The Emotional and Ethical Dilemmas of Body Integrity Dysphoria: A Case Report From England

Body integrity dysphoria is defined as a rare disorder with the characteristic feature of a persistent desire to have a physical disability, usually specific. Some people with body integrity dysphoria reach a stage where they search for surgical or self-removal of their body part/s. The aim of presenting this case report is to disseminate information about body integrity dysphoria and the emotional and ethical challenges that haunt the diagnosis. We present a case of a 52-year-old white British gentleman whom we diagnosed with body integrity dysphoria as he met all the International Classification of Diseases 11th Revision (ICD-11) criteria for diagnosis. Two months before his presentation to us, he went to the train tracks near his residence, also adjacent to a tertiary care hospital, with the intent to have his lower limb amputated by a moving train. He has wished to be an amputee since his childhood. He denied any intent or plan to end his life. He did not wish for an accidental death while trying to be an amputee. All other diagnoses were ruled out. As an infant, he was diagnosed with tetralogy of Fallot and underwent corrective surgery. A year ago, he was referred to secondary mental health services via his general physician and eventually received a diagnosis of autism spectrum condition. The patient himself has theorised that perhaps his 'underdeveloped heart led to poor oxygenation to his brain, or maybe his brain was broken in some way, which causes the heart's misconfiguration'. His management on the ward involved work with psychology. Rather than trying to 'change' the patient or the nature of his thoughts, as this would likely cause more distress and non-engagement, the psychological treatment plan was to focus on reducing risk. Many speculations have been made regarding the aetiology. However, the therapeutic difficulties remain a challenge in 2024 as the disorder is understudied. A literature review published in 2021 suggested that amputation remains the most 'satisfying' management strategy, even though it is shunned in the medical community. A once misunderstood and misdiagnosed disorder, body integrity dysphoria has been appreciated by the ICD-11 as a separate entity. Our duty of care urges us to understand not just the biology of the ailment but also the ethically questionable resorts used so far (self-amputation) to deal with the emotional turmoil of wanting to be an amputee. A holistic and personalised biopsychosocial model of care is needed for patients with body integrity dysphoria.