Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  (CHAPTER TWO)

  Fifty-Thousand-Dollar Skin

  And if thy right hand offend thee, cut it off, and cast it from thee:

  for it is profitable for thee that one of thy members should perish,

  and not that thy whole body should be cast into hell.

  —Matthew 5:30

  Late in my residency training, I had an outpatient practice in which I saw patients longitudinally over the course of a year. It was there that I first met thirty-four-year-old Eddie. When Eddie came to see me, he had just moved to Rhode Island from Utah. As a result, several months had passed since he had last seen his previous psychiatrist, and his antidepressant prescription had run out weeks earlier. With the gap in medication, Eddie’s always-troubling symptoms had worsened dramatically.

  “My skin is awful,” he said in a hushed tone filled with sad urgency. “And now, to top it off, do you see how my hair is thinning all across the back of my head here?” I didn’t. Eddie’s skin looked totally normal to me, and I could not see the faintest trace of thinning hair in the area of his scalp toward which he gestured. No one would look at Eddie and think of him either as balding or as having unattractive skin. Still, I neither argued with Eddie nor reassured him—I knew from reading his chart that whether or not I agreed with his self-perceptions was immaterial.

  “I’ve saved up all summer for a treatment,” he continued, referring to his work in a seasonal family restaurant. “My dermatologist told me about this new laser that goes at the acne scarring from underneath, so I’m hopeful maybe that will help, since nothing else has.” I did not share Eddie’s hope for improvement. Since the time he was eighteen, convinced that he had horrific acne scarring that made him repulsive to look at, Eddie had undergone dermatologic procedures as often as he could afford them: painful dermabrasion in which a high-speed rotary instrument with an abrasive wheel was used to remove the outer layers of his skin, repeated laser treatments, silicone injections, “desiccation” procedures in which supposedly scarred areas of his skin were burned, even a face lift in his late twenties.

  Eddie conservatively estimated the number of procedures he had undergone at twenty-five. He guessed he had probably spent close to fifty thousand dollars in an attempt to “repair” his skin. At his worst, unable to afford a medical procedure and still convinced that his acne scarring was horribly disfiguring, Eddie scoured his face with sandpaper in an attempt to smooth its surface.

  Now that the pace of summer work was slowing, Eddie had days when he spent hours at home, constantly in front of the mirror. “Some mornings I wake up and think my skin actually looks okay,” he explained, “and then I go back to the mirror to check after breakfast, and the sun is shining in the window and I can see how disgusting the scars are.

  “Everyone I know hopes for sunny days,” he went on, “but whenever I see the clear sky, I know it will only highlight how messed up my face is.” When I asked Eddie how much time he was spending in front of the mirror, he paused to calculate. “Yesterday? Maybe five hours. The day before?” He paused again to think. “Maybe eight.”

  Eddie’s thoughts about his skin and hair not only consumed his mind, they also interfered with the most basic aspects of his life. His girlfriend of many years had left him, fed up with the ways in which his preoccupations with his appearance affected their lives. In addition to the hours Eddie spent each day in front of the mirror, he also canceled plans to go out at the last minute, fearful that he was so hideous-looking that strangers would ridicule him on the street or that in a different light his new girlfriend would finally see him realistically and break up with him on the spot. He would ask her—sometimes hundreds of times a day—how his skin and hair looked. No matter how reassuring her comments were, he remained unconvinced that he was anything other than grotesquely disfigured.

  To make matters worse, Eddie was ashamed of his inability to change either his outlook or his behavior. “Some people think I’m really vain,” he said softly. “But people who are vain think they are beautiful and like to look at themselves.” He paused. “I hate looking in the mirror, but I have to try to fix how horrible I look.”

  Though Eddie’s symptoms sound remarkable, the fact is that in terms of the demographics of mental illness his affliction is as common as schizophrenia, anorexia, or bipolar disorder, plaguing one out of every fifty to a hundred people. Descriptions of the disorder can be found even in centuries-old case reports with a range of evocative names, like “imagined ugliness” and “dysmorphophobia,” but the crux of the symptoms is the same: a preoccupation with an imagined defect in one’s appearance or excessive concern about a slight physical anomaly. Today we call this illness body dysmorphic disorder (BDD).

