The Concept of Altered Perception in “Body Dysmorphic Disorder”

ISSN: 2641-2950 DOI: https://dx.doi.org/10.17352/jnnsd CLINICAL GROUP

Received: 04 April, 2020 Review Article Accepted: 19 May, 2020 Published: 20 May, 2020

*Corresponding author: Dr. Giulio Perrotta, Psycholo- The concept of altered gist sp.ing in psychotherapy with a strategic approach, Forensic Criminologist expert in sectarian cults, esoteric and security proﬁ les, Jurist sp.ed SSPL, International perception in “body Essayist, Italy; website: www.giulioperrotta.com, E-mail:

dysmorphic disorder”: The https://www.peertechz.com subtle border between the abuse of selﬁ es in social networks and cosmetic surgery, between socially accepted dysfunctionality and the pathological condition Giulio Perrotta* Psychologist sp.ing in psychotherapy with a strategic approach, Forensic Criminologist expert in

sectarian cults, esoteric and security proﬁ les, Jurist sp.ed SSPL, International Essayist, Italy

Abstract

The present work focuses on the general concept of impaired perception in body dismorphic disorder, to then extend the clinical refl ections also on some social phenomena of the last generations such as the massive use of cosmetic surgery practices and the selfi e trend (or “selfi tis”), shifting the centrality of the discourse on the subtle boundary between the dysfunctionality of socially accepted behavior and the well-known pathological diagnosis.

Contents of the manuscript Therefore, if sensation is the product of stimulation and receptor reactivity through the ﬁ ve senses (sight, hearing, The general concept of impaired perception [1] smell, touch, taste), we will speak of perception in the presence of the elaboration of the elementary sensation that has reached Perception is the psychic process that synthesizes, in the sense organ. forms with meaning, the innumerable sensory data that reach the brain from the environment around us, according to Thanks to the studies of Weber (on the differential threshold processes of synthesis, selection, integration and evaluation. or threshold of relevance of the perceived stimulus) and Fechner When it does not happen correctly, we will therefore speak of (on the sensation, directly proportional to the logarithm of the “impaired perception”, that is, an alteration of the ability to intensity of the stimulus), we came to say that: acquire (through the ﬁ ve senses) the sensory data or correctly The thesis that supported “sensation = perception” (so- transform it into perceptual data. called naive realism) is incorrect, while the hypothesis that 001

a) for Metzger, the level of visual perception is not fl at but 5) Synthetic Approach, or the schools of thought adhering three-dimensional to neuroscience, which attempt to overcome the top-down / bottom-up relationship, effectively integrating two models. b) for Rubin, the visual fi eld is differentiated in the Among the major exponents we mention: background and Figure a) Bruner: perception depends on one’s needs, expectations, c) for Wertheimer, the perceptual fi eld was organized by a moods, subjective values, emotional meaning and personality series of rules: good shape (the perceived structure is always characteristics (so-called New Look School) the simplest); proximity (the elements are grouped according to distances); similarity (tendency to group similar elements b) Neisser: the brain is a computer and perception is nothing based on similarities); proximity (tendency to group similar more than an analysis by synthesis, the result of a three-stage elements based on close distance); closure (tendency to group sequence: I) the selection of the stimulus through an automatic similar elements based on known closed forms); continuity pre-attentional (bottom-up) process; II) the voluntary shift (all elements are perceived as belonging to a coherent whole); of attention to the stimulus (top-down); III) the fi nal mental common destiny (if the elements are moving, those with a representation; coherent movement are grouped); fi gure-background (all parts can be interpreted both as an object and as a background); c) Marr: perception can be investigated on at least three intensity (in case the stimuli are ambiguous, the perception levels (so-called computational theory): I) computational level will be good based on the information taken from the retina). (the goal); II) algorithmic level (the means used); III) procedural level (the how). Marr’s approach is strongly “bottom-up” (as 3) Cognitive approach, which provided for the integration of it focuses on sensory processing) but includes the intervention the models of “top-down (ie information previously learned from the world)” factors: <>. b) “bottom-up”, i.e. the processing from the bottom up The analysis of the visual sensory input proceeds through four (guided by the sensory data processed then in the cortical way). specifi c stages: a) description of the gray levels; b) geometric A typical example is Gibson’s ecological approach, which provides primitive primary sketch; c) sketch in 2 and ½ dimensions (e.g. for very specifi c assumptions: the stimulus is described not in depth); d) 3D representation (three dimensions). However, terms of retinal projection but in terms of “optical structure” this model is strongly criticized because it does not take into (ie image that reaches the retina); the stimulus is perfect as it is; account an adequate explanation of how the factors at play and the set of information given by the context and the movement there are no functional tests outside the laboratory context. of the observer is called “environmental optical structure”. On these assumptions, perception (to function properly) 4) Constructivist Approach, which has its foundation in the requires the integrity of cognitive processes such as attention, following assumption: “perception is an inferential process alertness, memory and emotional state, but also the physical (ie based on hypotheses), given that the sensory information integrity of receptors, nervous pathways, primary sensory areas

