On the Air with… David B. Sarwer, PhD

Interviewed by
Cynthia Alexander, PsyD

When Bariatric Times asked me to interview Dr. David Sarwer, I jumped at the chance. There are only a handful of psychologists who really understand the field of bariatric psychology. Anyone keeping up with bariatric research will be familiar with David B. Sarwer, PhD. He is Clinical Psychologist and Associate Professor of Psychology in Psychiatry, University of Pennsylvania, Philadelphia, and also the Director of Clinical Services for the Center for Weight and Eating Disorders and the Director for Stunkard Weight Management Program. His research and expertise have been guiding forces in bariatric psychology. Of particular interest is his research on plastic surgery and the bariatric patient, as well as on psychological issues related to plastic surgery. I would like to thank Dr. Sarwer personally and on behalf of Bariatric Times for the time he invested in this interview. I am sure this exchange of questions and enlightening responses will be of interest to a wide variety of professionals working with bariatric patients, and should help us all better understand our patients in an effort to provide improved and informed multidisciplinary care.

-Cynthia Alexander, PsyD

Dr. Alexander: You have written many articles about cosmetic surgery and bariatric patients. I was interested in your finding that viewers of cosmetic surgery reality shows are more likely to feel dissatisfied with their own bodies. Can you tell us more about that?

Dr. Sarwer: A number of studies in the past few years have shown that exposure to mass media’s depictions of physical beauty is associated with a decrease in body image satisfaction in the viewer. Recently, one study showed that viewings of cosmetic surgery reality shows, such as “Extreme Makeover” and “The Swan,” are similarly associated with increased body image dissatisfaction. Thus, while these shows may be a harmless, guilty pleasure for some, they have the potential to negatively impact the body image of others.

Dr. Alexander: You suggest that these patients be given a “reality check” prior to surgery. What does this involve?

Dr. Sarwer: One of the unfortunate aspects of cosmetic surgery reality shows is that they often depict rather extreme forms of cosmetic surgery. That is, they focus on individuals who undergo numerous and extensive procedures, when in reality most patients undergo one single procedure at a given time. Regardless of whether an individual is interested in one or more procedures, it is important that patients have appropriate motivations for surgery and realistic expectations in terms of postoperative outcomes.

Dr. Alexander: How can we evaluate for realistic expectations?

Dr. Sarwer: Before pursuing a cosmetic procedure, it is important for a patient to ask him- or herself a few questions. First, is the appearance concern something that is readily observable to others? Second, what is motivating the interest in surgery at this time? Third, how does he or she anticipate that life will be different after surgery? Individuals with specific appearance concerns that are visible to others, those with internal motivations (who are interested in surgery to improve their self esteem and body image), and those with realistic expectations are believed to be most appropriate for surgery. Those individuals with unrealistic expectations are more appropriate for mental health counseling prior to surgery.

Dr. Alexander: How does breast reduction compare to body contouring with regard to psychosocial issues?

Dr. Sarwer: Women who present for breast reduction surgery typically have both physical and psychological reasons for surgery. In this regard, breast reduction surgery is both a reconstructive and cosmetic procedure. Body contouring surgery is quite similar in that patients typically have both physical concerns—issues related to loose, hanging, or redundant skin—as well as psychological concerns, namely body image dissatisfaction.

Dr. Alexander: Do you think every bariatric patient having plastic surgery should have a presurgery psychological evaluation?

Dr. Sarwer: In the cosmetic surgery literature, there is a consensus that only a small minority of candidates for surgery have psychological issues that warrant a psychological evaluation prior to surgery. Furthermore, there is little evidence to suggest that the presence of preoperative psychopathology is associated with postoperative outcomes. For those reasons, my colleagues and I have suggested that preoperative psychological evaluations on all cosmetic surgery patients are not warranted at the present time. Until we know more about the psychosocial issues of body contouring patients, it is similarly premature to suggest that all patients should undergo a consultation prior to surgery. However, body contouring surgeons who have concerns about the psychosocial status of their patients should strongly consider a preoperative mental health evaluation.

Dr. Alexander: What specifically do you think are the most important points that an evaluation should investigate?

Dr. Sarwer: The evaluation should cover the following three general areas: the nature of the appearance concern, the patient’s motivations and expectations for surgery, and the patient’s psychosocial history and current status (as would be done in most mental health evaluations).

Dr. Alexander: Is the patient’s compliance and follow-up record following bariatric surgery relevant to his or her pre-body contouring evaluation?

Dr. Sarwer: Individuals with a history of poor compliance following bariatric surgery are quite likely to show the same compliance problems following body contouring surgery. Behavioral noncompliance can compromise the outcome of a bariatric procedure and is probably the biggest threat to an optimal, long-term outcome. It is reasonable to think that dietary and behavioral noncompliance can contribute to postoperative weight regain and compromise the aesthetic result of a body contouring procedure as well.

Dr. Alexander: You found that 5 to 15 percent of cosmetic surgery patients may have body dysmorphic disorder (BDD). Do you believe BDD is a contraindication for all plastic surgery?

