Body Image 9 (2012) 180–183

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Body Image
journal homepage: www.elsevier.com/locate/bodyimage

Cosmetic surgery in inpatients with eating disorders: Attitudes and experience

Janelle W. Coughlin a,∗ , Colleen C. Schreyer b , David B. Sarwer c , Leslie J. Heinberg d ,
Graham W. Redgrave a , Angela S. Guarda a
a
The Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 600 North Wolfe Street, Meyer 101, Baltimore, MD 21287, United States
b
University of Maryland, Baltimore County, Catonsville, Maryland, United States
c
Departments of Psychiatry and Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
d
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Bariatric and Metabolic Institute, Cleveland, OH, United States

a r t i c l e i n f o a b s t r a c t

Article history: Body image disturbance is frequent among individuals undergoing cosmetic surgery and core to the
Received 6 April 2011 pathology of eating disorders (ED); however, there is little research examining cosmetic surgery in ED.
Received in revised form 24 October 2011 This study examined body image related measures, ED behaviors, and depression as predictors of attitudes
Accepted 24 October 2011
toward cosmetic surgery in 129 women with ED. Patients who had undergone surgery (n = 16, 12%) were
compared to those who had not. Having a purging diagnosis, linking success to appearance, and making
Keywords:
physical appearance comparisons were predictive of more favorable cosmetic surgery attitudes. All of
Cosmetic surgery
those who had undergone surgery had purging diagnoses and, on average, were older, had higher BMIs,
Eating disorders
Body image
and were more likely to make physical appearance comparisons and know someone who had undergone
Social comparisons surgery. In ED, acceptance and pursuit of cosmetic surgery appears to be related to social group influences
Anorexia nervosa more than weight and shape disturbance, media influences, or mood.
Bulimia nervosa © 2011 Elsevier Ltd. All rights reserved.

Introduction Disturbance in body image is an essential feature of anorexia

The pursuit of cosmetic surgery has risen sharply in recent years.
Between 2000 and 2010, cosmetic surgery volume increased by
almost 70% in the United States, with the documented number of
surgical and minimally invasive treatments for women, who make
up 90% of all surgical cases, approximating 11.5 million in 2010
(American Society of Plastic Surgeons, 2011). Body image evalua-
tion (i.e., the level to which one is dissatisfied with one’s body) and
body image investment (i.e., the degree to which one’s self-esteem
is derived from one’s body image) have been proposed as the main
factors driving pursuit of cosmetic procedures (Sarwer & Crerand,
2004). Studies of college women have found that both body dissat-
isfaction and psychological investment in appearance are related
to more favorable views of cosmetic surgery, with one study iden-
tifying increased body image investment as the strongest predictor
of cosmetic surgery attitudes (Cash, Goldenberg-Bivens, & Grasso,
2005; Sarwer et al., 2005). Another study found that more pro-
nounced body image concerns and greater acceptance of cosmetic
surgery in one’s social environment were the strongest predictors
of motivation to undergo cosmetic surgery in Norwegian women
(von Soest, Kvalem, Skolleborg, & Roald, 2006).
∗ Corresponding author. Tel.: +1 443 287 8315; fax: +1 410 502 7907.
E-mail address: jwilder3@jhmi.edu (J.W. Coughlin).
nervosa and bulimia (American Psychiatric Association, 2000).
Interestingly, although the relationship between body image dis-
turbance and eating disorders (ED) is well documented (Cash &
Deagle, 1997), as is the role of body image in the pursuit of cos-
metic surgery (Cash et al., 2005; Sarwer & Crerand, 2004; Sarwer
et al., 2005; von Soest et al., 2006), little research exists on the
topic of ED and cosmetic surgery. Extant literature includes mostly
case studies (McIntosh, Britt, & Bulik, 1994; Willard, McDermott, &
Woodhouse, 1996; Yates, Shisslak, Allender, & Wolman, 1988), with
authors suggesting that motivation for cosmetic surgery in persons
with ED is directly related to body image disturbance (McIntosh
et al., 1994). It has further been suggested that surgery tem-
porarily diminishes underlying depressive symptoms in bulimia
(Yates et al., 1988) and that surgical fat removal may be a vari-
ant of purging behavior (Willard et al., 1996). To the best of our
knowledge, there has been no empirical research describing atti-
tudes toward cosmetic surgery or past experience with cosmetic
surgery in individuals with diagnosed ED. The current study aimed
to determine the relationship between cosmetic surgery attitudes
and experience and body image related measures, disordered eat-
ing behaviors, and depressive symptomatology among women
with ED. We hypothesized that more favorable cosmetic surgery
attitudes and past experience with cosmetic surgery would be asso-
ciated with increased body image concerns, purging behaviors, and
depression.