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2) false perceptions: distorted interpretations of an People with this disorder experience signifi cant or, in any external sensory stimulus or of an internal sensation, case, frankly excessive and unfounded concern with respect to a determined by dopaminergic hyperactivity in the physical defect that is non-existent or considered negligible by mesolimbic pathway (neurobiological hypothesis) most people, manifesting serious discomfort for this supposed or by a mental representation capable of projecting deformity, and often describing their concerns as “intensely external internal parts (cognitive hypothesis) or painful”, “Tormenting “ or “devastating”. Patients tend to split parts of one’s personality (psychodynamic think repeatedly and obsessively about their own defects, real hypothesis). Examples of false perceptions are illusions or imagined that they are, throughout the day, also spending (errors of perception of a real stimulus determined by many hours a day identifying and implementing systems to inattention, personal belief or cognitive distortion), remedy them, eliminate them or, at the very least, hide them hallucinations (sensory perception to which no from others. They live the conviction of always being observed external stimulus corresponds or perception without and judged, and that their appearance conditions their value real object), pseudo-hallucinations (mental images for others. Often, this leads to the development of ritual clear and vivid, not necessarily psychopathological, actions, superimposable by nature and effects to those typical involuntary but recognized as not real as there is no of obsessive-compulsive disorder [2,3]. concreteness of perception, such as the phantom limb, delusional perceptions, distortions of the body image, In fact, repetitive and compulsive behaviors that aim to post-traumatic or dissociative fl ashbacks, hypnogogic examine, control, improve or hide the presumed defect on hallucinations and hypnopompic, synaesthesia and the which thought is polarized are common: mask parts of the doppelgänger hypothesis) and systematic errors. body (with makeup, hats, taking unusual positions); avoid direct light; excessive checks in the mirror or on refl ective Clinical profi les of the body dysmorphic disorder and surfaces to analyze the defect or tease / remove it or, on the psychological treatments contrary, phobia to support the sight of one’s own refl ected image, carefully avoiding to linger one’s gaze on mirrors and The distortion of the body image (technically, a pseudo showcases; excessive exercise or excessive body care such hallucination) is an altered perception at the basis of the as combing or washing repeatedly or numerous changes of “Dysformic body disorder”. According to the Statistical Diagnostic clothes and looks; continuous comparisons with the physical Manual of Psychiatric Diseases (DSM-5), this particular appearance of others; seeking reassurance or on the contrary disorder is part of the spectrum of “Obsessive Complusive attempting to convince others of their fault; repeated use Disorder and Related Disorders” and to be diagnosed the of medical treatments (dental or dermatological) or plastic patient must have the following symptoms [2]. surgery [2].

Concern with one or more physical defects that are not Those who suffer from dysmorphophobia are persecuted by objectively detectable or negligible by other people; their own imperfection and cannot stop negative thoughts about Adoption of repetitive or ritual behaviors (looking in the its appearance: no possible comfort regarding the irrelevance mirror, touching the defective part, seeking reassurance etc.) of the problem complained of will be sufﬁ cient to appease or mental attitudes (obsessive thoughts, constant comparison the anxieties, on the contrary, the lack of recognition of the with others, conviction of being observed and judged etc.), in defect or an attitude of carelessness can generate in the person response to the concern for the physical defect. the idea of not being adequately considered and understood. The pervasive thought of the physical defect, the fear of the Severe stress, anxiety and a drop in mood caused by judgment of others and the obsessively repeated practices to persistent concern about the physical defect. try to eliminate it, translate into a serious compromise in the

