Üsküdar Üniversitesi Founder Rector Psychiatrist Prof. Dr. Nevzat Tarhan addressed numerous dermatologists and plastic surgery specialists at the Holistic Aesthetics Congress. Making a presentation titled “Body Dysmorphic and Aesthetic Perception Disorder,” Tarhan stated that these individuals, excessively focused on their bodies and physical appearance, are overly anxious due to imaginary or minor flaws. Reminding that plastic surgery should be concerned not only with patients' physical health but also with their psychological health, Tarhan emphasized that in such cases, surgeons should collaborate with a psychiatrist on suspicion of body dysmorphic disorder. Stating that surgical operations should be avoided in these situations, Tarhan added that these patients can often request many aesthetic interventions and may pressure the doctor when their desires are not met.
The congress, held at Selectum City Hotel in Istanbul Ataşehir from September 26-29, attracted significant interest.
“Our biggest problem in face reading and measuring micro-expressions”
Psychiatrist Prof. Dr. Nevzat Tarhan, stating that he wanted to begin his speech by addressing the common issues for aesthetic specialists and psychiatrists, said; “What are the difficulties experienced by a plastic surgeon, an aesthetic specialist? What are the difficulties we experience as psychiatrists? Psychiatrists face a challenge with fillers. There was the Duchenne smile. This is a smile that has become a reference in positive psychology. It has entered the literature. People have crow's feet around their eyes. In these individuals, 50% of these lines go upwards. These people live eight and a half years longer and encounter fewer health problems. This has been determined and thus entered the literature as the Duchenne smile, becoming a reference for us. However, with aesthetics, these lines are eliminated or reduced with various touches. These individuals do not have a Duchenne smile. We cannot measure it. So, our biggest problem in this field, regarding measuring micro-expressions, is face reading. Because there are two types of emotional expressions in a patient's emotional expression. It starts from the brain, but we need to distinguish whether the emotional expression is central or peripheral. Some people become very obsessive. They suppress it, their face becomes like a mask, without expression. Is it like that, or is it due to a peripheral blockage? This is a difficulty we face. I say, if you have had botox or anything, don't go to the mirror and look for a Duchenne smile on yourself.”
“If a person places their physical appearance at the center of their life, an aesthetic perception disorder emerges”
Underlining that individuals with body dysmorphic disorder have excessive mental preoccupation, Tarhan said; “The patient group with body dysmorphic disorder, these patients particularly suffer from body image disorder. That is, they are excessively focused on their bodies and physical appearance. We see that these individuals are overly anxious due to perceived, imaginary, or minor flaws. These people frequently check mirrors. The most common behavior we observe in them is repeatedly going in front of a mirror. Another characteristic is that these individuals constantly seek approval from their environment regarding their physical appearance. When they come to us, the most important thing is an excessive mental preoccupation with physical appearance. 50 minutes out of 60 are spent feeling good, standing in front of the mirror, or constantly following fashion magazines, comparing themselves to others – in short, there are excessive mental preoccupations. They constantly try not to accept the body parts they dislike. They are excessively interested in constantly grooming and adjusting themselves. When we encounter these individuals, there are various tests that determine which body part is of concern regarding body dysmorphic disorder. These are performed. There are those within acceptable limits here. This applies to everyone, but what's important is if the person has made this the center of their life. If someone places their physical appearance at the center of their life, after a while, an aesthetic perception disorder related to this body dysmorphic disorder emerges. This aesthetic perception disorder does not simply go away with phrases like, ‘Don't worry about it, you are beautiful, there's nothing wrong with you, you're just imagining it…’ and so on. Absolutely not, because the program in the brain areas related to this somatic perception in these individuals is disrupted.”
“The perception area in the brain is disrupted”
Drawing attention to the phantom phenomenon in aesthetic perception, Tarhan said; “Sometimes we encounter cases where somatic perception is at a delusional level of body dysmorphic disorder, in the form of eating disorders. For example, even though a person weighs 29 kilos, they perceive themselves as 150 kilos. The perception area in the brain is disrupted. We can explain this with the following examples. For instance, how aesthetic perception is related to a person's mental perception, there is a phantom phenomenon in aesthetic perception. For example, there is an amputated limb. A person's arm is amputated, and after the arm is amputated, they feel pain in the arm that is not there. They say, ‘My arm hurts,’ but they don't have an arm. Here, the person actually knows their arm has been cut off, but their brain doesn't know. The brain doesn't know, it says it's there. It says that limb hurts. The person is not lying. They perceive it that way, they feel that way, and mirror therapy is applied to them. A mirror is placed in place of the missing limb; when they raise their right arm, nothing rises, but when they raise their left arm, its reflection in the mirror also rises. Based on this, when we teach that person's brain that their arm is not there by doing these exercises, their pain subsides. Painkillers are not effective in these individuals. This phantom phenomenon is something that exists in the literature. What is this? The same thing is present here. That is, the brain perceives something that doesn't exist as if it does and takes a position accordingly. It shows mental preoccupation with this, establishes connections related to it, and starts interpreting everything in relation to it.”
