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Assessment of psychological, psychiatric,
and behavioral aspects of patients with
cellulite: a pilot study
Avaliação dos aspectos psicológicos, psiquiátricos e
comportamentais de pacientes com celulite: estudo-piloto
Original
Article
Authors:
Doris Hexsel1
Carolina Siega2
Juliana Schilling-Souza3
Amanda Stapenhorst4
Ticiana Costa Rodrigues5
Cristiano Brum6
1Dermatologist Physician; Dermatology
Specialist (accredited by the Brazilian
Society of Dermatology); Preceptor,
Dermatology Clinic, Pontifícia
Universidade Católica do Rio Grande do
Sul (PUCRS) – Porto Alegre (RS), Brazil;
Technical Director, Centro Brasileiro de
Estudos em Dermatologia (CBED) – Porto
Alegre
2BSc in Biological Sciences; Researcher,
CBED
3Pharmacist; Researcher, CBED
4Biomedical Academician; Researcher, CBED
5 Endocrinologist Physician; PhD in
Endocrinology from Universidade Federal
do Rio Grande do Sul (UFRGS) – Porto
Alegre (RS), Brazil; Physician at the
Endocrinology Department of the Hospital
de Clínicas de Porto Alegre – Porto Alegre
(RS), Brazil; Post-graduate Instructor,
Endocrinology, UFRGS; Researcher, CBED
6Psychiatrist; MSc in Psychiatry from the
Universidade Federal de Ciências da Saúde
de Porto Alegre (UFCSPA) – Porto Alegre
(RS), Brazil; Researcher, CBED .
Correspondence:
Dra. Doris Hexsel
Dr. Timóteo, 782 - Moinhos de Vento
90570-040 - Porto Alegre - RS
E-mail: doris@hexsel.com.br
Received on: 16 April 2012
Accepted on: 29 May 2012
This study was carried out at the Centro
Brasileiro de Estudos em Dermatologia
(CBED) – Porto Alegre (RS), Brazil.
Financial support: This study was funded by
the Centro Brasileiro de Estudos em
Dermatologia (CBED).
Conflict of interest: None
ABS TRACT
Introduction: About 50% of the population reports some kind of dissatisfaction related to
their physical appearance. Patients’ motivations for seeking cosmetic treatment are not yet
fully understood.
Objectives: To evaluate the behavioral, psychological, and psychiatric characteristics of
patients with cellulite.
Methods: In the first phase of this cross-sectional, descriptive and observational study,
forty-six volunteers answered a self-administered questionnaire. In the second phase, a
psychiatrist administered the M.I.N.I. questionnaire.
Results: Most interviewees described the forthcoming of cellulite during puberty.
Discomfort caused by cellulite was mainly felt at the beach (87%) and pool (67,4%).
Almost half of patients reported having been subject to an embarrassing comment relat-
ed to their cellulite, while 78.3% felt pressure to seek treatment. The eating disorders
described included the use of drugs, compulsive ingestion of food, feeling guilty after eat-
ing, and self-induced vomiting. The most frequently found specific emotional disorder
was generalized anxiety.
Conclusions: Patients with cellulite can experience emotional distress and negative feel-
ings in everyday situations. Changes in specific behaviors and the presence of psycholog-
ical and psychiatric co-morbidities can be present in some patients.
Keywords: celullitis; skin; behavior; questionnaires.
RESU MO
Introdução: Cerca de 50% da população refere algum tipo de insatisfação com a aparência. Os
hábitos comportamentais que motivam os pacientes a procurar tratamentos cosméticos ainda não estão
completamente entendidos.
Objetivos: Avaliar os aspectos comportamentais, psicológicos e psiquiátricos de pacientes com celuli-
te.
Métodos: Estudo transversal observacional descritivo. Na primeira etapa, 46 voluntárias responde-
ram a questionário autoaplicável e, na segunda etapa, um psiquiatra aplicou o questionário Mini.
