How to psychologically evaluate patients before selection for surgery

By Gracie Awalt

Evaluating a patient’s mental health is an essential risk management consideration for physicians who perform plastic surgery.

In a study that examined 1,000 elective plastic surgery patients, 41% had a history of a psychiatric disorder¹, exceeding the estimated 26% of adults who suffer from a diagnosable psychiatric disorder each year in the U.S.²

Plastic surgeons must evaluate potential patients for factors that predispose them to be dissatisfied with procedure results. A literature review of 37 studies observing the effects of cosmetic intervention on psychological well-being and patient satisfaction found useful trends surgeons should consider when deciding which patients to select for care.³

Throughout the studies, the factors associated with poor psychological outcomes included:

• being young (exact ages not recorded);
• being male;
• unrealistic expectations of surgery results;
• a previous unsatisfactory surgery;
• minimal deformities;
• expecting surgery to solve relationship problems; or
• a history of depression, anxiety, personality disorder, or body dysmorphic disorder.³

The studies also found a list of common behaviors patients with psychological issues exhibit after cosmetic surgery. These patients may request repeat procedures in a harassing manner, complain, or express anger towards surgeons and staff if the results are perceived as unsatisfactory. Dissatisfaction can lead to social isolation, familial dysfunction (conflict, abuse, neglect), and self-destructive behaviors. Patients may also pursue legal action.³

Patients who are consistently unhappy with objectively successful surgical outcomes, sometimes referred to as “insatiable patients” or “polysurgical addicts,” often have body dysmorphia.³ This condition is defined as the “pathological preoccupation with an imagined or slight physical defect of one's body to the point of causing significant stress or behavioral impairment.”⁴

Risk management suggestions

Before selecting a patient for a cosmetic procedure, consider asking the following questions to give you more context about the patient.³

• What is your specific appearance concern? Please provide as much detail as possible.
• How long have you considered getting a procedure?
• How many surgeons have you consulted with or seen about this issue?  How many produced unsatisfactory results?
• What are your expectations and desired outcomes?

Then ask yourself, are the patient’s answers realistic? Did the patient reference a history of legal proceedings, threats, or violence toward practitioners? Is the patient motivated by a desire to improve his or her body image, or to solve external life problems (enhance social network, establish relationships, get a job, decrease social isolation)? The latter is more concerning.

To screen a patient to determine if they have body dysmorphic disorder, consider asking the following questions.³

• How much time do you spend each day worrying about the appearance problem?
• How much distress does the (perceived) flaw cause?
• Does the concern have any behavioral consequences? Or, do you feel like your problem hampers you in your day-to-day life — with relationships, socializing, or work?

From the patient’s answers, ask yourself the following.

• Does the patient report being preoccupied with the perceived appearance flaw?
• Does the concern cause the patient significant distress or impairment in functioning?
• Is the patient’s issue much more trivial than the patient perceives it to be?

The patient’s psychiatric history and current mental state can often predict his or her response to surgical outcomes, and those responses may be negative and result in legal action. If you recognize psychiatric conditions while screening a patient, consider referring the patient to a qualified mental health professional to receive appropriate care before pursuing surgery.

Sources

1. Benjamin, J, Bhavsar, DR. The Prevalence of Psychiatric Disorders Among Elective Plastic Surgery Patients. Eplasty. March 18, 2019. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432998/. Accessed April 3, 2020.
2. Mental Health Disorder Statistics. Johns Hopkins Medicine website. Available at https://www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-disorder-statistics. Accessed April 3, 2020.
3. Honigman RJ, Phillips KA, Castle DJ. A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery. HHS Author Manuscripts. January 4, 2007. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1762095/#R7. Accessed April 3, 2020.
4. Definition of Body Dysmorphic Disorder. Merriam-Webster online dictionary. Available at https://www.merriam-webster.com/medical/body%20dysmorphic%20disorder. Accessed April 3, 2020.