Psychosocial Issues and the Cosmetic Surgery Patient

The psychiatric exam

The importance of obtaining the mental status of a patient is unique in its ubiquity. It is a mainstay of every examination, regardless of where the patient encounter takes place – the exam table in the emergency room, or on the psychiatrist's couch. Even though the psychiatrist and the emergency room physician will undoubtedly have very different goals for their evaluations, the general structure of the exam and the information obtained are generally the same.

The psychological exam is also unique, as it begins the moment the patient walks into the office. Often with bizarre patients, nurses and office staff alert the physician that the patient may be acting strangely or unusually. In any case, the physician should begin to evaluate the mental status of the patient from the moment they meet, throughout the visit, until the moment the patient walks out of the door. For most physicians, and in particular cosmetic surgeons, this is a simple task, as a highly developed power of observation is warranted by their chosen occupation.

Initially noticeable to the physician, is the appearance of the patient. Taken alone, appearance means very little in our society, as fashion and grooming styles are no longer accurate indicators of occupation, intelligence, or mental status. However, the appearance of a patient may give the physician clues as to the line of questions that will be most appropriate in obtaining information about this particular patient. Often, the most informative indicator of appearance is clothing, which might be dirty or disheveled, tight or flashy, grotesque or gothic, or seductive. For instance, a female patient who is very neat and well dressed, with a blouse that precisely matches her earrings, nail polish, and shoes might be considered for screening for obsessive-compulsive disorder. It is, of course, important to remember that these are not concrete associations that can be stereotyped, but such observations may lead a physician to specific lines of questioning.

The next attribute the physician will typically notice is the patient's orientation to time and place. Normally, orientation is not an issue that needs direct questioning unless patients appear to be noticeably confused or vague about their surroundings.

Having noted appearance and orientation, the next and possibly most important factor to consider is the patient's mood and affect. Occasionally, the patient may actually tell you about their current mood if attention is paid to such phrases as, “I've been a little down” or “I'm happier than I have been.” When not told directly, the physician must rely on observation. In some cases, such as mania or severe depression, the behavioral signs are straightforward. With depression, there may be signs of sadness, indifference to the questioning with reluctance to answer questions at length, or use of a monotonous voice. At the other extreme, those with mania often express inappropriate happiness and extreme eagerness to answer questions, sometimes preventing the doctor from getting a word in. At this point, it may be appropriate to question patients about their use of psychiatric services or other mental health services. This may seem like a very direct personal question, but those who are not being treated will simply say no, while those who are being treated are usually no more embarrassed than someone undergoing treatment for a disease such as diabetes. The information gained by asking this question is far more valuable than any temporary embarrassment or discomfort one would cause to the patient. It may be useful to have questions on a medical intake form that assesses current and past psychiatric conditions. Naturally, this would not replace the techniques described above but would provide some indication that something may be awry.

Depression and mania are usually readily recognized by physicians. Other conditions, such as schizophrenia, require a heightened level of psychiatric observational skill. To identify schizophrenics, the doctor should look for what are called “colorless affects.” These affects include monotonous speech and other non-reactive, non-responsive behaviors. In these cases, it is very important to distinguish between patients truly suffering from schizophrenia and those who may be too scared or too nervous to ask many questions or to respond appropriately. For this reason, it is important that the physician does not guide the patient's answers too much, and close attention should be paid not just to the content of the speech but also to how the patient speaks.

The next part of the psychiatric exam deals with establishing the patient's thought processing ability, judgment and insight. Again, certain psychological diagnoses can be gleaned from observed patterns of behavior. For example, those affected by mania will often be very flighty and skip from one idea to another, lacking the ability to stay focused on one topic. On the other hand, severely depressed people typically find it harder to answer questions and will have slower response times. Other abnormalities may be noticed if the patient is excessively concerned with details or is not interested in anything past an overly generalized description of the procedure. Understanding the patient's background may also be helpful in investigating these attributes. The purpose of evaluating the patient's thought processes, judgment, and insight is to determine if they are able to arrive at a rational decision independently. In all these areas, it is important for the physician to focus on asking specific but open-ended questions, so that more of the patient's personality and character will come through in the answers.

With some procedures, it may be worthwhile to evaluate the patient's intelligence and level of comprehension. If a patient is to undergo an extensive procedure that may lead to dramatic alterations of appearance, or that carries a risk of significant untoward effects, the physician must be confident that the patient possesses the intellect to process and understand the details of the procedure. Most of the time the screening described above will allow a reasonable assessment of cognitive ability. If there is doubt, however, several mental status exams have been developed that can be used by non-psychiatrists to screen patients with limited cognitive function. One of the more widely used is that developed by Folstein, called the Mini-Mental Status Exam. Tools such as these provide a simple and efficient way for physicians to ensure that only mentally fit patients are selected for procedures.

By the end of the appointment, the doctor should be able to ascertain the following:

• How long the patient has been dissatisfied with the relevant body part

• Why the surgery is requested at this time

• The motivation(s) for requesting the surgery

• The patient's expectations: what the surgery will do for them and how it will influence their life

• What surgeries or procedures have been done in the past, and what these experiences were like; whether there were real or perceived problems with the procedures or physician

• Whether the patient is having a life crisis

• Whether the patient suffers from any known psychiatric condition that would preclude them from undergoing the procedure

• If the physician or office staff are suspicious of an unreported or unrecognized psychiatric condition that would reduce surgical candidacy

• Whether family and friends support the surgery and how they might react.

By taking the time to go through these aspects of the initial interview and receiving relevant answers, the surgical team will be able to reduce the number of complications due to psychiatric factors. The very best time to screen patients for the presence of these conditions is during preoperative consultation.

Personality identification

Some may question the need to perform a thorough psychiatric screening in a cosmetic surgery setting. Under most conditions, the personality type of the patient will have little or no effect on the major outcome of the indicated procedure. However, by identifying certain personality characteristics in patients, the physician will be able to estimate what level of care the patient will require throughout the course of treatment, how to best handle any questions or problems that may arise, and how to ensure that both doctor and patient view the procedure as a success. Some common personality characteristics and generalizations about the type of care each type of personality prefers or elicits are described below.