1740-1445/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bodyim.2011.10.007
 J.W. Coughlin et al. / Body Image 9 (2012) 180–183
Method
Participants
Participants were 129 women diagnosed with an ED and admit-
ted to the Johns Hopkins Hospital ED Program inpatient between
2005 and 2010. ED diagnoses were made using the ED module of
the Structured Clinical Interview for the Diagnostic and Statisti-
cal Manual of Mental Disorders (First, Spitzer, Gibbon, & Williams,
1997). Twenty-three percent (n = 30) of patients were diagnosed
with anorexia nervosa restricting type (AN-R), 30% (n = 39) were
diagnosed with anorexia nervosa binge-eating/purging type (AN-
P), 25% (n = 32) were diagnosed with bulimia nervosa (BN), and
the remaining 22% (n = 28) met criteria for a subthreshold ED.
The vast majority of patients were Caucasian (84%), and the
mean age of participants was 29.07 years (SD = 12.42). Partici-
pants who were diagnosed with AN-R or AN-P had a mean BMI
of 16.05 kg/m2 (SD = 2.49) at admission to the inpatient unit;
the mean BMI for the remaining participants was 22.35 kg/m2
(SD = 5.24).
Procedure
Patients consented to participate in an IRB-approved study
of inpatient treatment for ED and agreed to be contacted after
discharge for an assessment of outcomes. Self-report measures uti-
lized for the current study were completed within 3–4 days of
admission.
Measures
Cosmetic surgery attitudes. The Cosmetic Surgery Attitudes
Questionnaire (CSAQ) was used to assess attitudes toward cos-
metic surgery procedures (Sarwer et al., 2005). Attitudes were
assessed on a scale ranging from 1 (strongly disagree) to 5
(strongly agree), with the mid-point reflecting “indifference”;
higher scores on the CSAQ indicate a more favorable attitude
toward surgery. Sample items of the CSAQ include: “I think
cosmetic surgery is a waste of money” (reverse scored) and “I
approve of a person’s undergoing cosmetic surgery to increase
their self-esteem”. The CSAQ was initially designed as a 10-item
scale; however, previous internal consistency analyses suggested
that only eight items demonstrate adequate correlations with
other scale items (Sarwer et al., 2005). As such, only those eight
items were summed and used to measure attitudes toward cos-
metic surgery in this study. Cronbach’s ˛ in this sample was
.86.
Experience with cosmetic surgery. Six items assessed partic-
ipants’ experiences with cosmetic surgery (“Do you know anyone
that has had cosmetic surgery?”, “If yes, how many people?”, “Has
anyone in your family had cosmetic surgery?” “If yes, how many
people?”, “Have you ever had cosmetic surgery?”, “If yes, how many
times?”). As participants had consented to be part of a follow-up
study, those who indicated they had ever had cosmetic surgery
were contacted by telephone at a later date to inquire about the
type of cosmetic surgery undergone.
Body image related measures. The seven-item Drive for Thin-
ness (DT) and nine-item Body Dissatisfaction (BD) subscales of the
Eating Disorders Inventory (EDI-2; Garner, 1991), a widely used
self-report instrument that assesses severity of ED disturbance,
were used to measure patients’ fear of weight gain and preoccupa-
tion with dieting (DT) and body dissatisfaction. Items are rated on a
0–6 point scoring system and are then converted to a score ranging
from 0 to 3, with higher scores indicating increased DT or BD. The
psychometric properties of the EDI-2 have been well-established
181
(Garner, 1991). In the present study, Cronbach’s ˛ coefficients for
DT and BD scores were .89, and .93, respectively.
The Sociocultural Attitudes Toward Appearance
