Body Dysmorphia (BBC Horizon)

[TragicMonkey]

Where they will need support from society to manage their lives without the appendage in question.

Someone wants an ear removed? Meh, ok I guess;

Someone wants both legs removed? (extreme example) No.

The degree of "support from society" one needs varies with one's personal wealth. Oprah could easily afford to hire platoons of servants to run her errands or indeed carry her about on a palanquin wherever she desires. Would that make the desire to amputate her own legs sane for her, but crazy in a poorer person?

 

[Emily's Cat]

This is partly a legal issue. The role of the psychiatrist in this instance is not to say whether the leg should be amputated or not, it is to say whether the patient is legally able to consent to the surgery. If delusional e.g. believing that there are insects burrowing under the skin of the leg that will spread if the leg is not removed then they cannot give legal consent. If they are psychotic and a voice has told them they need to amputate their legs because ... then they cannot give consent. If the patient is not psychotic or delusional and has adequate cognitive function then they are competent to make a decision about their body, there is no requirement for that decision too be rational.

However there is no requirement for a surgeon to operate, it might well be illegal.

People can become very fixed on their bodies, hence the existence of cosmetic surgery.

The problem is that treatment of body dysmorphia with drugs or psychotherapy is not very effective (but can be effective for some people), sometimes the easier option seems to be surgery. Time does seem effective most people grow out of body dysmorphia (but not all).

Hmm... I'm not sold on that view of what constitutes a delusion. A delusion is a false belief, whereas a hallucination is a false perception. I would tend to think that believing that one's healthy body parts should not be there would qualify as a false belief.

Where it might get a bit trickier is when a person acknowledges that the body part is there, is natural to be there, is supposed to be there... but dislikes the body part and wants to remove it for some reason. "I know these are my legs, and there's nothing physically wrong with them, but I hate them and my life will be better if I cut them off" may not technically qualify as a psychiatric disorder... but it seems as if it would certainly be a behavioral disorder.

Having an irrational and harmful emotional response (and attendant behaviors and actions) is still a category of mental health disorders.

 

[Emily's Cat]

The difference is what lies at the heart of all non-medically required "cosmetic" surgery. The patient may be happy with the outcome, but the surgeon is still causing injury to the patient for no medical or (physical) health reason. Is someone wanting a breast enlargement psychotic or delusional because they feel they will be better in some undefined way with larger breasts? (Indeed we should note that they do not actually get larger breasts all they achieve is a semblance of larger breasts.)

Despite the prevalence of cosmetic surgery and its legal and social acceptability in our societies I do wonder if many people having cosmetic surgery would be better served by it being approached as a mental health issue and dealt with treatment for a mental health issue rather than resorting to irreversible "cosmetic" surgery.

I generally agree with your take on this. I might consider an argument that purely cosmetic surgery, while it may not "fix" anything, also doesn't directly cause harm - with the caveat of people "addicted" to cosmetic surgery. I mean, getting a boob job doesn't generally cause medical problems or inhibit the ability to go about one's life in a relatively normal fashion. Getting a "leg job", however, definitely causes harm and hardship.

 

[Emily's Cat]

Who gets to decide which desires are acceptable and which are not, when it comes to other people's bodies?

Rational, prudent people who can reasonably foresee whether the desired modification will cause *harm* to the person seeking the modification.

The concept of a "reasonable person" interpretation is commonplace and highly effective. It's employed throughout a multitude of legal and regulatory standards.

 

[Emily's Cat]

You're assuming this is a question of disease, a failing in the health that ought to be cured. What if it's just a desire? People want different things, and most people would define happiness as being able to fulfill their desires. Who gets to decide what desires are just desires, and what desires are just symptoms of disease? My grandma desired to wear purple velour tracksuits with shiny gold sneakers and carry a tiger-patterned cane: was she suffering from a disease like dementia, a psychological disorder in which she believed she was a stereotypical pimp, or merely afflicted with peculiar taste in fashion? And yes, I know that's much less extreme than wanting to lop off a healthy limb; my point here is that from the outside how can we tell for someone else? Where does their desire to do as they will with themselves become someone else's business to judge and interfere?

At the point where their desire to do as they will with themselves confers an obligation for accommodation or support on other people.

