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Table of Contents
Year : 2021  |  Volume : 29  |  Issue : 5  |  Page : 44-52

Problematic patient

1 Department of Psychiatry, School of Medicine, Bezmialem Vakif University, Istanbul, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Gazi University, Istanbul, Turkey
3 Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Bezmialem Vakif University, Istanbul, Turkey

Date of Submission16-Jun-2020
Date of Acceptance26-Dec-2020
Date of Web Publication17-Mar-2021

Correspondence Address:
Dr. Ethem Guneren
Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Bezmialem Vakif University, Istanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_81_20

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The group of patients defined as “problematic patient” in aesthetic plastic surgical practice has distinctive features. The “problematic patient” is the patient who blocks the establishment of a therapeutic relationship with him/her. In other words, the patient who does not adapt to the patient role that the health-care professional expects, has different values, beliefs, or personal characteristics than he/she expects to see, and sometimes causes the professional to even suspect himself/herself. They are not good candidates for esthetic surgery, and they should definitely not be operated, so to speak, these patients should be removed from the game by removing a red card, and somehow be disqualified from the process.

Keywords: Body dysmophic disorder, biopsychosocial, histrionic, personality disorder, narcissistic, simulation, factitious disorder, difficult patient, challenging patient, problematic patient, difficult case, challenging case, problematic case

How to cite this article:
Kirpinar I, Ayhan M S, Guneren E. Problematic patient. Turk J Plast Surg 2021;29, Suppl S1:44-52

How to cite this URL:
Kirpinar I, Ayhan M S, Guneren E. Problematic patient. Turk J Plast Surg [serial online] 2021 [cited 2022 Jun 29];29, Suppl S1:44-52. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/5/44/311438

  Introduction Top

Regardless of the initial cause, aesthetic surgery improves the physical appearance of the individual, helping him/her to be more at peace with himself/herself and adopt a more positive view on life. Therefore, aesthetic surgery is said to be a form of psychotherapy or psychosurgery. This is, indeed, an appropriate attribution in that aesthetic surgery helps the patient to improve his/her view on life, nurture a sense of well-being, and increase his/her self-esteem by widening his/her range of action when comparing himself/herself to others on the social plane. Self-esteem can be defined as self-recognition, self-acceptance, and self-respect of an individual. The individual thereby accepts his/her abilities and powers as himself/herself are. Self-esteem is closely related to the person's body image, which is shaped by the emotions, perceptions, convictions, and associated attitudes about one's own body.[1]. Body image is largely subjective, with no measurable values, and is shaped by the person's conception of their body. Aesthetic surgery has thus been shown to provide benefits also by enhancing the quality of life, self-esteem, and body image apart from the physical results of the intervention.[2]

In today's modern society, physical beauty is very important to many people. Individuals care about how they look and how they are perceived by others and strive to improve and create a “more attractive” appearance. They spend a lot of time, energy, and money for this purpose. Cosmetics and fashion industries and bodybuilding and beauty salons are giant sectors that are basically built on this effort. Especially in developed countries, the variety of aesthetic procedures is increasing, and such procedures are becoming a more common part of the daily life. According to a study conducted in the USA in 2008, $13.2 billion was spent on 11.7 million aesthetic surgical and nonsurgical medical procedures in 1 year, accounting for a 457% increase from 1997.[3]

The change in the standards of beauty over time lead to an increase in the demand for aesthetic surgeries and also increase the dichotomy between the ideal and the reality of the individual. Therefore, the increase in the demand for aesthetic procedures functions as an adherence strategy in a culture that values physical appearance.[4] Whereas dissatisfaction with one's body image is the main source of motivation for aesthetic surgery, media personalities and television shows are also effective in popularizing such treatments.[5],[6] Another important issue is that the concept of “beauty” is largely a personal and subjective perception. The word “aesthetic” comes from the ancient Greek words “aisthesis” or “aisthanesthai,” meaning “of sense perception.” Even this etymological fact does emphasize that aesthetics is a relative concept. Beauty is a quality that varies from age to age, from society to society, and from person to person, and even changing with age, profession, and social and psychological state of an individual. Immaneuel Kant calls the judgment that reports that something is beautiful 'the judgment of taste.” According to Kant, the judgment of taste is of a subjective nature. In other words, the judgment of taste is an emotional proposition which expresses emotion, not conceptual or objective information. “… the beautiful (is) what simply Pleases.”[7]