Questionnaire—Eating Disorders (SATAQ-ED), a nine-item self-
report instrument, was used to assess investment in culturally
established standards of attractiveness (Heinberg, Coughlin, Pinto,
Haug, Brode, & Guarda, 2008). The SATAQ-ED, derived from the
original SATAQ (Heinberg, Thompson, & Stormer, 1995), comprises
two subscales: Internalization (SATAQ-I), which measures the
extent to which individuals have accepted or “bought into” cultur-
ally accepted standards of beauty, and Success (SATAQ-S), which
assesses the perceived relationship between attractive appearance
and achievement. Items are rated on a scale of 1–5 (completely
disagree to completely agree), and higher scores indicate increased
internalization and tendency to link appearance to success. Both
subscale scores have shown good internal consistency (Heinberg
et al., 2008). In this sample, the Internalization scores had excellent
internal consistency (˛ = .90) and the Success scores showed good
internal consistency (˛ = .87).
The Physical Appearance Comparison Scale (PACS) is a five-item,
self-report questionnaire that measures the level to which individ-
uals make social comparisons related to appearance, especially in
social situations (Thompson, Heinberg, & Tantleff, 1991). Responses
range from 1 to 5 (never to always), with higher scores indicat-
ing greater likelihood to make physical appearance comparisons.
The PACS has shown adequate internal consistency (˛ = .78) and
test–retest reliability (r = .72); in the current study, internal consis-
tency was good (˛ = .81).
Eating disorder behaviors. Current eating behaviors, including
binge eating, vomiting, laxative, diet pill, and diuretic use, exercise,
skipping meals, and restricting food portions were assessed on self-
report items querying frequency of each behavior in the 8 weeks
prior to assessment, ranging from never (1) to several times per day
(7).
Depressive symptomatology. The Beck Depression Inventory
(BDI) is a 21-item measure designed to assess severity of depres-
sive symptomatology in adolescents and adults (Beck & Steer,
1987). BDI total scores range from 0 to 63, with higher scores
indicating greater symptomatology. The BDI has good internal con-
sistency in clinical (˛ = .86) and nonclinical samples (˛ = .81). In
the current eating disorder sample, Cronbach’s ˛ coefficient was
.91.
Data Analysis
Data were analyzed using SPSS 17 (SPSS Inc., Chicago, IL).
The potential relationships between relevant demographic, body
image, and clinical variables and cosmetic surgery attitudes were
assessed using a hierarchical linear regression model with age,
admission BMI, and diagnostic subtype entered in the initial block,
and DT, BD, SATAQ-I, SATAQ-S, PACS, and BDI scores in the second
block. Patients were then dichotomized into one of the two groups
based on their response to the question: “Have you ever had cos-
metic surgery?” Chi-square tests of independence were conducted
to examine the relation between participants’ personal experience
with cosmetic surgery and categorical variables. Student’s t-tests
were used to compare these two groups for continuous depen-
dent variables. As these two groups had a disparity in sample size,
the variances for each group were examined. If the variances were
dissimilar, a t-test with unequal sample size was conducted. Anal-
yses of covariance were used to examine the effect of experience
with cosmetic surgery on dependent variables of interest (DT, BD,
SATAQ-I, SATAQ-S, PACS, and BDI). Covariates in these analyses
included admission BMI, age, and diagnostic subtype.
182 J.W. Coughlin et al. / Body Image 9 (2012) 180–183