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Citation: Perrotta G (2020) The concept of altered perception in “body dysmorphic disorder”: The subtle border between the abuse of selfies in social networks and cosmetic surgery, between socially accepted dysfunctionality and the pathological condition. J Neurol Neurol Sci Disord 6(1): 001-007. DOI: https://dx.doi.org/10.17352/jnnsd.000036 https://www.peertechz.com/journals/journal-of-neurology-neurological-science-and-disorders quality of life, interpersonal relationships, performance (and Recognizing the existence of the problem from the fi rst signs consequent success) in the study or at work. These people may allows you to undertake effective and safe pharmacological and develop anxious states among other people, for fear that they psychotherapeutic treatments, which allow you to re-establish will notice the alleged physical defect, have diffi culty leaving a balanced relationship with your body and to focus attention the house, having social contacts, going to school or to work. on the basic psychological discomfort that led to develop the Unfortunately, however, being these obsessive concerns, they obsessive attitude towards a nose, mouth, chin or skin that is are independent of the actual physical appearance and therefore actually free of any particular aesthetic defects. Psychotherapy the solutions, however drastic, never lead to improvements in this sense can be very useful to overcome the dysmorphic in the mental state, indeed attempts to eliminate the defect, body disorder and must always be taken into consideration in the presence of any aesthetic intervention that is aimed the outcome of which is never considered good enough, they at a defi nitive and irreversible modifi cation of the body. The generate frustration and anxiety [2-4]. strategies that have proven to be most effective are cognitive- If not treated early with specifi c therapies, the disorder behavioral and strategic therapy, aimed at desensitizing can lead to a serious deterioration in the quality of life, the patient towards the negative stimulus through gradual numerous practical problems at a family and work level, and calibrated exposure to the stimulus itself, quickly and as well as psychiatric complications following possible effectively and with meetings timed over time systematically. Digitized images of the person are also extremely useful. On comorbidities with additional disorders such as depression [5], the other hand, drugs are rarely effective, unless there is obsessive compulsive disorder [6], social phobia [4], conduct comorbidity with major depression, obsessive-compulsive and impulsivity disorders [4], sleep-wakefulness [7] and/ disorder or a disorder of impulsivity and conduct: in these cases or behavioral [8] or substance dependence [2]. A profound antidepressants and mood stabilizers can be prescribed to help disturbance of the body image, not only perceptive, but linked patient in the stabilization phase. Particular attention, however, to the emotional relationship with one’s body, is also a central must be paid to understanding the value of the symptom element in the psychopathology of eating disorders [25]. The which, sometimes, can represent a secondary advantage or a body represents the support of one’s identity and a medium form of extreme defense against psychotic disorganization. In in the relationship with others. It can be hyper-invested and this case, only dysmorphophobia will not be subject to therapy, exploited, thus becoming a sketch of identity, a way to regain but the entire personality of the individual [2]. a space, to express one’s needs, to communicate a profound unease. Therefore, the anorexic paradox emerges: the intent Body dimorphism differs from symptoms such as to martyr and cancel physicality to affi rm the rights of the hallucinations and delusions, as the latter have a psychotic mind. Initially, there is the fantasy of being able to govern matrix, while dimorphism is part of the obsessive-compulsive the body and its forms, denying its needs and raping it for disorder, even if it may evolve or be in comorbidity with a its own purposes. However, over time, his language becomes delusional or psychotic disorder. In fact, in the absence of incomprehensible to consciousness, distorted and distorted in a symptom of this seriousness, the people who manifest meanings; it rebels, escapes control, to be subjected again in a dimorphism are simply anxious and distressed because of the belief that some aspects of their appearance are not attractive, spiral in which body and mind alternate the roles of “tyrant” but deformed, or in any case “wrong”, even if, in reality, the and “victim”: the confl ict between willpower and body perceived defect is minimal or non-existent. Typically, these power occupies the entire anorexic universe, and mediation concerns stem from low self-esteem, feelings of shame and between both becomes increasingly diffi cult, sometimes embarrassment, the feeling of being unworthy and the fear impossible. The anorexic thinking and reasoning processes are of community rejection. Not surprisingly, almost all subjects characterized by the presence of cognitive distortions, such as affected by this pathology perform repetitive and compulsive hypergeneralization, selective abstraction, arbitrary inference behaviors in order to observe and analyze the perceived defect, and dichotomous thinking, to name a few; irrational beliefs, trying to hide it: however, in most cases, anxiety instead of magical thinking and maladaptive thinking patterns about decreasing increases more and more, resulting in in behaviors the self, weight and body forms, which hinder the individual that continue to maintain the state of unease resulting from in the process of adaptation to his environment, instead of concern about one’s body image [2]. facilitating him. The basic premises underlying this type of thinking therefore force the person to formulate exaggerated, Neurobiological and etiopathological profi les [9,10] hypergeneralized and absolute conclusions and are generally The construction of the body image and its possible summarized in absolute terms such as “Always” or “Never” alterations derive from a set of neurobiological, psychological and in terms of the imposition “I have to ...” [2]. and socio-cultural aspects. About the former, the main brain On the physical level, however, the fury towards defects areas that can be connected to the body image are. to be eliminated can expose to serious health risks otherwise The right hemisphere, crucial for the regulation of emotions. avoidable (for example, in the case of invasive cosmetic surgery) or determine really unacceptable results that make the overall The insula, the amygdala and the upper gyrus, which situation worse (for example, continuous retouching of the mediate the reactions of disgust and aversion related to visual face or body, losing its natural constitution) [2]. perceptions.

