“My Face Is My Fate”: Biological and Psychosocial Approaches to the Treatment of a Woman with Obsessions and Delusions

CASE REPORT

At the time of her initial evaluation, Ms. A was a 21-year-old, single, Asian-American woman presenting with the belief that she was extremely ugly and had acromegaly. She had been begging her parents to allow her to undergo extensive plastic surgery on her face. She was a thin, well-dressed college student who was obviously bright and articulate, with an animated and dramatic style of speaking. While describing her life, she made frequent references to philosophical ideas, ancient literature, celebrities, and popular films. She emphasized that her interest in having cosmetic surgery on her face stemmed from her desire to “manipulate people’s responses” to her and to “reinvent” herself in order to regain the control that she felt she had exerted over others earlier in her life, when she believed she had been more attractive. She denied that she had any kind of mental illness, and said that she was coming to treatment only because her parents had insisted. She reported no perceptual abnormalities or symptoms of depression or mania.

Ms. A was born in China. During her childhood she moved many times, both within China and to and from the United States, because of her father’s career advances. Her parents were members of China’s educated elite, and she was their only child. She was born with a left-sided, congenital hip dysplasia that was repaired when she was two years old; she spent the year following the surgery in a leg cast. Until the age of four, she was raised by her grandmother and other members of her extended family because both of her parents worked and resided in other cities. Ms. A described herself as having been a “charismatic,” “entertaining,” and “extremely cute” child whose family had spoiled her and loved her unconditionally. Nevertheless, she said that when she entered school, she had difficulty getting along with other children because of her social awkwardness and inability “to share.” She reported that at age eight she had been sexually abused for six months by her best friend’s teenaged older brother. Because the boy was a trusted and admired family friend, she did not understand, at the time, that his behavior was unusual. Several years later, she described to her parents what had happened; according to her, they had little reaction to this information.

Ms. A and her parents moved to the United States permanently when she was ten years old. She attended twelve schools altogether (including several in China) and reported experiencing social difficulty and a sense of being an outcast in the majority of them, as she was teased for her poor English, poor social skills, and bad hygiene. During her adolescence and while in treatment, she described yearning for the experience she had had as a very young child, when she had felt that she was adored and surrounded by a “halo of love and affection.”

During her senior year of high school, Ms. A experienced an episode of depression, during which she was consumed by the sense that she was always going to be an outsider and was never going to be able to get married or have children because she was so unattractive and disliked. She became suicidal but was not hospitalized; she took a leave from school for several months and began to see a psychiatrist, who treated her with sertraline and risperidone. She improved and gradually recovered. She repeated her senior year of high school and then left home for a college that was far from where her parents lived, leaving her family for the first time in her life. Upon arrival at college, she immediately discontinued her medications. She described her first semester of college as one of the best times of her life; she felt attractive, popular, and envied by everyone. She began to feel that she did not need to study. Toward the end of the semester, she experienced a gradual change in her state of mind; she started to feel that all of her friends and admirers had begun to hate her. She reported an experience during this period of looking in a mirror and suddenly seeing a mustache on her face. She began to notice changes in her body such as cystic acne, hirsutism, and irregular menses. A boy whom she had been dating broke up with her at the end of the semester, and she did not take her final exams. She failed all of her courses and returned to her parents’ home.

When Ms. A was evaluated medically, she was found to have an elevated testosterone of 155 ng/dL, and polycystic ovarian syndrome (PCOS) was suspected. She was told that she would not be able to have children if she had PCOS, and this news was very upsetting. She was started on spironolactone and oral contraceptives. Over the following weeks, the elevated testosterone level normalized. During this time she had become increasingly despondent about perceived and actual changes in her appearance. The sertraline and risperidone were reinstituted by her psychiatrist. She continued to worsen, however, and after developing suicidal thoughts, she was hospitalized. In the hospital, she was given the diagnoses of body dysmorphic disorder (BDD) and histrionic personality disorder. She made some recovery following the hospitalization and was able to return to school the following fall, attending a local college while living with her parents. During this period, her psychiatrist announced that he was retiring, and she was subsequently referred to her current therapist’s clinic. At the time of her initial evaluation, Ms. A was being treated with sertraline (150 mg every morning) and risperidone (4 mg at bedtime). She had no known allergies and no history of suicide attempts or any history of alcohol or other substance abuse.

Ms. A’s medical history was significant for congenital hip dysplasia, elevated testosterone levels, and episodic neuroleptic-induced hyperprolactinemia. There was no known history of any psychiatric illness in Ms. A’s family, although her father believed that he may have some form of bipolar disorder because of his bursts of creativity, moodiness, bouts of depression, and difficulty controlling his temper.

During the initial period following her hospitalization, Ms. A’s mood improved dramatically. She still spent much of her time, however, focused on her perceived ugliness, believing that the people she encountered on the bus, in class, or in the clinic were frightened and horrified by her appearance, and that they would, as a result, walk away or visibly recoil from her. She believed that her face was too wide, that her upper lip was too protruding, and that her nose was too big. She said that she wanted to look less Chinese or more like the people of northern China—who, according to her, are more Caucasian-looking and also “have all the economic power.” At home she frequently gazed at herself in the mirror, and she was fixated on finding a way to determine whether or not she was ugly. She planned to consult a plastic surgery center in another city and also a Web site called “Are you hot or not?” Her degree of doubt about her ugliness appeared to fluctuate somewhat with her mood. Attempts to increase her level of doubt by examining the evidence for her ugliness generally led only to fleeting periods of insight during individual sessions. She traced her obsession with her appearance to the high importance that her mother and other family members placed on physical beauty, and to the emphasis that her culture placed on human physical characteristics as indicators of particular internal qualities such as intelligence and genetic superiority. During one psychotherapy session she said, “I want to be perfect on the outside because I feel so fragmented and imperfect on the inside. I want the illusion of perfection.” When asked what was imperfect about her, she replied, “I’m not always a nice person; I’m sometimes selfish, egotistical. If I made myself more feminine, it would be a red herring.”

The treatment initially included a combination of medications, cognitive-behavioral therapy, and attention to the frequent shifts in Ms. A’s sense of self-worth, often manifested by her beliefs about the attitudes of others concerning her appearance. During sessions, she often switched rapidly between extremes: positive and negative descriptions of her appearance; descriptions of craving, and then disdaining, relationships and interactions with people; expressing a desire to be a perfect beauty admired by men and then imagining herself as an independent type of woman who would not be concerned about how others view her; and discussions of feelings (often brief) and intellectual analyses (long). Other than her conviction that she was ugly, there was little evidence of overt psychosis. During one session, she described listening to one of her teachers reading a story aloud; the teacher accidentally read “this is your face” instead of “this is your fate.” Ms. A interpreted this verbal slip as meaning that she would be able to change her fate by changing her face.