Although aesthetic surgeries are rapidly increasing worldwide, patients who want to undergo such surgeries cannot be said to give much effort to their sources of motivation.[8] The motivation of the patient may be intrinsic (self-confidence based), extrinsic (anxiety in seeking a job or a partner), or environmental (spouse or fiancée, family, relatives, or friends) pressures. The patient seeks to undergo aesthetic surgery under the influence of one or more of these factors. Intrinsic sources of motivation are often acceptable. The effects of extrinsic and environmental sources, however, should be analyzed well because it is almost impossible to satisfy extrinsic and environmental motivation. For instance, regardless of the outcome of an aesthetic surgery, this procedure can by no means be in a cause-and-effect relationship with the patient's employment or promotion. Many patients are therefore not satisfied with the outcome despite the high quality of the procedure and force surgeons to carry our further procedures. Given the subjective and relative nature of the notions of “aesthetics” and “beauty,” it is very difficult to materialize the patient's expectations. Whether or not the expectations of the patient are met directly affects the patient's level of satisfaction with the services they received from the health-care institution. Whereas some patient expectations are within realistic limits, sometimes unrealistic goals or expectations come into play. The high or abstract expectations of the patient and the absence of an effective solution to the problem can augment the difference between the perceptions of the patient and the surgeon. While this situation can create a narcissistic injury in the patient with the thought that his/her expectations are disregarded, it can also give rise to a feeling of helplessness and inadequacy in the doctor.

How long the patient has been thinking about having the aesthetic surgery is also an important criterion. There are serious differences in terms of the likelihood of regretting their decision after their procedure between a patient who wants to undergo surgery because of the discomfort caused by a developmental deformity and a patient who opts for a surgery during an emotional period or a life crisis. These emotional concentration issues can also be an indication of an acute or chronic mental problem. The outcome of the aesthetic surgery cannot provide any guarantees about the problems they experience in their business life, their unhappiness at home, or in their effort of resolving a problem in their marriage because a good outcome will not have any effect on these matters. The surgery decision should not be based on reasons independent of the outcome. If an individual who has difficulties with being socially accepted also has difficulty in self-acceptance, it will be impossible to change these conditions with an aesthetic surgery, therefore this cannot be accepted as an appropriate motivation. One important aspect patients should be informed about is the limitations of the planned aesthetic procedure. Patients need to be fully aware of these aspects. The impossible (the limits) are even more important. Patients want to have a flat stomach, a curvy waistline, and they do not want any scars. For instance, they want breast augmentation with silicone prostheses, yet they want a natural and upright appearance with no external sign of the prostheses. There should be no loss in nipple sensation. Breasts should not expand to underarms. The cleavage should be smooth and well rounded. Requests can be countless. In fact, it is almost impossible to find all of these features in a single organ of a single person. The patients get these from multiple images that they view online.

Such patients who put health-care professionals in difficult positions with their demands, attitudes, or reactions and further irritate, anger, and cause feelings of helplessness and inadequacy are defined as “problematic patients” in routine practice. Health-care professionals sometimes try to avoid them by keeping silent, but sometimes they cannot prevent an explicit dispute. Nevertheless, both situations negatively affect the mental state of the doctor. Sometimes, in such cases, doctors react and argue with patients or their relatives, or unpleasant incidents can occur. Such problems, which can lead to material and moral losses for the patient and their relatives, the doctor and other health-care professionals, as well as the institution where the doctor works, must be addressed and resolved.

  The Problematic Patient Top

Problems are expected to rise gradually as the communication moves from a human-to-human interaction to doctor-to-human, to doctor-to-patient and doctor-to-problematic patient interaction. While the term patient already conveys an image that implies the presence of problems, the magnitude of the problem doctors are faced with when the term becomes “problematic patient” should be noted. The “problematic patient” is defined as a patient who hinders and disrupts the clinician's efforts to establish a therapeutic relationship.[9],[10] In other words, a problematic patient is a person who does not conform to the patient role expected by the health-care professional, whose values, beliefs, or personal characteristics are different than what the health-care professional expects to see, and who sometimes causes the professional to suspect himself/herself.[11]

Patients that are defined as “problematic patient” in aesthetic surgical practice have distinct characteristics. These patients see many doctors for the same issue. They speak ill of their former doctor and procedures. They believe that all their previous procedures were done wrong and articulate this at every opportunity. Therefore, when these patients see a doctor for the first time, they tend to speak ill of all of the doctors whom they previously saw or who have examined them or operated on them.

