Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (10 page)

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 patient’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.

“Once I’ve got the money and the appointment is scheduled?” he went on. “That’s the only time in my life I feel anything close to happiness. That’s like . . .” He paused. “That’s like my one little bit of peace.”

It seemed to me that what Eddie was really talking about was hope. He had been in some form of psychiatric treatment for years, and although his symptoms improved somewhat when he was on the class of antidepressants known as serotonin reuptake inhibitors (SRIs), they didn’t fully subside. As he spoke, I realized that the reason the useless surgeries were so reinforcing had nothing to do with their outcomes. They were addictive because they promised relief, and living with the promise provided a respite from the torture of feeling as if he would always be hideously ugly.

Of course, the promise didn’t ever last. “Right after the procedures, I still feel pretty excited, but I guess that’s when the first worries start to creep back in,” Eddie explained. “What if this last-ditch new laser didn’t do what it was supposed to? What if my skin is exactly the same? Or, Jesus Christ, what if it actually looks worse instead of better? For the first couple of days, I can hold on to what the doctor told me: that there’ll be redness, or swelling, or whatever. But still I start to see that nothing’s really changed. Then . . .” And here Eddie’s voice trailed off. He shrugged.

“Then what?” I pressed him.

“Then . . . God. Then it’s . . . it’s an absolute pit of despair, you know?”

I nodded.

“The money’s gone, the excitement is gone . . .”

“The hope?” I asked.

“Yeah,” he said softly. “Whatever shred of that there was, that’s totally blown out of the water. Those are the days, after the procedures don’t work like they’re supposed to, that I find myself thinking, ‘You know what? I just need to die.’”

Eddie laid out this course as a true expert, familiar with every inch of its terrain. His fluid navigation of it was heartbreaking. That he would subject himself to it over and over again, despite an ability to map it out with utter precision, spoke to . . . what? Some way in which he had been failed by psychiatric treatment? A resistance to healing buried deep within his own mind? My inability to steer him toward safety, toward sanity? The brutality of this disease that would not release its bitter hold?

In writing about what might cause BDD, Dr. Phillips gives an explanation that is as maddeningly inexact as my own questions about why Eddie is trapped in its horrible lockstep. Her explanation feels like grasping. It also is almost certainly true. “You probably first need to inherit a genetic predisposition to BDD,” she writes. “This may consist of a vulnerability or susceptibility to developing the disorder BDD specifically or a more general genetic predisposition to worry and obsess—or both. This tendency may involve the brain chemical serotonin and other neurotransmitters, as well as certain areas of the brain. Let’s say you’re also born with a tendency to have a shy and self-conscious personality; if this temperament is combined with a tendency to obsess and worry, it may further increase your chance of getting BDD. Environmental factors may further increase this biologically based risk; for example, if you’re teased a lot as a child or experience lots of rejection, this may further funnel your genetically based worrying tendency and self-consciousness toward BDD symptoms. And if you’re already predisposed in these ways to develop BDD, you may be hyperalert to media images of perfection (such as flawless skin) and buy into them more than the average person does. Then, if your boyfriend breaks up with you, that may trigger feelings of inferiority and full-fledged BDD.”

While the consequences of BDD can be grave for patients, the consequences can also be grave for those who treat them. When patients like Eddie have put all their hope and all their money into surgical procedures that do little or nothing to alleviate their symptoms, they conclude that the procedures have failed. Some, like Eddie, internalize that disappointment. Others may hold their physicians accountable for these perceived failures. Sometimes the blaming takes the form of litigiousness. Occasionally it turns violent. A 1996 paper in the medical journal
Dermatologic Clinics
cautions physicians that BDD patients’ anger “may be directed at the attending physician with vitriolic letters, death threats, and even physical violence. In recent times in the United Kingdom,” the paper continues, “one dermatologist and two plastic surgeons have been murdered, and practitioners working in this field should know that there is a small but definite risk of assault when managing these patients. The long and arduous consultations, repeated telephone calls, and constant need for reassurance can put a significant strain on the medical practitioners involved.”