Table 1 Table 2
Hierarchical multiple regression analysis predicting attitudes toward cosmetic Comparisons of participants with and without a history of cosmetic surgery.
surgery.
M (SD) t
Predictor r R2 ˇ Effect sizea
History of No history of
Block 1 .17*** cosmetic cosmetic surgery
Age .15* −.03 <.01 surgery (n = 16) (n = 113)
BMI .28** .11 .01
Diagnostic Subtype .41*** .24* .05 Age 37.75 (7.62) 27.84 (12.50) −4.43**
Block 2 .17*** BMI 23.69 (8.39) 18.46 (4.24) −2.30*
Drive for Thinness .38*** −.03 <.01 Frequency of vomitinga 5.06 (2.46) 3.84 (2.68) −1.72†
Body Dissatisfaction .36*** −.12 <.01 Frequency of laxative usea 4.13 (2.92) 2.12 (2.01) −2.66*
Internalization .46*** −.09 <.01 Frequency of diet pill usea 3.25 (2.82) 1.47 (1.39) −2.49*
Success .52*** .35** .06 Drive for Thinness 15.94 (6.28) 13.35 (6.70) −1.46
Physical Comparison Scale .52*** .33* .03 Body Dissatisfaction 18.38 (8.25) 17.17 (8.60) −0.53
Depression .25** −.05 <.01 Internalization 26.44 (5.88) 24.90 (7.23) −0.95
Success 8.20 (2.18) 7.18 (2.07) −1.78†
a
Effect sizes represent squared semi-partial correlations. Physical Comparison Scale 19.81 (4.40) 17.17 (4.39) −2.25*
*
p < .05. Depression 30.64 (10.94) 24.63 (12.09) −1.89†
**
p < .01.
a
***
p < .001. Frequency of use refers to the eight week period prior to hospitalization.
†
p < .10.
*
p < .05.
**
p < .01.
Results
significance, F(1, 112) = 3.32, p = .071, 2p = .03. Cosmetic surgery
Cosmetic Surgery Attitudes
status was not related to DT, BD, SATAQ-I, or BDI scores.
The mean CSAQ score in this sample was roughly 3 (M = 2.83,
SD = 0.91). Increased age and admission BMI, and a purging diagno- Discussion
sis were associated with higher scores on the CSAQ (Table 1). Higher
CSAQ scores were also related to higher scores on BD, DT, SATAQ-I, The current study assessed attitudes toward and experience
SATAQ-S, PACS, and BDI subscales. A hierarchical linear regres- with cosmetic surgery in ED. The mean attitude toward cos-
sion examining these variables concurrently showed that a purging metic surgery in this sample was indicative of overall indifference,
diagnosis, increased tendency to link success to appearance, and or neutrality. These attitudes are similar to those expressed by
greater likelihood to make physical appearance comparisons in college-aged women (M = 2.71, SD = 0.79); however, the rate of
social settings were each predictive of more favorable attitudes patients who actually had at least one cosmetic procedure in their
toward cosmetic surgery. lifetime (∼12%) was more than double that of college-aged women
(Cash et al., 2005; Sarwer et al., 2005). Although our data were
incomplete regarding type of surgery received, it is interesting
Experiences with Cosmetic Surgery to note that the three most commonly reported procedures in
our sample (breast augmentation, rhinoplasty, and liposuction) are
Sixteen (12%) participants reported having at least one cosmetic identical to those most typically sought by women in the general
surgery procedure in their lifetime. Five of those patients (31%) had population (American Society of Plastic Surgeons, 2011). Future
more than one procedure. Of those who reported on surgery type studies with larger sample sizes are needed.
(n = 11, 69%), there were 15 surgeries reported. The most frequently Both attitudes toward and experience with cosmetic surgery
reported procedure was breast augmentation (n = 5, 33%), followed were associated with diagnostic subtype. Interestingly, every one
by rhinoplasty (n = 4, 27%), and liposuction (n = 3, 20%). The remain- of the 16 patients who reported having cosmetic surgery had a
ing procedures included eyelid repair surgery, breast reduction, and purging diagnosis. Although the few articles written on the topic
labiaplasty, which were each reported by one participant. Partici- of cosmetic surgery in ED have focused mostly on patients with
pants who had undergone surgery were significantly more likely bulimia (Willard et al., 1996; Yates et al., 1988), this is the first
to know of someone who had undergone cosmetic surgery, 2 (1, study to provide strong empirical evidence that having cosmetic
N = 129) = 6.17, p = .013, or to have a family member who had had surgery is associated with purging behaviors in general, and with
cosmetic surgery, 2 (1, N = 129) = 5.04, p = .025. greater frequency of laxative and diet pill use more specifically.
