Skin is the first organ noticed in an individual and hence plays a major role in appearances, social relations and communications. Due to the current scenario and the development in the field of aesthetic medicine, there are a lot of options and treatments available to change or better one’s appearances. Additionally, due to the amount of focus and emphasis put by the society on what is perceived as ideal beauty, via advertisements of beauty products, movies or social media, there has been an exponential growth in the demand for aesthetic procedures worldwide. However, this has also led to many people having societal pressure to reach unreachable standards of physical beauty[Walker C, Papadopoulos L. The psychological impact of skin disorders. New York: Cambridge University Press; 2005.].
If this psychological impact of not having the ideal looks increases, it may be associated with underlying component of stress, depression or obsession.Such patients are likely to approach aesthetic surgeons for correction and hence they need to be monitored carefully for an underlying psychosomatic component. Clinical studies have shown that 20-48 % of patients presenting for cosmetic surgery have a psychiatric diagnosis [Napoleon, A. The presentation of personalities in plastic surgery. Ann. Plast. Surg. 31: 193, 1993.]Hence evaluation of psychology of an aesthetic patient should play a major part in the training of an aesthetician to avoid dire consequences. It is the physician’s responsibility to segregate such patients, counsel them, and in most cases refer them or rarely themselves become the psychotherapist.
TYPES OF EXPECTATIONS AND PSYCHOLOGIES:
In an aesthetic clinic, there are different types of patients. They come from different age groups, different social backgrounds, and different financial status. Each patient comes with specific complaints and specific expectations. Chart 1 simplifies and divides these patients as per their approach to their problems:
Depending on their expectations, the physician can get a clue towards the psychology of the patient. Patients with unrealistic expectations are one of the warning signs of an underlying psychiatric disorder. Patients of the type 1 group are the best candidates. The type 2 patients usually have an insight and on adequate counselling they may decrease their expectations and willingly accept them, however a detailed evaluation is advised in them. Type 3 and 4 patients also need careful assessment to identify an underlying psychiatric component if present. Most cases of body dysmorphic syndrome fall in type 3 category, such patients will never be satisfied with the surgery and get repeated surgeries. They will benefit only with psychiatric interventions.[Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-243.]
ASSESSMENT OF THE PATIENT’S PSYCHOLOGY:
In 1818, Heinroth described the term ‘Psychosomatic’ referring to the influence, the mind has on the body. Hence, examining an individual’s mind is as important as examining the physical body. The easiest way for a physician of a non-psychiatric background to assess the psychology or thinking of the patient is via a good doctor-patient relationship. This is easier said than done. Despite the best medical education and training, good communication and interpersonal skills come naturally to health-care providers or with great experience and observation. Only a physician with good communication skills can have a successful psychologically based aesthetic practice
Most important thing while evaluating a patient’s psychology is to give the patient time. Minimum 15 minutes per consultation are a must.[Poot, F., Sampogna, F. and Onnis, L. (2007), Basic knowledge in psychodermatology. Journal of the European Academy of Dermatology and Venereology, 21: 227–234. doi: 10.1111/j.1468-3083.2006.01910.]Following points give a stepwise guideline on evaluating a patient’s psychology when he enters an aesthetic clinic.
- GENERAL OBSERVATION:Assessment of the patient should start from the minute the patient enters the clinic. Subtle signs like, who is accompanying the patient? Is the patient’s dressing sense provocative or subtle? Is the patient maintaining eye-contact? Who is talking more during the visit, the patient or the accompanying person? Does the patient’s tone seem over-excited or monotonous? Continuously fidgeting with their hair or looking at the mirror frequently?
Being anxious, nervous and self-conscious is a normal feeling while visiting a doctor and hence it is important to make the patient feel comfortable during his visit. Anxiety may mask any underlying expression or behaviour of the patient. Occasionally a second visit may be required in over-anxious patients.
- CLINICAL OBSERVATION: Notice if the patient has exaggerated frown lines or glabellar lines, indicating stress. Any sign of a past cosmetic procedure carried out? Early signs of aging? Any sign of depression, such as hesitation marks?
