diagnoses.
An August 2022 independent review by the Australian Health Practitioner Regulation Agency and the Medical Board of Australia recommended that the guidelines around mental health assessment should be “strengthened” and emphasized the importance of medical practitioners receiving more training in the detection of psychiatric disorders.
The American Society of Plastic Surgeons also identifies body dysmorphia as a primary concern among plastic surgeons.
Ultimately, as cosmetic practitioners are treating patients who are seeking treatment for psychological rather than medical reasons, they must have the well-being of the patient front of mind, both out of professional integrity and to protect themselves from legal action. Mandatory evaluation of all patients seeking any kind of cosmetic procedure would likely improve patient satisfaction overall.
If this article has raised issues for you, or if you’re concerned about someone you know, visit the Butterfly Foundation or call the national helpline on 1800 33 4673.
Gemma Sharp is an NHMRC early career senior research fellow at Monash University in Australia, and Nichola Rumsey is an emeritus professor of psychology at the University of the West of England in the UK. This article is republished from The Conversation.