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The dorsal occipital cortex, the right temporo-parieto-occipital has in mind; consequently, instead of blaming the typology of junction, the fusiform gyrus, the inferior parietal lobe and the the photos in large part, we tend to blame it on our own defects dorso-lateral prefrontal cortex, which if dysfunctional could and imperfections. The pitiless confrontation then with the give rise to distortions in the perception of faces and body and stars of cinema and jetset does not help at all. contribute to the inability to correct perceptual distortions Beyond some speculations and clinical hypotheses that generated by other malfunctioning systems. have never been demonstrated, the direct correlation, as The ventro-medial prefrontal cortex, which if dysfunctional much as the possible contributing cause to the dysmorphic could give rise to the inability to inhibit reactions of disgust phenomenon, is evident. The altered perception of the subject and anxiety deriving from perceived body defects. [11], with evident low self-esteem [21] or narcissistic traits [22], leads him to exacerbate the image captured in the The right parahippocampal gyrus, which if dysfunctional selfi e, often taking excessively pronounced positions of the could give rise to incongruous self-assessments regarding its erogenous zones (breasts, buttocks, hips) and completely appearance, negative interpretative distortions and reference unnatural and non-harmonious facial expressions (lips forcibly ideas. pronounced, squeezed or twisted on the sides, to imitate the effect of the surgical retouching of movie and fashion stars). The fronto-striatum, which if with anomalies, could This method, depopulated on the web from the middle of contribute to executive dysfunction and the intrusive nature of the fi rst decade of the 21st century, completely colonized the obsessive thoughts and compulsive behaviors. socio-anthropological scene, making future generations, especially those in pre-adolescent age, enslaved by this The exact causes of the body dysmorphic disorder are fashion; these same people, victims of this dysfunctional not known, however, and a multifactorial profi le is always modality, if they are already affected by psychopathologies suspected. Certainly, among the mechanisms involved, the such as depressive disorder, obsessive-compulsive disorder existence of an alteration in the transduction / processing of or personality disorders (especially those of cluster B), can visual stimuli was hypothesized, which would lead to incorrectly easily increase dysfunctionality by aggravating their starting assessing one’s appearance regardless of the interference of psychopathological condition . And what is even more serious psychological factors. This relationship remains, however, is the ease with which this fashion affects entire generations, to be verifi ed. Brain imaging studies have also highlighted from pre-teenagers to adults. activation anomalies in the brain areas responsible for verbal and non-verbal memory processing and transmission defects Of course, it is necessary to distinguish case by case. Taking of nerve stimuli between these areas and the prefrontal occasional selfi es is not pathological in itself nor should cerebral cortex, similar to those found in obsessive compulsive the action be demonized. It begins to become “suspicious” disorder. That the disorder has a biological basis and that it is when unnatural positions are taken in the self-timer, the related to obsessive compulsive disorder also on this front and frequency of the shots is medium-high and spread over the not only on that of clinical manifestations is demonstrated by day, graphic fi lters are constantly used to alter the shapes the fact that the body dysmorphic disorder tends to recur in and colors and these actions are not aimed at advertising or multiple members of the same family (which it also emphasizes economic propaganda. These signals are highly indicative for heredity) and in families where one or more people with a psychological response and therefore it would be appropriate obsessive compulsive disorder are present. Furthermore, a key to evaluate the subject’s profi le, in a psychosymptomatic key, role of the serotonergic system in the onset and chronicity of before it becomes something more serious. the disease is believed to be almost certain. The details of this Following some parodies and speculative attempts, a group report, however, remain to be clarifi ed. of Indian and English researchers [11] decided to investigate Selfi es and psychological correlates the psychopathological hypothesis (the so-called “selfi tis”) on a sample of 400 subjects, also trying to draw up a rating Recently, some scientifi c research [11-20] has really made scale 1-100 out of three distinct classifi cations (acute, chronic, people discuss about the possible correlation between the borderline), to measure the severity of the pathological incidence of cases of body dysformism and the “selfi e” craze, condition. The test to be performed consisted of ten questions, a social trend that has spread in recent years thanks also to the where if you answer 1 you disagree, if you answer 5 you totally social media that consists of in photographing (precisely self- identify yourself: portrait) through the smartphone and then inserting the image 1) I publish my selfi es to create a healthy contest with my on social networks. With these shots, you usually photograph friends and colleagues. the close-up of the face or a detail that you want to show, at any time, condition and anywhere. It is implied that in this 2) Selfi es attract a lot of attention in social media. mode the photos are not taken as professional shots and in addition we are framed in the worst conditions that highlight 3) My stress level decreases when I take selfi es. the defects and alter the proportions of some body parts. Seeing 4) I feel more confi dent when I take selfi es. oneself in those photos can lead the person to not be satisfi ed with himself, because most of the time it happens that the real 5) I am more accepted within a group when I publish selfi es image does not correspond to the ideal one, that is, to what one in social media. 005

