What is the connection between cosmetic procedures and mental health?

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Although we cannot be sure of the exact number of Australians undergoing cosmetic procedures, as there is no requirement for healthcare professionals to report their statistics, there is consensus demand which is on the rise.

In 2015, the Cosmetic Physicians College of Australasia found that Australians spend over $1 billion a year on non-invasive cosmetic procedures like Botox and fillers. This is more than 40% more, per capita, than in the United States.

In the United States, where procedure statistics are reported, there has been a 42% increase in filler procedures and a 40% increase in Botox procedures performed in the last year alone.

Rates of mental health problems in this group may be higher than in the general population, but apparently not enough is being done to provide psychological safety for people seeking cosmetic procedures.

Body dysmorphic disorder

Body image concerns are usually the primary motivation for seeking cosmetic procedures of all kinds. These concerns usually focus on the part of the body where the cosmetic procedure is sought, such as the nose for rhinoplasty.

Serious body image issues are a key feature of many mental health conditions. Body dysmorphic disorder is most common among people seeking cosmetic procedures. In the general community, about 1-3% of people will experience body dysmorphic disorder, but in populations seeking cosmetic surgery, that figure rises to 16-23%.

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 others. In response to distress about the defect, the person with body dysmorphic disorder will engage in 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 impact on a person’s daily life, with some people being too distressed to leave their homes or even dine with family members for fear of being seen by others.

Since the distress associated with body dysmorphic disorder appears to stem from issues with physical appearance, it makes sense that someone with body dysmorphic disorder is far more likely to present to a cosmetic clinic for treatment than a mental health clinic.

The problem is that the cosmetic procedure usually makes the person with body dysmorphic disorder feel the same or worse after the procedure. They may become even more concerned about the perceived defect and seek other cosmetic procedures.

Patients with body dysmorphic disorder are also more likely to take legal action against their treating cosmetic practitioner after they feel they did not get the result they wanted.

For these reasons, body dysmorphic disorder is generally considered by medical professionals to be a “red flag” or a contraindication (a reason not to undergo medical intervention) for cosmetic procedures.

However, it is not entirely clear. Some studies have shown that people with body dysmorphic disorder may improve their symptoms after a cosmetic procedure, but the obsession may simply shift to another part of the body and the diagnosis of body dysmorphic disorder remains.

What about other mental health issues?

Body dysmorphic disorder is by far the most studied disorder in this area, but it’s not the only mental health condition that may be associated with poorer outcomes from cosmetic procedures.

According to a recent systematic review, rates of depression (5-26%), anxiety (11-22%) and personality disorders (0-53%) among people seeking cosmetic surgery may be higher than in the general population (which is estimated at 10%, 16% and 12% respectively).

However, these rates should be interpreted with some caution, as they largely depend on how the mental health diagnosis was made – clinician-led interview (higher rates) versus mental health questionnaire ( lower rates). Some interview approaches may suggest higher rates of mental health problems, as they can be quite unstructured and therefore have questionable validity compared to highly structured questionnaires.

Besides body dysmorphic disorder, research on other mental health conditions is limited. This may simply be because body image is central to body dysmorphic disorder, making it a logical focus for cosmetic surgery research over other types of psychiatric disorders.

So what should happen?

Ideally, all cosmetic surgeons and practitioners should receive sufficient training to enable them to perform a brief routine assessment of all potential patients. People with signs that they are unlikely to gain psychological benefit from the procedure should undergo further evaluation by a mental health professional before undergoing the procedure.

This could include an in-depth clinical interview about the reasons for the procedure and completing a series of standard mental health questionnaires.

If a person was found to have a mental health issue during the assessment process, this does not necessarily mean that the mental health professional would recommend against proceeding. They may suggest a course of psychological therapy to address the concern and then undergo the cosmetic procedure.

At this time, assessments are only recommended rather than required for cosmetic surgery (and not at all for injectables like Botox and fillers). The guidelines say an assessment should be undertaken if there are signs that the patient has “significant underlying psychological problems”.

This means that we rely on the aesthetic doctor’s ability to detect such problems when he may have only received basic psychological training in medical school and his business may possibly benefit from not not deal with such diagnoses.

An August 2022 independent review by the Australian Health Practitioner Regulation Agency and the Medical Board of Australia recommended that mental health assessment guidelines be “strengthened” and stressed the importance for doctors to receive more training on the detection of psychiatric disorders.

Ultimately, because aesthetic practitioners treat patients who seek treatment for psychological rather than medical reasons, they must have the patient’s well-being in mind, both for professional integrity and to protect themselves from legal action. Mandatory assessment of all patients wishing to undergo a cosmetic procedure would likely improve overall patient satisfaction.

Provided by The Conversation

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