Another characteristic of these red flag patients is that they run to doctors with some photographs of other people. This is called “Photo pack syndrome.” They bring with them the photographs of celebrities and ask the plastic surgeon to make them look like these celebrities. This is an unrealistic expectation. Patients with photo pack syndrome should never be associated with the success of an aesthetic procedure as they are most likely to continue with their complaints or search after some time, this time with the photograph of another celebrity that they want to look like. Perhaps, the most dangerous of these are those who edit their own photographs using image-editing software. These patients bear the highest risk of dissatisfaction after surgery.

In clinical practice, doctors are seen to experience more problems with patients who are defined as problematic patients and are unable to establish the necessary patient–doctor relationship. Such situation hinders the possibility to effectively carry out the interventions in daily practice; it psychologically exhausts the doctor and leads to delay in the patient's treatment, thereby creating discontent for both the doctor and the patient.[12],[13] Hence, “problematic” or “demoralizing” patients take up more resources than necessary, and in fact most of them have unidentified psychiatric problems.[14],[15]

We also may have to look at the situation from a different perspective. It is evident that in many cases the characterization of the patient as a “problematic patient” is actually a stigma. In fact, in daily practice, it is observed that some patients that have been defined as problematic patients by some doctors are not perceived as such by other doctors, and that the patient is unfairly characterized as problematic patient for reasons not caused by the patient. Because of this kind of stigma, a person who is noncompliant only under certain conditions can sometimes be wrongly positioned. When the difficulties in patient–doctor communication are examined, the causes are seen to also arise from the doctor or the health system and not only from the patient.[12] It should be borne in mind that these problems are usually the result of several causes. In many cases, the difficulties arise from particular patients with the above-mentioned characteristics. Nevertheless, the doctor's “inadequate interaction and communication skills,” “inexperience,” and “stress due to personal or institutional reasons” also strain the therapeutic relationship. Challenging cases are responsible for the problems experienced in patient–doctor interaction, it would be more appropriate to use a characterization that emphasizes a certain type of interaction.[16],[17]

Studies in the literature report that at least 10%–20% of the patients who undergo an aesthetic procedure experience dissatisfaction after the surgery despite its acceptable results.[18],[19] Dissatisfaction of the patient can lead to requests of repeat surgery, depression and adjustment problems, social isolation, domestic problems, self-harming, and anger to the extent of aggression toward the surgeon and other health-care professionals.[20] Some of the interaction issues between the patient and the surgeon can take a certain course with simply by providing information or by adjusting the communication resources. However, communication techniques will not work in some patients. This is to say that these patients who are not suitable candidates for aesthetic surgery should absolutely not be operated on. “Effects of the psychological stress caused by illness,” “personality disorders or personality traits,” and “mental illnesses” can turn patients into more incompatible and problematic individuals.

Considering that aesthetic surgery, including patient selection, is in many aspects elective, exclusion of those patients who are thought to be difficult or have such a potential will reduce postoperative dissatisfaction rates. This, however, is not as easy as it sounds and is affected by many factors. The main challenge, which contests the desire to reduce the likelihood of failure of the procedure and the patient's relative dissatisfaction, is how to decide on which patients to exclude. In this context, psychiatric problems that arise in patients who demand surgical procedures or who have undergone these procedures should be carefully addressed. Indications which may arise later on, especially in those who undergo aesthetic procedures at a young age, or even in those who undergo the procedure merely for aesthetic concerns, should be defined well. For instance, how the psychologies of a person who undergoes a nose procedure for opening the respiratory tract and a person who undergoes aesthetic surgery to reshape the anatomy of their nose will be affected should be individually assessed. Because the latter, as in the other areas of life, with an emphasis on appearance, may convey this type of a message: good things in life can be easily achieved through an effortless procedure, therefore you do not need to strive, toil, etc., to improve yourself spiritually; just find the money! This way you can easily find both a job and a partner!

Among the patients who request aesthetic surgery, those with unrealistic expectations are those who are unhappy/hopeless; those who have low self-esteem; those who are overly proud/arrogant, perfectionists, rude, and very important persons; those whose desires are not very clear or fully focused; and those who know-it-alls. Collaboration of aesthetic surgeons with psychiatrists at the decision phase before the surgery and the follow-up period after the surgery may help to avoid some of the drawbacks. It should also be noted that some psychiatric disorders are absolute contraindications.

