The narcissist and the cosmetic surgeon.


Raj Persaud Consultant Psychiatrist.


Carly Simon wrote and released one of the most iconic songs of the 1970’s, and controversy has raged ever since as to who the mysterious stranger was, who ‘had one eye on the mirror’, as they watched themselves gavotte. Possible candidates include Warren Beatty and Mick Jagger, but the mystery has never been solved, with Simon only hinting enigmatically, and she even remains mysterious as to whether she actually had a relationship with them.


The song is a wonderful piece of entertainment, but in fact, the lyrics reflect a deep insight into the internal workings of a narcissist. Narcissism and in particular Narcissistic Personality Disoder, when narcissism becomes extreme, is crucial for anyone working in the appearance enhancing industry to understand, as it has implications for their work. Sufferers from NPD are particularly likely to pursue appearance enhancement, and yet are also more liable to be disappointed by the outcome and then become extremely angry with their doctors.


This means that all in the industry should listen carefully to the Carly Simon song, and grasp its darker implications.


Everyone who endeavours to enhance the appearance of others, cosmetic surgeons and similar health professionals, work hard to ensure their clients are happy with the good result that is aimed for. However, it is increasingly recognized in the field that some patients are not at all pleased with their outcome, despite the fact that as far as the health professional is concerned, a dispassionate assessment would suggest nothing serious has gone awry.


This is the classic nightmare for the surgeon. You have exercised your skill to the best of your ability, and when you inspect the post-operative result – you feel delighted with the result, but the patient isn’t.


Increasingly the existence of various personality and psychological predictors of low satisfaction are being evaluated pre-operatively. These would include the recognition of disorders like Imagined Ugliness Syndrome or Body Dysmorphic Disorder. In this, once considered rare, psychiatric disorder, the patient becomes convinced there is something grossly unpleasant about their appearance despite no objective evidence for this view. They seek multiple procedures as their assessment of flawed features arises out of psychological dysfunction rather than objective assessment.


However, while Body Dysmorphic Disorder is increasingly recognized and discussed in the field, there is probably a much more common psychological issue, which is frequently missed in patients by routine psychological screening, and which predicts an ominous outcome for happiness in the patient with the surgeon’s skill. Furthermore it is likely to lead to a dramatically deteriorating clinician-patient relationship.


This point is made well in a recent review paper entitled ‘Psychological Risks Associated with Appearance-Altering Procedures: Issues “Facing” Cosmetic Surgery’ and published in the journal, Oral and Maxillofacial Surgery Clinics of North America, by Walter Ricci and colleagues based at  University of Missouri-Kansas City. 


This collaboration between surgeons and psychological experts has produced an intriguing discussion, highlighting the importance to aesthetic health professionals of being more aware of Narcissistic Personality Disorder. 


Narcissism is an over-used word in modern day parlance and is frequently juxtaposed with self-centred, but the concept is a bit more complicated than that. The reason why it’s important for non-psychologically trained cosmetic specialists to be more aware of it is twofold; the area tends to attract those suffering from Narcissistic Personality Disorder (NPD) and, they are also likely to become unhappy post-operatively with their outcomes. Even more vital is the fact this kind of person is apt to fly into a rage with their surgeon. This is referred to as Narcissistic Rage, it’s such a common feature of the condition.


To get a handle on NPD and narcissistic wrath, it’s useful to understand that this anger in the patient arises when the surgeon or surgeon’s staff, is not being so perfectly obedient to the patient’s wishes and view of the world, that they appear almost to be acting as an extension of the narcissist’s self. So, the narcissist expects and demands total control, usually the kind of connection and obedience one experiences and expects to have over one’s own limbs. The Narcissist expects the world to be obedient to their wishes as their own body is.


