The Cosmetic Readiness Questionnaire (CRQ; Pikoos, Buchanan, Hegarty, Rossell, 2024a) is an assessment tool which helps cosmetic professionals assess a patient’s mindset and readiness to undergo a cosmetic procedure, including identifying 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 a well-validated psychometric scale 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; Pikoos, Buchanan, Hegarty, Rossell, 2024a).

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

1. Psychological Distress: Identifies the presence of anxiety and depression symptoms.
2. Body Dysmorphia: Identifies symptoms related to body dysmorphic disorder (BDD), including body related shame, checking and avoidance.
3. Self-Criticism: Identifies self-esteem problems, propensity to be self-critical and experience shame about themselves and rumination about personal failings.
4. Unrealistic Expectations: Identifies heightened and potentially unrealistic social and psychological expectations for change following a cosmetic procedure across both internal (e.g. self-esteem) and external (e.g., professional or social) domains.

The Cosmetic Readiness Scale also includes a ‘Lack of Openness’ scale which is designed to assess the presence of ‘socially desirable responding’ where a person may try to present themselves in a more favourable light in order to avoid judgement or to access cosmetic treatment. A high score on the Lack of Openness scale may indicate that the patient has not been completely open or honest in their responses, and therefore may require a more in-depth consultation to gauge their true motivations, expectations and psychological suitability for cosmetic treatment. The Lack of Openness scale is a ‘validity check’ and allows the Cosmetic Readiness Scale to be resilient to patients who engage in biased responding.

The CRQ classified overall risk and subscales as either high, moderate or low risk. Individuals scoring in the high risk zone on the CRQ are 78% more likely to be dissatisfied with cosmetic procedures than individuals in the low risk zone (Pikoos, Buchanan, Hegarty, Rossell, 2024) . Individuals who are high risk may benefit from a thorough assessment of risks and benefits of the procedure prior to receiving a cosmetic procedure.

The CRQ overcomes many of the limitations of other BDD screening questionnaires and assessment procedures in cosmetic settings, namely:
a) Most cosmetic screening questionnaires focus solely on BDD, and disregard other psychological factors which may increase the risk of dissatisfaction.
b) On typical 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 CRQ’s Lack of Openness scale overcomes this challenge.

The Cosmetic Readiness Questionnaire represents psychological risk factors identified which can impact on patient satisfaction or the distress experienced after a cosmetic procedure. Scores consist of an overall risk rating as well as a risk rating for five subscales. Scores for each of the subscales are calculated by summing the items relevant to that subscale, divided by the number of items. This produces an “average score” between 1 and 4, representing the general level of agreement with the subscale, where:

0 – Strongly Disagree
1 – Slightly Disagree
2 – Neither agree nor disagree
3 – Slightly Agree
4 – Strongly Agree.

A total score is computed by summing all the questions together except for questions in the Lack of Openness Subscale. Higher scores represent greater psychological risks associated with dissatisfaction with a cosmetic procedure, where:

• – Low risk = Scores of 49 and below.
  Patients scoring in this range have minimal psychological vulnerabilities associated with dissatisfaction with appearance and cosmetic procedures.
• Moderate risk = Scores between 50 and 70.
  Patients in this zone have some identified psychological risks that can make them vulnerable to dissatisfaction with cosmetic procedures. While research suggests that most people who score in this zone are satisfied with cosmetic outcomes, 45% express at least some reservations about past cosmetic procedures. It is recommended that subscales in the yellow (moderate) or red (high) zone are reviewed to identify specific risks.
• High risk = scores of 71 or above.
  Patients in this zone have significant psychological risks that can make them vulnerable to distress or dissatisfaction with cosmetic procedures. Research suggests that patients who score in this zone have an approximate 50% probability of experiencing dissatisfaction with a cosmetic procedure. It is recommended that psychological risks are thoroughly assessed before proceeding with a procedure.

The Cosmetic Readiness Scale also includes a final ‘Lack of Openness’ scale which is designed to assess the presence of ‘socially desirable responding’ where a person may try to present themselves in a more favourable light in order to avoid judgement or to access cosmetic treatment. A moderate (14 and 15) or high score (16 or above) on the Lack of Openness scale indicates that the patient has not been completely open or honest in their responses. These patients may require a more in-depth consultation to gauge their true motivations, expectations and psychological suitability for cosmetic treatment. The Lack of Openness scale is a ‘validity check’ and allows the Cosmetic Readiness Questionnaire to be resilient to patients who engage in biased responding. Patients who score red or yellow on Lack of Openness are likely to score low on overall risk, but this result should be interpreted with extreme caution, and a thorough risk assessment should be conducted with these clients before proceeding with a cosmetic procedure.

