How looks can kill

People obsessed with their appearance suffer from a biological disorder, researchers now say. But not so fast: It's still our culture that warps our brains.

By Robert Burton

Read more: Health, Science, Neurology, Brains, Life, Mind Reader

Jan. 31, 2008 | Anybody so inclined can see the psychological demons behind Michael Jackson's facial work-in-progress. In contemporary psychiatric jargon, such morbid obsession with one's looks is called body dysmorphic disorder (BDD), from "dysmorph," the Greek word for misshapen. Though few are as alarming as Jackson, we all know folks who are preoccupied with the shape of their nose, the cleft of their chin or the size of their breasts, and are constantly seeking the latest cosmetic fix, be it surgery, Botox, collagen, fat injections or various implants. Estimates of the incidence of BDD vary widely; there is no yardstick for when body image concerns should be considered excessive and presumably pathological. A good guess is that BDD occurs in about 1 to 2 percent of the general population, but in as much as 7 to 30 percent among those seeking repeated cosmetic surgery.

Such patients are easy to mock; some less than sympathetic journalists have dubbed BDD the "imagined ugliness syndrome." However, to the sufferers, every bodily deviation from perceived perfection is both real and profoundly disturbing. Many become socially isolated, have difficulty holding jobs and suffer from serious depression. In a prospective study, over 50 percent of patients with BDD admitted to thoughts of suicide, with an attempted suicide rate of 2 to 3 percent per year, and an overall suicide rate of greater than 20 percent.

Because BDD is a serious disorder with potentially tragic consequences, a better understanding of its root causes would be a welcome medical advance. But how are we to think about a condition that is associated with widely disparate personality types and seems so driven by cultural pressures? Unlike mental illnesses such as schizophrenia and bipolar disorder, where biology clearly plays a major role, it's hard to see how excessive concern with the shape of one's nose or lips arises from brain mechanisms gone askew.

Now medical researchers believe they have found a biological cause. In December, a team of UCLA psychiatrists conducted an fMRI study of BDD patients. Their results suggest that BDD patients may suffer from faulty visual processing, causing them to have skewed images of themselves and others. While it's an intriguing study and could provide some insights into BDD, it is ultimately inconclusive and underscores the fallacy of basing behavior on fMRI brain scans.

At UCLA's obsessive-compulsive-disorder treatment program, James Feusner and colleagues asked 12 patients with BDD and 13 normal control patients to examine a series of photographs of unfamiliar faces, while undergoing fMRI (functional magnetic resonance imaging) scans. Each face was shown in three versions: an unaltered photo, a blurry image that eliminated detail and a photo that exaggerated facial outlines. Previous fMRI research has suggested that each category -- -- normal, blurry or exaggerated -- is processed by separate neural pathways. When the image was normal or blurry, control subjects used neural pathways involved in analyzing the face as a whole; only when presented with exaggerated facial features did the control patients activate neural pathways known to focus on details. However, the BDD group viewed all three categories via the neural pathways that zero in on details, while not engaging those pathways that evaluate the face as a single unit.

Feusner's interpretation is that BDD patients' "brain hardware is fine, but there's a glitch in the operating software that prevents patients from seeing themselves as others do ... There is an abnormality in how BDD patients' brains interpret what they see." Though not offering an explanation of why "their brains are programmed to extract details -- or fill them in where they don't exist," Feusner says that "BDD has a biological link and can no longer be attributed solely to our society's focus on appearance." He adds that in the future, patients' brains might be retrained to perceive faces more accurately.

The study has been widely reported as being the first demonstration of "a biological reason for BDD patients' distorted body image." Newsweek opined, "Doctors and patients can only hope that such tangible evidence of pathology will help remove the stigma attached to most mental illnesses."

But can an fMRI determine a "glitch in the brain software" or that a mental condition is the reflection of an underlying brain abnormality? Can it make the arbitrary determination of whether a behavioral disorder has a primary psychological or biological basis? To approach these questions, let me briefly present a classic study of brain development that offers a basic insight into the "biology" of "hard-wiring." Though I've chosen a simple rat study, the underlying principle of neural organization applies equally to humans.

Next page: The best medicine for body dysmorphic disorder is a simple lesson