  Psychiatric Disorders Affecting Aesthetic Surgery Top

Most of the individuals who request an aesthetic surgery procedure appear to be psychologically healthy. Some of them, however, do have psychiatric problems, and surgical procedures in these individuals may cause problems for the patient and the surgeon, leading to an unfavorable process.[21],[22] Therefore, candidates should be screened for psychiatric disorders before any aesthetic surgery.[23] It has been reported that more than 47.7% of the patients who want to have an aesthetic procedure met the diagnostic criteria for a mental disorder.[24]

Body dysmorphic disorder (BDD), narcissistic personality disorder, and histrionic personality disorder (HPD), in particular, are the most common psychiatric conditions in people seeking aesthetic surgery.[8],[25],[26],[27],[28] Moreover, various studies report that high rates of anxiety disorders and depression were observed in people who present for aesthetic procedures.[25],[26],[29]

Psychotic patients who have delusions that their body is being manipulated or they hear voices that give them instruction or humiliate them for their bodily appearance (hallucinate) and request aesthetic procedures with the effect of such psychotic symptoms are absolutely contraindicated and psychiatrist help should be provided.

The literature also shows that mental problems, such as those leading to suicide, emerging after some aesthetic surgery procedures, are also very important. For instance, Brinton et al. (2001) who examined more than 13,000 women who had undergone aesthetic surgery for breast augmentation in the USA showed that the rate for the risk of deaths by suicide on an average 14 years after the operation was 1.54 times the expected rate in the general population. After 5 years, the same rate had increased to 1.63.[30],[31] There are also other studies that reported 2–4-fold increases in suicidal rates.[32],[33],[34],[35] Although no definitive explanation has yet been provided for these results, lower body mass index, higher smoking rates, higher miscarriage and less live birth rates, lower educational levels, and younger ages at first birth are reported in women with breast implants, and perhaps suicidal attempts may be associated with these conditions.[36],[37],[38] There are, however, not many publications on the role of the developing psychiatric disorders.

Psychiatric problems seen in patients who seek aesthetic surgery are not limited to psychiatric disorders that correspond to the diagnostic criteria. Most of the patients may have various psychological symptoms, complaints, or tendencies at varying severity levels. For instance, dissatisfaction with body image, low self-esteem, lack of self-confidence and feelings, and thoughts of embarrassment were shown to prevail more in women who seek breast augmentation surgery.[6] Aesthetic surgery patients with psychiatric problems, instead of seeking psychiatric help for their dissatisfaction after an operation, move on to demand new surgical interventions.

Excessive preoccupation with one's appearance can be associated with psychopathologic characteristics that may not always be easily recognized, and disregarding this fact can lead to several iatrogenic and medico-legal problems. Therefore, clinicians should always seek out psychopathologies before the surgery, and, if suspected, consult a psychiatrist. Some of the psychopathologies that should be questioned are given below.

Body dysmorphic disorder

BDD is a psychiatric condition in which a person is consumed with and is intensely anxious about an imaginary or an actually minor physical defect in his/her appearance. In BDD, the individual believes to have bodily features that are “not sufficiently good-looking and attractive” or “flawed.” There are no apparent physiological or general medical reasons that explain the physical/somatic complaints of the individual. Even in the presence of such a reason, this physical condition alone would not suffice to explain the individual's anxiety, all of their symptoms, and loss of functionality.

The surgeon should also take into account that the notion of beauty is rather a relative concept, and first establish that the person's mental effort and anxiety are excessive before suspecting BDD. Patients are exposed to complications from repeated surgeries and medical treatments, as they may seek remedy in nonpsychiatric disciplines such as aesthetic surgery and dermatology due to their obsession with physical defects. Their condition becomes even more complicated as these treatments bring useless and even “worse-than-before” outcomes.


