The Cosmetic Readiness Questionnaire (CRQ, Pikoos & Buchanan, 2022) is an assessment tool which helps cosmetic professionals determine a patient’s mindset and readiness to undergo a cosmetic procedure, including body dysmorphic disorder and other psychological concerns.

The CRQ has 45-items and assesses psychological risk factors relating to readiness to undergo a cosmetic procedure. It is composed of well-validated psychometric scales assessing important dimensions of the cosmetic patient experience and factors which have previously been identified as predictors of patient dissatisfaction or poor treatment outcomes (e.g., Bowyer et al., 2016; Honigman et al., 2004).

The four core domains assessed in the Cosmetic Readiness Questionnaire include:

1. Body Dysmorphia: Identifies the presence of body dysmorphic disorder (BDD) utilising items from the Body Dysmorphic Disorder Questionnaire – Aesthetic Surgery (BDDQ-AS; Lekakis et al., 2016) and Appearance Anxiety Inventory (AAI; Veale et al., 2014).
2. Psychological Distress: Identifies the presence of anxiety and depression symptoms.
3. Self-Criticism: Identifies self-esteem problems, propensity to be self-critical and experience shame about themselves or their appearance.
4. Perfectionism: Identifies perfectionistic tendencies such as excessively high standards, intolerance of and rumination about mistakes.

The Cosmetic Readiness Questionnaire also includes a final ‘Openness’ scale which is designed to assess the presence of ‘response bias’ where a person may try to present themselves in a more favourable light in order to avoid judgement or to access cosmetic treatment. The Openness scale informs the overall readiness score by providing an adjustment and allows the Cosmetic Readiness Questionnaire to be resilient to patients who engage in biased responding.

Each of the four core scales, and the Openness scale are scored and classified as red (indicating high scores on the scale), yellow (indicating moderate scores on the scale) or green (indicating low scores on the scale).

An overall score (red, yellow or green) is computed for each patient based on the combination of their scale scores. This overall rating informed the recommendations provided regarding readiness for the procedure, referral to a mental health professional or prompts for the consultation.

Psychometric Properties

The Cosmetic Readiness Questionnaire is a composition of well validated psychometric scales measuring psychological constructs known to be of empirical and psychological importance for satisfaction with cosmetic procedures.

There is an empirical or theoretical basis indicating that the above constructs represent psychological risks 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). Similarly, perfectionism, low self-esteem, shame and general psychological distress such as anxiety and depression have also been associated with patient dissatisfaction (Lou et al., 2023; von Soest et al., 2012).

The CRQ was developed as a response to concerns regarding other BDD screening questionnaires in a cosmetic setting, namely: 

a) Most cosmetic screening questionnaires focus solely on BDD, and disregard other psychological factors which may increase the risk of dissatisfaction.

b) Other questionnaires may not be specific enough as many people in a cosmetic setting express body dissatisfaction, but not everyone will be dissatisfied with outcomes. Therefore a nuanced decision-making process regarding BDD and other co-morbid psychological risk factors is needed to detect individuals most at risk of dissatisfaction.

c) On short BDD questionnaires where the purpose of the assessment is clear, patients may conceal important information in order to ‘pass’ the screening and access a cosmetic procedure. 

The items in the CRQ were selected to overcome these shortcomings, based on both an inductive process utilising existing research literature, and a deductive process based on responses from qualitative interviews with 15 cosmetic patients about their motivations and expectations for cosmetic treatment (Boateng et al., 2018). Items were assessed for content and face validity by a panel of field experts including clinical psychologists, rhinoplasty surgeons and non-surgical cosmetic doctors.

Over and above the existing validation of the individual subscales, the CRQ was initially validated with a group of 70 individuals who had received at least one cosmetic procedure. This process allowed typical patterns of responding to be assessed in this population in order to inform cut-off scores for the green, yellow and red markers relevant for the CRQ. Since then, a second validation study with over 4000 participants has been conducted which led to an update of the cut-off scores for the Psychological Distress and Self-Criticism subscales.   

This data, combined with existing cut-off criteria, was used to establish the following cut points:

Body Dysmorphia

Body Dysmorphia utilises items from the Body Dysmorphic Disorder Questionnaire – Aesthetic Surgery (BDDQ-AS; Lekakis et al., 2016) and Appearance Anxiety Inventory (AAI; Veale et al., 2014). The BDDQ-AS is a well-established and validated measure of body dysmorphic disorder in cosmetic settings (Turk et al., 2023). Score above 24 on the BDD scale corresponds to a score above >20 on the BDD-YBOCS and a positive BDD-DM screen, which is considered the gold-standard clinician administered BDD assessment with 83% sensitivity, 89% specificity (Pilot data, Pikoos & Buchanan, 2023)

•    Green = scores below 1.4 – 47% of the validation group fell into this category
•    Yellow = score from 1.4 to 1.9 –  22% of the validation group fell into this category
•    Red = scores above 1.9 – people in this range are likely to meet the diagnostic criteria for BDD (Lekakis et al., 2016, Pikoos & Buchanan, 2023). 31% of the validation group fell into this category.