Participants who had undergone cosmetic surgery also tended We also found that those who had actually undergone cosmetic
to be older and have a higher BMI (Table 2), and were more likely surgery were older and had a higher BMI. These findings are likely
to have a purging diagnosis than participants who had not had interrelated with the purging finding, because research has shown
cosmetic surgery, 2 (1, N = 129) = 8.26, p = .004. In fact, all of the a natural progression over time from purely restrictive behaviors
patients who had undergone surgery had a purging diagnosis (11 to binge-purging behaviors in approximately 60% of ED patients
with AN-P and 5 with BN-P). Those who had surgery reported sig- (Eddy, Keel, Dorer, Delinsky, Franko, & Herzog, 2002).
nificantly more frequent laxative and diet pill use, and a trend The current study found a significant association between body
toward more frequent vomiting. There were no observed differ- image related measures and a more favorable attitude toward cos-
ences between the groups in terms of binge eating, diuretic use, metic surgery. More specifically, we found that linking success
exercising, skipping meals, or other restricting behaviors. to appearance and making physical appearance comparisons in
When examining body image related measures, participants social situations were associated with more favorable cosmetic
who had had cosmetic surgery scored significantly higher on the surgery attitudes. Interestingly, the PACS subscale was the only
PACS than individuals who had not had cosmetic surgery, above appearance-related measure that significantly differentiated those
and beyond the effects of admission BMI, age, and diagnostic who had undergone cosmetic surgery from those who had not. As
subtype, F(1, 118) = −4.10, p = .045, 2p = .03. Individuals who had patients who had undergone surgery scored higher on this mea-
cosmetic surgery also had higher SATAQ-S scores. When control- sure, we speculate that, in ED, undergoing cosmetic surgery is
ling for the above covariates, however, the relation only approached driven more by sociocultural factors, particularly social group and
 J.W. Coughlin et al. / Body Image 9 (2012) 180–183
peer influences, than by body dissatisfaction, preoccupation with
thinness, or media influences. This is further supported by our find-
ing that those who had undergone surgery were more likely to have
a family member or to know someone who had also had surgery.
Contrary to our hypothesis, those who underwent surgery did
not have significantly greater depressive symptomatology; how-
ever, there was a trend in this direction. Even if this relationship
had been significant, the current study would not have addressed
whether patients with elevated depression presurgically experi-
enced temporary or sustained improvements after surgery, as has
been suggested in a previous case report (Yates et al., 1988). Lon-
gitudinal research is needed to address the cross-sectional nature
of the current study.
Additional limitations of the current study should be noted. First,
while our study utilized commonly used measures in ED as indices
of body image disturbance, future research should include more
specialized body image measures (e.g., the Appearance Schemas
Inventory-Revised; Cash, Melnyk, & Hrabosky, 2004). Second, based
on our findings, it is clear that social network is important. It
would also be helpful to understand other social influences, such
as patients’ history with appearance-related comments and teas-
ing, as recent research has shown a link between appearance-based
rejection sensitivity, past comments about appearance, and inter-
est in cosmetic surgery (Park, Calogero, Harwin, & DiRaddo, 2009).
Third, we did not have information on type of cosmetic surgery for
all participants, nor did we have information on minimally inva-
sive and dermatological interventions, therefore we are unable to
thoroughly present the range of appearance-altering behaviors in
the ED population.
The current study is the first to empirically describe attitudes
toward and experiences with cosmetic surgery in patients with ED.
Future research should help discern whether having a past or cur-
rent ED should be a contraindication to cosmetic surgery. In the
absence of such research, surgeons should have basic screening
methods in place to identify, educate, and refer those who are at
high psychiatric risk.
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