Dr. Sarwer: A number of studies throughout the world have found that up to 15 percent of cosmetic surgery patients suffer from BDD, which is defined as a preoccupation with a slight or imagined defect in appearance that negatively impacts daily functioning. Other research suggests that approximately 90 percent of individuals with BDD experience either no change or a worsening in their BDD symptoms after a cosmetic procedure. Furthermore, there are anecdotal reports to suggest that patients with BDD may be more likely to threaten or undertake legal action or acts of violence against their surgeons. For all of these reasons, BDD is typically seen as a contraindication to cosmetic surgery.

Dr. Alexander: If BDD is a contraindication to cosmetic surgery, in your opinion, then in general would a person be appropriate for surgery after a course of therapy to address the disorder?

Dr. Sarwer: Patients with BDD who are interested in cosmetic procedures should be referred for psychiatric assessment and treatment prior to surgery. Both cognitive behavioral psychotherapy and several psychiatric medications have shown to be effective in treating the disorder. After treatment, some individuals may be less preoccupied with their appearance and potentially more appropriate for cosmetic surgery.

Dr. Alexander: How open to this evaluation process to do you think plastic surgeons may be?

Dr. Sarwer: Many plastic surgeons are very interested in the psychological wellbeing of their patients and, as a result, will send their patients for psychological evaluations prior to surgery.

Dr. Alexander: As for breast augmentation surgery specifically, your research discusses the higher suicide rate in people seeking this particular surgery. Can you give us any insight into this? Any suggestions for patients seeking breast augmentation?

Dr. Sarwer: There are now seven large, retrospective, epidemiological studies that have found an association between cosmetic breast implants and suicide. Collectively, these studies suggest the rate of suicide is 2 to 3 times greater among women who underwent cosmetic breast augmentation as compared to other women. As these were retrospective studies, we know very little about the reasons for this association. There is some evidence, as well as some consensus of opinion, that the higher rate of suicide can be attributed to some preexisting psychopathology, rather than something specific to the implants themselves. However, we need additional research on this issue to help us better understand the relationship between breast implants and suicide.

Dr. Alexander: Speaking of body contouring surgery, you point out that most patients are considering surgery two years after bariatric surgery, but this is the same timeframe in which some patients begin to regain weight. What do you suggest in terms of length of stable weight history before body contouring?

Dr. Sarwer: Most patients acknowledge that they are thinking about body contouring surgery even before they undertake the bariatric procedure. What many patients—and body contouring surgeons—do not always understand is that patients typically reach their maximum weight loss 18 to 24 months after the bariatric procedure. After that, several studies suggest that patients enter a period of at least modest weight gain. Unfortunately, this is the period of time when many patients present for body contouring surgery. While there has been little research on this topic, it is easy to imagine how even a small weight regain could jeopardize the aesthetic result of a body contouring procedure.

Dr. Alexander: You point out that more patients desire cosmetic surgery than those who actually have it. How can we help the post-bariatric surgery patient who cannot afford body contouring?

Dr. Sarwer: We know that many patients will save money for months or years to pay for cosmetic surgery, often delaying a family vacation or other large purchase, or using money that they could have been putting toward retirement. A Google search of the term cosmetic surgery links to a number of companies that provide financing for cosmetic surgery, including body contouring. While some people see this as a particularly troubling artifact of our consumer culture, another way to look at the issue is to realize that it truly underscores the importance of physical appearance and body image for some people.

Dr. Alexander: In my practice, I have seen patients become almost obsessed with plastic surgery, some having five or more procedures. While in group, one patient described plastic surgery as “fun.” Have you seen this in your practice?

Dr. Sarwer: In the plastic surgery literature, clinical descriptions of the minimal deformity patient—who is obsessed with a slight defect in appearance—as well as the “insatiable” patient—who returns for repeated procedures on the same or different features—predated the official recognition of BDD by the American Psychiatric Association. Today, we are much more likely to consider the possibility that these patients are suffering from BDD.

Dr. Alexander: What can we do, or how can we educate bariatric patients so they will be less likely to become obsessed with plastic surgery after a bariatric procedure?

Dr. Sarwer: Dissatisfaction with one’s physical appearance and body image is believed to be a motivational catalyst to many appearance-enhancing behaviors—weight loss (including bariatric surgery), health club memberships, cosmetic and fashion purchases, as well as cosmetic surgery. In this regard, some degree of body image dissatisfaction is typical among patients who present for body contouring. It is when patients find themselves being preoccupied about their appearance—thinking about it repeatedly throughout the day—and begin to engage in behaviors that negatively impact their daily functioning, that there develops the concern that these persons are suffering from BDD. As with other psychiatric conditions, when the symptoms begin to affect a person’s ability to do the normal, day-to-day things that others often do with ease or take for granted, that is when mental health treatment is warranted.

Dr. Sarwer is a Clinical Psychologist and Associate Professor of Psychology in Psychiatry, University of Pennsylvania, Philadelphia. He is also the Director of Clinical Services for the Center for Weight and Eating Disorders and the Director for Stunkard Weight Management Program.

Dr. Alexander is a psychologist and is the Bariatric Coordinator of the Bariatric Institute, Cleveland Clinic Florida. She also works with the 17th circuit court of Florida performing incapacity evaluations.

Category: Interviews, Past Articles