Body Dysmorphia
A long time ago, when I was working as a general practitioner in my hometown Vaasa, a very elderly lady came to my office. Her face had seen a lot of life and sunshine. Her well-traveled face was covered with countless lines—or wrinkles, as we call them. Wrinkle after wrinkle. The problem was the wrinkle between her eyes. It was too much, and the old lady wanted it removed. One wrinkle among millions?
First, doubt gnaws at your mind, then suspicion and confusion. What is the point of removing one wrinkle among many? Young, ignorant, and lucky, I removed it, and lo and behold: the old lady was happy to be rid of the annoying wrinkle. The other wrinkles did not bother her. At least not at that time.
The situation becomes more problematic when a patient complains of a problem that you cannot see. Another patient complained of a bothersome mole on her left cheek. The cheek was completely clean, with no mole to be seen. It is very difficult to remove a skin lesion that you cannot see. It is not surprising that the patient was dissatisfied with the treatment they received: I did not remove the invisible mole. No matter how much I explained that I could not remove an invisible skin lesion with a scalpel, it did not help.
A condition in which a person sees flaws that do not exist, or in which a minor flaw causes unreasonable daily discomfort and preoccupation, is called body dysmorphia, or dysmorphophobia. Although the apparent flaw may be minor or non-existent to an outsider, it is a real and highly debilitating problem for the person suffering from dysmorphia.
Typically, the "issue" is examined in the mirror for hours every day. Life revolves around it day after day. Most commonly, the problems are focused on the nose, various scars, acne, or hair and body hair, but any part of the body can be a cause for concern. It is common for the problem to move to different parts of the body during a person's lifetime. Typically, issues appear during puberty, and patients have 5-7 different problem areas during their lifetime. Body dysmorphia is often associated with eating disorders or other psychological problems.
It is estimated that one in eight patients of plastic surgeons, dermatologists, and ear doctors suffer from dysmorphophobia. Some studies suggest that the number is even higher! Typically, patients seek treatment for a physical condition that is difficult or impossible for an outsider to perceive; the complaint is severe, but the findings are non-existent or absent.
Surgery is not an option. After surgery, the patient is very likely to be dissatisfied with the treatment and demand a new operation to replace the "unsuccessful" one. By agreeing to this request, we are caught in a cycle of surgery from which there is no escape. It is also common to run from one doctor to another in search of help when the first doctor understands the nature of the problem and tries to end the cycle.
Body dysmorphic disorder is an obsessive personality disorder that is often accompanied by depression, bulimia, and suicidal thoughts. Focusing on flaws can severely impair one's life, work, and social relationships. Aggression toward medical staff is common.
What to do? Obsessive personality disorders are difficult to treat. Psychotherapy and mood stabilizers may help. The most important thing for a surgeon is to recognize the symptoms and pathological personality in advance and refrain from operating. Once the damage has been done, help is not found under the knife, but in avoiding the knife. It is better to have the doors of the clinic slam shut than to try to carve a dysmorphic person into someone who is satisfied with their body. The surgeon is not a god, and the knife is not a cure-all.
The old lady? The lady had a noticeable defect. I still don't understand what was so particularly bothersome about that wrinkle, but the treatment may have been just right. At least for a moment. Perhaps time had passed the lady by? Ten years later, I began studying plastic surgery and only later realized that I had encountered the first dysmorphics in my career.
Usually, things can be resolved by talking and listening, but not always. Someone suffering from a phobia may be so overwhelmed by their illness that they have no time to listen to what is being said, let alone understand it. There is no room for the desire to listen when the "reality" of the condition takes up all of their mental capacity and attention.
I wish a happy start to autumn to all our readers!
Asko Salmi
Specialist in Surgery and Plastic Surgery