6) I feel more capable of expressing myself in the social more envy than news, and the sculpted abdominal, or anti- environment by sharing selfi es. gravity gluteus, impose itself on the mass as a standard to be reached by any means. 7) Taking selfi es with different poses increases my social status. On the other hand, the psychological and psychopathological implications of aesthetic medicine are less well known and less 8) I feel more accepted and popular when I publish my discussed, even if they present themselves with increasing selfi es. evidence in the most diverse forms. For example, the number of “beautifi ed” patients who are dissatisfi ed with the result and 9) Taking many selfi es improves my mood and makes me require further operation increases; the proportion of people who happier. after a fi rst intervention trigger a real escalation of retouches, 10) Selfi es encourage my self-esteem. additions or plastic reductions grows proportionally. Finally, others vote for the scalpel for life, forced to the unpredictable However, these data should then be analyzed in a systematic or poorly calculated eventuality of adapting or renewing their key, also interviewing family members and friends, to have an obsolescent prostheses. This ostentatious and sparkling beauty objective and external point of view of the patient’s behavior, is in many cases the icy refl ection of a psychological disorder, who interested in the fi rst person could underestimate the such as anorexia, bulimia or depression. frequency and importance of their actions related to the ‘selfi e. And in this frankly bleak picture there are more or less The socially accepted extreme remedy: cosmetic sur- successful attempts to speculate on the manias and fears of gery and the need for «retouching». Conclusions people to feed a market, that of plastic surgery, which is always growing, to the detriment of patients who should fi rst of all The strong social pressure to adhere to well-defi ned face a serious psychotherapeutic path and structured [24- canons of beauty and the evolution of increasingly advanced 26], thus distinguishing from the necessary interventions and minimally invasive techniques in the dermatological those which are the consequence of a primarily emotional and and cosmetic surgery fi elds, accompanied by a relative psychological discomfort. reduction in costs for the most common treatments, has led to a considerable increase the number of people who choose Future research should focus on the analysis of the to correct physical defects of various types and relevance that relationships between the pathology analyzed here and the nature has “imposed” on a genetic basis or occurred following use of technology (with reference to selfi es) and the use of the physiological aging process [23]. cosmetic surgery (not aimed at reconstructing body parts attacked by traumatic events such as road accidents, defects In principle, there is nothing wrong with exploiting the physiological and oncological processes), on a representative “reparative” or corrective potential that biology and medical statistical sample. science have made available to eliminate a little loved physical detail, to like yourself more and to feel comfortable in References relationships interpersonal and professional. 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