Resultados: A maioria das entrevistadas referiu o início das lesões de celulite após o início da puber-
dade. Os ambientes que mais causaram desconforto quanto à celulite foram praia (87%) e piscina
(67,4%). Quase metade das pacientes referiu já ter recebido algum tipo de comentário constrange-
dor em razão da sua celulite e 78,3% delas sentem-se pressionadas a procurar tratamentos.
Distúrbios de alimentação apresentados incluíram uso de drogas, ingestão compulsiva de alimentos,
culpa após as refeições e indução de vômitos. O transtorno emocional específico mais encontrado foi
ansiedade generalizada.
Conclusões: Pacientes com celulite podem apresentar desconforto emocional e sentimentos negativos
em situações comuns do dia a dia. Alterações em hábitos comportamentais específicos e presença de
comorbidades psicológicas ou psiquiátricas podem estar presentes em algumas pacientes.
Palavras-chave: celulite; pele; comportamento; questionários.
131
Surg Cosmet Dermatol 2012;4(2):131-6.
Surg Cosmet Dermatol 2012;4(2):131-6.
132 Hexsel D, SIega C, Schilling-Souza J, Stapenhorst A, Rodrigues TC, Brum C
INTRODUCTION
Approximately 50% of the population has reported some
degree of dissatisfaction with his or her appearance. Part of this
group seeks cosmetic procedures to correct features that are
considered undesirable in order to improve their self-esteem and
confidence and, consequently, their quality of life.1
The demand for minimally invasive cosmetic treatments
has been expanding every year; there was a 77% increase in cos-
metic procedures in the United States between 2000 and 2010.
2In Brazil, the demand for cosmetic treatments has always been
high, and has grown considerably in recent years. Therefore, it is
necessary to understand the psychological factors that underpin
people’s motivations for these treatments, as well as their expec-
tations and anticipated psychological benefits. 3
The term cellulite is used to describe the skin’s surface
when it resembles an orange peel or padding. The condition is
prevalent in women of all races, especially in Caucasians. 4 There
seems to be an important hormonal component in cellulite,
given that it is rarely found in male patients, mostly affects
women after menarche, and reportedly worsens with the use of
contraceptives. There are three etiological hypotheses for cellu-
lite: inflammatory factors, vascular alterations, and changes in the
conjunctive tissue’s septa. 4
Since there is greater exposure of the body in tropical
regions, cellulite has become a concern among women living
countries such as Brazil. As a result, cellulite can have a signifi-
cant social impact and drive the search for specific treatments.5
Making the distinction between emotionally healthy peo-
ple seeking to improve their appearance and those with self-
image perception disorders can be difficult in a physician’s daily
practice, and dermatologists may be the first professional to have
contact with such patients. Ishigooka and colleagues reported
that more than 47.7% of patients who seek cosmetic procedu-
res meet some of the criteria for the diagnosis of mental disor-
ders, 6the most common of which are body dysmorphic disor-
der and narcissistic and histrionic personality disorders. 7A
recent study conducted in Brazil found that cosmetic patients
had a higher prevalence of body dysmorphic disorder (14%)
compared to patients from the general dermatology outpatient
clinic (6.7%) and to controls without skin conditions or com-
plaints (2%). 8
Few studies in the literature address the psychological
aspects of patients seeking treatment for cellulite. Based on the
hypothesis that understanding the emotional context of each
patient will help the dermatologist’s assessment, this study’s
objective was to investigate the psychological and behavioral
characteristics, and the presence of psychiatric symptoms, of
women who sought medical care for cellulite.
METHODS
A descriptive cross-sectional observational study was car-
ried out involving patients who sought care for cellulite at the
Brazilian Center for Studies in Dermatology (Centro Brasileiro
de Estudos em Dermatologia – CBED) between 2008 and
2011. All participants signed a term of free and informed con-
sent, and the study protocol was approved by the Ethics
Committee of the Hospital Moinhos de Vento de Porto Alegre
(Approval Opinion number 2008/115).