At the time of this treatment, Ms. A was obviously very dependent on her parents. Her father drove her to every appointment, and she frequently slept in her mother’s bed at night. Her parents took care of her laundry and food as if she were a young child. Ms. A described her father as an outspoken, highly respected man with a quick temper and a tendency to become moody or depressed, and her mother as a self-interested woman who knew how to get people to like her. Ms. A described her sense that she takes after her father, both in temperament and appearance. She also felt that she used to look more like her mother—during a time when Ms. A was, or so she believed, more attractive.

Because of galactorrhea, a mildly elevated prolactin level, and some extrapyramidal symptoms, the risperidone was switched to quetiapine. Although Ms. A had been on a relatively high dose of risperidone at 4 mg/day, she was unable to tolerate quetiapine at doses greater than 25 mg at bedtime due to excessive sedation. The dose of sertraline was gradually increased to 200 mg/day in an attempt to treat her BDD symptoms. Since she continued to be very talkative and energetic, and also had difficulty sleeping without the quetiapine, the diagnosis of bipolar disorder was considered; valproic acid was prescribed. Ms. A at first agreed and then refused to take this medication. She continued to deny that she had any sort of mental illness, and complied with treatment reluctantly. During one session, she said to her therapist, “You’re forcing your opinion on me, trying to coerce me. You’re trying to bring me down with all this psychobabble …. I want to change the situation, not feel better about it.”

Four months into the treatment, Ms. A started dating a 22-year-old man whom she had met at a coffee shop. She had never had a significant romantic relationship before and was very excited. According to Ms. A, her parents objected to this relationship because of the man’s low socioeconomic status and his ethnic background, and Ms. A battled with her parents about being allowed to see the man. Also according to Ms. A, her parents began to listen to her phone calls, delete phone messages, and search her wallet for evidence of contact with her boyfriend. Family therapy was begun. Ms. A’s relationship with her new boyfriend became highly charged, with frequent breakups and reconciliations. The boyfriend frequently told her that she was beautiful, and she was often approached by other men who were interested in her. Very quickly her belief that she was ugly and her interest in having cosmetic surgery seemed to disappear, although it would occasionally resurface briefly during some of the relationship’s breakup periods. She began to dress in sexually provocative clothing, and her speech was increasingly animated and pressured. She described an abundance of loosely connected ideas about ancient notions of ideal love that she associated with her relationship with her boyfriend. The sertraline was decreased to 100 mg/day, but she continued to refuse other medication changes.

Suddenly, over the course of one week, Ms. A rapidly deteriorated. A male cousin staying in her family’s house had made some sexual advances toward her. When she told her mother about these advances, her mother was dismissive of her claims. This attitude reminded Ms. A of her parents’ indifferent response to her report of being sexually abused as a child. She began to feel extremely unsafe in her house, even after the male cousin left town, and during one appointment she refused to leave the office because she did not want to go home. Over the following weekend, she stopped sleeping and began to believe that her parents were not her biological parents, but Communist spies. She also thought that her boyfriend was using her to get his Green Card and was involved in a terrorist plot. Her father eventually took her to a local emergency room, and she was hospitalized.

During her first night in the hospital, Ms. A experienced a vision of her boyfriend coming into her room through the window. The following day, she said that she thought that she, her boyfriend, and her therapist were the same person. She suspected that her boyfriend was actually God.

During the hospitalization, Ms. A was diagnosed with bipolar disorder, and the sertraline was discontinued. She was started on valproic acid and risperidone, and she appeared to improve. After being discharged to a residential program, she began to express the belief that God had called her on the telephone, and she became agitated and sleepless. Ms. A was readmitted to the hospital, where the risperidone was changed to olanzapine. She improved over the following month and was discharged from the hospital. While still in the hospital, however, she had developed facial acne, which raised concern about her endocrine status. She was found, as before, to have an elevated testosterone level (177 ng/dL), as well as a reduced estrogen level. A consulting endocrinologist believed that her clinical picture was not consistent with PCOS since her menstrual cycle and LH and FSH levels were normal; he felt that the excess testosterone was likely adrenal in origin, resulting from elevated stress. She began treatment with estrogen to normalize the testosterone level. Because of some reports of an association between valproic acid treatment and elevated testosterone levels, the valproic acid was switched gradually to lithium. Ms. A appeared less sedated on lithium, although she did experience a mild bilateral hand tremor.

Following her release from the hospital, Ms. A continued to express the concern that other people could read her mind, that people were speaking in code about her, and that possibly the CIA and the FBI were monitoring her. She worried that she had failed some “messianic mission” and was thus responsible for all of the bad things that had happened to her and possibly to the world, including the September 11 terrorist attacks. She made remarks such as “the internal has become external” and “every time I think something, it happens.” She focused on the significance of particular numbers and palindromes. She attributed great significance to any coincidences, particularly any association that reminded her of her boyfriend, with whom she had lost contact while she was in the hospital. Her olanzapine dose was increased to 30 mg at bedtime. Perphenazine was subsequently added and then increased to 12 mg at bedtime. She also developed nighttime panic symptoms, which were effectively treated with low-dose lorazepam. Over time, some of her psychotic symptoms appeared to improve, with some decrease in the paranoia and ideas of reference, and since Ms. A had been complaining about feeling overmedicated and stiff, the perphenazine was discontinued. At this point, however, she began to ruminate excessively, and then to talk almost exclusively, about several phone calls that she had received while in the hospital. She believed that they might have been from God (these calls were probably from a harassing patient who had just been discharged from the same unit), and she worried for hours each day about whether or not she was going to be sent to hell because she may have hung up on God. She debated endlessly about the evidence that supported or refuted this possibility. She repeatedly asked her therapist what she thought: Were these calls from God? Would God send her to hell? Had she done something wrong? Will she ever stop thinking about these phone calls? She searched in her environment for indicators of her fate, performing tests such as “if the bathroom light is on now, I’m going to go to heaven.” She began to experience unpleasant, intrusive sexual fantasies that filled her with a sense of shame. An overwhelming sense of guilt and responsibility seemed to pervade all of her thoughts and behavior. Sertraline was started again, with a slow increase in the dose; at 150 mg/day, Ms. A experienced a dramatic decrease in ruminations. She appeared less depressed and more animated. She continued to improve over time, working at several volunteer jobs and taking courses at a local community college, with plans to return to college full time the following semester.

