Childhood Abuse, Body Shame, and Addictive Plastic Surgery

Front matter

CHILDHOOD ABUSE, BODY SHAME, AND ADDIE TIVE PLASTIC SURGERY

“I am extremely excited about the opportunities that Dr. Constantian’s innovative, courageous pursuit offers. I have told my colleagues about how we found each other, and how his open-minded response to my books led to his own; I experienced a similar epiphany with Peter Levine’s writings. This is a golden chance to enlighten the lay and medical communities and pave the way for a dramatic break-through in the role of trauma in body dysmorphic disorder.”

—Robert Scaer, MD, author of The Body Bears the Burden, The Trauma Spectrum, and 8 Keys to Brain-Body Balance

Foreword

David L. Corwin, MD Preface Acknowledgments

THE FIRST PIECE The Tip of the Thread

1 Where the Thread Began: What Surgeons Learn From Patients and Their Families

2 What the Mental Health Literature Says About Body Dysmorphic Disorder

THE SECOND PIECE The Roots: Developmental Trauma and Its Effects

3 The Valley of the Shadow: Core Issues and Parenting xt x Contents

THE THIRD PIECE The Fruits: How We Suffer and Medicate

5 The Ways We Suffer: Body Shame and the Astounding Spectrum of Its Ravages

6 The Ways We Medicate: Addictions and Behaviors Most Relevant to Body Image

THE FOURTH PIECE How Nature Copes

8 Behavior, PTSD, and Surgical Compulsion in Plastic Surgery Patients: Trailing the Trauma Prevalence

THE FIFTH PIECE Toward the End of the Thread: Trauma, Body Image, Plastic Surgery, and Resilience

9 Adverse Childhood Events in Medical and Plastic Surgery

Patients and Their Effects on Adult Health, Personality, and Surgical Happiness

10 Resilience: The Antidote and the Inspiration

Afterword Index

311 314

FOREWORD

Mark B. Constantian, MD, has devoted much of his career over the past 40 years caring for patients who are referred to him because of his reputation and skill performing revision rhinoplasties. As an academically oriented plastic surgeon, this area of specialization within the field of plastic surgery has given him a unique opportunity to better inform our understanding of Body Dysmorphic Disorder BDD). BDD is a frustrating and perplexing condition where individuals with often relatively minor or even no discernable facial abnormalities seek out seemingly endless plastic surgical procedures like repeated rhinoplasties and are often disappointed with the results. The disappointment in BDD patients is usually contrary to their surgeon’s and other observers’ impression that the plastic surgery accomplished what the patients said they wanted to achieve. Dr. Constantian’s description of these patients’ obsessive, often negative, and accusatory post-surgical communications, begging for revisions and other additional plastic surgery, sometimes even threatening legal and more rarely physical violence toward their surgeons leads me to believe that this book should become required reading for all practicing and plastic surgeons in training. He acknowledges that BDD patients’ suffering is real but that he has come to believe that it has more to do with their childhood adversity than actual physical deformity. Treating these perceived facial deformities with plastic surgery may too often be treating the patients’ symptoms of distress and often results in negative consequences and feelings in these patients and accusatory accusations against the surgeons. Dr. Constantian and others who have done research on BDD suggest that the actual cause of BDD is likely associated with childhood abuse, neglect, and other severe childhood adversity.

Dr. Constantian references the paradigm changing Adverse Childhood Experiences Study (ACE Study) by Drs. Vincent J. Felitti and Robert Anda, who first published their findings, with their collaborators, in 1998. He also presents the xii Foreword findings from his clinical case series that used the same questions as the original ACE Study and yielded similar findings.

I worked with both Felitti and Anda to produce two DVDs, the second of which includes videos of their lectures and individual interviews with each of them designed to help educate professionals and the public about their study and findings. In reading some of the chapters from The Face of Trauma, Dr. Constantian’s description of the insatiable nature of BDD patients reminded me of Dr. Felitti’s statement, shared with me and others attending his presentations, that it is “hard to get enough of something that almost works.” That the observations and insights in this book come from a plastic surgeon and not a mental health researcher or professional makes total sense. Few mental health professionals see enough of these patients to discern the patterns in their presentation, histories, and discouraging outcomes. Plastic surgeons are the front line caring for BDD patients. Dr. Constantian’s lack of preconceptions, rooted in the ideological schools and conventional wisdom of psychiatry and psychology, helped him think and observe “outside the box.” He recognized the relationship between childhood abuse and neglect and addictive plastic surgery. Drs. Felitti and Anda are both internists, not psychiatrists. That fact may have also freed them to make the paradigm shifting observations and discoveries of the ACE Study. Major shifts in science and other areas, in some case even disruptive innovations, often come from outside the close circle of individuals viewed as authoritative in those particular fields or topics.”

Hopefully, this book is the beginning of a journey that will lead to better recognition and more effective care for BDD patients. Dr. Constantian describes his great frustration and the bewilderment that he shares with other plastic surgeons treating these unhappy and often disruptive patients. Fortunately, he has not just described how to identify and to avoid these challenging patients. Rather, he seeks to understand the roots of their misery. This is a book of hope and belief in the resilience of human beings to overcome their travail and suffering. It is also a book very much rooted in the tradition of medicine that effective treatment begins with accurate diagnosis and understanding of the pathogenesis of disease. Treating symptoms rather than their root causes is still too common, particularly in the most complex areas of psychiatry and psychology where the pathways, complexity of the brain, and the multiple systems interacting makes the determination of proven pathogenesis much more difficult than infectious disease, metabolic illness, or orthopedic injuries.

This book serves as a bridge between the worlds of plastic surgery and the inter-disciplinary fields focusing on childhood and later life trauma. If read and understood, it may help BDD patients by assisting the plastic surgeons who treat them to better understand the source of these patients’ unhappiness and how to better care for them. With time and development of more effective ways of caring for these patients, this knowledge can also diminish the suffering of plastic surgeons who treat BDD patients. As Dr. Constantian reaffirms, effective treatment begins with accurate diagnosis and understanding. At the conclusion of his book,

Foreword xiii

Dr. Constantian suggests this may begin with asking these patients what happened to them during their childhoods. Dr. Felitti once commented that it took him many years to realize that listening closely to his patients talk about their lives is a most powerful form of doing!

Understanding the associations and connections between adverse childhood experiences and the many later diseases and dysfunctions, including BDD, that afflict so many of those who experience these kinds of adversities, as so eloquently described by Dr. Constantian, is an important foundation for understanding and caring for patients with BDD. It is an important first step for addressing the “Face of Trauma.”

David L. Corwin, MD

President, American Professional Society on the Abuse of Children, 2018—2020

Professor and Director of Forensic Services, Department of Pediatrics

Note

* Kuhn, Thomas, The Structure of Scientific Revolutions, Chicago: University of Chicago Press, 1962.