  Descriptions of patients who would today be diagnosed with BDD periodically surface in the psychiatric literature of the nineteenth and twentieth centuries. The Oxford English Dictionary dates the word “dysmorphophobia” (from the Greek dysmorpho-, meaning “misshapen or deformed,” and -phobia, meaning “fear”) to 1891. The first use of the term is attributed to the Italian psychiatrist Enrico Morselli, who gave his article the enticing title “Dysmorphophobia and Taphephobia.” The fear of being deformed, alongside the fear of being buried alive. The triumphant subtitle of Morselli’s article reads like an exploration of the new world: “Two Hitherto Undescribed Forms of Insanity with Fixed Ideas.” Morselli writes, “The dysmorphophobic, indeed, is a veritably unhappy individual, who in the midst of his daily affairs, in conversations, while reading, at table, in fact anywhere and at any hour of the day, is suddenly overcome by the fear of some deformity that might have developed in his body without his noticing it.”

  Like Bethlem’s Charles Harold Wrigley in 1890, the patients whom Morselli describes are indistinguishable from those I see more than a century later. He writes that the dysmorphophobe “fears having or developing a compressed, flattened forehead, a ridiculous nose, crooked legs, etc., so that he constantly peers in the mirror, feels his forehead, measures the length of his nose, examines the tiniest defects in his skin, or measures the proportions of his trunk and the straightness of his limbs, and only after a certain period of time, having convinced himself that this has not happened, is able to free himself from the state of pain and anguish the attack put him in. But should no mirror be at hand, or should he be prevented from quieting his doubts in some way or other by means of some mechanism or movements of the most outlandish kinds, . . . the attack does not end very quickly, but may reach a very painful intensity, even to the point of weeping and desperation.”

  Indeed, patients with BDD, both current and historical, are frequently in true agony, their lives dominated by their constant symptoms. They may check the body part in question hundreds of times a day, smoothing their hair, touching or sizing up whatever it is they believe to be errant.

  Eddie’s case is not atypical among patients who live with BDD, in that he spends hours looking closely at—and being tormented by—his perceived flaws and going to great lengths in an attempt to correct them. Still, the details of patients’ suffering can vary dramatically, even within a single diagnosis. Another of my patients routinely digs into the pores of her face with needles. A third has spent tens of thousands of dollars on multiple elaborate cosmetic dental surgeries. She remains convinced that her teeth are “disgusting” and has gone to numerous dentists in an attempt to find one who will “just pull” all of them “and start over.”

  Patients with BDD may endlessly compare themselves to others. One patient told me that she lost her job as a bank teller because she would watch each customer walk away and then have to go into the bathroom to look in the mirror to attempt to assess whether her thighs were bigger or smaller than those of the customer she had helped.

  Stricken with the belief that they will be seen as hideous by others, people suffering from BDD will isolate themselves to varying degrees. Many will decline social invitations. Many will be hours
late to events because they are stuck rewashing and styling their hair over and over or are unable to tear themselves away from the mirror, examining their perceived deficits. Some miss the weddings of siblings, of best friends. A few refuse to leave their homes at all, trapped by their obsessive thoughts, their fear of others’ judgments, and their own self-hatred.

  These patients view their flaws as horrific and thus impossible for others not to see and shrink from. In fact, the traits about which they obsess are hardly noticeable, if they are noticeable at all. The patients may even focus on an imperceptible flaw—crooked toes, for instance—while feeling no discomfort at all about traits we might imagine could give rise to insecurity, such as baldness or weight gain. In many cases the actions taken in an attempt to fix the problem are what draw negative attention to the person’s appearance—as when Eddie’s dermatologic procedures would leave his skin raw or his face bruised, when patients’ minuscule blemishes were picked and poked until they transformed into large and angry sores, when one patient drenched her head with tonics that left her hair coated in an oily sheen, when another combed his hair so compulsively that it caused his scalp to bleed.

