When you are thinking of seeing a cosmetic surgeon is it something on the outside that needs to change, or something on the inside? Consultant Psychiatrist Dr Raj Persaud investigates.





Every cosmetic surgeon wants to achieve a good outcome for their clients – and cosmetic surgery requests and inquiries are going up year on year. It’s likely that in the future, the way the current trends are going, getting ‘something done’ could be the norm rather than the exception. Large numbers of us are dissatisfied with some aspect of our bodies – psychological research confirms this. If it’s impossible to produce the change we want by adopting a healthier lifestyle – if we can afford it we could try seeing an ‘aesthetic professional’. Future generations may even wonder at why there was such a taboo over the issue?


However, there are a group of people seeking surgery, often vigorously, who are unlikely to benefit, and indeed may even be made worse, in terms of their underlying psychological difficulties. It’s vital that cosmetic surgeons become more aware of this group, and learn how to detect them, as early as possible in the referral process. If this doesn’t happen, then the likelihood of a series of formal complaints, or protracted litigation, becomes the prospect. This doesn’t make economic or professional sense.


Dr Mohammad Alavi and colleagues at the Shiraz University of Medical Sciences in Iran have just published a psychological investigation into one of the largest series of patients being referred for cosmetic surgery. The study was designed to investigate the true prevalence of ‘Body Dysmorphic Disorder’ (BDD) in this population. Previous estimates have ranged as high as 20% of referrals suffering from this difficulty.


BDD is a condition that is frequently missed or mis-diagnosed. It’s often confused with social phobia, depression or somatization disorder. Patients are often extremely guarded and therefore don’t confess to others, far less clinicians the core symptoms. These are a preoccupation that a specific part of their bodies is misshapen or disfigured in some gross manner that produces revulsion in others.


They seek surgery, but because they were not viewing that part of the body more objectively, and their perception is driven by an underlying psychological problem, they are rarely satisfied with the outcome. Instead they then seek more and more surgery with results that are very disfiguring in the longer term, or they complain and begin a vendetta against the surgeon. There are several high profile examples of this predicament in the rich and famous who were unchecked in their search for surgery.


In Alavi’s study 306 patients referred to cosmetic surgery clinics were interviewed by two psychiatrists. To have such a large number being investigated so in-depth by such qualified professionals is unusual in the field. BDD was uncovered to be a relatively common disorder among individuals seeking aesthetic surgery, in particular in rhinoplasty. The authors conclude that a proper in-depth preoperative psychiatry assessment avoids subsequent risk for both patients and surgeons.


Of course the practical problem when a patient comes to see a surgeon is how do you persuade them to go and see a psychiatrist? The stigma surrounding this area of medicine means a surgeon could become an object of ire at such a suggestion and the patient may storm off to see another less rigorous colleague. As a clinician who has seen a large number of these kinds of client my experience is that firstly pointing out this is routine procedure for most if not all of such cosmetic surgery referrals is a good way of de-stigmatising the referral to a psychological professional.


And indeed it should be a routine part of the procedure.


I have seen several patients who had symptoms of BDD, but who, with the correct psychological treatment, went on to have a procedure, and had a much better outcome as a result. They may not have in the end have asked for the same operation they first presented with, but nonetheless for a determined patient, this slight re-shaping of their expectations and approach went a long way to avoiding a spiral into more and more unnecessary surgery, or ending up in litigation with their surgeon.

There are many aspects of psychology involved in the coping skills required to navigate such surgery and change to appearance, and that this is why seeing a psychological professional is routinely a good idea. This is also an aspect of practice it is probably advisable to move towards. After all, the key moment that many approach a surgeon for the first time is a turning point like post-divorce or the discovery that a partner is having an affair. This background is often vital in helping such patients get to a better place in the longer term.


If a client is thinking that cosmetic surgery is going to solve their marital problems, then it might be useful to help them in other areas as well, besides their appearance.


It’s sobering to realize appreciate that this large in-depth study found 41% of patients had an associated psychiatric disorder and 24.5% fulfilled the strict US Diagnostic and Statistical Manual criteria for BDD.


Body Dysmorphic Disorder is extremely rare in the psychiatric clinic. Its prevalence in the population is around 2% so its actually more common than most of the problems that dominate a routine out-patient clinic in a community mental health setting. The rate of BDD climbs routinely in previous studies to 20%, so cosmetic surgery is indeed the key place where the opportunity to detect this disabling psychiatric condition presents itself. If these clients can’t be helped to make contact with a psychological professional at this point then the medical system is failing them. This is particularly because the NHS for various reasons is unlikely to detect this disorder.


If almost half of this client group referred for cosmetic surgery had a formal psychiatric problem as defined by very strict criteria. This is telling us that these figures are just the tip of the iceberg, and that in fact its probably the case a majority of cosmetic surgery referrals also have other psychological problems they could be hiding beneath the surface – problems that could surface after surgery and which will lead to an extremely unhappy outcome for surgeon and patient.




Body dysmorphic disorder and other psychiatric morbidity in aesthetic rhinoplasty candidates Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 64, Issue 6, June 2011, Pages 738-741 Mohammad Alavi, Younes Kalafi, Gholam Reza Dehbozorgi, Ali Javadpour


Dr Raj Persaud FRCPsych is a Consultant Psychiatrist working in Private Practice at 10 Harley St, London W1.