- AMBIENCE: To make the patient comfortable, greet the patient with their name and get them seated comfortably. This helps in relieving the initial anxiety too.Notice if the patient is quite most of the time or talkative, reluctance in mentioning the complaints or over-zealous and demanding.
- QUESTIONING: Ask details about the expectations? The reason behind getting the surgery? If anyone else wants them to get the surgery? For how long have they wanted to get this surgery? Asking open-ended questionshelps in allowing the patient to talk more and open up.
- SCIENTIFIC HISTORY : History of any sleep disturbances, alcohol consumption or smoking, appetite loss, weight gain, give a hint about the physical and mental well-being. Family history regarding relations may be asked indirectly, such as recent divorce or marriage, which gives a hint on interpersonal relationships. The patients work type tells about their job satisfaction. Any hesitation to answer a question may also indicate a stress factor and should be noted.[(reference repeated )Poot, F., Sampogna, F. and Onnis, L. (2007), Basic knowledge in psychodermatology. Journal of the European Academy of Dermatology and Venereology, 21: 227–234. doi: 10.1111/j.1468-3083.2006.01910.]
UNDERSTANDING THE ROOT CAUSE BEHIND THE PARTICULAR PSYCHOLOGY:
Not all patients who ask for an aesthetic procedure necessarily have an underlying psychological issue. However all patients do have an underlying emotion or motive behind getting an aesthetic surgery. Most of the reasons are purely physiological or due to an ‘Ideal’ self-image built by the person, rarely we encounter patients with psychosomatic causes asking for a surgery. These are the patients that need to be segregated.
- ‘IDEAL’ self-image: every decision an individual takes, as per his choice of clothes or house or car is based on a self-image that he considers ideal for him. Similarly patients usually have an ideal image in their mind when they approach for an aesthetic procedure. There is a goal, an ‘ideal’ self-image they imagine, this determines the patient’s behaviour and their obsession and demands of different aesthetic procedures. For example; a perfectly good looking male patient may demand for a cleft in the chin, even when it’s not required, only because he sees his ideal self-image with a cleft in the chin. [Higgins, E. Tory.Self-discrepancy: A theory relating self and affect. Psychological Review, Vol 94(3), Jul 1987, 319-340.]
This is the most common reason patients get cosmetic surgery and if the patient has realistic expectations and is self-motivated, the procedure is going to benefit the patient not only physically, but also emotionally.
- Psychosomatic causes: One-third of the patients visiting a dermatologist have associated emotional and psychosomatic factors.[Gupta MA, Gupta AK. Psychodermatology: an update.J Am Acad Dermatol 1996;34:1030–46.]Only treating the physical aspect in these patients is not going to yield any results, the psychosomatic factor needs to be resolved too. Most common presentation of these factors seen in an aesthetic clinic is in cases of body dysmorphic disorder (BDD) and depression.
BODY DYSMORPHIC DISORDER: BDD has been reclassified and considered as a type of obsessive-compulsive disorder.[Phillips, K. A., McElroy, S. L., Hudson, J. I., et al. Bodydysmorphic disorder: An obsessive-compulsive spectrumdisorder, a form of affective spectrum disorder, or both?J. Clin. Psychiatry 56: 41, 1995.]It is characterised by extreme appearance pre-occupation. Harth et al described a subtype of BDD known as botulinophilia; characterised by persistent demands of Botox injections to treat hyperhidrosis despite absence of syndromes. [Harth, W., and Lines, R. Botulinophilia: Contraindicationfor therapy with botulinum toxin. Int. J. Clin. Pharmacol. Ther. 39: 460, 2001]
Eitiology: Poot et al have tried to simplify the factors behind psychosomatic disorders in figure 1.
Reference repeated. Poot F, Sampognat F, Onnis L. Basic knowledge in psychodermatology. JEADV 2007; 21: 227-234.
