PSYCHIATRY AND MEDICINE © 2006 Elsevier Ltd 93 PSYCHIATRY 5:3 Attractiveness is a valued attribute in all societies, though its defi- nition may vary. Nearly half the population report dissatisfaction with their appearance and an increasing proportion turn to cosmetic procedures in the private sector to enhance their appearance. In the USA, the top six non-surgical procedures are Botox injections, chemical peel, microdermabrasion, laser hair removal, sclerotherapy and collagen injections. The most popular surgical procedures are rhinoplasty, mammoplasty augmentation or lift, liposuction, blepharoplasty, rhytidectomy (facelift) and mammoplasty reduction. In conditions of disfigurement, there is no relationship between the degree of disfigurement and the amount of distress caused by it; on the contrary, minor physical disfigurement may be associated with great distress and handicap and vice versa. 1 Psychiatrists (or psychologists or counsellors) are sometimes asked to assess the suitability of patients prior to cosmetic surgery. In the UK, the National Care Standards Commission has stated that ‘referral to appropriate psychological counselling is available if clinically indicated prior to surgery’. 2 Although there are no opera- tional criteria to guide surgeons when to refer for an assessment, the NICE guidelines on treatment of body dysmorphic disorder (BDD) recommend that ‘people with suspected or diagnosed BDD seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professional with specific expertise in the management of BDD’. 3 A psychiatric consultation may also be requested by a patient’s relative, concerned that the surgery is unnecessary. It is for patient and surgeon together to decide on a cosmetic procedure while the role of a psychiatrist is to advise them on the psychiatric status of the patient, and to assess the individual’s mental state and the realism of their psychosocial expectations of the proposed procedure. Surgeons want clear advice on whether to operate. The first problem is that patients are aware of this and may be economical with the truth. The second problem is the lack of prospective data to guide a psychiatrist’s decision-making. Psychosocial effects of cosmetic surgery Sawyer et al. and Castle et al. have reviewed the literature on psy- chosocial outcomes after cosmetic surgery and identified only 36 longitudinal studies of varying design and quality. 4,5 Overall, most patients were satisfied and felt more self-confident after surgery. Psychological aspects of a cosmetic procedure David Veale Clinically, only a minority of patients are dissatisfied with their out- come. Putative factors associated with poor outcome include: • being male • being young • suffering from depression or anxiety • having a personality disorder. Other authors have suggested that the nature and degree of surgical change can affect outcome; i.e. ‘type-change’ procedures (e.g. rhino- plasty) are more difficult to adjust to than ‘restorative’ procedures (e.g. rhytidectomy). Lastly, the patient’s expectation of outcome appears to be important: a distinction may be drawn between expectations regarding the self (e.g. improve self-confidence) and expectations relating to external factors (e.g. the patient’s wish to please their partner). The latter is linked with lower levels of satisfaction. However, it should be emphasized that a single factor by itself is unlikely to be relevant and they have not been properly evaluated in any prospective studies. Contraindications A cosmetic procedure is usually contraindicated in three groups of patients. The first group of patients are those with psychosis, mania or severe depression, whose judgement about the need for a pro- cedure may be impaired or who may have systematized delusions or command hallucinations about cosmetic surgery or the surgeon. The second group in whom cosmetic surgery might be contrain- dicated are those with eating disorders, who might be attracted to procedures such as liposuction or abdominoplasty. Screening for a history of bulimia would be important if only because of the possibility of electrolyte imbalance and cardiac arrhythmias during surgery. However, there is likely to be a publishing bias in the few negative case reports of patients with an eating disorder. The third group in whom cosmetic surgery is usually contraindicated consist of individuals with a diagnosis of BDD. Body dysmorphic disorder BDD is characterized by a preoccupation with an ‘imagined’ defect in appearance or, in cases of genuine though slight physi- cal anomaly, the person’s concern is markedly excessive. Figure 1 includes diagnostic criteria for BDD and Figure 2 has suitable questions to ask in order to make the diagnosis. It may be difficult to diagnose BDD in a cosmetic clinic: to differentiate between a minor physical anomaly and a significant one and to determine when the concern becomes ‘markedly excessive’ (by consensus more than 1 hour a day). Cosmetic procedures are designed to enhance a normal appearance and therefore many patients will look perfectly ‘normal’ to you. Bear in mind that a surgeon may describe the appearance in medical jargon when it is still part of a normal variation and that there is a danger of patients latching on to such descriptions like a medical diagnosis to prove that they have an abnormal appearance. Comorbidity and location of defect in BDD There is frequent comorbidity in BDD especially for depression, social phobia and obsessive–compulsive disorder (OCD). The most common preoccupations concern the skin, hair, nose, eyes, eyelids, mouth, lips, jaw, and chin. However, any part of the body may be involved and the preoccupation is frequently focused on several body parts simultaneously. Complaints typically involve perceived David Veale is a Consultant Psychiatrist in Cognitive Behaviour Therapy at the South London and Maudsley Trust and the Priory Hospital, North London, UK. He runs a national service in body dysmorphic disorder (BDD) and obsessive–compulsive disorder (OCD). He is an Honorary Senior Lecturer at the Institute of Psychiatry, King’s College London, and was on the committee that produced the NICE guidelines on the treatment of OCD and BDD.