The high proportion of people scoring above the BDD cut-off is not uncommon in populations seeking cosmetic procedures (Veale et al., 2016; Lekakis et al., 2016). The involvement of the other CRQ subscales therefore allows a more nuanced decision-making process to occur regarding the risk profile of individuals who score above the BDD cut-off to prevent over-detection.

Psychological Distress

The Psychological Distress subscale utilises items from the Depression, Anxiety and Stress Scale – 10 Item version (DASS-10; Halford & Frost, 2021).

•    Green = scores below 0.8 – 64.6% of the validation group fell into this category.
•    Yellow = scores between 0.8 and 1.7 – 27.4% of the validation group fell into this category.
•    Red = scores above 1.7 – 8% of the validation group fell into this category.

Self-Criticism

Self-Criticism uses all 5 items from the Brief Rosenberg Self-Esteem Scale (Monteiro et al., 2022), 5 items from the Internalised Shame Scale (Cook, 1988) and 3 items from the Compassion Motivation and Action Scale (CMAS-Self, Steindl et al., 2021).

•    Green = scores below 2.2 – 89.4% of the validation group fell into this category.
•    Yellow = scores between 2.2 and 2.6 – 4.6% of the validation group fell into this category.
•    Red = scores above 2.6 – 6% of the validation group fell into this category.

Perfectionism

Perfectionism uses items from Brief Frost Multidimensional Perfectionism Scale (BFMPS; Burgess, Frost & DiBartolo, 2016). The BFMPS is shown to be related to psychological distress, psychopathology and greater consideration of cosmetic surgery (Lou et al., 2023). A desire for perfectionism is also associated with greater risk-taking and less considered decision-making in cosmetic surgery recipients (Ceylan et al., 2022).

•    Green = scores below 2.5 – 90% of the validation group fell into this category.
•    Yellow = scores between 2.5 and 2.75 – 6% of the validation group fell into this category.
•    Red = scores above 2.75 – 4% of the validation group fell into this category.

Openness

The Openness scale is designed to assess how candid a respondent has been, and how likely they are to disclose or conceal information regarding their mindset. To preserve the integrity of the Openness scale, we have not reported the specifics of how this scale is constructed or scored. In the validation group:

•    Green = 87% of the validation group fell into this category.
•    Yellow = 8% of the validation group fell into this category.
•    Red = 6% of the validation group fell into this category, indicating that they may have concealed important information in their answers on the CRQ.

Cosmetic Readiness Rating

Criterion validity of the CRQ was established by testing it against the gold standard diagnostic tools for BDD: the BDD Diagnostic Module (Phillips, 2016) and the BDD-YBOCS (Phillips et al., 1997). The CRQ total score was strongly correlated with gold standard BDD diagnosis, established in a clinical interview (r = 0.65, p < .001).

The CRQ total score (r = .55, p < .001) and Psychological Distress (r = .42, p < .001) subscales were also moderately correlated with dissatisfaction with past cosmetic procedures. The Body Dysmorphia subscale was strongly correlated with past dissatisfaction with cosmetic procedures (r = .65, p < .001).

Finally, to assess the validity of the Cosmetic Readiness Rating, an experienced clinical psychologist conducted interviews with patients who had undergone cosmetic procedures about their motivations, expectations and mental health and gave them a rating of their psychological readiness for treatment based on the clinical interview. The psychologist was blinded to the participants’ survey responses. The Cosmetic Readiness Rating was significantly correlated with blinded psychologist ratings’ of patient readiness (r = .51, p = .003).  

Scoring and Interpretation

The Cosmetic Readiness Rating represents the psychological risk factors identified which can impact on patient satisfaction or the distress experienced postoperatively.

Scores consist of an overall risk rating as well as a risk rating for five sub-scales. Scores for each of the subscales are calculated by summing the items relevant to that sub-scale, divided by the number of items. This produces an “average score” between 1 and 4, normalising scores across sub-scales.

Green scores indicate that MINIMAL risk of dissatisfaction or distress is identified. Scores are green when 4 out of 5 subscales in Part B are green, and there were no scores in the red.

Yellow indicates that MODERATE risk of dissatisfaction or distress is identified. Scores are yellow when 2 or more scales are in the yellow zone, or there is 1 red and 1 yellow scale score.

Red indicates that HIGH risk of dissatisfaction or distress is identified. Scores are red if there are more than 2 red scale score, 1 red and more than 2 yellow scale scores, or 4+ yellow scales.

The Cosmetic Readiness Questionnaire is designed to inform and aid 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.  

References:

Ceylan, G., Kolsarici, C., & MacInnis, D. J. (2022). Perfectionism paradox: Perfectionistic concerns (not perfectionistic strivings) affect the relationship between perceived risk and choice. Journal of Consumer Behaviour, 21(4), 880-895.

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.

Lou, L., Sun, Y., Zhang, H., Shi, X., & Ye, J. (2023). Physical appearance perfectionism in blepharoplasty patients: A prospective observational study. Journal of Plastic, Reconstructive & Aesthetic Surgery, 80, 102-106. 

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.

von Soest, T., Kvalem, I. L., & Wichstrøm, L. (2012). Predictors of cosmetic surgery and its effects on psychological factors and mental health: a population-based follow-up study among Norwegian females. Psychological medicine, 42(3), 617-626.

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), 1058-1060.