Psychological Evaluation Of Patients Undergoing Cosmetic .

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Psychological evaluation of patientsundergoing cosmetic proceduresPractice guide

AcknowledgementsWe would like to acknowledge the following people who provided theirexpert review of the content of this practice guide:Dr Gemma Sharp MAPSDr Ben Buchanan MAPSDr Ryan Kaplan MAPSAustralian Psychological Society. (2018). Psychological evaluation of patientsundergoing cosmetic procedures. Melbourne, Vic: Author.Disclaimer and CopyrightThis publication was produced by The Australian Psychological Society Ltd(APS) to guide psychologists in best practice in the assessment of individualsseeking to undergo a cosmetic procedure. The information provided does notreplace clinical judgment and decision-making. While every reasonable efforthas been made to ensure the accuracy of the information, no guaranteecan be given that the information is free from error or omission. The APS,their employees and agents shall accept no liability for any act or omissionoccurring from reliance on the information provided, or for the consequencesof any such act or omission. The APS does not accept any liability for anyinjury, loss or damage incurred by use of, or reliance on, the information. Suchdamages include, without limitation, direct, indirect, special, incidental orconsequential.Any reproduction of this material must acknowledge the APS as the sourceof any selected passage, extract or other information or material reproduced.For reproduction or publication beyond that permitted by the Copyright Act1968, permission should be sought in writing.Copyright 2018 The Australian Psychological Society Ltd

Table of ContentsIntroduction . 4Consultations and external review. 4Definition of cosmetic procedures as covered in this practice guide. 4Procedures not considered ‘cosmetic’ and not covered in this practice guide . 5Limitations . 5Background . 6Prevalence of people seeking cosmetic procedures or surgery. 6Potential adverse outcomes . 6Patient characteristics associated with adverse outcomes . 7Psychosocial assessment of adults . 9Aims and outcomes of an assessment . 9Assessment step-by-step. 9Rating scales and assessment measures . 13Concluding the assessment . 14Psychosocial assessment of specific populations . 15Assessment of transgender individuals . 15Assessment of minors. 15Summary . 17References . 18psychology.org.au3

IntroductionIn October 2016, the Medical Boardof Australia issued the ‘Guidelines forregistered medical practitioners whoperform cosmetic medical and surgicalprocedures’.1 The Medical Board of Australiaguidelines make clear that some patientsmay be unsuitable for cosmetic surgery andmandate the referral of patients of concernfor a psychological evaluation to establishtheir suitability for the intended procedure.Consultations and external reviewA draft version of this practice guide was reviewedby experts in the area (please see the section‘Acknowledgements’ for a list of these experts).The writing and editorial team revised the guide inresponse to reviewer suggestions.Reviewers were asked to review and provide feedbackon the guide, including a focus on the following fourquestions for each section: Are there significant gaps (in the coverage of thistopic, the literature, other)? Are there errors in the content?Under the Medical Board of Australiaguidelines, a patient is considered torequire an assessment prior to undergoinga cosmetic procedure if they are: under the age of 18 and seeking a majorcosmetic procedure; or an adult or a minor displaying indicatorsof significant underlying psychologicalproblems which may make them anunsuitable candidate for any cosmeticprocedure.This practice guide has been developed by theAustralian Psychological Society (APS) to provideguidance to APS member psychologists undertakingassessments of individuals intending to undergo acosmetic procedure, for their psychological suitabilityfor such a procedure.This practice guide reviews and synthesises currentevidence about best practice in the assessment ofsuch individuals. Is the structure logical and easy to use?Definition of cosmetic proceduresas covered in this practice guideThe ‘Guidelines for registered medicalpractitioners who perform cosmeticmedical and surgical procedures’ providethe following definitions for cosmeticprocedures and these have been adopted inthis practice guide:Cosmetic medical and surgical procedures:These are operations and other procedures thatrevise or change the appearance, colour, texture,structure or position of normal bodily featureswith the dominant purpose of achieving whatthe patient perceives to be a more desirableappearance or boosting the patient’s self‑esteem.Major cosmetic medical and surgical procedures(‘cosmetic surgery’): These procedures involvecutting beneath the skin. Examples include;breast augmentation, breast reduction,rhinoplasty, surgical face lifts and liposuction.Minor (non-surgical) cosmetic medicalprocedures: These procedures do not involvecutting beneath the skin, but may involvepiercing the skin. Examples include: non-surgicalcosmetic varicose vein treatment, laser skintreatments, use of CO2 lasers to cut the skin,mole removal for purposes of appearance,laser hair removal, dermabrasion, chemicalpeels, injections, microsclerotherapy and hairreplacement therapy.4Psychological evaluation of patients undergoing cosmetic procedures