QUESTIONS TO THE CONSULTANTS

1. What is the relationship between Ms. A’s mood disorder and obsessive-compulsive spectrum disorder? Could a delusional form of an obsessive-compulsive spectrum disorder represent a manifestation of an affective disorder with psychotic features?

2. What is the relationship between the patient’s Axis I pathology and her unstable sense of identity, sense of inner “fragmentation,” mood reactivity, and tumultuous relationships?

3. How have Ms. A’s two cultures and her conceptions of female identity contributed to the expression of her symptoms?

RESPONSES OF THE CONSULTANTS

Dr. Phillips

The case of Ms. A, an attractive young woman who thinks she is extremely ugly, reflects how fascinating, puzzling, and complex body dysmorphic disorder (BDD) is. How could an attractive woman be convinced that she is ugly? And how could such a concern derail her life, leading to suicidal ideation and hospitalization? What is the relationship between her preoccupations with her appearance and her mood disorder? What treatment might be effective? Will cosmetic surgery help? Ms. A has a fairly typical case of BDD (which is classified as a somatoform disorder in DSM-IV) because she is preoccupied with minimal or nonexistent appearance flaws, and this preoccupation causes clinically significant distress or impairment in functioning (in her case, both). This diagnostic label barely captures the richness and complexity of Ms. A’s psychopathology, life trajectory, and inner experience, yet it is essential to make the diagnosis. Diagnosing BDD will enhance both the patient’s and clinician’s understanding of the patient’s presentation and experience, and will provide a necessary road map for treating these distressing and impairing symptoms.

BDD usually begins during adolescence,¹ as it did for Ms. A. In about a quarter of the cases, the disorder begins suddenly and after an apparent stressor. Over the course of their illness, most patients are preoccupied with the appearance of several body parts, often involving the face or head. Concerns with the skin (e.g., facial acne or scarring), hair (e.g., thinning or not “looking right”), and nose (e.g., size or shape) are particularly common, although any body part can be the focus of concern.^1,2

Virtually all individuals with BDD perform repetitive behaviors aimed at diminishing anxiety about the perceived appearance flaws.^1,2 Ms. A excessively checked mirrors and frequently discussed plastic surgery with her therapist. Other common behaviors include excessive grooming, skin picking to remove minor blemishes, and seeking reassurance about one’s appearance from others (including therapists). Some patients barely focus on their treatment sessions because they are so distracted by worries about looking deformed and because they compulsively compare themselves with their therapists (usually thinking that the therapists look far better than they do).

BDD patients often feel isolated and alone because others may consider them simply superficial or vain. BDD is nevertheless an unusually distressing and impairing disorder. More than 80% of patients assessed in a clinical setting have experienced suicidal ideation; 25% have attempted suicide; and 40% have been psychiatrically hospitalized.¹ Mental health–related quality of life is poorer than for patients with depression, other psychiatric disorders, and a variety of nonpsychiatric medical disorders such as diabetes and a recent myocardial infarction.³

It is noteworthy that Ms. A’s endocrine abnormalities were considered stress related. In the only study that has assessed stress in relation to BDD, patients with BDD had notably higher levels of perceived stress than were found in a large national probability sample and in a variety of normal, medical, and psychiatric samples. While Ms. A’s level of perceived stress was undoubtedly influenced by factors other than BDD, this study found that levels of perceived stress were highly correlated with BDD severity (n = 78, r = .51, p < .0001).⁴

Regarding comorbidity, BDD is like any other Axis I condition in that it can co-occur with any disorder. Co-occurrence with major depression is most common, with lifetime rates of approximately 80%; in many cases, the depression appears secondary to BDD.⁵ Co-occurrence with bipolar disorder is far less common; in the largest series of patients with BDD, 9% had a lifetime history of bipolar disorder.⁵ From an anecdotal perspective, many bipolar patients report that while manic, their BDD symptoms tend to recede or even remit, only to recur when their mania clears. It appears that Ms. A also developed obsessive-compulsive disorder (OCD), which is common in patients with BDD. While rates of comorbid OCD have varied in different studies, the largest study to date (n = 293) found that one-third of BDD patients had comorbid lifetime OCD.⁵ This high comorbidity rate raises the question of whether BDD might be related to OCD, although BDD is also often comorbid with major depression, social phobia, and substance use disorders.

Ms. A’s personality style raises interesting questions about the relationship of BDD to normal personality traits and Axis II disorders. Ms. A was diagnosed with histrionic personality disorder, although her quest for a perfect appearance and certain of her other personality characteristics suggest the additional presence of narcissistic features. In fact, one might wonder whether BDD is a feature of histrionic or narcissistic personality disorders. One of the diagnostic criteria for the former is using one’s physical appearance to draw attention to oneself, and the criteria for the latter include having fantasies of, among other things, ideal beauty. Rates of cluster B personality disorders are relatively low, however, in BDD: in the largest study (n = 74), only 4% of BDD patients had histrionic personality disorder; 5% had narcissistic personality disorder; and 8% had borderline personality disorder.⁶ This study and also others⁷ have found that avoidant personality disorder is most common, occurring in more than 40% of patients with BDD. Consistent with these findings, BDD patients tend to score very low on measures of extraversion⁶ and to have high levels of social anxiety. Taken together, these findings concur with clinical impressions that most patients with BDD are not in pursuit of ideal beauty or excessive attention from others. Although some are, most are highly socially anxious and simply want to look normal instead of ugly or deformed.

The contribution of early life experiences to the development of BDD is unknown; research on this disorder is still at an early stage. One study, however, which used the Parental Bonding Instrument—a validated and widely used measure of parental care and overprotection up to age 16—found that BDD patients scored lower than normative means on parental care and somewhat higher than normative means on overprotection.¹ Although Ms. A professed that she was greatly loved as a child, it seems likely that being raised early in life by someone other than her parents, who worked and lived in other cities, actually made her feel abandoned and unloved. Her later perceptions—for example, that she was teased and was an outcast among her peers—indicate that she felt inferior and socially rejected during adolescence. From a clinical, anecdotal perspective, this theme is a very common one in the early life of these patients. Many say that they were rejected by others, inferior to their siblings and peers, and the “runt of the litter” or the “ugly duckling.” Such experiences are congruent with BDD’s clinical features, which involve a profound sense not only of physical ugliness, but of more general defectiveness, low self-esteem, rejection sensitivity, and unlovability. It is difficult to determine, though, which is the cart and which the horse. Are these features, if they really do tend to characterize BDD patients early in life, risk factors for BDD? Or do they result from BDD? Or both? Or is there another, even more complex, relationship between these characteristics and BDD? Because BDD usually has an early onset (the early teenage years) and is so often chronic, it is difficult to disentangle cause from effect. Prospective studies are needed to shed light on this important issue.

