Mind and body

When not to cut: Cosmetic surgery cannot fix body dysmorphia

People with body dysmorphic disorder see themselves as ugly, malformed, misshapen or hideous.

Most of us have some insecurities about how we look, and some aspects of our appearance that we might secretly wish were different. But for people with body dysmorphic disorder, these issues become an obsession and constant focus of concern.

Body dysmorphic disorder is a psychiatric condition that leads people to adopt extremely distorted negative beliefs about their appearances: seeing themselves to be ugly, malformed, misshapen or hideous. Such beliefs do not reflect the reality of how they appear to others. The degree of concern and distress they may feel about their appearance is vastly out of proportion to any actual physical “defect”.

A small minority of the population is believed to experience the condition. One study found about 2.3% of participants had the condition.

The mirror is a major problem for people with body dysmorphic disorder. Some sufferers become fixated with mirror checking, with hours of their day absorbed in inspecting their appearance. Mostly this checking is counter-productive, making them feel worse and increasing their distress.

Other people with the condition may avoid mirrors altogether. Some can even have catastrophic reactions should they happen to glance at themselves in a reflective surface such as a shop window. Lots of sufferers conceal themselves under hats, scarves, wigs, dark glasses or excessive layers of makeup or concealing clothing in an attempt to hide their supposed defects.

Body dysmorphic disorder should not simply be dismissed as an expression of extreme vanity or insecurity about looks. This condition often leads to substantial distress and social and occupational impairment. Rates of depression are high, while suicide is not an uncommon outcome for those who do not receive appropriate treatment. Many avoid social situations for fear of others judging them negatively because of how they look.

Cosmetic solutions?

Because people with body dysmorphic disorder “see” themselves as having a cosmetic problem, it’s not surprising they often seek a cosmetic “solution”.

The highest rates of body dysmorphic disorder are found among people using cosmetic services like plastic surgeons, cosmetic dermatologists and cosmetic dentists. One study found up to 70% of people with body dysmorphic disorder had sought cosmetic procedures, and half had received such interventions.

The tragedy is that cosmetic procedures – by definition – do not solve the underlying psychological problem. They leave a majority of sufferers worse off: they pay for the procedure and suffer the pain and inconvenience of it, yet “see” the resulting cosmetic outcome as unsatisfactory, even if objectively the result is excellent.

This often leads to requests for more treatments, with ensuing worsening of the mental state of the patient and increasing frustration on behalf of the cosmetic specialist. The situation can become so heated that legal action, physical threats and even homicide have been known to be perpetrated by body dysmorphic disorder patients.

Screening for body dysmorphia

Cosmetic interventions of all types are becoming increasingly accessible to a wider public. Therefore, it would be ideal for cosmetic specialists routinely to screen for body dysmorphic disorder.

Australian cosmetic specialists are not mandated to screen for body dysmorphic disorder and there’s no available information on the proportion of cosmetic clinics that screen for the condition. From my experience of speaking to patients who have sought cosmetic intervention, screening is variable at best.

There are certainly some practitioners who are very aware of the risks associated with body dysmorphic disorder and ensure their clients are screened and offered referral for further help if required. Unfortunately, too often screening is not performed and patients suffer as a consequence.

Screening should be mandated for people seeking any cosmetic procedure that might be seen as “enduring”: this includes surgical procedures. My colleagues and I have developed a questionnaire for practitioners, which through a series of simple questions can help diagnose body dysmorphic disorder.

For those who may body dysmorphic disorder, careful further questioning and referral to a body dysmorphic disorder specialist is required. A range of psychological therapies (such as cognitive behaviour therapy) and medications (mostly antidepressants) can be very effective at treating the condition’s underlying problems.

Simply providing cosmetic clinics with screening tools won’t guarantee all doctors accurately assess for body dysmorphic disorder. This is because we cannot expect all clients to answer questionnaires truthfully. However, in my experience, having seen hundreds of people with body dysmorphic disorder, they usually do.

At the end of the day, it would be ideal if cosmetic specialists did everything in their power to fulfil their ethical obligations. To not screen and then deliver cosmetic procedures to people who may have body dysmorphic disorder goes against the medical dictum “first do no harm”.

The writer is chair of psychiatry at the University of Melbourne.

This article was first published on The Conversation.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.