The importance of physical appearance is not a new concept and has links to evolutionary theories relating to youth, attractiveness, and reproduction.1 According to Darwin’s theory of sexual selection, specific physical characteristics have evolved not because it helps with survival, but because of the benefits of reproduction, with reproduction being the main aim.2
Through the ages, cultures and generations have sought ways to improve their appearance, consequently influencing the abundance of procedures available today. This article will explore the motivations for aesthetic treatment, and how mental health considerations impact these decisions.
Factors for treatment motivation A person’s mental state fluctuates resulting in a changeable perception of how they perceive themselves, from day to day or week to week. This perception of oneself can have a significant impact on procedures both pre- and post-treatment. It is important to understand a person’s motivations for seeking out cosmetic procedures to ensure safe practice. Having said that, Maisel et al. claim there is little known information surrounding the motivations behind the pursuit of cosmetic procedures.3
The authors of this study, consisting of 511 participants, concluded that reasons for seeking treatments were for themselves rather than to please others. Some motivations included a desire to improve confidence and wellbeing (67.2%), seeking procedures to treat themselves (61.3%) and seeking preventative treatments or to minimise the risk of further ageing (53.3%). Note this study used a small sample size and did not include men.3
In his book, plastic surgeon Dr Panagiotis Milothridis claims that motivations to undergo cosmetic procedures are multifaceted, stating that previous theories on vanity and psychopathology are obsolete.4 In his 2020 paper he also proposes that personality traits and how people perceive themselves impacts on reasons for undergoing cosmetic procedures.1
According to Walker et al., research demonstrates the impact of older media systems such as television and radio having an influence on cosmetic procedures.5 The authors claim there is less research on more modern forms such as Instagram, Facebook and Snapchat, but acknowledged it is a powerful influence focusing on the perfect body image. This is turn can lead to dissatisfaction in a person’s appearance and therefore influencing and motivating to undergo cosmetic procedures.5 The American Academy of Facial Plastic Surgery assert that social media is a crucial element when deciding to undertake cosmetic procedures.6
Other motivations include pressure from peers and the media.7 Thompson et al. claim that the perception of beauty is strengthened and communicated through the combined influence of social and cultural factors which includes the media, peers, and family.7
Hopkins et al. propose that celebrities have an impact on people choosing to undergo cosmetic procedures.8 An example of this is Kylie Jenner – when she revealed that she had lip fillers it resulted in a considerable increase in searches for the procedure online.9 It should be noted that celebrities/influencers can project unobtainable goals, which is further complicated with the use of filters on photos to idealise appearance such as Snapchat and Instagram filters.
Taking all this into consideration, a person’s motivation for seeking out non-surgical cosmetic procedures is not simple and varies from individual to individual and day to day. Consequently, the treating practitioner needs to take all these factors into consideration during the pre-treatment consultation and formulate a realistic treatment plan which combines a holistic mental health assessment whilst ensuring that the patient is suitable for treatment.
The complexities of mental health Mental health is not a new concept and is a fundamental component of a person’s physical health. Historically, there has been a lot of stigma associated with mental health, and people still sadly hide their illness and do not wish to talk about it. The stigma is slowly reducing, but still exists, and, for whatever reason, patients coming into our clinics may not always disclose that they have an illness and/or are receiving treatment for their illness.
According to the World Health Organization, ‘Mental health is related to mental and psychological wellbeing. Mental health includes our emotional, psychological, and social wellbeing. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices.’10,11
According to NHS England, one in four people experience mental illness at some point in their life.12 This means if you are seeing 12 patients a day, potentially three of those patients would have a mental illness or would have had a mental illness as some point in their life.
In a 1960 study of 98 patients reporting minor flaws, 72.4% undergoing plastic surgery suffered with mental illness.13 In 2007 study of 140 patients undergoing cosmetic surgery, 43% had a suspected psychiatric disorder.14 In 2008 other authors claimed that patients requesting cosmetic procedures have a history of mental illness, however, their research is limited to body dysmorphic disorder (BDD), narcissistic personality disorder and histrionic personality disorders. They neglect to discuss all mental health conditions within their research.15 This research is limited and not representative of the general population as well as being out of date. In 2019, Jang et al. proposed that having a mental illness is linked to dissatisfaction following cosmetic procedures, therefore, assessing patients for predictors prior to treatment optimises results. They conducted a study comprising 1,000 patients and found that 44.1% of the patients wanting plastic surgery had/has a history of mental illness. They concluded that mental illness is common with patients seeking cosmetic procedures and advise awareness.15
A 2021 study by Bascarane et al. reviewed 120 articles looking at the prevalence of mental illness and cosmetic procedures. Despite the research being predominantly focused on BDD, they found that 4-57% of patients were diagnosed with BDD, 4.8-25.8% for depression, 10.2-22% for anxiety, and 0-53% for personality disorder.17
The authors concluded that there is a relationship between mental health and cosmetic procedures, but acknowledged and recommended that more research within this area is required to establish a correlation between all mental health diagnosis and cosmetic procedures.