A frequently asked question is whether BDD patients have a high rate of childhood abuse. The answer to this question is not known, either. One would wonder if, as in the case of Ms. A, sexual abuse might be a risk factor for later dislike of, or even revulsion toward, one’s body. Clinical impressions suggest that a history of abuse is no more frequent than in patients with other psychiatric disorders, but an abuse history can be missed. The previously noted themes of being unlovable, defective, and less worthy than others appear to be far more common and prominent, although such themes are certainly compatible with a history of abuse.

Another important and unanswered question is how cultural factors might influence the development of BDD. This condition occurs around the world and—although cross-cultural comparison studies of BDD’s clinical characteristics are lacking—appears to have more similarities than differences across cultures in terms of clinical features, functional impairment, and other characteristics.^1,2 Nonetheless, cultural values regarding appearance may provide nuances and accents on a basically invariant, or universal, expression of BDD. For example, case series from Asian cultures often note concern with the eyelids, whereas such a concern is rare in Western cultures. Cross-cultural studies are needed to better understand the influence of culture on BDD’s phenomenology, prevalence, and development.

Turning to treatment, Ms. A received very appropriate pharmacotherapy. Although there are still relatively few treatment studies of BDD, these studies consistently indicate that serotonin reuptake inhibitors (SRIs) are often effective, although most patients achieve a partial response rather than remission.⁸ These data come from a placebo-controlled trial, a controlled crossover trial, several open-label studies, and case series.^8–10 Fluoxetine, fluvoxamine, clomipramine, and citalopram have been best studied, but sertraline and paroxetine also appear effective. It is important to note that many patients with BDD need relatively high SRI doses, which is in keeping with Ms. A’s response to up to 200 mg/day of sertraline. Some patients benefit from an SRI dose that exceeds the maximum recommended dose. In addition, many patients need a longer treatment trial than would typically be used for depression and many other psychiatric disorders. Most treatment studies have reported a mean time to response of 6 to 9 weeks, with a sizable percentage of patients requiring 12 weeks to respond, and occasional patients requiring even longer.⁸ In the only placebo-controlled trial (with fluoxetine) in BDD, half of the patients who responded by week 12 of treatment had not yet responded by week 8, despite a fairly rapid dose titration.¹⁰

Whether antipsychotics are effective for BDD has received very little investigation. This lack of data is surprising because 40–50% of patients with BDD are delusional—that is, they are completely convinced that they are ugly, hideous, or deformed, and they cannot be convinced otherwise.^1,2 In addition, a majority have ideas or delusions of reference (like Ms. A, who believed that people were horrified by her appearance and that they visibly recoiled from her). Historically, delusional patients were considered to have a form of monosymptomatic hypochondriacal psychosis, which metamorphosed into delusional disorder, somatic type, in DSM. In DSM-IV, delusional BDD is diagnosed as a different disorder (delusional disorder) than nondelusional BDD, although these disorders may be double coded (i.e., a delusional patient may receive diagnoses of both delusional disorder and BDD). So, on the one hand, DSM implies that delusional and nondelusional BDD are different disorders, but on the other hand, double coding reflects the possibility—indeed, the likelihood—that BDD’s delusional and nondelusional variants are the same disorder, characterized by a spectrum of insight. Similar diagnostic problems and complexities beset other disorders, such as hypochondriasis and OCD, which are also characterized by a spectrum of insight. The problem is that DSM’s categorical classification system does not easily handle spectrums or dimensions, such as the insight/delusionality dimension.

Although this classificatory issue might seem an unimportant and arcane matter of interest only to remote DSM committees, it has important clinical implications. Should we treat delusional patients any differently than nondelusional patients? Thus far, a surprising and consistent finding is that delusional and nondelusional BDD patients respond equally well to SRIs.^8–10 And while nearly all data on antipsychotics are retrospective (and therefore should be considered preliminary), antipsychotics alone appear ineffective for BDD, either its delusional or its nondelusional form.⁸ An equally important question is whether antipsychotics are effective SRI augmentation agents. The only published data are from a chart-review study, which found that they were effective in only a small percentage of cases.¹¹ In another study (Phillips KA, unpublished data), pimozide was not more effective than placebo in augmenting fluoxetine. But these results are, at best, only very preliminary, and the important question of whether atypical antipsychotics are effective SRI augmenters deserves further study, in large part because antipsychotics are often effective in combination with SRIs in near-neighbor disorders, such as OCD and psychotic depression. Until more data are available, it is reasonable (but should not be considered necessary) to add an antipsychotic to an SRI, especially for delusional patients. In the case of Ms. A, an antipsychotic was clearly necessary for her non-BDD psychotic symptoms.

Because Ms. A also had bipolar disorder, the addition of a mood stabilizer was warranted. Although one might have concerns about prescribing an SRI for a bipolar patient, in my clinical experience it has been necessary to add an SRI after starting a mood stabilizer; without the SRI the BDD symptoms tend to be persistent and problematic.

Cognitive-behavioral therapy (CBT) is the other form of treatment that appears effective for BDD.^12,13 This treatment usually comprises a combination of exposure (e.g., to feared and avoided social situations), behavioral experiments, response prevention (stopping compulsive behaviors such as mirror checking), and cognitive restructuring. Cognitive restructuring focuses on unrealistic thoughts about appearance and may also address underlying core beliefs, such as feelings of unworthiness or being alone. CBT has been shown to be efficacious in case series and in studies using wait-list controls;^12,13 more rigorous studies using attentional controls are needed. It is unclear whether CBT is as effective for delusional as for nondelusional patients; at the very least, delusional patients are more challenging to treat. The efficacy of CBT has not been compared to that of medications, and it is not known whether their combination is more effective than either treatment alone. Because some patients are too severely depressed or suicidal to participate in CBT, partial improvement with an SRI may be required before beginning CBT.

The effectiveness of other types of psychotherapy for BDD has received virtually no empirical investigation.¹ In case series, such therapies were found to be generally ineffective, but more rigorous studies are needed to answer this important question.¹ While BDD is often ripe with underlying themes that would seem to lend themselves to psychodynamic psychotherapy, clinical impressions suggest that such treatment may increase patients’ understanding of themselves and their symptoms, but do not seem to diminish the disorder’s core features, such as the obsessions, repetitive behaviors, or referential thinking. Nonetheless, some patients benefit from and even need non-CBT psychotherapy (e.g., psychodynamic, supportive, or family therapy) in addition to medication or CBT. Non-CBT therapy may aim to improve functioning, resolve interpersonal difficulties, increase insight, address problematic personality traits, or offer additional support in coping with the illness.

