Report into the psychological effects of PIPs on women.

Mr M Bradley Director, MBA Summary I have been asked to prepare a brief document describing the mental health issues that I believe are affecting the women who have been identified as having had PIP implants. The evidence for this document comes from communication with women who have had the PIP implants and a brief survey on a support site. The conclusions are based on personal experience of working in the mental health arena for the past 15 years and the extensive evidence base of the psychological effects of cosmetic surgery. The document will highlight in particular the possible dangers of delay in treatment and issues arising from practical treatment such as removal only. To understand the psychological damage an individual may suffer as a result of the PIP issue it is important to understand some background to the decision to undergo breast augmentation. Given the deeply entwined role the breast has with sexuality and attractiveness it is also important to dispel the myths that abound, driven by unconscious sexual processes in men, around breast augmentation and women. The first part of this document therefore briefly outlines drives behind the desire to adapt and change our bodies, how this is a normal function and that the women who choose breast augmentation are also, in laymans terms, normal. From this context the mental anguish that is being caused by the PIP health scare and its future implications can be better understood; devolved of any thoughts regarding, vanity, emotional disturbance or the misplaced idea of a group of women driven by an impossible concept of body image. I have been asked to write this document in a plain English style making it easily digestible and understandable. I have however attached a complete list of the relevant references and should further information be required I am available for comment.

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Cosmetic surgery, culture & body image Our body is the immediately observed part of our concept of self and is connected to a complex system of self-consciousness. Though we may consider ourselves as a consciousness and feel we exist in our mind and its thoughts I think therefore I am we are in fact intimately connected to the world via our bodies and our bodies are in many ways beyond our control. The concept of body schema how we view ourselves and its complex connections are still not fully understood, we develop, neglect and view with pleasure or distaste, all or parts of our bodies, at different times of our lives. We age, grow, become sick, strong and eventually decay. The body at a basic level defines us, malefemale, short-tall, beautiful ugly, abled-disabled and for centuries we have been shaping and changing our bodies in relation to all these factors. Body image is the mental representation we create of what we think we look like; it may or may not bear a close relation to how others actually see us. That is, it is subject to all kinds of distortion from internal elements like our emotions, moods, early experiences, attitudes of our parents and much more; and it strongly influences behaviour. Preoccupation with and distortions of body image are widespread among women (less so among males) and a desire to change our bodies to become more socially attractive is universal and as old as humans have gathered in social groups. Our society has changed dramatically in this century. There are few remaining hierarchies or social structures based on religion, parentage, money, or education. Society has become more egalitarian, but intrinsic to human nature is the desire to judge, evaluate and compare ourselves to others. If class and lineage are no longer the premier tools for measuring ourselves against others, what is? The answer is the more visible, tangible, observable aspects of ourselves, first among these, the body.

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This comparison commonly takes form in how we dress, our grooming, diet and exercise and recently via surgery. Cosmetic surgery is just the latest technique in a long history of changing our bodies to be adapted to our internal desires and is increasingly accepted, though often misrepresented, especially in the case of breast augmentation, in wider society. Careful mental health screening is part of the process to be accepted for cosmetic surgery and the women are no different, from a clinical view point, regarding their mental health than the general population. Their dissatisfaction with their bodies falls well within the normal range, their choice of

what to do to correct it is a new trend but it is not driven, on the whole, from a mental health issue. It is important here to differentiate between decorative nature of change such as clothing and the more permanent nature of surgery. Women are well aware that once they undergo surgery it is a permanent change, though one that may have to be repeated periodically. They take seriously their decision and invest a great deal of time and effort both emotionally and intellectually thinking about, discussing and planning their surgical choices. In this they are guided by their own desires, the consultations with the surgeons and often family and friends. There is a common misconception that to undergo cosmetic surgery, and in particular breast augmentation with its sexually laden connotations is part of the growing pressure to conform to a social norm of beauty that does not exist outside of media driven concepts. There has always been a move towards trends in social attractiveness what is considered attractive today will change tomorrow, Greta Garbos place skin and eyebrows were the height of desirability in the 1930S but are now considered unattractive. Though this may be true in some cases the vast majority of women undergo breast augmentation for a variety of reasons that fall well within a normal desire to be socially attractive. It is also a mistake to think that concern with appearance and weight is simply an aberration of contemporary Western culture. Generations of ancient Chinese women hobbled themselves by binding their feet in order to match the beauty ideal of the time. MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com

Some call such focus on ones appearance vanitybut that misses the point. We are responding to the deep psychological significance of the body. Appearance does indeed affect our sense of self and how people respond to us; it always has and always will. Presenting psychological issues As we have previously discussed the body is deeply entwined with our concept of self; it is the image we present to the world, a physical representation of ourselves. The decision for a woman to have breast augmentation is directly connected to the manner in which women regard their body image, selfconcept, total self image and selfesteem. Therefore there is a great deal of emotional investment in the procedure and it follows any negative outcomes from the surgery are likely to have a devastating effect upon the patient. This effect will not just present in the present but is likely to affect them long into the future; it will also not only effect their emotional health but also their physical health. Breast augmentation is possibly the cosmetic surgery that most affects the concept of a womens sexuality; by this I am commenting on a deeper understanding of human sexuality, of how we understand and position ourselves within our societal group(s). Sexuality is a complex process; it incorporates a wide spectrum of external factors, such as familial, societal and religious beliefs, health status and aging. In addition, each person brings to the relationship a unique set of attitudes, needs and responses that together make up an individual experience of their body and their sexuality. Breasts are intrinsically linked to a womans self-representation, aesthetical conceptualisation and societal norms. To suggest the removal of a womans breasts when there is a viable alternative has powerful psychological implications; these include the fracture of the corporal imaginary related to the disappearance of a valuable organ, emotional disturbance linked to the feeling of loss of personal attractiveness, low self-esteem and possible avoidance of social relationships. Many women may keep in mind the idea of mutilation, as a hole which is impossible to integrate.

