This document discusses psychological assessment of patients undergoing orthognathic surgery. It notes that all patients should be assessed by a psychologist to evaluate their motives and determine if surgical goals are realistic. It also discusses body dysmorphic disorder, noting that some patients have a distorted body image and unrealistic expectations about how surgery can change their appearance. The document provides criteria for diagnosing body dysmorphic disorder and recommends that surgery only be considered if there is a physical defect and the patient receives psychological support. It offers guidance for surgeons on how to approach patients showing signs of body dysmorphic disorder.

1. Psychological assessment
 Ideally all patients should be assessed by a psychologist to establish their motives and to
determine whether their goals are realistic.
 A few patients have great difficulty in adapting to significant changes in their facial
appearance. This is more a problem in older individuals.
 Also, a period of psychological adjustment following facial surgery must be expected. In
part, this is related to the use of steroids and steroid withdrawal, causes mood instability at 3
to 6 week post-surgery.
Body Dysmorphic Disorder
 Surgeons who perform orthognathic procedures need to be familiar with a common and
usually severe body image disorder known as body dysmorphic disorder(BDD).
 Patients with BDD have a distorted view of their appearance, believing that they look
abnormal or deformed in some way when they actually do not.
 A majority of these patients seek and receive cosmetic procedures, including orthognathic
surgery, for their perceived appearance defects.
 This is problematic, because available data indicate that cosmetic treatment usually does not
improve BDD symptoms, and individuals with this disorder are typically disappointed with
the results.
 BDD was diagnosed in 7.5% of patients attending for orthodontic treatment and 2.5% of the
general population (Hepburn and Cunningham, 2006).
 Higher rates have been reported among cosmetic surgery and dermatology patients, due in
part to the fact that persons with BDD frequently seek and receive cosmetic treatments to try
to correct their perceived appearance defects.
 Three criteria must be fulfilled for a diagnosis of BDD to be made (American Psychiatric
Association, DSM-IV, 1994):

2. 1. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is
present, the person's concern is markedly excessive. Usually patient spends 3-8 hours every
day preoccupied with appearance (obsession), spent 4-5 hours a day performing excessive
compulsive behaviours such as comparing jaw and chin with that of other people, asking
friends if they looked okay.
2. The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
3. Presence of another mental disorder (anorexia nervosa)
 Philip et al 2009 and 2010: In the two studies (N = 200and N = 188), 17% of patients were
preoccupied with the appearance of their chin or jaw. 20% were preoccupied with the
appearance of their teeth and 6% with their mouth. An additional 14% were preoccupied with
the appearance of their overall face and an additional 12% with the size or shape of their face,
which in some cases involved the structure of the chin/jaw area. More than 25% of individuals
with BDD have at least one concern that involves asymmetry (e.g., asymmetric eyes or jaw
line)
 BDD usually onsets in early adolescence; two-thirds of individuals have onset before age
18.51
 Treatment of BDD should ideally involve counseling and behavior therapy or
pharmacological treatment. Surgery should only be considered if there is a defect to correct
and there is appropriate psychological support (Cunningham and Feinmann, 1998).
How surgeons can approach patients with BDD
 If the surgeon suspects that a patient has BDD,he/she is encouraged to inform the patient of
theirimpressions and to provide some brief educationabout the disorder (e.g., ‘It sounds like
you havea body image problem known as body dysmorphic disorder, a known and treatable
condition’).68,77The surgeon can encourage the patient to learnabout BDD by offering
educational resources (e.g.,www.BDDprogram.com).

3.  We recommend that surgeons inform patients withsuspected BDD that they are concerned
that thepatient will be dissatisfied with the outcome of thesurgery and that cosmetic
procedures rarely help BDDsymptoms, and can in fact make them worse.
 Then,patients should be briefly made aware that thereare effective treatments for BDD,
including psychiatric/psychological treatments, and referrals to a psychiatristand/or
psychologist can be made.
Ethnic Dysphoria
 It is an uncommon BDD variant.
 Dentofacial aesthetic norms are varied between ethnic groups and when planning surgical
changes special consideration should be given as to whether they are racially appropriate.
 Some ethnic patients, influenced by popular Caucasian features, may demand changes
which are either unsuitable or unattainable.
Gender dysphoria
 It is an uncommon BDD variant in which the patient, usually a male, wishes to change
gender.
 Where this is stated, or when the patient is referred from a psychiatric unit specialising in
gender reorientation, the aim of the treatment is obvious.
 However, occasionally the demand for a less prominent mandible or more prominent malar
bones in an otherwise satisfactory face can be difficult to understand unless seen as part of
this problem.
 Again, psychiatric assessment of the patient is essential.
Patient motivation types and reaction to orthognathic Treatment
 Internal motivation is more likely to have satisfactory treatment outcomes
 External motivation poor outcomes
 Patient with unachievable expectation like BDD has high dissatisfaction

