10/05/2010 01:29 pm ET | Updated Nov 17, 2011

Surgery, Identity and the Body

Michael Jackson at 50 looked quite different from the way he appeared in his teens and 20s. Most of us expect the usual age-related changes that alter our bodies over the years, but for Mr. Jackson, there was another explanation. He underwent a series of elective surgeries in order to change his looks. Many people were repulsed by this surgical quest for an altered appearance. Others, including Mr. Jackson, denied that there might be psychological struggles that drove him to rework his face so dramatically.

In my new book, "The Naked Lady Who Stood On Her Head: A Psychiatrist's Stories of His Most Bizarre Cases," I describe an unusual case I call "Take My Hand, Please." A young carpenter kept injuring his left hand. His estranged wife told me about a "one-armed man costume" he'd been wearing since Halloween. When he finally admitted that his arm felt foreign to his body and that he had a table saw at home in the basement, I had to hospitalize him. Eventually, he told his wife about his secret desire to be an amputee, and she actually felt closer to him because he was finally being honest with her. Psychotherapy and medication helped him feel more comfortable with his body as it was, and their marriage improved.

My patient suffered from an extremely rare condition called Body Integrity Identity Disorder (BIID). Patients suffering from BIID believe their bodies don't match the image of themselves they have in their minds. They may feel their unwanted limb is not necessarily ugly, but it makes them incomplete or disabled. They're often jealous of actual amputees and experience such shame about their feelings that they rarely discuss them. They are not suicidal, but just want the limb gone, so they seek out surgeons for elective amputation. Occasionally BIID victims will damage the unwanted limb to the extent that it requires amputation. In one reported case, a man rigged his car with automatic hand controls and then froze his unwanted legs in dry ice until they were unsalvageable. He then calmly drove himself to the hospital where his legs had to be amputated.

Many of us have had mild feelings of discomfort about our bodies from time to time, whether it's a bad hair day, a few extra pounds we're trying to lose, or perhaps some forehead wrinkles we'd like to smooth out. Scanning the ads and story photos in any magazine like Vogue or Elle makes many people feel like altering their bodies to look better, at least for a moment. That's generally a normal, everyday experience.

But for most BIID victims, the wish for self-mutilation begins in childhood or adolescence. Some experts think the condition results from a brain disorder that somehow disrupts body image, but a specific cause has not been pinpointed. Treatment involves both psychotherapy and medication, and though the patient may continue to have thoughts of removing their extremity, they can be helped to improve their quality of life and find ways to function reasonably well with their unwanted body part. Antidepressants can reduce the obsessive thoughts, and an important aspect of therapy is helping the patient reveal their secret to people in their lives who can offer support.

Multiple elective procedures in the pursuit of beauty or a wish to have a limb cut off to feel whole again are not normal. Michael Jackson's serial plastic surgeries and quest for external beauty clearly differed from my patient's desire for a single surgery to make him feel better about himself. However, multiple-surgery seekers and BIID patients both aim to improve a feeling about themselves -- they are pursuing a surgical treatment for a psychological state. These are unusual cases, but at what point do we define surgical intervention for physical alteration extreme? Are five procedures too many? What about four or three? Or is it the extent of the procedure the defining variable? Is a tummy tuck too much? How about an eyelift? What do you think?