Procedures not considered ‘cosmetic’and not covered in this practice guideThe ‘Guidelines for registered medical practitionerswho perform cosmetic medical and surgicalprocedures’ provide the following definitions forprocedures not considered cosmetic and so notincluded in this practice guide:Procedures which are medically justified: Surgery or aprocedure may be medically justified if it involves therestoration, correction or improvement in the shapeand appearance of body structures that are defectiveor damaged at birth or by injury, disease, growth ordevelopment for either functional or psychologicalreasons. Surgery and procedures that have a medicaljustification and which may also lead to improvementin appearance are excluded from the definition.Reconstructive surgery: The medical specialty ofplastic surgery includes both cosmetic surgery andreconstructive surgery. Reconstructive surgery differsfrom cosmetic surgery as, while it incorporatesaesthetic techniques, it restores form and function aswell as normality of appearance.This practice guide applies to plastic surgery when it isperformed only for cosmetic reasons. It does not applyto reconstructive surgery or surgery considered to bemedically justified.In practice, this can be a grey area with some patientsreporting the motivation to be functional or physicalwhilst also desiring surgery for cosmetic reasons.2Regardless, determining whether a procedure ismedically justified ultimately falls to the treatingmedical practitioner. For the psychologist, of primaryconcern in the evaluation is the client’s state of mind,emotional and cognitive preparedness, and theirpsychological fitness to undergo the procedure.LimitationsWhile every effort has been made to provide thereader with current, up to date information on theassessment of this client group, research is ongoingand relevant new original studies and systematicreviews may be published after this practice guide hasbeen finalised. As such, clinicians need to continueto update their knowledge and skills and use theirprofessional judgement when evaluating clients.Medical Board of AustraliaGUIDELINES FOR REGISTEREDMEDICAL PRACTITIONERS WHOPERFORM COSMETIC MEDICALAND SURGICAL PROCEDURES1 October 2016MBA1608 03psychology.org.au5

BackgroundPrevalence of people seekingcosmetic procedures or surgeryUnfortunately national data is not available onthe prevalence of cosmetic procedures or surgeryuse in Australia for a number of reasons. Currently,cosmetic procedures can be performed by a range ofpractitioners, including medical practitioners suchas plastic surgeons, GPs and dermatologists, andnon-medical practitioners such as beauticians, andthere is no single body to which such data is reported;secondly such procedures are elective, so are notcovered and therefore recorded by Medicare.3A survey conducted by the Cosmetic PhysiciansCollege of Australasia in 2015, estimates thatAustralians collectively spend more than 1 billiondollars a year on minimally or non-invasivecosmetic procedures, with around one quarterof the 1020 respondents reporting to havehad some kind of procedure performed in thepreceding month, double the number reportedin the previous year.4 There is a consensus thatthe use of cosmetic surgery in Australia is onthe rise.3Potential adverse outcomesAlthough this field of research is characterised bymethodological limitations, what is known suggeststhat the majority of people seeking a cosmeticprocedure are satisfied with the outcome and reportimprovements in self-esteem, quality of life andrelationships.5-7 Research also suggests however thata minority do experience adverse psychological andsocial outcomes.7Where there is dissatisfaction with the outcome ofa procedure, the patient may experience personaldistress and adjustment problems, social isolation,relationship strain, requests for additional andunnecessary procedures, and anger toward the serviceprovider and his or her staff.7 In some individuals,pre-existing mental health concerns, particularlybody dysmorphic disorder (BDD) may indeed worsenfollowing the procedure.8Those seeking cosmetic procedures may be at higherrisk for self-harm and suicide than the generalpopulation, though research is scant.9-12 While thereason for this increased risk is unclear, it is speculatedthat unmet expectations (particularly whereexpectations are unrealistic), mental health issues, ordistress associated with medical complications arisingfrom the procedure may all contribute to negativemood, and to the increased risk of suicide.12, 13In Australia (2015)Most common ageMore than 1bspent per year onnon-invasive procedures90%of procedures areperformed on women6Psychological evaluation of patients undergoing cosmetic procedures35-50Most popular procedurefor women:breast augmentationMost popular procedurefor men:liposuction

