The Cosmetic Procedure Screening Questionnaire (COPS) is a brief screening tool developed for cosmetic settings where a practitioner may wish to screen a patient for body dysmorphic disorder (BDD).
The COPS includes a preliminary question asking patients to describe their features of concern, and what proportion of time they spend worrying about their appearance. This can provide useful insight to the cosmetic practitioner around which areas of appearance may cause the most concern and distress to the patient.
It is then followed by 9 items scored from from 0 (least impaired) to 8 (most impaired). The total scores range from 0 to 72 with a higher score reflecting greater impairment and likelihood of a diagnosis of BDD. It is recommended that individuals who score 40 or more on the COPS should be referred for further assessment before going ahead with a cosmetic surgery or procedure.
The COPS is designed as a screening tool, rather than a diagnostic tool, and is not considered to be an official diagnosis of BDD. An official diagnosis should be made by a suitably qualified mental health professional.
There is strong empirical and theoretical basis indicating that the presence of BDD poses a psychological risk for patients undergoing cosmetic procedures (Honigman et al., 2004; Moulton et al., 2018, Pikoos et al., 2021). For example, 82.3% of individuals with BDD who undergo cosmetic procedures will experience no improvement or worsening in their mental health condition after the procedure, and many report dissatisfaction with the outcomes (Bowyer et al., 2016). Individuals with BDD are at three times higher risk of experiencing complications and more significant post-operative pain, when compared to a control group (Wooley & Perry, 2015).
The Medical Board of Australia guidelines (2023) stipulate that cosmetic practitioners should assess for BDD, prior to administering any cosmetic surgery or non-surgical procedures. The COPS is a validated screening measure which is fit for this purpose (Veale et al., 2012).
Validity and Reliability
The COPS is a nine-item questionnaire developed based on BDD diagnostic criteria, expert opinion and previous research in cosmetic rhinoplasty patients. It was developed and validated in a sample of 108 community-based participants and 98 patients with body dysmorphic disorder (BDD) who were seeking a cosmetic procedure.
In the validation sample, the COPS had a Cronbach alpha of .83, and .84 for controls, indicating high internal consistency. Test-retest reliability over a one week period was strong (r = .87, p < .01). Scores above 40 on the COPS resulted in a maximal kappa coefficient (k = 0.82, p < 0.001), in which 88.9% of BDD patients and 93.2% of community group were classified correctly. Scores on the COPS are highly correlated with depression, anxiety and lower body image quality of life (Veale et al., 2012). When tested in a population of patients seeking labiaplasty, 18% (10/55) of patients scored above the cut-off for BDD (Veale et al., 2013). Since it’s development, the COPS has been used and cited widely across over 100 other research studies.
Scoring and Interpretation
The questionnaire asks for the feature(s) that the person finds unattractive, and follows the diagnostic criteria of BDD. The COPS questionnaire comprises 9 items. Items are scored from 0 (least impaired) to 8 (most impaired). The score is achieved by summing Q 2-10. Items 2, 3 and 5 are reversed. The total ranges from 0 to 72 with a higher score reflecting greater impairment.
The total COPS score is created by summing items 2-10. A patient screens positive for a potential diagnosis of BDD if they score 40 or above on items 2-10 of the COPS.
Item 1 does not contribute to the overall score but is useful for your understanding of the patients’ aesthetic concerns, and areas of their body that they may be more likely to fixate on or request cosmetic treatments for.
When a patient screens positive, the cosmetic practitioner should consider whether the patient may be an unsuitable candidate for the cosmetic procedure, or if a referral to a mental health professional is needed before proceeding with any cosmetic treatment.
The COPS is a screening tool, and is therefore not designed to provide a diagnosis of body dysmorphic disorder (BDD). Patients who screen positive on the COPS may need to be referred to a mental health professional for further assessment.
The COPS is designed to inform your assessment and evaluation of your patient, but not as a standalone tool. If you have identified other concerns or risks during your consultation, please use clinical judgement as to whether or not to proceed with treatment or if referral to a mental health professional is indicated.
The COPS may also be susceptible to dishonest responding, especially if a patient really wants to receive a cosmetic procedure. You should consider these results along with your consultation to determine how open the patient has been about their true motivations and expectations for treatment. If you would like to assess patient openness as well as their BDD scores, you can use the Cosmetic Readiness Questionnaire (CRQ).
Veale, D., Ellison, N., Werner, T. G., Dodhia, R., Serfaty, M.A., & Clarke, A. (2012). Development of a cosmetic procedure screening questionnaire (COPS) for body dysmorphic disorder. Journal of Plastic, Reconstructive & Aesthetic Surgery, 65(4), 530-532.
Bowyer, L., Krebs, G., Mataix-Cols, D., Veale, D., & Monzani, B. (2016). A critical review of cosmetic treatment outcomes in body dysmorphic disorder. Body Image, 19, 1-8.
Honigman, R. J., Phillips, K. A., & Castle, D. J. (2004). A review of psychosocial outcomes for patients seeking cosmetic surgery. Plastic and reconstructive surgery, 113(4), 1229.
Lekakis, G., Picavet, V.A., Gabriëls, L., Grietens, J. and Hellings, P.W. (2016), Body Dysmorphic Disorder in aesthetic rhinoplasty: Validating a new screening tool. The Laryngoscope, 126: 1739-1745. https://doi.org/10.1002/lary.25963
Moulton, S. J., Gullyas, C., Hogg, F. J., & Power, K. G. (2018). Psychosocial predictors of body image dissatisfaction in patients referred for NHS aesthetic surgery. Journal of Plastic, Reconstructive & Aesthetic Surgery, 71(2), 149-154.
Pikoos, T. D., Rossell, S. L., Tzimas, N., & Buzwell, S. (2021). Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures. Australian & New Zealand Journal of Psychiatry, 55(12), 1191-1201.
Veale, D., Gledhill, L. J., Christodoulou, P., & Hodsoll, J. (2016). Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image, 18, 168-186.
Woolley, A. J., & Perry, J. D. (2015). Body dysmorphic disorder: prevalence and outcomes in an oculofacial plastic surgery practice. American Journal of Ophthalmology, 159(6), 1058-1064.