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are discussed. The prevalence of body dysmorphic disorder in cosmetic populations is highlighted. Treatments for body dysmorphic disorder, including medical, psychiatric, and psychological interventions, are reviewed. Results: Body dysmorphic disorder is an often severe, impairing disorder. Among patients presenting for cosmetic treatments, 7 to 15 percent may suffer from the condition. Retrospective outcome studies suggest that persons with body dysmorphic disorder typically do not benefit from cosmetic procedures. Pharmacotherapy and cognitive-behavioral psychotherapy, in contrast, appear to be effective treatments for body dysmorphic disorder. Conclusions: Because of the frequency with which persons with body dysmorphic disorder pursue cosmetic procedures, providers of cosmetic surgical and minimally invasive treatments may be able to identify and refer these patients for appropriate mental health care. Directions for future research are suggested. (Plast. Reconstr. Surg. 118: 167e, 2006.) PSYCHIATRIC DIAGNOSES IN COSMETIC SURGERY PATIENTS The popularity of cosmetic procedures has exploded over the past decade, with more than 10 million cosmetic surgical and minimally invasive procedures performed in 2005.1 Not surprisingly, both surgeons and mental health professionals are interested in the psychological characteristics of this growing population of individuals. Such interest is by no means new and dates back over 40 years to the groundbreaking work of Edgerton and colleagues.2– 4 We have previously categorized the literature regarding the psychological aspects of cosmetic procedures into three generations of research.5–10 Studies from each generation shared a common purpose: to determine whether some patients present with psychiatric disorders that make them inappropriate candidates for surgery and to determine whether changes in physical appearance relate to postoperative improvements in psychosocial functioning. The first generation of studies (approximately 1950s to 1960s), which relied heavily on unstructured clinical interviews, implied that psychopathology was the norm among patients presenting for cosmetic surgery. Results regarding postoperative psychological outcomes were mixed; several studies reported postoperative benefits and other studies noted symptom From the Department of Psychology, Division of Plastic and Reconstructive Surgery, Children’s Hospital of Philadelphia; Department of Psychiatry, Center for the Treatment and Study of Anxiety, and Department of Surgery, Division of Plastic Surgery, University of Pennsylvania School of Medicine; and Department of Psychiatry, Weight and Eating Disorders Program, Edwin and Fannie Gray Hall Center for Human Appearance. Received for publication October 6, 2005; accepted February 6, 2006. Copyright ©2006 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000242500.28431.24 www.PRSJournal.com 167e exacerbations.2– 4 Second-generation studies (1970s to 1980s), which often included reliable and valid psychometric measures, reported lower rates of psychopathology.11–18 Furthermore, studies from this generation implied that surgery could lead to postoperative improvements in psychological functioning.19 Studies from the third generation of research, including most recent investigations, typically incorporated methodological improvements, such as the use of established diagnostic criteria, preoperative and postoperative assessments, and inclusion of appropriate comparison groups. Clinical interview studies found that 20 to 48 percent of patients present for surgery with a formal psychiatric diagnosis.20,21 However, these studies did not use well-structured, validated interviews, thus calling into question the accuracy of the findings. Postoperative benefits (e.g., improvements in depressive and anxiety symptoms and quality of life) have been reported in studies that used psychometric measures.22–29 Many third-generation studies also have focused on the body image concerns of cosmetic surgery patients. Several studies suggest that cosmetic surgery patients typically present with heightened body image dissatisfaction before surgery 30 –34 and experience body image improvements postoperatively.22–25,29,35 Because of methodological problems from all three generations of research, coupled with the lack of any large-scale investigations of the rate of psychopathology in cosmetic surgery patients, it is difficult to draw firm conclusions regarding the psychological characteristics of cosmetic surgery patients and how they relate to postoperative outcome. We, however, have drawn two tentative conclusions from the three generations of research.6,7,9,36 First, persons presenting for cosmetic treatments, like those in the general population, likely experience a wide range of psychiatric symptoms and conditions. Second, although it appears that most patients experience improvements in body image following surgery, there currently is not enough evidence to conclude that the majority of patients experience additional psychosocial improvements postoperatively. All psychiatric disorders are likely to be represented among the large population of persons presenting for cosmetic treatments. Disorders that involve an individual’s physical appearance or body image,

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