The inclusion criteria were: women aged 18-45 with cel-
lulite (regardless of the degree of severity), who had completed
primary education and had the ability to understand the ques-
tionnaire, and the absence of serious systemic and/or serious
skin conditions that could cause psychological distress.
Volunteers who presented significant hearing or visual pro-
blems, or difficulty understanding the study’s language, were
excluded.
The volunteers initially answered a self-administered ques-
tionnaire with 50 questions on demographic, anthropometric,
and lifestyle aspects and their use of medications. Issues linked
to the psychological aspects of cellulite, symptoms related to
eating disorders, and time and money spent on cosmetic proce-
dures were also assessed.
The women who consented to participate in the second
stage of the study were then interviewed by a psychiatrist (CB),
who administered the key questions related to each of the psy-
chiatric disorders contained in the Mini International
Neuropsychiatric Interview (MINI). If this initial assessment
was positive for any psychiatric disorder, the volunteer would be
reassessed with the MINI, using questions relevant to the diag-
nostic criteria of the suspected disorder, in order to confirm or
deny the psychiatric diagnosis.
The MINI is a short (15-30 minutes) standardized ques-
tionnaire that is consistent with the DSM-III-R/IV and CID-10
criteria. It is intended for use in clinical practice, research, prima-
ry care, and psychiatry, and can be used by clinicians after a short
training session (1-3 hours). 9It was developed by researchers at
the Pitié-Salpêtrière Hospital in Paris and the University of
Florida 10, and is widely used to select patients in multicenter
psychopharmacological trials, in other clinical protocols, in psy-
chiatry, and in primary care in Europe, the USA, and Brazil. The
Brazilian translation of the updated version of the MINI DSM-
IV (version 5.0) has been previously validated. 10
The results regarding the reliability and validity of the
MINI are broadly satisfactory. Compared to the CIDI
(Composite International Diagnostic Interview) and the SCID-
P (Structured Clinical Interview for DSM-III-R), the MINI
proved to be broadly adequate for diagnosing disorders. Given
that it cuts the evaluation time in half (or more) compared to
long questionnaires, the sensitivity and specificity of the MINI
are considered to be very satisfactory. 10
The data were described using mean values and standard
deviations for the continuous variables, and percentages for the
category related information. The statistical analyses were per-
formed using SPSS 16.0 (Chicago, IL, USA).
RESULTS
The study included 46 volunteers. The majority of patients
were Caucasian, with higher education and permanent employ-
ment, and used oral contraceptive (Table 1). Most volunteers
Surg Cosmet Dermatol 2012;4(2):131-6.
Psychological aspects of cellulite patients 133
described the onset of cellulite during puberty. The group’s
body mass index (BMI) was 23.5 ± 3.4 kg/m2(range: 16-39
kg/m2); only 23.9% (n = 11) of patients presented with excess
body weight (BMI > 24.9 kg/m2) and only two patients were
considered obese (BMI > 29.9 kg/m2).
The environments described by the patients as causing the
most discomfort regarding their cellulite were the beach
(87,0%), swimming pool (67.4%), gym (19.6%), and bath
(8.7%), with 4.3% reporting no discomfort. Situations and envi-
ronments involving leisure (beach, swimming pool, and parties),
everyday life, and media (magazines and television) were cited
as responsible for stressful and uncomfortable situations by
76.1%, 39.1%, and 8.7% of the patients, respectively.
