I was really interested to read a Huffington Post story published a week ago, "Woman Spends £4000 on 100 Lip Injections to Look Like Jessica Rabbit". My first thought was "Sorry love, you don't look like Jessica Rabbit". Perhaps a healthier choice would be a role model that is a) not imaginary and b) predominantly human. Maybe I'm prejudiced.
My second thought was "This seems oddly familiar."
I think I know what this is and I think I've seen it before.
Obviously, it would be presumptuous of me (though instinctive as a psychiatrist) to diagnose somebody I've never met, but she draws strong parallels to a previous patient of mine with a body dysmorphic disorder (aka body dysmorphic syndrome). The main feature is a powerful, pervasive preoccupation with one particular element of the sufferer's appearance, that other people do not necessarily see. I guess it's akin to the obsession with being overweight in anorexia (though this bears the burden of its own unique problematic, dangerous behaviour). My previous patient, 'Mr N', was obsessed with his nose. It's classified within the 2 bibles of Psychiatry; ICD-10 and DSM-IV. In other words, it may be weird and wonderful, but it's also an official psychiatric disorder.
It's just as common in men and women, and effects about 1% of the population. It tends to run in families, and there's a 60% risk of major depression, and a whole host of other psychiatric baggage. For example, sufferers often have social phobia (ie too scared to go out in public lest people recoil at their supposed 'disfigurement'), and also suicide rates can be 50 times higher than the rest of the population. That's pretty shocking to me.
I was a little disheartened by the negative judgements and insults made towards her on the comment section of the post (shame on you!) and it saddens me to hear her report that strangers make hurtful comments to her when she's out and about. In my opinion, people who suffer from this disorder, like any other psychiatric or medical disease should be treated with dignity and respect. I guess that's the age-old issue with psychiatric disorders and stigma. However, if you refute my psychological proposition, and think this is all about attention-seeking, then I guess it's only natural to judge her. Maybe in the same way you'd judge a man showing off his physique by going topless in an urban, non-beach environment when it's not sunny - "I bet he's a tool".
Sufferers very often go for repeated plastic surgery, and I think any surgeon who provides this service when it clearly isn't necessary must be prioritising money over morals. As a wise man once said: "Quality care makes the world go round - I'm pretty sure they don't reach that at business school."
Despite surgery, any satisfaction afterwards is short-lived. It can be treated with high doses of anti-depressants (specifically a class called SSRIs - Selective Serotonin Re-uptake Inhibitors) or even anti-psychotics, such as those used in schizophrenia. But here lies the problem - if a sufferer has no insight, then what motivation do they have to acquiesce to a pesky doctor, who's offering medication instead of surgery for their nose? Cognitive Behaviour Therapy (CBT - where your ideas, beliefs and behaviours are discussed, tested, challenged, and hopefully adapted) is the best therapy. But again, this is difficult to initiate without some degree of insight.
It usually becomes a monstrous preoccupation, and impinges on one's day-to-day living, with people constantly checking mirrors, avoiding social contact, and even picking and scratching at their particular apparent anatomical anomaly. For more serious psychiatric disorders, like severe depression, in exceptional circumstances some people are detained and treated against their will under the Mental Health Act, 1983 (amended 2007), though for this to happen, the disorder must be "of a nature or degree to affect their own health or safety or the protection of others". One could argue that body dysmorphic syndrome does cause long-term psychological damage, though equally one could argue that the sufferer understands the risks and benefits of repeated cosmetic surgery, and so has the capacity to make that decision.
I vividly remember my consultations with Mr N. The entire time, he sat with his head tilted downwards, and pretended to have an itchy eye, and would rub it, just to cover up his nose with his hand. It was really frustrating, and as a fairly naive junior doctor at the time, I couldn't help but try to convince him that his nose was of a normal size. We ended up in a surreal, circular polite argument!
At times, I just wanted to step out of my role as a psychiatrist, reach over the table, shake him vigorously and shout "There's nothing wrong with your frickin' nose! Please stop going on about it!" I even used to feel like he was wasting time and resources, that could have been used to treat people with 'proper' mental illnesses. Looking back at it, I regret my attitude (shame on me!) He was suffering from a genuine disorder, and my difficulty in handling the lack of tangible problem was my problem, not his.
As it happens, Mr N's case was very unusual - his preoccupations crossed the dark line into delusion. Worryingly, he actually had intentions to carry out his own 'surgery' using a stanley knife. He had even done some research, and had meticulous plans. Only after thorough, persistent investigation by my consultant did Mr N disclose these morbid thoughts. I hadn't revealed them because I hadn't given him the time he deserved. I shudder to think what would have happened if my consultant hadn't been there as my safety net. It was an invaluable life-long lesson for me.
We decided that he did need to be detained under the Mental Health Act for treatment against his will (which is very unusual with this condition) as the risk of self-harm was so high. He had a long, arduous, hospital admission, and his insight did improve slightly with a great deal of effort, encouragement, and CBT from a diligent psychologist. He was not 'cured' and still believed his nose was oversized, but was able to distract himself from the obsession, and able to put things in perspective far more rationally. He was able to go outside - a mini-victory in itself.
I find it interesting how keen we are to vilify 'freaks', and define them by their eccentricities. Yet often when the outcome is something as serious as a suicide, or a breakdown, then we quickly do a U-turn. We deem the case 'tragic' and retrospectively show pity.
Obviously, I think everybody is entitled to their own opinion. I just feel that instead of being so quick to judge and chastise people like Miss Rei, it's more helpful to take a step back and try to objectively analyse why she has these thoughts. That way, if her ideas are seen as pathological, at least help rather than criticism, can be offered.
(PS. I must confess I was tempted to make some kind of pun about Mr N 'spiting his face' but I did manage to refrain!)
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