Ms. A’s strong desire for cosmetic surgery is not unusual. From nearly one-quarter to one-half of BDD patients seen in psychiatric settings have had surgery;^7,14 conversely, studies from surgical settings indicate that 6 to 15% of patients seeking cosmetic surgery have BDD.¹ Some high-profile lawsuits involving BDD have recently brought this disorder to the attention of our surgical colleagues. Available data indicate that most BDD patients respond poorly to surgical, dermatologic, and other nonpsychiatric treatments (e.g., electrolysis). In the largest, most systematic study of this issue (n = 289), only 7% of such treatments led both to a decrease in concern with the treated body part and to an overall improvement in BDD.¹⁴ These findings may be somewhat biased toward a poor outcome since they involved patients who subsequently sought psychiatric care. Nonetheless, it seems wise to counsel patients to avoid such treatment, especially more drastic surgical interventions, because some patients remain dissatisfied even with objectively acceptable surgical results. In occasional cases, the patient may attempt either to commit suicide or, possibly, to physically harm the surgeon.² It is worth underscoring that it can be difficult to engage BDD patients in psychiatric treatment. Because many are delusional, and many, like Ms. A, do not believe they that have a psychiatric illness, they may resist such treatment. Educating them about BDD and focusing on the treatment’s potential to diminish their preoccupation and distress—and also to improve their functioning and quality of life—may facilitate engagement in treatment.

The relationship between Ms. A’s mood disorder and OCD spectrum disorders is largely a matter of theorizing and speculation. It has been proposed that the putative OCD spectrum disorders (disorders hypothesized to be related to OCD) can be conceptualized, in turn, as belonging to an even larger family of affective spectrum disorders¹⁵—a concept first proposed by Hudson and Pope.¹⁶ It has further been suggested that putative OCD spectrum disorders characterized by high degrees of harm avoidance, risk aversion, resistance, anticipatory anxiety, and lack of gratification may be more closely related to depression, whereas disorders of impulse control (which have been proposed by some also to belong to the OCD spectrum) may be more closely related to bipolar disorder.¹⁷ While available data (e.g., treatment response, familial transmission, course of illness) can provide some clues about these disorders’ relationships to one another, the nature of those relationships will remain murky until their etiology and pathophysiology are better understood.

The differential diagnosis of these disorders can be challenging. For example, I treated a patient with a history of classic BDD responsive to fluvoxamine who later presented with severe agitated depression and a paralyzing conviction that he had AIDS, which he obsessed about for most of the day. Did this patient have psychotic depression with somatic delusions, delusional OCD with secondary depression, or delusional hypochondriasis plus depression? The patient recovered fully with fluvoxamine and clonazepam (without an antipsychotic). While treatment response is only one clue to what is actually ailing our patients, this outcome (along with the presence of checking behaviors) suggests that delusional OCD may have been the most accurate diagnosis.

From a practical clinical perspective, it is important that BDD not be considered simply a symptom of depression or psychotic depression. Such a view can lead down the wrong treatment path. BDD appears to respond to SRIs but not to other antidepressants or ECT (although data are limited), and it seems often to require a longer treatment trial and higher SRI doses than those typically needed for depression.⁸ Furthermore, BDD seems to require different CBT techniques, including exposure and response prevention, than depression alone.^12,13

Finally, it is a tribute to Ms. A’s clinicians that BDD was recognized, diagnosed, and targeted in treatment. These patients are often too embarrassed and ashamed to raise their symptoms with their clinicians,² and studies have found that this relatively common disorder nearly always goes unrecognized in clinical practice.^1,18 Despite their secrecy, patients consider their BDD symptoms to be important and disturbing.¹⁸ And while not all patients welcome the diagnosis, many do: learning that they have a treatable illness can diminish feelings of isolation and offer hope that their suffering may be alleviated.

Dr. Shapiro

There are three different discussions in this conference: one (of Dr. Phillips) from the perspective of the patient as representative of a large group of patients with similar symptoms; a second (of Dr. Becker) about the patient as representative of a larger group of people with similar cultures, beliefs, and values; and my own, from the perspective of this particular patient from this particular family. In some ways, it is a confusion of tongues. The learning dilemma is to integrate these different perspectives, while retaining the ability to listen to this particular patient as unique.

Whatever the neurological or biological components of this complex presentation, a major problem facing this patient is that she is disordered within herself. She feels that she looks ugly and that her life is out of control. She wants plastic surgery so as to be able to manipulate others’ reactions to her and regain the control that she felt she had at other times of her life. A psychosocial approach to this young woman would attempt to understand her experience from the inside: in what respect are her perceptions valid, and how do her symptoms make sense?

Though this patient had experienced stress and some early disorganization in childhood, her acute psychiatric illness developed in the senior year of high school, a time when young people regularly feel enormous separation stress. Adolescence has been called a “second separation-individuation period,” parallel to the first one occurring around age two. As Ms. A approached graduation and contemplated leaving home, she became psychotically depressed, feeling like an outsider, unattractive, and suicidal. On medication, she transiently improved and, after successfully repeating her senior year, left home for a distant college—where, somewhat manically, she felt popular and envied by others. Her manic defense could not sustain her, however. Her psychosis reemerged, and she failed all of her classes. Unable to manage a competent separation from her family, she developed a repetitive-symptom picture involving her looks. The psychosocial question is what happened to her in her family development that left her unprepared to leave home. How did her psychological structure turn out to be so weak, and why does her symptomatology take this particular form? Her formulaic statement is, “I am unappealing.” Apparently, her characteristic response to stress evokes excess adrenal testosterone, resulting in manifest bodily changes, a reality that supports her increasingly delusional thinking. But this symptom picture has its roots in the family relationships from her childhood.

In order to help this young woman, a psychodynamic approach would attempt to place this distressing psychic disorganization and somatic preoccupation in the perspective of her life’s experience, helping her to recognize and bear the feelings that she could not master at earlier developmental periods, and freeing her to take responsibility for her adult choices. But where do we look for the building blocks for such an exploration and reconstruction? Knowing about the individual’s psychological development provides the basis for understanding the symbolic origins of her symptoms. What we are looking for (and, in therapy, listening for) are the “salient facts”—the issues that she presents or that emerge as containers of unbearable feelings in her talking about her life. For the purposes of this discussion, we have to limit ourselves to the written case report, which is inevitably less personal and comprehensive than the study of the patient’s narrative in the context of a deepening therapeutic relationship. The following parts of her history are the ones that stand out to me.

