Cosmetic Surgery and Psychological Disorders

The number of cosmetic procedures in the US has dramatically increased over the last decade with an estimated 18 million undergoing surgical or minimally invasive procedures in 2018 alone. Studies have identified two primary stimuli for seeking cosmetic surgery: 1) to raise self esteem and 2) to improve image satisfaction (i.e., self image).

While these factors are both considered by the plastic surgery community to be reasonable motives, it is important to recognize the potential effect that an underlying mental health disorder such as Body Dysmorphic Disorder (BDD), a mood disorder, or a personality disorder may have on the desire to seek treatment.

Body Dysmorphic Disorder (BDD) is common among people who have an interest in plastic surgery. BDD is characterized as a preoccupation with a slight or non-observable defect in appearance that is associated with obsessive thinking and compulsive behaviors and leads to a disruption in the activities of daily life. Compared to the 1-2% prevalence of BDD in the general population, rates of up to 7-15% have been identified in the cosmetic surgery population.

The key distinguishing factor in a patient suffering from BDD is the degree of distress or impairment. Unfortunately, this can be a gray zone that is difficult for many plastic surgeons to define. In a study published in 2017, Joseph et al. examined the rates of BDD in nearly 600 patients who sought facial plastic surgery consultations over a one year period. They found that without a standardized screening tool, surgeons diagnosed only about 40% of those with BDD.

The prevalence of mood disorders is also much higher in the cosmetic surgery population. A recent study found that 44% of their patient population had suffered from a psychiatric disorder, most commonly depression and generalized anxiety disorder. Both of these conditions were found to be correlated with lower self-esteem and lower image satisfaction.

Several personality disorders are also known to be factors in the pursuit of cosmetic surgery. Narcissistic personality disorder, defined by someone's need for admiration and lack of empathy, has been found in up to 25% of people seeking cosmetic surgery, especially rejuvenation procedures. Similarly, 3-9% of cosmetic surgery patients can be categorized as having a histrionic personality disorder, which is classified as emotional excess with the need to gain the attention of others.

A degree of dissatisfaction with one’s physical appearance is a prerequisite to cosmetic surgery, and plastic surgeons are uniquely positioned to directly help with these concerns. However, we must also be prudent in considering the influence an underlying mental health disorder may have on our patients’ well-being, and it is our responsibility to refer for mental health care when there are concerns that go beyond what can be addressed by the knife and the needle.