Most of the time when we talk about addiction, we’re referring to the compulsive or harmful use of substances. Only one behavioral addiction—gambling—is included in the Substance-Related and Addictive Disorders chapter of the DMS 5. Other behavioral addictions require further peer-reviewed research to become categorizable, diagnosable conditions. Addictive disorders involve a lack of ability to control substance use, social problems as a result of substance use, risk-taking to fulfill substance use urges, developing tolerance, and experiencing withdrawal symptoms when the substance is removed.
We no longer define addiction solely as physiological dependence on an ingested substance. We now have better categorizations for addictions, and the medical field is regularly adding more to the list, as society is constantly changing and addictive patterns become more apparent with time and research. The crux of what causes addiction is still an evolving conversation, one that keeps circling back to trauma.
New Hampshire-based plastic surgeon Mark Constantian believes plastic surgery can become an addiction in people who have experienced childhood trauma. Outside of moral judgements, issues of class and privilege, and other health implications, plastic surgery is a choice, and for many people it has no negative mental health effects. Then there are those who get plastic surgery and are profoundly upset even though they obtain the exact aesthetic results they originally desired. Constantian became interested in the experiences of patients who responded with profound anger and disappointment despite good results.
He describes this category of patients as being unhappy to an irrational degree. They expressed feelings of being betrayed and felt deceived. Constantian explains that they behaved “the way people behave when they’re traumatized and then triggered back to their childhood, they start acting and saying things that would have been appropriate to their abusers when they’re five or six years old but they’re no longer appropriate when they’re 40.”
Constantian has been practicing since 1978 and has taught in his field with a focus on nasal surgery, particularly with people who have had prior nasal surgery. Patterns emerged, and he wrote a book chronicling his findings. He found that many people who have multiple plastic surgeries are looking for self-worth, not correction of a deformity.
Body Dysmorphic Disorder
Plastic surgery addiction, while not a diagnosable condition, seems to exist alongside body dysmorphic disorder, a mental illness defined in the DSM 5 as “preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.”
According to Dr. Constantian, “Body dysmorphic disorder is looked at as a problem that arises out of the blue.” But that’s incorrect. “[A]ll of this starts in childhood. The family problems, the self-esteem problems are already there and it just percolates. Then you get to the teenage years and you start to compensate in some way, and you medicate the pain and it can be medicating with an eating disorder, with obesity, depression, cutting, drug or alcohol abuse. The characteristics I’m seeing are shared by all kinds of addiction.”
People wanted to be different from who they were as children. “The original genesis of the original problem had nothing to do with the cosmetic issue.” The self-harming behaviors are fulfilling a need to soothe the loneliness and the isolation, which are the result of shame.
Adverse Childhood Experiences Survey
To test what he was seeing in his patients, Constantian surveyed patients using an adapted version of the Adverse Childhood Experiences survey (ACE). The ACE study is one of the biggest studies on childhood abuse and neglect and other difficult experiences, and how they affect health later in life. The ACE study has been found to be one of the best predictors of conditions in adulthood.
Through years of neglect, abuse, or other traumas during childhood, we learn what adults are like. We learn how important we are in the world, what kind of space we occupy and how safe we are. We learn how dangerous the world is. How much we’re loved. Children learn to cope with those environments.
Constantian’s working theory was that if trauma works on the brain long enough, eventually it develops enough damage to create a disorder that a mental health professional can diagnose. It takes time to damage the brain to that extent. Traumatic experiences in childhood can influence an entire lifetime of decisions and alter how a person perceives themselves and the world around them.
Chronic unpredictable stress in childhood and adolescence can echo into adulthood with reverberations that translate into mental and physical health conditions. In Constantian’s study, he found that overall, 80% of surveyed plastic surgery patients had one or more Adverse Childhood Experience (compared to about 64% in the original study). For those with more than one cosmetic surgery, 90% had higher ACE scores than those in the original study. Emotional neglect was about four times higher. Drug abuse or alcoholism in the family was almost double. He noticed that emotional abuse was common in his patients.
How to Prevent Plastic Surgery Addiction
Categorizing someone as a poor candidate for plastic surgery cannot be calculated with something like the ACE score, because it leaves out a key feature: resiliency. Life changes and stressful situations arise for everyone at some point or another. Most people are able to recover from these conditions and adapt to change.
“Having cosmetic surgery is not a bad thing, as long as the reason for that is body dissatisfaction. As long as the person feels he or she has self-worth,” Constantian says. Lack of resilience is a huge factor in whether someone is more at risk of using plastic surgery as a maladaptive coping tool. Using the ACE study cannot rule out people not suitable for plastic surgery. Constantian couldn’t predict a patient’s trauma score, no matter how well he knew them.
Resiliency is the ability to overcome challenges and bounce back from difficult, even traumatic, events. Resilience can be learned, although there is some evidence that suggests some people may develop resilience due to genetic and other natural factors. Children learn how to be resilient through their parents, or other caretakers. If those caretakers are unavailable, abusive, or otherwise neglectful, a child may not learn appropriate coping mechanisms and lack resiliency later in life.
Resilience is like the antidote to childhood trauma. Often people with strong resiliency and high ACE scores had someone in their life who created a sense of stability and support. It might have been a teacher, a religious leader, a friend’s parent, a coach. Someone who made them feel capable and loved, and could model healthy coping methods.