Ms. A was born with a congenital hip dysplasia, repaired when she was two years old. From ages two to three—the crucial developmental period for toilet training and ambulation, when the infant first attempts to master separation-individuation and to experiment with autonomous functioning—this infant was abandoned by her parents, even while she was in a leg cast. It is during this period of life that a child—as she takes over care of her own bodily functions and, more generally, experiments with moving away from the intimate attachment with caretakers—learns to say “No!” to grownups and develops the capacity for aggressive expression. Ms. A was severely limited in all of these endeavors. Inevitably, the leg cast must have frustrated her efforts to walk away, manage her own wastes, and engage her aggression. At the same time, and continuing until she was four years old, Ms. A’s parents walked away from her—abandoning her to the care of her extended family, who found her cute and entertaining. Not only was her body constrained, but she did not have the sustaining love of her parents to sustain her efforts at individuation. Developmental failures at this vulnerable period provide the backdrop for subsequent boundary disturbances. To be seen as entertaining at this age—engaging the family as audience—suggests either that they did not see her inevitable struggles or that she may have had to suppress her aggression, grief, and frustration about the loss of her parents and about the inevitable limitations of her leg cast.

The case history focuses our attention on the bodily care provided by her caretakers. It is striking that despite being described as “entertaining” as an infant, she was found to be poorly socialized and unable to share, when she began her schooling. It seems likely that her caretakers, rather than responding to her difficulties or engaging her aggression with play or limits, used her as a narcissistic object for their own pleasure, leaving her excessively focused on her external appearance and unprepared for the give-and-take of genuine social interaction. Her caretakers did not help her to form a boundary around herself that would enable her to recognize and tolerate the needs of others.

At age eight, her friend’s brother sexually abused her for six months in her own home. The duration of the abuse, the early age of involvement, and the parents’ apparently indifferent response all contribute to a picture of the family’s neglect of her body and her bodily communications. There was no protection from sexual overstimulation. This child was not seen according to her needs.

In order to have a distorted picture of oneself, one must be presented with a particular kind of a mirror. Children identify with the views others have of them.¹⁹ If those views are distorted, the child’s view of herself will accommodate to the distortions. There is evidence that this child was seen in a way that was distorted by the needs of those around her. For example, her extended family seems to have focused on their perceptions of Ms. A as cute. But, abandoned by her parents, Ms. A may have needed to be seen, instead—and more accurately—as a depressed, rageful, and desperate infant. The views of others were coercive; witness her statement, in transference, to her therapist that “You’re forcing your opinion on me, trying to coerce me.”

Ms. A attended twelve schools, more than one school and group of classmates for every year of schooling. A primary developmental task for school-age children is the development of peer relationships. These rapid school shifts did not help her with this task; they were responses to her parents’ needs, not hers. There appears to be no element of parental response or of Ms. A’s external world that adapted to her needs and development. Feeling like an outcast, she could not take care of or appreciate her own body. The report indicates that as a school child, she had “poor hygiene”—a striking symptom for a child who, in her own view, was surrounded by love.

This report presents the picture of an abandoned child with narcissistic parents.²⁰ Ms. A’s father is described as self-preoccupied, with bouts of depression, moodiness, and temper. Mother focuses on external beauty and is seen by her daughter as self-interested. It is not clear whether anyone was interested in Ms. A.

Strikingly, even at age 21, the parents have set few limits for this young woman. Mother sleeps in her bed, and both parents manage her laundry and food, intruding into her social life. They are taking care of their own worries—not their daughter. The breaking point for Ms. A occurs when a family member in her family’s home makes a sexual advance that her parents dismiss. Ms. A begins to feel a sense of being unimportant to her parents and develops a paranoid idea that her parents are not her biological parents, but Communist spies. This psychotic thought seems to me to be based on her reaction to her parents’ listening to her phone calls, deleting her messages, and searching her wallet. Her parents cannot tolerate her romantic involvement with someone who seems outside the family, so they intrude in order to control her and keep her for themselves. Her unfolding psychosis then includes a psychotic defense of grandiosity, which substitutes for an unbearable sense of personal insignificance in the face of this relentless abandonment and efforts at narcissistic control.

The developmental perspective is a central framework for listening to patients’ concerns. I would understand Ms. A’s symptoms as efforts to communicate about her internal life. “I am ugly” can mean “I have found no way to present myself so that people will love me—it must be because I am unappealing.” This young woman has things to say that people around her cannot tolerate.

Ms. A’s effort to take all responsibility into herself for what has happened to her is characteristic of children. They will preserve the illusion of having good parents at all costs, even if it involves bending their minds. “I am ugly” is so much safer to feel than “They are indifferent,” “They are using me for their own needs,” or “They hate me.” I wonder what story this infant unconsciously told herself in order to explain her parents’ abandonment. Was it that “They left me because I am ugly”? There is, indeed, some evidence in support of this suggestion. For example, when men became interested in her and told her that she was beautiful, her belief that she was ugly would disappear. It resurfaced only when they left her—and as an explanation of why they had done so.

The psychosocial approach to such a disturbed person focuses on the individual’s internal life and development, attempting to uncover the relationship between developmental needs and familial responses that contributed to the creation of psychopathology. The goal is not to blame the parents for the child’s illness, but to take seriously the child’s experience of the parents’ limitations and of their failures to meet developmental needs. This approach can thereby enable the patient to recognize and bear her infantile reactions, and to place them in the context of her more mature adult capacities. If Ms. A recognized that during her childhood she could not bear how lonesome she was, and that her capacity to create an external persona to engage and respond to those around her was limited by their own needs, she might be able to make different adult choices about engaging important people in her life.

Dr. Becker

This interesting case presents an opportunity to understand the pivotal role that social forces and cultural contexts play in generating, channeling, and shaping mental illness. Ideals of body aesthetics, the emphasis placed on such aesthetics, and notions about appropriate gender roles are all deeply culturally embedded. This patient’s concerns about her appearance, as well as her expressed conflict about social roles, consequently reflect both her psychopathology and the play of sociocultural forces.