The prevalence of BDD, which is 1%–6% in the general population, rises to as high as 16% in patients presenting to psychiatry clinics.[39],[40] Despite being a common disorder, it is a condition that is rather seen in aesthetic surgery clinics than in medical practice and psychiatry units.[41],[42] While BDD is reported at rates from 6% to 15%[5],[43],[44] in aesthetic surgery patients, there are also studies that report as a high as 53%.[45]

Typically, the symptoms emerge during childhood or adolescence when physical appearance is considered particularly important, and sometimes after menopause.[46] The mean age of onset is 16–17 years. In two-thirds of the cases, symptoms emerge before the age of 18 years. Symptoms that do not yet meet the clinical diagnostic criteria set on at the age of 12–13 years. Although cases with onset in advanced ages are reported, there is little information about these incidents. Suicidal attempts, presence of comorbidities, and progressive course are more common in cases with an early onset compared to those emerging in adulthood.

Some studies report BDD to be more common in women.[47],[48] There are, however, studies that report varied results for gender ratio and indicate that it equally affects men and women. Studies conducted on adolescents reported that the disorder was more intense in women and as high as 80%.[48]

Symptoms, diagnosis, and classification

While BDD has been observed in different eras and different cultures, it rather seems to be a problem of the modern times. Despite being first defined as “dysmorphophobia” by Enrico Marsell in 1868, the condition was not seen as a disease by international diagnostic systems for a long time. BDD was only revised in 1987 in American Psychiatric Association's classification system and The Diagnostic and Statistical Manual of Mental Disorders (DSM).[3] It was included in the contemporary classification systems after the publication of DSM-III-R. Some changes were made in its diagnostic criteria in DSM-IV and DSM-IV-TR, and later included under Obsessive-Compulsive Spectrum Disorders in DSM-5. In International Statistical Classification of Diseases and Related Health Problems-10, the classification system of the World Health Organization, BDD is evaluated as a type of hypochondria. Social and cultural standards and differences in methodology affect diagnostic and treatment efforts.

According to the DSM-5 criteria, patients constantly dwell on the thought that a mild defect or a situation, which actually is not visible to others, is a serious defect or imperfection. Because of this conviction, the person engages in repetitive behavior (such as looking at the mirror, grooming, skin-plucking, concealing, and seeking assurance) or mental actions (comparing one's own features with others). Moreover, this leads to serious decline in the social and functional departments, and severe impairment of quality of life. As in other psychiatric disorders, in BDD, the most important distinction between the normal and the pathological is “disruption/impairment in functionality.” This is to say that as is in many psychiatric disorders, the difference between the normal and the pathological is not qualitative, but quantitative.

In the muscle dysmorphism subtype, the individual is concerned that his/her body is too small or that he/she is not muscular enough, and therefore engage in athletic and bodybuilding activities or use anabolic agents for a long time to increase his/her muscle mass. Some of those with BDD are insightful; in other words, the person knows that his/her concern is not realistic. Some other patients, however, have no insight. They convinced of their imaginary defect to a delusional degree.

Complaints typically are of imaginary or minor defects in the face or head. Individuals may describe their flaws as “ugly,” “repulsive,” “disgusting,” “apelike,” or “horrible.” Mental pursuits are intrusive, unintentional, time consuming (3–8 h a day on an average), and difficult to resist or control.[49] Concerns are mostly about the skin (acne, scars, wrinkles, and color changes), the face, the nose (large, ill shaped), the eyes, the lips, the hair (thin hair or excessive growth of hair), or the genitals. Nearly 68%–98% of BDD patients have concerns about more than one body region.[50] Some patients believe to have asymmetrical body parts. The average number of body regions which patients find defective and are anxious about is reported as 5–7. While BDD can be about the appearance of a body part, it can also be caused by concerns about a function of the body. Examples include thoughts about sweating, hence smelling bad. In BDD cases, anxieties become prominent in social situations. As most BDD patients believe that their physical defects are also noticed by others, avoidance behaviors such as not being able to leave the house or going out only after dark, not being able to enter social environments, dropping out of school, and leaving work are common. They excessively look in the mirror or try to avoid mirror-like reflective objects as much as possible, use make-up to conceal the areas they believe to be defective, and make changes in their clothing style.


There are studies which show that BDD could be associated with sexual, emotional, and physical abuse experienced in childhood. A study conducted on obsessive-compulsive disorder (OCD) and BDD patients revealed childhood trauma in 38% of BDD and in 14% of OCD patients.[51] Shy, perfectionist, and anxious individuals; those who were bullied; those who were exposed to physical violence or sexual abuse; those who lacked social support; and those who could not sufficiently interact with their peers in childhood are reported as the risky groups. Negative emotional responses, such as anxiety, disgust, and embarrassment, may be observed in relation to an instinctive stimulus in individuals who have developed negative body perception due to their learning models and past experiences.