BDD in particular is associated with an increased riskfor suicide and self-harm, with rates similar to that ofanxiety and depression and greater than that of mostother mental health disorders.11, 14-16 In addition to thereasons for increased suicide risk above, which are allrelevant to understanding suicide risk in BDD, beingrefused cosmetic surgery or other cosmetic proceduresis also thought to be a particular risk factor, due to theimportance people with BDD can place on cosmeticsurgery being a solution to their distress, and thedegree of distress they experience in relation to theirperceived flaw.9, 11Cosmetic professionals treating unsuitable patientsare at risk of experiencing adverse outcomesthemselves, including harassment by the patient,repeated demands for unnecessary procedures,complaints, and legal action.7, 9 Practitioners may alsoexperience threats of physical violence or in rare cases,actual harm from dissatisfied clients.9Potential adverse outcomes include: dissatisfaction with the outcome of theprocedure personal distress and adjustment problems social isolation relationship strain requests for additional and unnecessaryprocedures anger toward the service provider and staff worsening of pre-existing mental healthconcerns (particularly body dysmorphicdisorder (BDD)) risk of self-harm.Research suggests thatunrealistic goals – such as adesire to achieve perfectionrather than for more realistic,specific or functionalimprovements are associatedwith poorer outcomes.17Unrealistic goals or expectationsResearch suggests that unrealistic goals – such asa desire to achieve perfection rather than for morerealistic, specific or functional improvements areassociated with poorer outcomes.17 Unrealisticexpectations include those in which the hope is fordistal, exaggerated or global life improvements, suchas obtaining a job promotion, or attracting a newromantic partner. Unrealistic expectations may also bereflected by vague descriptors such as a desire to be‘prettier’ or for a feature to be ‘nicer’.12, 18External motivations for the procedureExternal motivations such as family or partnersinfluencing the client to undergo the cosmeticprocedure rather that the client themselves being thedriver of the process, or the belief that the surgery orprocedure will improve relationships, the likelihood ofemployment, or popularity are also associated withpoorer outcomes.7, 13Identity concernsIn some cases, a certain physical characteristicmay be linked to a patient’s personal, cultural, orfamilial identity. Without adequate considerationof the ramifications of altering this trait, the patientmay experience a loss of identity or ructions withinrelationships following the loss of a shared physicalfamilial or cultural characteristic.19Negative self-image and other psychosocial issuesPatient characteristics associatedwith adverse outcomesResearch suggests that adverse outcomes are morelikely in patients with certain characteristics, mostcommonly those with: unrealistic goals or expectations for the procedure external motivations for the procedure identity concerns negative self-image and other psychosocial issues certain mental health concerns such as bodydysmorphic disorder.Individuals seeking cosmetic procedures or surgerydo so in response to dissatisfaction with an aspectof their appearance, and the majority report beingsatisfied with the outcome of their cosmetic procedureand with the specific change in their appearance.20Many also experience broader positive outcomes postcosmetic intervention, such as increased confidenceand a more positive body image.7, 21A positive global self-concept, despite dissatisfactionwith an aspect of one’s physical appearance, isassociated with good outcomes from cosmeticinterventions.22 Satisfied patients for example oftenreport feeling that their outward appearance did notmatch their otherwise positive internal self-concept,psychology.org.au7