It can be noted that research studying mental health within aesthetic medicine is mostly focused on BDD. The research not only neglects other mental illnesses such as mood disorders, substance misuse, psychotic illnesses and organic disorders, but fails to address the impact both positive and negative of non-surgical procedures on a person’s mental state. The lack of research, and research with small sample sizes makes it difficult for practitioners in clinic, as without the research there is no guidance to support a person in safely managing this patient group.
Considerations for practice
Having a mental illness is not necessarily a diagnosis of exclusion and everyone should be assessed holistically. However, patients with certain mental illnesses may be attracted to cosmetic procedures due to the increased worry about their physical appearance which, in turn, leads to an increase in dissatisfaction and post-procedure regret following treatment.3 Therefore, some mental illnesses such as BDD are a contraindication to cosmetic procedures due to their abnormal perception of themselves. However, Felix et al. proposed that patients presenting with mild to moderate symptoms of BDD could benefit from cosmetic procedures.18 Similarly, Ericksen et al. proposed that those presenting with a mental illness that is being managed, and under control, could potentially benefit from cosmetic procedures, which could enhance their quality of life.19
As medical professionals we have a duty of care, which includes ensuring that we do not cause any harm to our patients; the safeguarding of a patient’s mental health should be included within this. Mental health is a specialty and most practitioners working within medical aesthetics do not have a background in mental health, hence their knowledge and experience is limited.
Without adequate skills and training, it could be argued that as a profession we are failing patients. There is no industry standard with regards to training and training providers have often neglected mental health. Although with the emergence of the Level 7 in aesthetic medicine there is a module on mental health, it is limited, and the Level 7 is certainly not compulsory.
According to NHS England, one in four people experience mental illness at some point in their life
As well as this, aesthetic trainers often do not have a background in mental health and therefore lack experience and knowledge in this specialist subject area and only cover the basics. Without adequate training and support the consequences could be damaging to the patient; this damage can also be caused by a refusal to treat due to their diagnosis and how that refusal is managed. Mental health is not always clear cut or apparent and mental states can be unpredictable and can fluctuate, with triggers not always known. This in turn impacts on a person’s capacity and ability to provide informed consent.
The little training that is out there is usually limited to BDD, neglecting all aspects of mental health. This is further compounded by the lack of regulation within the UK, which makes it difficult to propose a minimum standard of training. Industry standard training with an emphasis on mental health will be a start in protecting all patients, in particular those with mental health needs.
There are a few screening tools used within medical aesthetics and again, they are limited to BDD. These tools are modality specific; not all practitioners use them and without the right training could cause more problems. It could also be argued that asking a few questions does not give a true picture of what is going on for the individual. It is also easy to lie when answering questions. Spending time with patients during the pre-treatment consultation is imperative, building a therapeutic relationship and getting to know them is beneficial. Patients are more likely to be open, honest and to engage, which in turn minimises risk.
Inarguably, it is essential that the treating practitioner has a good understanding of mental health and has an ability to assess and formulate treatment plans to minimise the risk of harm to the patient. Cooling-off periods are particularly important for those with mental health conditions to be able to weigh up the benefits versus the risks of the treatment, and to acknowledge and digest the realistic expectations set out by the practitioner. Two weeks should be offered to all patients as per guidelines set by the General Medical Council.20
Consider mental health
Whilst undertaking cosmetic procedures improves a person’s appearance it is important to understand their motivation for treatment. Practitioners need to ensure they are educated in this area and training providers need to ensure that healthcare professionals are trained to manage patients with mental illness within their clinics. This includes recognising a range of mental illnesses, how to assess for mental illness, communication skills and motivations for treatment and management of this patient group. Having the skills to assess mental illness assists the practitioner with the decision-making process. By doing this the practitioner will be well equipped to offer support by signposting to relevant agencies if there are any causes for concern.