“Approaches like ‘be your own doctor’ don't work…”
Referring to paranoid disorders as a subgroup within delusional disorders, Tarhan said; “I know a patient with somatic delusion who says, ‘My back hurts, I will be paralyzed,’ without getting out of bed for 1.5 years. We also see this in panic disorder with the fear of being paralyzed related to bodily perception. The person even goes to the toilet by waiting, moving in slow motion, keeping their door open. These individuals' perception is mostly dominated by fear of death and illness… They deal with an extreme degree of delusion with the feeling of being paralyzed at home. The person's life is restricted. In those days, this illness was not recognized, it was panic disorder, not having entered therapy. And despite weighing 130 kilograms, they don't leave the house, don't move at all, for fear of falling ill. In the manner of, ‘If I move, I will have a heart attack,’ and even a small movement invites fear. Therefore, I wanted to emphasize that approaches like ‘be your own doctor’ are not effective.”
“Each of us is a chemist”
Referring to how individuals pursuing ideas, ideals, and meaning can teach their brains to secrete serotonin, Tarhan said; “Each of us is a chemist. In our lives, as we manage ourselves, we work like a chemist in our brains. In our brains, for example, dopamine is related to pleasure, and this aesthetic perception increases dopamine even more. For instance, ecstasy, but it increases all kinds of dopamine, and in the same way as endorphin secreted during orgasm, but in those who live pleasure-focused lives, the brain secretes dopamine. One pleasure ends, and when that pleasure ends, they seek another. When that pleasure ends, they seek another. But in a person who pursues ideas, ideals, and meaning, when one step on that path ends, because they are pursuing an idea, a goal, an ideal, and thinking long-term, the brain continues to secrete serotonin. Serotonin is long-term, and the chemical in the brain, dopamine, is related to short-term, instant pleasures. That is, cocaine and so on secrete dopamine. Such substances cause dopamine secretion. For this reason, individuals who pursue an idea, an ideal, and meaning can teach their brains to secrete serotonin. This leads to peace, to well-being. For example, reducing sadness is a situation observed in people who are at peace with themselves, and they manage the chemicals in their brain.”
“Body dysmorphic disorder is 12-13% in adolescents…”
Drawing attention to beauty as a measure of worth being a kind of consumption strategy offered by modernism, Tarhan stated; “Actually, there are genetic factors, environmental factors. There is a lack of self-confidence. There are psychological problems. For example, let's say genetic factors, this body dysmorphic disorder is 2-3% in adults but 12-13% in adolescents. That is, adolescence is a period when physical appearance comes to the forefront the most. All adolescents compete. Therefore, there are many psychological situations for adolescents. An adolescent behaving like four seasons is not sick at all. They are doing what adolescence requires. This needs to be known. In them, especially in adolescent girls, excessive beauties regarding physical appearance are very common. If you don't listen to them, if you don't understand them, it secretes more. Sometimes there are many things in family upbringing. Beauty becomes a measure of worth. That is, a person has goal pyramids in their life. At the top of this goal pyramid, it is taught, ‘If you are beautiful, you are valuable; if you are not beautiful, you are worthless.’ So, when we teach this to that person, what does the person do? This time, they make being beautiful an ego ideal. When they are not, they feel bad. Beauty being a measure of worth is a kind of consumption strategy offered to us by modernism. That is, the consumption strategy provided by the capitalist system, unfortunately, continues to affect all of us with the entertainment industry. There are environmental factors, upbringing methods, and people with a lack of self-confidence also want to use physical appearance as a label. Many people with depression also try to express themselves in this way.”
“It should be clarified that the problem is psychological, not surgical”
Speaking about what specialists should do when encountering a patient with body dysmorphic disorder, Tarhan said; “In such situations, what should we do as a plastic surgeon? I would say, perform a psychological evaluation of the patient. Here, especially if you are working as a plastic surgeon or a dermatology specialist, evaluate the patients' psychological states to determine whether surgery is appropriate. If the patient raises suspicion of potentially having body dysmorphic disorder, surgeons should pay attention to this situation and collaborate with a psychiatrist. That is, even if a good master performs the surgery, you cannot prevent this. They will come back, and when they don't achieve what they want, they will pressure you repeatedly. So, as they say for preventive reasons, you will have to detect this. It is easy to avoid hasty surgical intervention. Patients with body dysmorphic disorder usually request many aesthetic interventions, but surgical intervention based on expectations that will not truly be met does not solve the problem. In such cases, surgical operations should be avoided. It should be clarified that the problem is psychological, not surgical.”
“Not only physical health, but psychological health should also be addressed…”
Underlining that patients should be concerned not only with their physical health but also with their psychological health, Tarhan said; “Patients with body dysmorphic disorder have psychological treatments and referrals. When you receive a diagnosis, if behavioral therapy is needed, if psychotherapy is needed, with pharmacological treatments, these individuals undergo excessive surgery because their perception of illness is distorted and their aesthetic perception is impaired. Aesthetically, their initial states might be more accepted than their final states, and while doing this, it is necessary to establish open communication with the patient first. That is, generally understanding patients' expectations and carefully discussing whether their expectations are realistic. Open and empathetic communication is very important to be able to notice whether the patient's external appearance flaws are reduced or increased. Another important feature is that if surgical intervention is performed with the given support, it is important to monitor the patients' psychological states in the longer term. That is, it is important for plastic surgery to be concerned not only with patients' physical health but also with their psychological health.”