by Harvey Widroe, M.D.
American Reporter Correspondent
November 2, 2007
ORINDA, Calif. -- The locked hospital room was almost too dark for me to see if anyone was there. But someone was, curled into a ball, hiding beneath the sheets and blanket, taking up a minimal space in the universe. His intent had been to take up no space at all, and, after his overdose, his life had been saved only by skilled and heroic medical intervention.
Lee was a 19-year-old college sophomore about whom the medical record provided remarkably little information. Once admitted to the hospital he lived in a dorm, but no one had come forward claiming to be his friend. His next door neighbor had described him as "a loner".
My first fifteen minutes with Lee were a monologue, with my doing all of the talking. It isn't easy trying to talk to someone who is mute. I could sense that he hated my barrage of questions, all pulling for an answer, any answer. For Lee, all answers, even unstated, were painful. They confirmed a connection with the real world, the one that existed outside his mind and from which he desperately wanted to escape.
Still hiding underneath the covers, when he finally did utter a few barely audible single phrase responses it was more to make me go away; more to merely appease my stubborn inquiry rather than to seek in any way to communicate.
He acknowledged that he suffered a kind of unbearable pain, and that he felt it all over. He wanted so much to be dead, gone, and thereby relieved of an impossible, agonizing and insoluble problem. He had to die, he explained, because he was too awful. I tried to reassure him that no problem could be that bad, and that I would help him if he told me what the problem actually was. But my first efforts were to no avail. I was certain that he was still a high risk for suicide, and required seclusion and almost continuous staff observation.
The next day I renewed my nonstop questioning. Finally he sat up and pointed to a one inch square bandage on his right cheek. "What is it?" I asked. He blurted out, "It's the scar!" It was the scar that was ruining his life. It was too hideous for anyone to see, but it was there, hidden under the bandage, disfiguring, disgusting, making him unfit to be alive.
He explained that other doctors who had seen it had said nothing could be done, that he should learn to live with it. But he couldn't live with it. He knew that no one would ever talk to him or look at him without shuddering. The scar was all he could think about. The image was on his mind all of the time.
I came to see Lee daily. After a few days he became a little more talkative. He began to sit up in bed during my visits. His answers to questions were soft and slow. He still felt there was no way out because of the scar, to him a kind of brilliant brand on his face. I asked him to show me the scar, almost certain that no matter how bad it was, I would be able to look at it without grimacing. No doctor runs screaming from an examination room because a wound appears too hideous. Finally, in response to my badgering, Lee tore the bandage off his face. "Look!" he shouted.
When he had torn off the bandage, I was truly amazed. The problem was not a scar too hideous to behold. Beneath the bandage, there was no scar at all!
I told him that I couldn't see anything but he insisted that I look more closely, that I couldn't miss it. The best I could do was spot a tiny slightly pink zit scar that no one would have noticed had it not been spotlighted.
Lee suffered from BDD, otherwise known as Body Dysmorphic Disorder. BDD is a type of obsessive-compulsive disorder that afflicts adolescents and young adults. Victims of BDD experience a very serious but circumscribed distortion of reality.
Usually, some single feature of the face or head such as the nose or ears is perceived as huge or malformed. Or the appearance of a skin condition like ordinary facial acne is markedly exaggerated in the mind of the BDD patient.
BDD sufferers tend to think about their distorted self-image almost all of the time. They come to feel that anyone who comes in contact with them will instantly spot their hideous condition, and will feel only total revulsion and disgust.
The distorted body image comes to be the central focus of life. Those young people with BDD may spend hours every day standing before the mirror, their attention riveted by their perception of a disfigured appearance. And work, school, and relationships with other people all suffer greatly.
It is no wonder that BDD sufferers become severely depressed. They have total conviction in their distorted reality. They feel trapped with their delusional perception, and helpless to do anything about it. Many, like Lee, even become suicidal.
Fortunately, psychiatrists can help BDD victims. Psychotherapy in iearly phases helps the patient strengthen his or her grasp of reality, and later will deal with other problems in the patient's life, especially how he or she relates to other people. In addition, antidepressant drugs of the SSRI family can help a great deal. Paxil, of all the SSRI antidepressants, seems to be the most useful.
Within a week or two after beginning treatment, patients will obsess a much less about their symptoms. Because they think about the symptoms less, their spirits improve, and they gradually become more able to resume functioning in other areas of life. Some will come to terms with what they conclude is a realistic problem, and it doesn't seem to bother them anymore. Others realize that the symptom was never of sufficient severity to merit the kind of horrific response they had experienced earlier.
Occasionally, BDD patients will insist on having plastic surgery to correct a feature they find extremely upsetting. The surgery may or may not be useful. Some find it the answer to their dreams, especially if the symptom has been the perceived size or shape of a particular facial feature. Others will find fault with the results of the surgery and use the apparent failure of the surgery to support their conviction that their symptoms are truly hopeless. A rare BDD patient may go on to seek repeated plastic surgical procedures.
Most of the time BDD, as bizarre as it may seem, is a very treatable condition with an excellent prognosis over a period of time.