  In my residency practice, I treated a number of patients with BDD and was incredibly fortunate to be supervised in weekly meetings by Dr. Katharine Phillips, the world’s preeminent expert on the disease. Dr. Phillips speaks openly about the drastic measures that have been taken by her own patients in an attempt to camouflage or rid themselves of their perceived flaws. One patient would not leave her home because she believed she had a hair mask on her face, like a gorilla. Another patient wore a curtain of bangs obscuring her face, down to her chin, in order to hide what she felt was a disfigured nose. The patient had had three rhinoplasties—nose jobs—at the Mayo Clinic, one of the world’s most renowned medical centers, and had a nose that most objective bystanders would classify as perfect. She eventually did cut her bangs, only to wear a face mask over her nose and mouth for three years. Instead of functioning as camouflage, these tactics brought even more public attention to her appearance than her flawless nose would ever have done, paradoxically increasing her anxiety further. Eventually her symptoms improved, but only when she engaged fully in a combined treatment program of psychotherapy and psychiatric medications.

  The illness sounds fantastically odd, but the consequences can be grave. Patients with BDD often unintentionally harm themselves, sometimes severely. Dr. Phillips describes a woman who picked so deeply at a blemish on her neck that her tweezers reached all the way down to the fragile sheath surrounding her carotid artery. She tells of a man who performed self-surgery to try to implant the cartilage he had whittled down from a chicken carcass into his own “malformed” nose. Her patients have superglued ears they perceive to stick out too far. They have used staple guns to perform home face lifts. A woman allowed her nose to sunburn and peel, sunburn and peel, over and over again in the hope that the constant peeling would somehow make her nose smaller. A man cut off fingers on one hand that he perceived to be too long. A young woman felt that her nipples were “grotesque” and carved them from her chest.

  The greatest danger, however, to Eddie and others who suffer from BDD is that they are at a significantly increased risk of suicide. Eighty percent of patients with BDD will have death wishes or thoughts of killing themselves. Twenty-five percent will try to end their own lives. The rate of completed suicides among BDD patients is about thirty-one times that of the general population.

  I treated Eddie for a year. Each time I saw him, I asked whether he had thoughts of killing himself. Each time he said no, but I didn’t find his rationale reassuring. “I want to be dead, yeah,” he’d say with his characteristic candor, “but I don’t know whether I could bring myself to do it. I think I’d be too scared to carry it through. If someone with a gun asked for my wallet, though . . .” And here he paused until I gestured for him to continue. “I’d say, ‘Shoot. Go right ahead.’”

  Eddie’s passive suicidality—wishing he were dead but not actively planning to kill himself—arose directly from his unrelenting torment. Though tragic, and a call for real intervention, Eddie’s thought process nevertheless contained a misguided logic. So overcome by hopelessness and so miserable, he felt that only death would bring him relief. As his doctor, I could understand how he had come to that place of desperation, but I could also help to foster hope. I reminded him that in the past, with antidepressants and psychotherapy, he had felt better and had been glad to be alive. We could—and would—try to get him back to that place.

  In addition to the increased risk of suicide, BDD symptoms can cause such profound psychic distress that people will endure unimaginable physical pain in an attempt to alleviate their bodily concerns. Dr. Phillips treated a man who, when fifteen surgeons refused to perform elaborate cosmetic procedures on his face, planned an automobile accident in which he could “destroy” his face and force doctors to reconstruct it. The plan had an additional benefit: Even if he had found a doctor willing to conduct the elective procedures, his insurance wouldn’t have covered them, as they would have been deemed cosmetic, and he would not have been able to afford to pay for them. An accident, he reasoned, would certainly be covered by insurance.

  Another of Dr. Phillips’s patients, a woman she calls Julie, became absolutely obsessed with the possibility of harming her nose. Twenty years prior to being seen by Dr. Phillips, Julie had had minor surgery on her nose to “remove a small bump.” “After surgery,” Phillips writes in her book on BDD, The Broken Mirror, “the surgeon commented, ‘I worked really hard on your nose, so take care of it and don’t damage it.’ Julie took this to mean that her nose was fragile, and it triggered her obsession.”

