Psychiatry has long grappled with where extreme-but-acceptable behaviours end and where pathological ones begin.
Body Dysmorphic Disorder (BDD) has a long history in psychiatry, previously known by the felicitous term of Monosymptomatic Hypochondriacal Psychosis (MHP). This described delusional beliefs about the body, a separate condition from schizophrenia or paranoia.
Typical examples were the belief that tooth roots could grow through the top of the head; a speck of glass in the eye could be a six-inch shard penetrating the brain; and, commonly, deformities of the genitals, found predominantly in males. A sub-category was Ekbom’s syndrome: the belief that the skin was infested with insects or vermin. All such conditions were without any organic basis and excluded by examination or tests. The diagnosis notwithstanding, psychiatry played a limited part in the treatment process as such patients were strongly resistant to seeing someone who carried the implication that there was no physical basis for their condition. If they did present, antipsychotic drugs were used with a preference for Orap (pimozide) although the results were, at best, mixed.
Diagnosis is never static and MHP fell victim to American psychiatric imperialism, namely the DSM which changed it to the more dreary term Body Dysmorphic Disorder with the alternate term of dysmorphophobia. This is defined as is a mental health condition whereby people obsess, often compulsively, over perceived flaws in their physical appearance. Since 1980 there have been several iterations, but the basic definition is largely unchanged.
Now, let’s look at how this plays out in the online postmodern 21st century universe – a world of tattoos, mutilating surgery, botox injections, implants, fillers and body building facilitated by powerful hormones.
Fifty years ago, there were still articles in psychiatry journals about the meaning of tattoos on psychotic and psychopathic patients. Now tattoos have progressed beyond a mere fashion accessory to a lifetime identity. Tabloids regularly write articles on someone who has not only covered every inch of the body with tattoos but progressed beyond the usual panoply of cosmetic surgery; more extreme than multiple piercings and metal insertions are injections to change the colour and appearance of the eyes, insertion of magnets or horns under the skin and surgical split of the tongue. Barroom psychologists can leap to calling them schizophrenic – which it may be in some cases – but that is not the point. Do such people have dysmorphophobia or are just an extreme manifestation of fashionable social behaviour?
Body changing, to the point of mutilation, goes back to the beginning of recorded history. Hunter-gatherer women used red ochre powder as a cosmetic. The Himba women of Namibia still cover their bodies like this. For centuries the Chinese would bind women’s feet to keep them tiny. There are plenty of cultural groups who engage in body tattooing as an expression of their identity, the Maoris are just one example. Other groups, such as the Kikuyu in Africa and Aboriginals in Australia, have initiation rituals involving cutting with the scars irritated to form prominent keloid scars. Other ritual activities involve modifying the teeth or the skull.
Body building, inevitably facilitated by huge doses of steroids, reflects another aspect of socially-approved body changes taken to extreme levels, although Clive James’ description of Arnold Schwarzenegger as a condom filled with walnuts reminds one that beauty is in the eye of the beholder. This is now done by women as much as men and, at least in some cases, there must be a compulsive element to continuing without a halt to the process, even if body breakdowns follow. The DSM lists this sub-category of BDD as muscle dysmorphia.
Another extreme body change can arise from apotemnophilia – the insistent belief that one or more limbs are supercilious and the discomfort can only be relieved by their removal. This has led to extreme behaviour such getting a train to run over the limb or covering it with snow to cause gangrene. The initial response was to condemn surgeons who wanted to remove the limbs. Now there is a more balanced approach. Such individuals seem to flourish in rehabilitation with prosthetic limbs. A theory is that it is caused by a cortical dysfunction that may be dealt with by treatment in future.
These extreme cases have attracted the label of body modification addiction. Behavioural addictions, it is widely agreed, can occur with activities like gambling or hair pulling (trichotillomania); whether sexual addition falls into this is more doubtful. Certainly, some people with extreme body modification admit that they have a compulsive need to continue with the modification and may even seek treatment.
There is much debate on the psychiatric diagnoses in these cases. Psychotic disorders, drug abuse (especially amphetamines and cocaine), depression, eating disorders and personality disorders usually come up. The compulsive element of OCD is often cited as the cause of body modification addiction, mostly for lack of any better explanation.
All of this implies the end of BDD. When such behaviours are prevalent in society, although there may be doubts about the mental stability of such cases, can we still consider it a valid diagnosis? If these extreme body changes are now a common feature in our society, then do such people have a psychiatric disorder?
One mooted solution is to see extreme body changes of this nature as constituting a disorder at the extreme end of a spectrum of behaviour. But where does one draw the line?
This reflects an epistemological problem in psychiatry. This is not new for psychiatry which has to constantly adjust its focus in a changing world, but it reflects a huge issue in society, namely the medicalisation of normal life. Everyone, it now seems, is ‘on the spectrum’ with ADHD, autism or PTSD, followed by rampant adoption of psychological jargon in ordinary discourse – witness the promiscuous use of terms like trigger, narcissism, trauma and borderline.
How to answer the problem of so many well-presented, accomplished, sedulous and articulate individuals who proclaim their heroism in overcoming their neurodiversity or whatever? Could it be that they just represent the diversity in human personality and behaviour that have been a feature of our existence as long as history has been recorded? Much of this must arise from the cult of victimhood, now so prevalent in all quarters.
It is not just those who seek extreme body changes that require scrutiny but those who do the mutilating surgery. Mainstream surgeons avoid such practices but there are always unqualified outliers ready to assist, especially in countries where enforcement tends to be lax. As much as the tabloids can be believed, these are fringe characters, at times leading to disastrous outcomes. Where are the ethical lines drawn?
BDD, as it stands now, has a doubtful future. What we are left with is the problem of making a distinction between extreme but socially accepted bodily changes and issues that represent serious pathology. Considering the crises that are affecting psychiatry at present, don’t hold high hopes that this will resolve soon.
Robert M Kaplan is a forensic psychiatrist who writes on the current state of psychiatry.