So when an outcome is not precisely as the patient had anticipated or imagined it, they fly into a fury. This anger, unless you have experienced it at first hand in terms of being a clinician at the receiving end of it, is a truly disturbing and frightening experience. The rage is of such an intensity, that it appears there is a serious desire to obliterate the clinician. Any surgeon, no matter how skilled, will encounter it at one time or another. Particularly if they aren’t screening out pathological narcissists from their surgical lists.  Walter Ricci and colleagues in their paper are arguing that just as there is rising awareness of the importance of managing Body Dysmorphic Disorder in cosmetic surgery practice, and therefore detecting it early, the same applies to Narcissistic Personality Disorder.


The fury of the NPD sufferer post procedure, arises because while the surgeon may feel they did what was asked of them, yet because of the perfection the patient pursues, it’s inevitable that the narcissist is disappointed and furious.


The bottom line is the narcissistically challenged patient’s expectation is highly vulnerable to disappointment and its consequences. This means that as managing expectations is a crucial part of the surgeon’s role, NPD is crucial to be aware of.

While a healthy sense of self-esteem and concern for yourself is vital for normal personality development and indeed survival in the social world, narcissism becomes pathological when work or social life is disrupted. Narcissism is a fascinating disorder because recent research suggests that Narcissists are rated as more interesting and enjoyable to be with in the short term than normal controls, but it’s only over the longer term  that interpersonal functioning becomes impaired as a result of the disorder.


Ricci and colleagues in their paper point out that the narcissist suffers from a sense of specialness, self-importance, omnipotence, and uniqueness. This means that narcissists are found at the top of most human endeavours – business, the professions (including medicine) and politics. It is likely that narcissists run our world.


The key problem for the rest of us is that while narcissists are charming enough on the outside to get elected or favoured, they’re basically so egocentric, the very existence of others isn’t on their radar. Others preferences are only of value to the extent they can be manipulated to the narcissist’s own ends.  


The goals of the narcissist are for perfection and power. When this does not arrive in the quantities that is demanded, the result is anger and contempt for the world around them. Narcissists relentlessly require validation of their special status and demand this with the intensity of addicts: the presence of an admiring audience is a cornerstone of their sense of well being. Encountering a narcissist, you will only avoid their indifference or hatred if you reflect back to them the self-perceived greatness, power, and superior status to which they believe they are rightfully entitled.


Because of their very high perfectionistic standards, need for an admiring audience and belief in specialness, the narcissist is much more likely to be found in cosmetic clinics than reflected in their prevalence in the general population. Cosmetic clinicians need to understand that this kind of patient is unable to tolerate any lack of dominance over the professional’s behavior or the desired outcome.


According to psychiatric classification systems NPD can be identified because it features a pervasive pattern of grandiosity (in fantasy or behavior), a need for admiration, or lack of empathy beginning in early adulthood and is present in a variety of contexts (not just on stage).


The 12 Key traits of the narcissist are:


1. Grandiose sense of self-importance, out of step with their actual station in life

2. Preoccupation with unlimited power, success, brilliance and beauty

3. An overweening sense and belief in own uniqueness or specialness

4. A requirement for continuous admiring responses from others in any relationship

5. A very strong sense of entitlement

6. Exploitative approach and attitude to all relationships

7. A lack of empathy for others

8. Envy of others, who will always appear to be at the pinnacle of endeavour

9. Arrogance or haughty behavior


This list might be useful to bear in mind when trying to raise awareness of NPD, detecting and managing it. Once you’ve worked out you have a case of NPD on your hands, be very cautious about proceeding with a procedure unless there is psychological management of the predicament in place before, rather than after.


Otherwise you are taking the risk of encountering narcissistic rage, which is anger and behaviour of a quantity and quality which is truly frightening.




Psychological Risks Associated with Appearance-Altering Procedures: Issues “Facing” Cosmetic Surgery  Oral and Maxillofacial Surgery Clinics of North America, Volume 22, Issue 4, November 2010, Pages 439-444 Walter F. Ricci, Steven J. Prstojevich, Harriet S. Langley, Matthew R. Hlavacek