Your grandparent's fashion choices don't result in any obligation (aside from perhaps having to control one's facial expressions while viewing the outfit). Having one's legs lopped off confers an obligation on other people to help support that person, to provide accommodations as a disabled individual, to help with accessibility, financial assistance, medical assistance, conveyance, etc. It's not a choice being made solely for themselves - it's a choice that affects everyone else around them. At the very minimum, the person who has decided to remove their legs will need a wheelchair, alterations to their home to accommodate their leglessness, alterations to their vehicle or access to transportation services provided by others... and those things are all being paid for by the public - either through direct taxation in the case of countries with universal health care, or through higher premiums for countries with private insurance. Either way, their desire is not theirs alone.

 

[Emily's Cat]

The degree of "support from society" one needs varies with one's personal wealth. Oprah could easily afford to hire platoons of servants to run her errands or indeed carry her about on a palanquin wherever she desires. Would that make the desire to amputate her own legs sane for her, but crazy in a poorer person?

Nah. It's still crazy. But it's a crazy that doesn't affect anyone else.

 

[theprestige]

Some people just want society to be a perfect system of formal logic, where all questions of propriety resolve to simple absolute binary propositions.

If breast enlargement is fine for some people, it must be fine for everyone. Society cannot possibly evaluate mental health on a case by case basis, and make allowances in some cases but not in others. If we let Evel Knievel indulge his death wish, we cannot possibly prohibit Legless McCrazypants from following her own dream of self-harm.

 

[d4m10n]

Someone wants both legs removed? (extreme example) No.

This was actually what Corinne was asking for: double amputation, well above the knee. I think it's fair to say she would need significant support from society to manage without them, at least at first.

 

[Elaedith]

It is elusive to be sure. I got the sense from the interviews that he'd definitely not recommend amputation if the patient was delusional or psychotic, but he would do so if the disorder was dysmorphic in nature.

Sent from my SM-G996U using Tapatalk

I'm not sure why the distinction is unclear?

The term disorder is often used to refer to a condition that causes distress or functional impairment or harm to others, and therefore may require diagnosis and treatment or accommodation. It is not synonymous with 'mental illness', and a large number of conditions classified as psychological disorders would not appropriately be described that way (e.g. autistic spectrum disorders). As we know from discussion elsewhere, the DSM defines numerous conditions that are only considered disorders if they cause distress/impairment/ or harm to others. Psychotic disorders are a subset of disorders that involve symptoms like hallucinations and delusions or disorganised thought, that could impair judgement.

There has been interest in the possibility that body integrity dysphoria involves some sort of inversion of the process involved in phantom limbs (where somebody is missing a limb and feels that it's still there). In the case of phantom limbs, the generally favoured (although still controversial) explanation is neurological - that each part of the body is 'mapped' onto a region of the sensory cortex, and the part of the brain devoted to mapping stimulation from the missing limb, receiving no sensory input, starts responding to stimulation in adjacent regions, which is misinterpreted as coming from the 'phantom'.

If the reverse is true, some parts of the body not being properly 'mapped' might lead to the sensation that a limb is not part of the body because the brain doesn't properly process sensory input from that part.

There seems to be some recent research along these lines, although the explanation is more complex and relates the issue to altered connectivity in larger scale networks.

 

[d4m10n]

The term disorder is often used to refer to a condition that causes distress or functional impairment or harm to others, and therefore may require diagnosis and treatment or accommodation.

This is one of those unusual cases where patients are hoping to trade off psychological distress for functional impairment.

ETA: Thanks for the link.

 

[Elaedith]

This is one of those unusual cases where patients are hoping to trade off psychological distress for functional impairment.

ETA: Thanks for the link.

Yes, good point. But if the person already feels impaired, it might come down to a perception of which form of impairment they think is worse.

Making somebody disabled is obviously not an outcome that would normally be an acceptable goal of a medical procedure.

 

[novaphile]

I'm not sure why the distinction is unclear?

The term disorder is often used to refer to a condition that causes distress or functional impairment or harm to others, and therefore may require diagnosis and treatment or accommodation. It is not synonymous with 'mental illness', and a large number of conditions classified as psychological disorders would not appropriately be described that way (e.g. autistic spectrum disorders). As we know from discussion elsewhere, the DSM defines numerous conditions that are only considered disorders if they cause distress/impairment/ or harm to others. Psychotic disorders are a subset of disorders that involve symptoms like hallucinations and delusions or disorganised thought, that could impair judgement.

There has been interest in the possibility that body integrity dysphoria involves some sort of inversion of the process involved in phantom limbs (where somebody is missing a limb and feels that it's still there). In the case of phantom limbs, the generally favoured (although still controversial) explanation is neurological - that each part of the body is 'mapped' onto a region of the sensory cortex, and the part of the brain devoted to mapping stimulation from the missing limb, receiving no sensory input, starts responding to stimulation in adjacent regions, which is misinterpreted as coming from the 'phantom'.