Of the volunteers evaluated, 84.8% regularly observed the
presence of cellulite in other women, 28.3% reported compa-
ring themselves to others regarding cellulite, 69.6% believed
Variable
Ethnicity
Education
Permanent employment
Moment when noticed presence of cellulite
Family history of cellulite
Sought information about treatment for cellulite
Other aesthetic treatments
Menstrual cycle
Use of contraceptive method
Caucasian
Black
Other
Did not complete
Secondary complete
Higher incomplete
Higher complete
Post-graduate
Yes
No
After puberty
> 30 years old
After pregnancy
After losing weight
After gaining weight
Other
Yes
No
Did not know
Yes
No
Yes
No
Did not complete
Regular
Irregular
Menopause
Interrupted
Did not complete
Oral
Other
Does not use
Did not complete
Frequency
36 (78,3%)
3 (6,5%)
2 (4,5%)
5 (10,9%)
10 (4,7%)
13 (28,8%)
21 (45,7%)
2 (4,3%)
42 (91,3%)
4 (8,7%)
263 (56,6%)
2 (4,3%)
2 (4,3%)
2 (4,3%)
2 (4,3%)
9 (19,6%)
41 (89,1%)
2 (4,3%)
3 (6,5%)
27 (58,7%)
19 (41,3%)
20 (43,5%)
25 (54,3%)
1 (2,2%)
33 (71,7%)
6 (13%)
1 (2,2%)
2 (4,3%)
4 (8,7%)
27 (58,7%)
7 (15,2%)
8 (17,4%)
4 (8,7%)
Tabela 1 – Characteristics of the 46 patients studied
Surg Cosmet Dermatol 2012;4(2):131-6.
134 Hexsel D, SIega C, Schilling-Souza J, Stapenhorst A, Rodrigues TC, Brum C
that men note and observe the presence of cellulite, and 41.3%
reported having received at least one embarrassing comment
about their cellulite. Most volunteers (78.3%) were embarrassed
about their cellulite and felt compelled to seek treatment. Table
2 describes the frequency of feelings reported by patients when
they look in the mirror and observe their cellulite.
The compulsive ingestion of food at least once was repor-
ted by 84.8% of the volunteers, and more than half (58.7%) felt
guilty after meals about the quantity and quality of the food
they had eaten. Some volunteers mentioned the habit of indu-
cing vomiting (10.9%) and counting calories (17.4%), with
67.4% reporting the use of weight loss medications – with or
without medical advice. The volunteers also reported great con-
cern about the presence of body fat (89.1%). Table 3 describes
the drugs used by the patients for losing weight; sibutramine was
the most frequently used drug. Table 4 shows the time (in hours
per week) and spending (in monthly monetary units) on cellu-
lite, the severity assessed by the volunteer, and the expectations
when seeking treatment. Table 5 shows the frequency of use of
different types of treatments for cellulite.
Of the patients evaluated in the study, 43.5% had already
had some type of cosmetic treatment for diverse conditions.
About 9,0% had undergone botulinum toxin injections, 15.2%
some type of facial peel, 4.3% some type of laser, 6.5% some
type of plastic surgery, and 21.7% reported other procedures.
Regarding the psychiatric diagnoses found, five patients
presented with generalized anxiety disorder, one presented a
specific phobia, two presented compulsive eating, and one pre-
sented attention deficit disorder with hyperactivity. The other
patients did not present criteria for recognized psychiatric disor-
ders.
DISCUSSION
This pilot study assessed the behavioral and psychological
issues of women with cellulite who seek cosmetic treatments
that mitigate the condition, and researched comorbid psychia-
tric diagnoses. The data obtained can be of great help in future
studies aimed at establishing the psychological profile of patients
who seek treatment for cellulite and understanding the feelings
associated with the condition, to contribute to a strong and
empathetic doctor/patient relationship.
Most women who seek treatment for cellulite feel uncom-
fortable about the condition and can develop morbid behaviors
linked to the condition or become preoccupied with their
appearance. The study data related to eating habits stand out.