There are several ways in which sociocultural context is generally thought to influence mental illness. Perhaps the most superficial and least useful of these is that there is a universal core of psychopathology, with an “overlay” of cultural dressing. On this view, cultural influences are, in effect, epiphenomenal; for example, psychotic illness is essentially the same across a variety of cultural contexts even though the specific content of the delusions or hallucinations is culturally shaped. There are far more helpful characterizations, however, of the impact of sociocultural factors on mental illness—in particular, those in which such factors form the very substrate of an illness (e.g., distress located in the social world is experienced as a bodily symptom), shape a “social course” of illness, or pattern how symptoms are attended to and expressed.²¹ I would like to suggest, moreover, that in the case presented, there are two especially useful ways to understand the impact of cultural forces: first, in the manner that this individual has found to express her distress (i.e., the particular somatic idiom of distress); and second, in the manner that specific developmental and familial conflicts, as well as concomitant distress, have been generated in the patient’s transitioning between two cultural contexts.

Cultural context as affecting developmental processes

First, it is helpful to note the culturally relevant features of the case that almost certainly have had important bearing on the patient’s development. Ms. A is a Chinese emigrant; she lived in China until she was ten. Her parents were part of the “educated elite” in China, which presumably also entailed a certain degree of economic privilege. Ms. A was an only child and describes herself as being spoiled by her caretakers—her grandmother and extended family. Of course, China’s one-child policy has made the single-child family the sociopolitical ideal and cultural norm since the mid-1970s, and it provides the context within which to understand Ms. A’s having been “very spoiled by her family.” Given that all parental and grandparental attention may be directed toward one child, an emerging phenomenon in China is that children are sometimes described as “little emperors.” It is tempting to speculate, however, that such highly focused attention at a young age—even if positive—may in some cases evolve into considerable pressure to fulfill the expectations of both parents and grandparents. Some studies conducted in China have suggested, indeed, that being an only child there does have developmental impact on children.²² For example, one study demonstrated that when compared to children with siblings, preschool girls in the Nanjing area who were only children had significantly different behavioral profiles, including higher scores on measures of depression, moodiness, and temper.²³

Because male children are still strongly preferred in China, it would be helpful to know whether and how this preference may also have had an impact on Ms. A’s development. Although there are no published data concerning the preference’s possible contribution to psychological development or psychopathology, several studies have demonstrated that female infants and children have higher mortality rates than male children, possibly stemming from discriminatory practices toward female children.²⁴ In the case of Ms. A, it would also be helpful to understand what parental pressures she may have perceived concerning achievement in both traditionally and nontraditionally female occupational and social spheres, and whether, as some of the case material suggests, she experienced conflict between Chinese versus American expectations or between those of her mother versus those of her father.

Ms. A’s childhood was characterized by frequent disruption of both peer and parental relationships. When she relocated to the United States at age ten, she recalls an enormous amount of difficulty socializing with her peers. On the one hand, this difficulty may suggest some premorbid impairment in social functioning. On the other hand, to the extent to that there was impairment, it was likely exacerbated by the distress and difficulty that is commonly seen among children who have immigrated. Indeed, Ms. A specifically attributes her social difficulties to deficits in language and social skills. Immigrant children typically find themselves engaged in the task of renegotiating their identities in their host cultures. Although parents are expected to guide their children through key developmental stages in most cultures, immigration undermines this process.²⁵ As Suarez-Orozco and Suarez-Orozco have argued, “When there is too much role confusion, when cultural guides are inadequate, and when there is cultural dissonance and strife, an adolescent will find it difficult to develop a flexible and adaptive sense of identity.”²⁵ Moreover, immigrant children are at risk of receiving social feedback that is “predominantly negative and hostile,” thus adversely shaping the child’s sense of self.²⁵ Indeed, the patient herself states that she needs to “reinvent” herself in order to reassert “control over her life.” Although she conceives the reshaping of her identity concretely—as through cosmetic surgery—this reshaping appears to be her attempt to fit into a foreign environment.

Finally, Ms. A’s report that her parents dismissed her concerns about sexual abuse and her cousin’s sexual advances also needs to be contextualized within Chinese cultural concerns with both social harmony and stigma. In many cultures—including, I believe, that of China—social harmony and family honor are protected at the expense of individual needs and feelings. For instance, it has been well documented that because of the stigmatization of mental illness in China, the somatic presentation of distress as neurasthenia is preferable there to the use of the psychological idiom of depression.²⁶ It would therefore be helpful to learn whether or not the response of Ms. A’s parents reflects a prevailing social concern with stigma and maintenance of familial harmony. Such a concern might be especially relevant to sexual abuse since it is heavily stigmatized in Chinese culture and can render a woman “unmarriageable” (Email, Lee D to Becker AE, 21 October 2002). In any case, her parents’ response appears to have reinforced Ms. A’s sense of emotional distance from them—which may have been heightened by her awareness of American cultural norms that at least nominally favor protection of a child over family concerns about privacy and honor. There is also a striking parallel here between inner turmoil and the wish to maintain a neutral facade. The patient appears convinced not only that her deep sense of internal fragmentation is obvious in her appearance, but also that it can be concealed by manipulating her appearance.

The “epidemiologic paradox”²⁷ often associated with migration may be applicable here. That is, it has been noted that children of immigrants frequently have poorer health status than their parents’ generation even when the children have improved access to biomedical health care, good nutrition, sanitary living conditions, and so on. The explanation appears to be that cultural practices that protect against illness in the cultural setting of origin are not available or not utilized in the new environment, thereby increasing health risk. Given that there are strong data to support that a major mental illness, such as schizophrenia, appears to follow a more benign social course in some other societies, presumably due to the social environment,²⁸ it is conceivable that this “epidemiologic paradox” might underlie the severity and course of the psychological symptoms exhibited in this case. For example, strong community and familial supports might protect an individual with major mental illness from social isolation and might provide daily structure and purpose that allow more effective social interactions. Unfortunately, Ms. A no longer lives within an extended family that might have the means of buffering her social isolation, but it is nevertheless possible that, through family therapy, the family might learn to engage in productive and positive ways of supporting her.

Culture, stigma, and embodied distress

It is not unusual for individuals to experience and express distress in a somatic idiom, especially if the immediate cultural context either (1) stigmatizes a more psychological idiom,²⁶ (2) does not legitimate a “rhetoric of complaint”²⁹ expressed in a more direct, verbal way, or (3) socializes individuals to channel distress in a particular “idiom of distress.”^30,31 We can reasonably infer that for both cultural and familial reasons, Ms. A may feel uncomfortable or unable to express her considerable inner sense of turmoil, fragmentation, and conflict directly. Major mental illness is heavily stigmatized in most social contexts and is particularly so in Chinese culture. Ms. A’s preoccupation with her physical appearance and its imagined ugliness concretizes her deep sense of being a social misfit. It may also reflect a fervent wish and magical thinking that “fixing” her face would address all that is wrong in her life. As Ms. A said: “I want to be perfect on the outside because I feel so fragmented and imperfect on the inside.” Later, when she became psychotic, she noted that “the internal has become external.” These thoughts parallel our understanding of the excessive concern with body shape and weight that characterize anorexia and bulimia nervosa. Individuals with a poor sense of self-worth often attempt to anchor their self-appraisal in concrete and external sources of validation.