As much as the psychological and environmental conditions that influence the individual's personal history, BDD can also occur due to the interaction of biological factors such as genetic predisposition and neurochemical dysfunction. Brain imaging studies can reveal the evidence of dysfunction in various brain neural networks in the specific regions of the brain.[52],[53]

As a result, the etiology of BDD, like many psychiatric diseases, can be explained by the interaction of many factors.

Prognosis and outcome

Although of heterogeneous nature comorbidities are common in BDD patients. These further increase the patient's distress. Depression is the most common accompanying disorder. Social phobia, OCD, and substance use disorders are other common comorbid conditions.[49],[54],[55]

Following an insidious onset, BDD usually shows a chronic prognosis with periods of recovery and exacerbation. Patients may have concerns about more than one body part or organ, or the body parts which they believe to be defective may change over time. If not treated appropriately, this disorder shows a chronic course, and the work, social, and personal lives of many patients shrink and most of them tend to completely isolate themselves. Most of the patients diagnosed with BDD display avoidance behaviors in social situations. This evokes the avoidance behaviors seen in socially phobic individuals.

Suicidal attempts are not uncommon among BDD patients. Retrospective studies showed that 80% of BDD patients had suicidal thoughts and 22%–29% did attempt suicide at least once in their lifetime.[56] Adolescents diagnosed with BDD were found to have significantly more suicidal thoughts than adults. In a study, it was determined that 80.6% of the adolescent patients diagnosed with BDD had suicidal thoughts and 44.4% had attempted suicide.[48]

Many scales have been developed for assessing BDD or body image. However, except for some that have been structured and evaluated by mental health professionals, most of these scales are not efficient for diagnosing BDD. It would therefore be appropriate for the surgeon to cooperate with a psychiatrist in suspected cases and ask for an evaluation, if necessary.

  Personality Disorders Top

While the overall anatomical structure of all humans is similar, not all of their physical features are identical. This is the case even for monozygotic twins. The same can be said for their mental structures. Despite having common features, our thoughts, emotions, and behaviors can never be identical. Each and every one of us has unique cognitive, emotional, and behavioral characteristics. Some of these characteristics are more distinct in some compared to others. These characteristics which distinguish individuals from one another and are generally seen as unchanging make the personality of the individual. Personality for the most part develops during childhood and adolescence as a result of the interaction of biological factors, especially the genes, with psychosocial factors such as family, school, friends, and culture.

  • Personality disorders, on the other hand, are defined as “continuous and rigid patterns of inner life and behavior that incongruously deviate from the expectations of the environment and culture which the individual is part of.” This continuous pattern presents as a long-term adjustment disorder and rigid tendencies that lead to clinically significant distress or impairment in social, professional, or other important areas of functionality. These disorders begin to take shape in late adolescence or young adulthood. As in normal personalities, they are influenced by biological and psychosocial factors
  • Personality disorders, all of which are classified into three general groups based on their common characteristics, present with compliance problems. These compliance problems become prominent especially in stressful or crisis-like situations such as those which require medical intervention and various behavioral problems arise. For instance, when working with a patient with paranoid personality disorder, it is necessary to act according to their irritated, suspicious, short-tempered nature. Whereas another patient with dependent personality disorder will leave the responsibility of each procedure to the persons they depend on (or to the surgeon). Obsessive individuals, on the other hand, can be very challenging because of their unsatisfiable obsessions such as order and symmetry, and their perfectionist nature. Therefore, understanding the personality of the patient during the medical and surgical processes will largely help to plan the mode and level of the potential procedures. However, narcissistic and HPDs such as BDD that may need to be eliminated before an aesthetic procedure become more important.

Narcissistic personality disorder

Narcissistic personality disorder is a particular condition in which the individual has an inflated sense of self-importance, superiority, and uniqueness, a need for admiration, and a lack of empathy for others. According to the DSM-5, it is a common pattern that begins in early adulthood and emerges in different contexts with arrogance (in fantasies or behaviors), the need for admiration, sense of entitlement, exploiting others, and the inability to empathize.[49] Their conviction of their aesthetic superiority such as beauty, handsomeness, glamor, and charm are among the most frequently observed features of arrogance. For them, the feelings, desires, and thoughts of others are insignificant. For them, other people have value to the extent they show a spark of admiration. They do not care about those people who don't show their admiration, hence cannot empathize.