The majority of volunteers (84.8%) had eaten compulsively at
Variable
Disappointment
Embarrassment
Frustration
Sadness
Guilt or anger
Tries to hide the condition
Impotence
Absence of feelings
Frequency (%)
49
28,3
21,7
21,7
13
10,9
8,7
6,5
Table 2 – Description of feelings related to cellulite
Variable
Use of weight loss
medications
Sibutramine
Laxatives
Prescribed formulations
Phytotherapics
Amphetamines
Diuretic
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Frequency
31 (67,4%)
15 (32,6%)
13 (28,3%)
33 (71,7%)
12 (26,1%)
34 (73,9%)
8 (17,4%)
38 (82,6%)
6 (13%)
40 (87%)
5 (10,9%)
41 (89,1%)
5 (10,9%)
41 (89,1%)
Table 3 – Medications used to lose weight
Cellulite
Hours per week spent treating
cellulite
Monthly expenditure on
cellulite
Self-assessed cellulite severity
Expectations when seeking
treatment
<3h
3h-6h
>6h
> R$ 100,00
< R$ 100,00
Zero
Mild
Moderate
Severe
Improve
Totally eliminate
Total
Other
Frequency
12 (26,1%)
10 (21,7%)
4 (8,7%)
8 (17,4%)
8 (17,4%)
27 (58,7%)
6 (13%)
28 (60,9%)
12 (26,1%)
20 (43,5%)
16 (34,8%)
6 (13,0%)
Table 4 – Time, monthly expenditure, cellulite severity perceived by
the patient, and expectations when seeking treatment
Surg Cosmet Dermatol 2012;4(2):131-6.
Psychological aspects of cellulite patients 135
some point. Negative feelings such as guilt after eating (mentio-
ned by more than half of the volunteers, 58.7%) and great con-
cern about the amount of body fat were observed, and are fac-
tors that can be related to the indiscriminate use of anorectic
and laxative medications.
In the present study 78.3% of volunteers reported feeling
embarrassed by their cellulite and compelled to seek treatment.
A small percentage of patients (6.5%) felt influenced by their
partners to seek treatment, while 28.3% were influenced by the
media.
The concern with physical appearance is directly related to
leisure and daily activities, causing attitudes of isolation and low
self-esteem, and others that negatively affect the quality of life.
A previous study by Hexsel and others showed that treat-
ment of cellulite improves patients’ quality of life and self-
esteem. 11
The authors acknowledge some limitations of the present
study; its results must be interpreted with these in mind. The
number of volunteers was small, the sample individuals were
chosen by convenience, and all study participants sought medi-
cal care for treating cellulite, which can be considered a selec-
tion bias and a factor responsible for the high degree of discom-
fort found among volunteers. The absence of a control group,
which has another aesthetic complaint or even no complaints
about cellulite and/or other cosmetic issues, can be considered
limiting. Those factors, however, do not invalidate the study’s
results, since this is an initial pilot study that has found a high
degree of psychological discomfort in patients with cellulite.
These factors can be controlled in future studies in order to
obtain new data.
CONCLUSIONS
Disruptions and emotional distress are frequently reported
by patients with cellulite, who also describe negative feelings in
everyday situations. Knowledge and understanding of patients
with cosmetic complaints, and their feelings, habits, and beha-
vioral and psychological characteristics – in addition to their
expectations regarding the treatments – are very important for
dermatologists and can lead to better results. l
Variable
Diet and physical exercise
Creams
Lymphatic drainage
Lasers
Carboxytherapy
Mesotherapy
Endermotherapy
Subcision®
Liposuction
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Frequency
9 (19,6%)
35 (76,1%)
23 (50%)
22 (47,8%)
18 (39,1%)
27 (58,7%)
3 (6,5%)
42 (91,3%)
4 (8,7%)
41 (89,1%)
4 (8,7%)
41 (89,1%)
3 (6,5%)
42 (91,3%)
4 (8,7)
41 (89,1%)
2 (4,3%)
43 (93,5%)
Table 5 – Types of treatment for cellulite used by the studied
patients
Surg Cosmet Dermatol 2012;4(2):131-6.
136 Hexsel D, SIega C, Schilling-Souza J, Stapenhorst A, Rodrigues TC, Brum C
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