Body Dysmorphic Disorder Can Lead to Self-Mutilation

Pretty well from the time our ancestors were living in caves, humans have been concerned with appearance.

Body Dysmorphic Disorder Can Lead to Self-Mutilation

Pretty well from the time our ancestors were living in caves, humans have been concerned with appearance. ("Does he have the muscles to be a good provider?" "Does she have the hips to be a good breeder?") Our criteria for what's appealing may have evolved, but our interest in being attractive hasn't diminished. Research suggests more than 80 per cent of today's men and more than 90 per cent of women care enough about their looks to make an effort to improve them.

But normal self-awareness and basic grooming sometimes descend into delusional self-loathing. The afflicted can develop an addiction to plastic surgery - continually seeking to alter an ever-so-slight or imaginary imperfection. The general condition - identified more than 100 years ago but only now gaining widespread attention - is known as body dysmorphic disorder, or BDD. In extreme cases, patients will self-mutilate, says Dr. Katharine Phillips, a psychiatrist at Brown Medical School in Providence, R.I., and author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. "One patient, for example, took a razor blade, cut open his nose and tried to remove his cartilage to replace it with chicken cartilage in the shape he wanted his nose to be in," Phillips says. "Another did a facelift with a staple gun. Some will do things like hit their teeth with a hammer to try and straighten them out. These people are desperate."

Not all cases are quite so severe - BDD sufferers are afflicted by a broad range of symptoms. And while no one knows what causes the disorder, there may be a genetic component, says Phillips. Being teased in childhood could also play a role, as might the ideal images of women and men as promoted by the media. Perhaps TV shows such as The Swan, Extreme Makeover and Nip/Tuck, featuring quick-fix self-improvement through plastic surgery, have an impact. As with all psychiatric disorders, the cause is undoubtedly complex.

According to medical journals, between one and two per cent of the population suffers from some form of the disease. And many never get help. Gary Goldfield, a psychologist at the Children's Hospital of Eastern Ontario in Ottawa, says some are too embarrassed to come forward. "A lot of these people," he adds, "suffer in silence."

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is considered the bible of mental health professionals around the world. Since 1987, it has listed BDD, which it describes as usually arising in adolescence, and a "preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive." As well, "the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." Patients' job performance may suffer, or they may go out only at night, for fear someone might see their "hideous" deformity. Common complaints include imagined or slight flaws of the face or head - thinning hair, acne, wrinkles, scars, pallor or a flushed complexion, and the wrong size or shape of facial features. The genitals, breasts, buttocks, abdomen, arms, hands, feet and legs can also come under unreasonable scrutiny. No body part is safe. (Some patients have gone so far as to seek amputations of perfectly good limbs, although this may be a case of BDD being confused with a condition known as apotemnophilia.)

Patients, a number of whom attempt suicide, can spend several hours a day obsessing over their perceived deformity. Some do so by checking themselves in mirrors, store windows, car bumpers, watch faces - anything with a reflective surface. Treatment includes cognitive-behavioural therapy and antidepressants (so-called selective serotonin reuptake inhibitors) to help control obsessional preoccupations and compulsive behaviours.

Some observers suggest that up to 15 per cent of individuals who opt for plastic surgery or dermatological treatment have BDD. Dr. Ken Murray, president of the Canadian Society of Plastic Surgeons, considers that high. "In my experience," he says, "it's probably much less than one per cent." Dr. Claudio De Lorenzi, a past president of the Canadian Society for Aesthetic Plastic Surgery, notes that spotting BDD patients can be difficult because, in plastic surgery, so much is malleable and subject to opinion. And, as BDD patients have so readily shown, "beauty is in the eye of the beholder, but so is the deformity."

Maclean's December 19, 2005