4.  Patients with congenital deformities are at greater risk of experiencing psychosocial
problems.
 Individuals with acquired deformities tend to be more critical and express greater
dissatisfaction compared to those with developmental problems who have never had an image
of normality
The Psychopathology of Facial Deformity and Orthognathic Surgery
1. Social Aspects of Facial Deformity
 Social reaction: Those who are blessed with an attractive face are frequently perceived as
being more friendly, sensitive and successful
 Personality: Certain facial stereotypes are inappropriately portrayed as being associated
with particular characteristics, for example a Class III malocclusion may be perceived as
aggressive or a marked Class II as weak or stupid.
2. The Psychological Assessment
The following standardised approach is essential to avoid overlooking problem areas and
should be done on a one-to-one basis and not in a large multidisciplinary clinic,
A. In addition to patients in whom the clinician intuitively feels concerns, those to be
considered for referral include patients with:
 A history of previous cosmetic surgery.
 Minimal facial deformity.
 Expectations that clearly exceed surgical feasibility.
 An obsessional concern with certain features.
B. There are 9 questions which should be asked:
1. What is the main complaint?
2. How does their dentofacial deformity interfere with their life?
3. How long has he/she been concerned about their face?
4. Why is he/she seeking treatment now?

5. 5. What does the patient expect from treatment?
6. What is the main source of motivation?
7. Does the patient have family support?
8. Has the patient previously sought treatment elsewhere?
9. Has the patient received any medical treatment that may be of importance from
psychological point of view?
In details
1. What is the main complaint? Those who offer vague non-specific complaints such as “I
just don't like my face” tend to make poor surgical patients compared with those who are
clear about their complaint — “I think my chin sticks out and is not symmetrical”.
2. How does their dentofacial deformity interfere with their life? A patient who can function
in a normal way at work, socialise with friends and has developed a reasonable body image
despite the facial deformity is likely to be satisfied following treatment. Those who have
become reclusive as a result of their concerns must be investigated further, especially where
the extent of the deformity does not justify this abnormal behaviour pattern.
3. How long has he/she been concerned about their face? Why is he/she seeking treatment
now? Patients should always be asked how long they have had these concerns. Those who
have become concerned only recently should again be assessed by a psychologist/psychiatrist
as their worries may have been triggered by a recent life event such as redundancy, divorce,
or bereavement.
4. What does the patient expect from treatment? It is helpful to ask “How do you think this
treatment will affect your life?” Those patients who want to look better and feel more self-
confident are classified as expecting primary gain from treatment and tend to be good surgical
patients. Patients requiring psychological assessment prior to agreeing to treatment include
those who:
a) Are concerned with secondary gain such as promotion, a better job or new partner
b) Do not have any idea what they expect from treatment
c) Are not able to verbalise their answers to these questions.

6. 5. What is the main source of motivation? Externally motivated patients may require a
change in their environment rather than orthognathic treatment. They require careful
psychological assessment and counselling prior to consideration for treatment. Patients who
are internally motivated usually make better candidates for orthognathic intervention.
6. Does the patient have family support? Obviously patients should not be refused treatment
if they have little family or social support. However, in this situation, the orthognathic team
may need to offer more support than usual, particularly in the immediate pre-and
postoperative periods when patients are at their most vulnerable.
7. Has the patient previously sought treatment elsewhere? Patients who embark upon
numerous consultations (or “doctor shopping”) often do so because they are dissatisfied with
a previous rejection or a treatment plan which does not meet their unrealistic expectations.
Other patients may already have undergone previous operations for dentofacial complaints.
Such a history should be investigated fully, prior to agreeing to further intervention .
8. Has the patient received any medical treatment that may be of importance? This is to
determine whether the patient has undergone any previous psychiatric treatment.
C. Dissatisfaction with Treatment
Dissatisfaction may manifest itself in a number of ways including
1. Obsessional behaviour,
2. Depression
3. Even frank psychosis
4. Seeking additional surgical procedures,
5. Physical aggression.
6. Litigation
There are a number of causes of postoperative dissatisfaction
1. Patients who experience pain and numbness
2. Steroid withdrawal

7. 3. Poor results
4. Unfavourable interpersonal relationship
Most forms of post-surgical dissatisfaction can be avoided by
1. Careful presurgical patient assessment
2. Realistic explanations of the procedure in terms of pain, swelling, speech, eating and
time off work.
3. Informed consent, the possibility of the most common and important complications