While the prevalence of narcissistic personality disorder in the community is around 1%, this rate is between 2% and 16% in the clinical population. This rate is reported as 25% in aesthetic surgery patients.[57] More than 70% of those diagnosed with narcissistic personality disorder are male.[49]

Individuals with narcissistic personality disorder believe that others should understand and admire their superiority, importance, and uniqueness. When faced with words and behaviors that are incongruous with these expectations, they are easily hurt and may experience disappointment defined as “narcissistic breakdown” or even become depressed. They believe that they deserve special treatment, and they expect to be served like “royalty.” They compare themselves to renowned, privileged people.

Narcissists are expected to be frequent among those who seek aesthetic surgery because they want to be more beautiful, thus attract more attention than others. Because individuals with such personality disorder believe that they will be more attractive when they look younger, they can sometimes have very odd demands to achieve a youthful body image. Aesthetic surgery may seem to be the most effective way to achieve these desires. They, without doubt, expect unique outcomes from medical procedures. Nevertheless, they are never satisfied with any of the surgical procedures because their understanding of beauty is unlimited, and a procedure has not yet been invented to satisfy this unlimited appetite.

Histrionic personality disorder

A generalized and continuous pattern that emerges in different contexts as excessive emotionality and constant attention-seeking is the typical characteristic of this personality disorder. They constantly use their appearance to attract attention and are disturbed when they do not get attention. Attention-seeking and excessive emotionality are a common pattern. Their emotions are superficial and change very quickly. Histrionic people tend to be emotionally manipulative and intolerant of delaying gratification. In their interpersonal relationships, they initially come forth as friendly and charming, but many get bored of their shallowness and neediness. Pretended and exaggerated speech and behavior, manipulative behavior, and being easily influenced by others are commonly seen. Indecent, sexually provocative, or seductive behavior is also observed, however inability to build emotionally and sexually intimate relationships is an associated trait. Therefore, their romantic relationships and friendships change rapidly.

Its incidence in the community is 2%–3%, and although it has been reported to be more common in women in clinical settings, its male-to-female ratio in the community is controversial.[49] Somatization, moodiness, and alcohol abuse can accompany this disorder.

HPD is the second most common disorder in patients who seek aesthetic surgery.[58],[59] It has been reported to occur in 9% to 10% of aesthetic surgery patients.[27],[57] They attach great importance to their appearance. They can spend a lot of time and a lot of money to look impressive. However, they have unrealistic expectations from aesthetic procedures and their outcomes. It should be noted that these individuals will never be satisfied with the results of the procedure. What they seek in their visit or the surgical procedures is in fact assurance, approval/appreciation, or praise. Moreover, as in every subject, they quickly get bored even if they set out for a surgical procedure with great enthusiasm.

Seductive behavior is a type of manipulative behavior that helps histrionics get the attention they long for. They seem to exaggerate their appearance and emotions to control others. For instance, a person with HPD may behave seductively to seek special care from the surgeon or the nurse. It is essential to be mindful of seductive behavior and maintain the professional stance. Despite coming forth as seductive and sexually enthusiastic, most actually have sexual function and desire problems.

  Simulation Top

Some people may pretend to be sick for some benefit or gain although they are not or can consciously manipulate their health to get sick. These people can be seen in across all departments of medicine as well as in surgical departments. The individual can self-injure, amputate an organ, and produce other symptoms to achieve secondary gains. Fully consciously, they attempt to present themselves as sick or disabled to escape from their professional or vocational responsibilities, to get sick notes for various purposes, to avoid military service, to use in personal relations, to deal with legal problems, or to make financial gain.

Sustaining the suspicion of simulation will be useful when there are situations that suggest such intentions. The clinician should scrutinize the patient's symptoms and history when such suspicion is present. When suspicious of such cases, it may help the doctor to look out for ulterior gains or interests, to listen more, to observe, and to carefully take the personal history of the patient candidate. If the reported symptoms and story are “textbook material,” distracting questions that fall outside of the formal nature of the presented disease may be used. If the expected response is implied, the patient is likely to provide the appropriate answers.