Selma, my patient who sought a dentist to pull all her teeth and “start over,” had not been violent, but she had been threatening. Selma attributed her perceived problems with the appearance of her teeth to the first dental procedure she’d ever had. “That woman destroyed the alignment of my whole jaw, my bite, everything,” she told me, referring to the technician who had applied a whitening solution to Selma’s teeth. That had been more than a decade ago. First, in the months following the procedure, Selma began going to the office to try to confront the technician. She sent letters to the office and to the dentist, threatening lawsuits and blaming the technician for “ruining” her appearance. Eventually she moved to another part of the country but returned three years later. She immediately went back to the dentist’s office, “to tell that woman what she had put me through since I had seen her last.” When she found that the technician no longer worked there, Selma found her home address and began stalking her, leaving her threatening letters and phone messages. Finally the technician informed the police and got a restraining order against Selma. She complied with the restraining order, but in each of our sessions ten years later she spent at least part of the time ranting about how angry she remained at the woman she blamed for all her unhappiness.

Eddie demonstrated that same persistent adherence to his delusional belief. During the year that I treated him, the frequency of our visits varied dramatically. We were initially scheduled to meet every month, to check in on Eddie’s symptoms, to see how the SRI that I had prescribed for him was working. When Eddie admitted he wasn’t taking the medicine reliably (“What’s the use?” he would say. “Prozac’s not gonna help my acne.”) and he found himself thinking more often that he would be better off dead, I saw him on a weekly basis. No matter how frequently or infrequently our appointments were scheduled, Eddie canceled half of them.

When we did meet, I tried every way I could think of to convince him of the potential benefits of cognitive behavioral therapy (CBT), a kind of psychotherapy proven to reduce BDD symptoms, sometimes dramatically. I showed him data about the treatment’s efficacy. I told him stories of patients very much like him whom I had treated with SRIs and CBT, and I told him that those patients had escaped the mirror’s hold, that they had entered into happier, fuller lives, without surgeries, without suffering.

Eddie remained absolutely certain that I had it all wrong. He believed I saw the same flaws on his body that he did but that I was pretending not to notice and trying to convince him otherwise. His delusion was so deeply entrenched that he
knew
the hideousness of his appearance to be true, as surely as he knew his own name, or his occupation, or his current state of despair.

“I’m not saying that it’s not great that those people got better, Dr. Montross, it is,” Eddie would say to me. “It’s just that they don’t have the skin I have. They don’t look like I do.” I tried to talk with Eddie about his reluctance to participate fully in treatment. I tried to cajole him into giving CBT a try. He could see no use in it. “The problem isn’t my thinking, it’s my
skin,
” Eddie would say to me over and over. “Why would I spend time and money on that therapy when I could be working during those extra hours and saving up for the new procedures that will target my real problem?”

Eddie believed so strongly that his problem was dermatologic, not psychiatric, that he saw my treatment—indeed any psychiatric treatment—as misguided at best and deceptive at worst.

He eventually capitulated after I challenged him yet again about his resistance to treatment. “Maybe your medicines and therapy
could
make me feel better about the way I look,” he allowed. “But I’d still look the way I do, so I’d be in some medicated state of denial, walking around. Even if I didn’t realize it because of the meds or whatever, I’d still be disgusting people with my ugly face.” Eddie was so convinced about his appearance that he feared that medicine or therapy would somehow make him blind to the horrors the rest of the world would see.

When I finished my outpatient year, another psychiatric resident took over the care of all my patients. I recently ran into that psychiatrist, and I asked about Eddie. It seemed that hardly anything about his condition had changed, that he remained plagued by his bodily concerns.

“He’s really struggling,” the doctor said. “There’s some new procedure . . . subcision? They put a needle under acne scars to try to break up the connective tissue making the scar, or something. Anyway, he’s gotten it done a bunch, even though he’s never had any acne scars that I can see.”

I remembered how hard it was to sit with Eddie and manage not to either argue with him about his symptoms or reassure him about them. Dr. Phillips repeatedly advised me how little there was to be gained by those actions, so I had always tried to meet him at the level of his sadness, his life losses, his suffering. But it wasn’t easy.