and cite wanting to align the two as motivation forsurgery.22 Therefore, apart from dissatisfaction with aspecific aspect of their appearance, those experiencingpositive outcomes from their cosmetic proceduretypically report being otherwise satisfied with theiroverall body image and sense of self.23Risk factors forpoorer outcomes unrealistic expectations forthe procedure external motivations or beinginfluenced by others to have theprocedure identity concerns negative self-image relationship issues certain mental health issues suchas body dysmorphic disorder.Conversely, pre-existing poor self-concept, low selfesteem, negative global body image, and relationshipdistress are associated with poorer outcomes.7Mental health concernsAlthough the actual prevalence of mental healthdisorders in this population is poorly understood9a sizable minority – a proportion greater than thatfound in the general population – are thoughtto experience mental health issues, whichresearch suggests may increase the risk forpatient dissatisfaction and poorer outcomes.9, 24-26Though there is little research in this area23 the fullcomplement of mental health disorders is likely seenin the cosmetic procedure-seeking population,27 withdepression, anxiety, eating disorders and traumahistory believed to be overrepresented.7, 9, 17, 25, 28It must be noted however that high prevalence mentalhealth disorders should not be considered ‘absolute’contraindications for cosmetic procedures as researchevidence is inconsistent regarding the benefits andadverse outcomes associated with a range of mentalhealth issues.5, 9Body dysmorphic disorder (BDD) however isgenerally considered a contraindication for cosmeticprocedures and has received the most attention instudies characterising cosmetic procedure-seekingpopulations. BDD is estimated to affect around1.9% of the general population29 with slightlymore females affected (2.1%) than males (1.6%).29Within populations seeking cosmetic surgeryor other procedures however, the prevalence isconsiderably higher. Among American samples, ratesof BDD among individuals presenting for cosmeticsurgery range from 7-13%.9, 29 International studiesusing rigorous methods of evaluation estimatethe prevalence of BDD cosmetic surgery-seekingpopulations to be in the range of 3.2-16%. Higherrates of BDD have been reported in those seekingrhinoplasty,29, 30 dermatological treatments,31 andlabiaplasty.9, 32poorer psychological outcomes, repeat cosmetictreatments, unnecessary surgical interventions, anddissatisfaction with the procedure.13, 33, 34 Given thelikely dissatisfaction, secondary risks include hostilitytowards treating medical staff, increased risk forself-harm and although rare, increased risk of harmto others such as the treating practitioner.8, 11, 34, 35There is also a risk of worsening of pre-existingmental health concerns, body image issues orBDD symptoms.25, 36, 37Degree of distress, reflecting substantialpreoccupation and dissatisfaction with appearance,is considered an important factor in predicting poorpost-procedural outcomes in individuals with BDDwith severity of symptoms associated with pooreroutcomes.38 Mild to moderate BDD symptomsmay not necessarily preclude cosmetic procedures,however in such cases it is important that patientexpectations are well-managed.39, 40Within an evaluation of an individual’s suitabilityto undergo a cosmetic procedure, it is importantfor a psychologist to conduct a thoroughpsychological and psychosocial evaluation,attending to all aspects of the client’s mentalhealth, risk factors, and other factors relevantto understanding the client’s motivation for thecosmetic procedure and expectations about thepsychosocial impact of the procedure.Unlike other mental health issues where mixedoutcomes of cosmetic procedures have beenreported, BDD is generally associated with8Psychological evaluation of patients undergoing cosmetic procedures

Psychosocial assessmentof adult

appearance or boosting the patient’s self -esteem. Major cosmetic medical and surgical procedures (‘cosmetic surgery’): These procedures involve cutting beneath the skin. Examples include; breast augmentation, breast reduction, rhinoplasty, surgical face lifts and liposuction. Minor (non-surgical) cosmetic medical

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