The cellular physiopathology has been explained in detail by the neuro-immuno-cutaneous-endocrine (NICE) model.[O’Sullivan RL, Lipper G, Lerner EA. The neuroimmuno-cutaneous-endocrine network: relationship of mind and skin. Arch Dermatol 1998;134:1431–1435].This model explains how abnormal serotonin and dopamine play a role in BDD.The psyche behind BDD includes cognitive-behavioural factors. Cognitive factors such as unrealistic ideas about the ‘ideal’ self-image with respect to symmetry and perfection in looks. There may also be obsession to a particular part of the body, such as nose or hair. Repeatedly looking in the mirror or fidgeting with hair is a type of maladaptive behaviour which develops as a result of these cognitive factors.Sarwer D.B., Gibbons L.M., and Crerand C. E. Treatingbody dysmorphic disorder with cognitive-behavior therapy.Psychiatr. Ann. 34: 934, 2004.
Interpersonal relationships-Rejection or neglectful nature of family may lead to BDD in the patients. Phillips, K. A. Body dysmorphic disorder: The distress ofimagined ugliness. Am. J. Psychiatry 148: 1138, 1991. Teasing in schools may lead to BDD in young adolescents too. Careful social history taking is important in such cases.
Studies have proven that 9-15% of the patients visiting dermatologist for aesthetic procedures suffer from BDD. [Uzun, O., Basoglu, C., Akar, A., et al. Body dysmorphicdisorder in patients with acne. Compr. Psychiatry 44: 415,2003.]This emphasises the need for aestheticians to be aware of this condition and its presentation in the cosmetic population.
INTERVENTION AND DECISION TO DO THE PROCEDURE:
An ideal case to perform a procedure is the one with no obvious psychopathology, clearly defined areas of dissatisfaction, realistic expectations and who is self-motivated. Contradictorily, aesthetics procedures should be avoided in patients with major depression, signs of self-mutilation, troubled or agitated on day of surgery or on psychotics.[Elsaie ML. Psychological approach in cosmetic dermatology for optimum patient satisfaction. Indian Journal of Dermatology. 2010;55(2):127-129. doi:10.4103/0019-5154.62733.]Depending on the assessment of the patient, if the physician feels there are no psychosomatic factors behind the patient’s demand for the surgery, he should go ahead. Borderline cases or mild cases of obsessive compulsive disorder or BDD also benefit with cosmetic procedures or a combination of psychiatric and cosmetic treatment. Reference repeated[Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-243.].BDD patients believe they have a ‘defective appearance’ and despite doing a corrective surgery they will feel it still looks defective, hence are always dissatisfied. They usually have a tendency to get multiple surgeries. Such patients also refuse to get psychiatric help initially. Counselling and communication skills are of utmost importance at stance instances. It is the dermatologist’s responsibility to act like a psychotherapist and explain the complexity of the condition to the patient. Only once the patient has insight, will he be willing to accept change. The dermatologists should work in a formalized collaboration with a psychiatrist, so it is easier for the patient to open up to psychiatric therapy without much resistance.[Koblenzer CS. Psychocutaneous disease. Orlando(FL)7 Grune & Stratton; 1987.] Occasionally a dermatologist may also have to prescribe selective serotonin reuptake inhibitors, such as fluoxetine or olanzapine, incase the patient is extremely reluctant to visit a psychiatrist.
Doing a procedure on a patient with BDD may have dire consequences too, as patients may occasionally turn violent. There are 2 cases of murder of surgeons by patients showing symptoms of BDD. [Yazel, L. The serial-surgery murder. Glamour May: 108,1999.]Surveys have shown that 29% of aesthetic surgeons have been threatened legally by BDD patients.Sarwer, D. B. Awareness and identification of body dysmorphicdisorder by aesthetic surgeons: Results of a survey ofAmerican Society for Aesthetic Plastic Surgery members.Aesthetic Surg. J. 22: 531, 2002.
CONCLUSION:
Only a psychologically fit patient will be satisfied by an aesthetic surgery. The aesthetician should not only be trained in aesthetics but also in psychotherapy and should know basics of pharmacology behind psychology.