  In the years that followed, Julie constantly went to her surgeon’s office—sometimes twice a week, sometimes waiting two hours to be seen—seeking reassurance that she had not inadvertently, unknowingly, broken her nose. Julie told Dr. Phillips that she had been unable to work and unable to keep her house in order: “I’m so focused on my nose that I can’t think of anything else.” This had not been the first time that her fears had become so all-encompassing. Julie told Dr. Phillips that her preoccupation was “a huge problem in my marriage, too. My first husband left me because of it. I drove him nuts! I asked him all day long about my nose and whether I’d damaged it, and I’d have him hold magnifying glasses and special lights to check it for damage.” Julie’s fear that her nose might be harmed dwarfed her fear and experience of actual physical pain. Dr. Phillips writes, “During childbirth, Julie was so petrified that her nose would be damaged that she hadn’t even felt labor pains.” Julie once required dental work but “was terrified the dentist would damage her nose by bumping it while she was anesthetized and that she’d be unaware” that it had been harmed. As a result of that fear, Julie opted to have the procedure without Novocain. Dr. Phillips observes that Julie “preferred the intense physical pain of unanesthetized dental work to the emotional pain of unrecognized nose damage.”

  In fact, some patients even use pain as a deterrent, in an attempt to interrupt endless cycles of BDD behaviors. A college student who compulsively trimmed her hair and carried scissors with her constantly to make sure it remained even, told Dr. Phillips that she had first tried to throw her scissors away, but when she found herself still unable to resist the urge to cut her hair, she hit her hands with a hammer and intentionally slammed them in a car door.

  Opting for physical pain over psychic agony is reminiscent of the intentional patterns of self-injury inflicted by those who cut and burn themselves, even by those who swallow foreign bodies. And yet within BDD, self-harm seems to be a frantic attempt to escape the disease’s confines. In chronic self-injury, the act of harm may provide its own form of respite, no matter how fleeting. In BDD the pain brings no such relief. It is the by-product of a despondent effort at making intolerable symptoms abate. And because the actions taken so rarely have any effect on the p
atient’s symptoms, the pain is often suffered in vain.

  In this very way, Eddie’s endless dermatologic procedures were in vain. BDD, it must be underscored, is a disease of the mind and not the body. Just as a patient’s deviated septum would be ill treated by psychotropic medications, so Eddie’s trail of cosmetic surgeries utterly failed to diminish any part of his crippling distress. I asked him why, then, he continued to schedule procedure after procedure after procedure.

  I half expected him to acknowledge that it must look irrational from my perspective. I thought he might admit to the travesty of saving up months of income only to hand it over, time and again, to treat some invisible scars.

  “What else am I supposed to do?” he asked me. “There’s nothing else to do. But you know, Doc, there’s a stronger laser coming down the pike . . .” And he’d be off, hitching his delusional wagon to the promise of new technology. The next novel treatment. The procedure that this time would really be created to address his kind of scarring. This one really, once he had enough money to try it, this one really might work.

  Though his fantasies about the future were just that, Eddie was able to accurately describe the trajectory of his past skin treatments and their bearing on his illness. Two-thirds of people who suffer from BDD have an onset of symptoms before they turn eighteen. As someone who first became obsessed with his skin at sixteen, Eddie was right in line with the majority of BDD patients. When he thought about the promise he attached to a dermatologic process, it often carried with it the hope of returning to the more carefree days he remembered from his early adolescence.

  “When I learn about a new treatment, I get almost giddy,” he explained to me, “like I might really have a chance at getting my life back. Like this time things might really change. Then I go into this stretch of frustration and anticipation,” he continued. “I’m excited and looking forward to the treatment, but I’m frustrated because I can’t just go do it, you know? I have to save up like crazy before it can happen, and that takes time.” Eddie had gone through so much money chasing perfect skin that he worked extra hours whenever he could in order to keep up with his treatments. He often canceled his appointments with me because he couldn’t give up the work time. He had moved in with his sister and her family to save money on rent.