If the reverse is true, some parts of the body not being properly 'mapped' might lead to the sensation that a limb is not part of the body because the brain doesn't properly process sensory input from that part.

There seems to be some recent research along these lines, although the explanation is more complex and relates the issue to altered connectivity in larger scale networks.

If I recall correctly, some of Oliver Sach's patients were people who developed this condition after a brain injury. That supports what you're saying.

I'm thinking of a patient who kept falling out of bed, because they kept pushing their own leg out of bed, as they perceived that leg to be an alien, dead thing, that shouldn't be there.

 

[Skeptic Ginger]

I cannot imagine any surgeon willing to amputate a good leg because a person was bothered by it. Sorry for not reading through the thread, I'm sure my comment ignores a number of facts.

This is a psych problem, not a physical problem. And it is in no way equivalent to tattoos, ear piercings or a tummy tuck.

Sorry, carry on.

 

[The Atheist]

By all means cut off your legs and arms as you desire.

But don't expect to receive a single cent of welfare money if you're then unable to work.

I don't see much difference removing a leg or a foreskin - one's just a bit bigger, and at least the person cutting their leg off consents to it. I haven't seen any babies consenting to having their penises cosmetically changed.

 

[TragicMonkey]

Rational, prudent people who can reasonably foresee whether the desired modification will cause *harm* to the person seeking the modification.

The concept of a "reasonable person" interpretation is commonplace and highly effective. It's employed throughout a multitude of legal and regulatory standards.

"Reasonable people" also thought slavery and marital rape were perfectly sensible, and that interracial marriage and public education were not sensible. Blind assumption that most people agree on what is reasonable, and that they are right, is not a secure basis for legal or regulatory standards. It's certainly not a good basis for ethical judgment.

 

[Orphia Nay]

To me, wanting a healthy leg removed is a perfect example of crazy. She IS psychotic on some level.

I think she's more delusional than psychotic.

Having said that, I can't explain why this is different to wanting to change your sex, even though I think it is different.

 

[Skeptic Ginger]

I think she's more delusional than psychotic.

Having said that, I can't explain why this is different to wanting to change your sex, even though I think it is different.

For one a sex change operation doesn't remove a limb. For two transgender is a well known diagnosis with standards of care.

There is no standard of care that removing a limb is a treatment for anything except physical reasons like massive trauma or gangrene, something like that.

 

[Planigale]

If I recall correctly, some of Oliver Sach's patients were people who developed this condition after a brain injury. That supports what you're saying.

I'm thinking of a patient who kept falling out of bed, because they kept pushing their own leg out of bed, as they perceived that leg to be an alien, dead thing, that shouldn't be there.

This is quite a common phenomenon following a non-dominant hemisphere stroke (ie usually one causing weakness of the left side of the body). It is called an attention deficit disorder. The way it is commonly demonstrated is lifting the paralysed left arm across and holding it on the right side (there may be an associated left visual field deficit) and asking whose hand it is, the patient fails to recognise their own hand.

ETA there is no sensory loss in the left arm in general, it is a perceptual problem not a sensory problem.

 

[Darat]

You're assuming this is a question of disease, a failing in the health that ought to be cured. What if it's just a desire? People want different things, and most people would define happiness as being able to fulfill their desires. Who gets to decide what desires are just desires, and what desires are just symptoms of disease? My grandma desired to wear purple velour tracksuits with shiny gold sneakers and carry a tiger-patterned cane: was she suffering from a disease like dementia, a psychological disorder in which she believed she was a stereotypical pimp, or merely afflicted with peculiar taste in fashion? And yes, I know that's much less extreme than wanting to lop off a healthy limb; my point here is that from the outside how can we tell for someone else? Where does their desire to do as they will with themselves become someone else's business to judge and interfere?

Thought I'd been clear about this, I'll try again using your terms. As long as the health assessment comes back OK then he should be allowed to make a decision based on his desires.

If the health assessment doesn't come back OK for instance he has COPD and has little chance of surviving the amputation then his desire alone wouldn't be enough.

 

[The Atheist]

I think she's more delusional than psychotic.

Having said that, I can't explain why this is different to wanting to change your sex, even though I think it is different.

I've been asking that exact question for five years in the Trans thread.

Personally, I'd rather lose a leg than my boy bits, so if anything, genital removal is worse.