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

1. Psychological Distress (items 28, 30, 32, 34, 36, 37, 39, 41, 42, 45): Identifies the presence of anxiety and depression symptoms. Scores between 8 and 17 are considered moderate risk, while scores 18 or above are high risk.
2. Body Dysmorphia (items 11, 13, 27, 29, 31, 33, 35, 38, 40, 43, 45): Identifies symptoms related to body dysmorphic disorder (BDD), including body related shame, checking and avoidance. Scores between 15 and 21 are considered moderate risk, while scores 22 or above are high risk.
3. Self-Criticism (items 12, 14, 15, 17, 18, 20, 21, 23, 25, 26): Identifies self-esteem problems, propensity to be self-critical and experience shame about themselves and rumination about personal failings. Scores between 22 to 26 are considered moderate risk, while scores 27 or above are high risk.
4. Unrealistic Expectations (items 1 to 10): Identifies heightened and potentially unrealistic expectations for change following a cosmetic procedure across both internal (e.g. self-esteem) and external (e.g., professional or social) domains. Scores between 22 and 26 are considered moderate risk, while scores 27 or above are high risk.

The Cosmetic Readiness Questionnaire is designed to inform the assessment and evaluation of cosmetic patients, but is not a standalone tool. If other risks or concerns are identified during consultation, clinical judgement should be used as to whether or not to proceed with treatment or if referral to a psychologist is indicated.

The Cosmetic Readiness Questionnaire (CRQ) was validated across three studies reported in two development papers (Pikoos, Buchanan, Hegarty, Rossell, 2024a; Pikoos, Buchanan, Hegarty, Rossell, 2024b). During the development and piloting phase of the Cosmetic Readiness Questionnaire, a number of favourable qualities of the questionnaire were reported, such as its capacity to measure broad psychological factors relevant to cosmetic procedures. The CRQ was validated using a sample of 8750 cosmetic surgery candidates (mean age 43 years, range 18 to 84, 57.8% female). Confirmatory factor analysis and item response theory were used to construct the five factors and select appropriate items.

For the CRQ’s Body Dysmorphia Scale, BDD diagnosis (based on BDD-DM and BDD-YBOCS) was used as an outcome variable for ROC curve analysis to determine which scores could best predict a positive BDD diagnosis. Area-under-curve scores were .87, indicating that the CRQ Body Dysmorphia scale was an excellent predictor of BDD diagnosis. A raw score above 24 (average score = 2) on the CRQ Body Dysmorphia scale was found to best predict a BDD diagnosis with 83% sensitivity and 89% specificity.

The CRQ predicted individuals with a BDD diagnosis as rated by a blinded expert clinical psychologist, with high sensitivity and specificity (Pikoos, Buchanan, Hegarty, Rossell, 2024b).
In a sample of 347 cosmetic patients who had received a previous surgical or non-surgical cosmetic procedure, participants were asked how satisfied they were with the previous procedure. In this sample 67% said the previous procedure was “completely worth it” while 33% expressed at least some reservations. Higher scores on the CRQ were significantly correlated with a great likelihood of dissatisfaction.

Cut-points were examined to determine the sensitivity in detection of dissatisfied patients. It was determined that individuals scoring 49 or below on the CRQ were at lowest risk of dissatisfaction, with 27% of individuals expressing some dissatisfaction with past procedures. Those scoring between 50 – 70 were at moderate risk of dissatisfaction, with 45% of respondents in that range expressing dissatisfaction. Individuals scoring 71 or above on the CRQ were at highest risk of dissatisfaction, with 48% expressing dissatisfaction with a past procedure. Based on these cut-points, 71% of the hold out sample were classified as low risk, 17% as moderate risk and 12% as high risk of dissatisfaction. These proportions represent those that would be expected in cosmetic settings (both non-surgical and surgical).

To account for the challenge of socially desirable responding which can invalidate the results from questionnaires, the Lack of Openness Scale was developed and evaluated. When comparing results between a research sample and patients who were administered the CRQ in cosmetic settings, it was found that overall CRQ scores were lower in the cosmetic patient sample, suggesting that patients may be engaging in socially desirable responding. This was confirmed by a significantly higher score on the Lack of Openness subscale in the cosmetic patients, with a large effect size (d = 1.11).

Overall, the Body Dysmorphia subscale was found to be an excellent predictor of BDD diagnosis and higher overall scores on the CRQ were associated with higher rates of dissatisfaction. The Lack of Openness subscale makes the scale resilient to patient deception.