Embodiment of social transition and conflict

Social transitioning presents difficulties for individuals in multiple, complex ways. When a developmental transition poses social conflicts that overwhelm the individual, it is possible for this conflict to be embodied—that is, articulated in a somatic idiom. It has been hypothesized, for example, that the weight loss associated with anorexia nervosa represents a “flight from puberty” and its associated social conflicts for young women.³² Cross-cultural epidemiologic data suggest that young women in immigrant or socially transitioning populations are often at higher risk for disordered eating than the population of origin and sometimes even the host population.³³ Historical epidemiologic data suggest increasing prevalence of eating disorders over the past several decades—a phenomenon that has been hypothesized as related to shifting gender roles and the conflict that young women experience between maintaining traditional gender roles and moving beyond them.³³

In much the same way as with eating disorders, this patient’s extreme preoccupation with her imagined ugliness can be seen to embody the conflict she experiences between fulfilling traditional Chinese expectations for a daughter (and possibly even for a son) versus being successful in terms of American values. The content of her bodily concerns and distortions are tied to this conflict in striking ways throughout the case presentation. Her ambivalence is expressed both in comments about wishing to look less Asian and more American, and in concerns about her femininity and fertility, as reflected in the case excerpts below, in which Ms. A

• “was consumed by the sense that she was always going to be an outsider and was never going to be able to get married or have children, because she was so unattractive and disliked”

• reported “looking in a mirror and suddenly seeing a mustache on her face”

• “had been told that she would not be able to have children if she had PCOS, and this news was very upsetting”

• noted that if she “made myself more feminine, it would be a red herring”

• felt that “she takes after her father, both in temperament and appearance[, and] that she used to look more like her mother—during a time when Ms. A was, or so she believed, more attractive than at present”

• expressed a desire to “look less Chinese” and “believed that her face was too wide, that her upper lip was too protruding, and that her nose was too big”

Body, self, and society: Core values, aesthetic ideals, and embodied experience

Finally, it is helpful to understand this case in light of the cultural context of embodied experience. Ms. A’s concerns about her appearance have much in common with the excessive concerns about body shape seen in eating disorders. Because eating disorders are believed to be more prevalent in Westernized, postindustrialized societies, the nature of the pathology appears to require a certain relationship between the individual and her body that is shaped by the local cultural context.

Core cultural values are often represented in body shape and in embodied experience. Youth, health, and wealth are arguably core values in American society. These are represented in a slim body, which has become the aesthetic ideal. Other core values are autonomy and industriousness; these are also represented in a slim body insofar as the individual is credited with the effort that comes from maintaining a slim and toned body. By contrast, traditional core values in Fiji include strength and social connectedness—both represented in a relatively robust body. Aesthetic ideals are thus locally defined and usually tied to core cultural values. Embodied experience also encompasses the relationship one has with an aesthetic ideal. In the United States, for example, independence and autonomy are valued, as is diligence. And these values also apply to the body. That is, Americans see themselves as responsible for their bodies—which can and should be reshaped through hard work and diligence.³⁴

This relationship of self to body is far from universal, however, and is, indeed, somewhat peculiar. Individuals in other cultures do not necessarily believe that they can manipulate their appearance; nor would they endeavor to do so. In cultures in which consensus, rather than autonomy and creativity, is valued, individuals are not motivated in the same way to distinguish themselves or to seek approval through their physical appeal. Their bodies might reflect their social positioning rather than their individual qualities. In such societies, psychopathology that focuses on excessive concern with the body might consequently be less prevalent. That is, indeed, the case with eating disorders, and it may also be the case with BDD. Although I am not aware of BDD’s cross-cultural distribution, my understanding is that the disorder is rare in China. In addition to the complete absence of prevalence data in the Western medical literature, there is only one published case report of muscle dysmorphia (a proposed variant of BDD) in a Chinese man.³⁵ Moreover, since BDD may be rare among Chinese, and since meanings attached to the body and its aesthetics, defects, and associated stigma are deeply culturally embedded, a full exploration of the ethnopsychological meanings of the imagined defects would be essential to understanding how the symptoms of BDD would evolve and what they would signify relative to their cultural context. It is helpful to note that Lee’s seminal work on eating disorders in China has demonstrated that anorexia nervosa has different phenomenologic manifestations in China than in the West.³⁶

In Ms. A’s case, some of her preoccupation with changing her bodily appearance seems to be specifically tied to her recognition of how physical features are imbued with different significance in the United States than in China. Whereas she herself describes her culture of origin as emphasizing “the importance of human physical characteristics as indicators of particular internal qualities such as intelligence and genetic superiority”—an emphasis that would appear to hold physical characteristics as fixed and given—she is well aware that her host culture supports the “manipulation” of personal image through improvement of appearance. She recognized, for example, “the high importance that her mother and other family members placed on physical beauty,” and she saw cosmetic surgery on her face as a way to “manipulate people’s responses” to her and to “reinvent” herself, and thereby to “regain the control that she felt she had exerted over others earlier in her life, when she believed she had been more attractive.”

Summary

It appears that Ms. A may be struggling to negotiate Asian and American cultural identities, as well as to resolve the conflict she experiences between traditionally masculine and feminine identities. This combination of conflicts, especially in the setting of a fragmented and fragile sense of inner identity, most likely led her to become dependent upon external sources of validation. We see, for example, that she experienced “frequent shifts in her sense of self-worth, often manifested by her beliefs about the attitudes of others concerning her appearance,” and that “her belief that she was ugly and her interest in having cosmetic surgery seemed to disappear” when her boyfriend repeatedly told her that she was “beautiful.” These conflicts also appear to have led to her persistent attempts to mask her inner turmoil through changes in her outer appearance. The specific conflicts between Asian and American and between male and female appear to be embodied in her perceived ugliness.

In summary, this case provides an illustration of psychopathology deeply embedded in its cultural context. The case also serves as a general reminder that treatment that is culturally decontextualized is, at best, insensitive and, at worst, ineffective or harmful. Her treatment must be informed by a culture-specific understanding of identity, intergenerational conflicts, and social and familial stressors and supports—factors that have undoubtedly contributed to her illness and its expression, and that may ultimately determine the success of her treatment. Finally, the therapist must continue to probe the personal and ethnopsychological meanings of the symptoms relative to the patient’s cultural context.