Sometimes, telling them that it is necessary to talk to a family member can also be effective. Successful narration of the same story by two people is unlikely unless the disorder is genuine. Finally, if necessary, the surgery decision can be delayed for some time to avoid hasty decisions.

  Factitious Disorder/Munchausen Syndrome Top

There is no secondary gain or benefit in this interesting condition. However, a patient role has been adopted; the disease is real, but the symptoms are created. Physical or psychiatric syndromes such as dermatitis artifact (deliberately self-inflicted skin lesions that can present in various appearances), infections, injuries and scars, hyperglycemia, and diarrhea are sometimes artificially induced with the help of drugs.

The classic example of factitious disorders with somatic signs and symptoms is known as Munchausen syndrome. The term Munchausen syndrome was proposed by Asher in 1951, to define the artificial syndromes described by those who travel between hospitals, mimicking acute medical or surgical pictures and providing incomplete and false information and about their social and medical history, and sometimes giving accounts that force the boundaries of logic, yet with no ulterior motive of gain.[60]

They repeatedly visit health-care institutions and doctors. Some have multiple unnecessary scars on their abdomen due to repeated emergency surgeries. This syndrome is mostly seen in men in their early adulthood.

A subtype in which parents induce the symptoms of a condition on their child was described by Meadow in 1977 as “Munchausen by Proxy.”[61] To indirectly impose the role of the patient, the abusive person, mostly mothers, purposefully reveals physical or psychological signs or symptoms in another person under their care (usually their child) or acts as if that person has such symptoms or signs.

  Conclusion Top

Anyone who applies to a plastic surgeon is, in fact, a client. If, in the first minutes of the visit, the surgeon thinks that the conversation is suggesting a problematic patient or that the topic does not fall within their field of interest, it will be more beneficial for both parties that the surgeon informs, hence rejects the client as soon as possible. This, however, is easier said than done because the skill of handling problematic patients is acquired through a long and enduring process. This largely begins with accepting that the medical model which is most valid and realistic for every patient is the “biopsychosocial” model. It is known that according to the definition of health, a person can be considered healthy if they are in a state of wellness not only physically, but also mentally and socially. While the relationship between the patient and the doctor is an extremely humane and close relationship, it is also a professional relationship and the professional party in this relationship is the doctor. Therefore, regardless of whether the problem is caused by the patient or the doctor, it is the duty and responsibility of the doctor to maintain the relationship and to ensure the best course of the treatment process. The doctor has to enhance his/her communication and relationship skills. Doctors should make the effort to understand how the patient perceives, interprets the problem, and expects of the doctor. The expectations of the patient should be met to the extent possible, and those that cannot be met should be clarified. The doctor should recognize his/her own limitations and limits, and manage to stay within these limits in his/her relationship with the patient.

Nevertheless, there will be problematic patients and “problematic relationships,” and it is impossible for every doctor to cope with all such cases. Not only as much as what should be done, but also it is equally important to also focus on what should not be done. The patient should not be retaliated against, told to leave, or be humiliated. The surgeon should review the working conditions of problematic patients and try to find ways to spare more time for them. It may be necessary to focus, sometimes even more, on the patient's personal story than his/her complaints and physical findings. While seeking answers to questions such as how they perceive themselves and their flaws, their level of insight, and to the extent to which their complaints match their objective appearance, the doctor should consider the patient's actual expectation from the procedure and to what extent these expectations can be met.

When aesthetic surgeons are convinced that the aesthetic problems which the patient reported are not genuine or are insignificant, and do not get results through long interviews or persuasion efforts, they usually understand that the patient has a psychological condition. Even if they tell the patient that they do not have a major defect and that a psychological treatment would be more appropriate, the patient may move on to find another surgeon who will do the procedure. It is essential to get support from the psychiatrist when the patient is suspected to have a psychiatric disorder, or a personality problem, even if minor, that could adversely affect the treatment. It is, however, important not to allow the patient to perceive this as if the surgeon is dodging or ridiculing him/her or treating him/her as a crazy person. Normalizing this consultation process as to create the impression of a routine and necessary procedure will lead to favorable results. Instead of hasty and irritating advice such as “your problem is psychological,” “the problem is in your head,” or “you should see a psychiatrist,” statements emphasizing that it would be necessary to seek the opinion and perhaps the support of a psychiatrist since the procedure could have some psychosocial consequences will lead to positive effects.

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