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Therefore the present offer of removal but not replacement of implants is an offer fraught with both complex physical complications i.e. possible estrogen deprivation and deep emotional issues i.e. long term anxiety and depression. Whilst the nature of this document cannot explore these issues fully it is important to recognise that the implications of the PIP implants are complex and I would argue that any delay in treatment will only serve to compound these issues. For now I will concentrate on what I believe is the most immediate psychological issue: Acute Stress Response which may lead to Acute Stress Disorder (symptoms present up to one month from event) and finally Post Traumatic Stress Disorder (if symptoms have not been alleviated three months from event). In this case the Event may be taken as the date the client became aware of the health risk to her via PIP. For the purpose of this document I will define Post-traumatic stress disorder (PTSD) as a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma.

Understanding Trauma In medical terminology, a trauma is simply a wound or injury that happens suddenly or violently. Similarly, psychological trauma results when stress overwhelms a person and causes lasting psychological effects. A traumatic event, whether a natural disaster such as an earthquake or a man made one such as the PIP event can happen to anyone; it is usually unexpected, even if forewarned of possible risks, and takes the victim by surprise. All humans have a post-traumatic stress reaction or (ASR). Psychology views different types of fears and reactions caused by fears as adaptations that may have been useful in the ancestral environment in order to avoid or cope with various threats, commonly referred to as the fight or flight. Humans generally display several defensive behaviours roughly dependent on how close the threat is: avoidance, vigilant immobility, withdrawal, aggressive defence and appeasement. With PIPs the threat is MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com

internal, has been placed there by a trusted person in the surgeon and cannot be avoided. Once the perception of threat becomes real the victim needs to be able to respond, to take a certain amount of control of the situation, given that flight is unavailable, fight is the option. Regarding PIPs one would expect this to come in the form of removal, as one would with any other internal threat such as appendicitis, however for the reasons already discussed; removal without replacement is highly unappealing. The situation the women with PIP implants found themselves in was unacceptable, they were offered relief from one threat, a physical one, that came attached with a powerful psychological threat to their concept of female self. However they recognised that they could avoid the second threat by the simple act of replacement, which would take place at the time of removal, provide them with the sense of physical security they required and protect them from future issues. Most people have a strong support system that allows for a way of adapting to the trauma: sharing stories and emotional experiences. PIP women have been doing this through a variety of social platforms. Talking about an event should allow a person to get a handle on the event and so help it eventually to slip into place alongside other life experiences. If the event is a single experience in time i.e. the Costa Concordia sinking which I provided psychological support for, this is a positive first response approach. However the PIP event is on-going, the women cannot escape their sense of threat and fear. So though they are talking about the issues they alos feel that they are not being heard by government, clinics or the media. In cases of trauma not being heard or receiving acknowledgement and positive strategies only serves to increase the sense of vulnerability, helplessness and hopelessness. The debilitating effects of trauma derive from its ability to overwhelm a person emotionally while driving out any rational understanding of what is happening psychologically. Without a way of adapting a person may find that symptoms develop to the point that they become unmanageable. If at the beginning of the PIP event a concerted effort by the health services, private and public to create a clear and open communication with the women involved some of the presenting issues would have been managed and the MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com

women would have had better predicted outcomes. The fact they have been in limbo has increased the prospects of secondary trauma not being taken seriously and this is more difficult to alleviate. The efficacy of Psychological First Response is well established and is a straightforward process. Instead the PIP women feel that they were offered confused and conflicting advice; they heard of women in other countries being offered different treatment/health advice which only served to increase the lack of security rather than allay their fears. Common mental health issues linked to traumatic events Below are some of the common affects associated with trauma, many of these have been reported by women who underwent PIP surgery. The oppressive psychological weight of trauma can lead to a wide range of reactions; you do not have to experience all of them to be considered affected. Common responses to traumatic events 1. Common symptoms following exposure to the PIP event include any of the following: 2. An unusual feeling of being easily startled (Hyper-vigilance) 3. 4. 5. 6. 7. Difficulty falling asleep or staying asleep; waking up early Nightmares and/or flashbacks Difficulty concentrating or paying attention Carelessness in performing ordinary tasks Outbursts of irritability or anger, sometimes without apparent reason 8. Family or work conflicts that were not usually experienced before the trauma 9. Unusual fatigue emotional and physical 10. Feelings of emotional numbness, feeling as if you are in a film or watching life go by 11. Recurrent anxiety over personal safety or the safety of loved ones MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com

12. Feeling especially alone e.g., having a They arent affected 13. An inability to let go of distressing mental images or thoughts 14. Feelings of depression, loss, or sadness 15. Feelings of helplessness, powerlessness, and lack of control 16. Unrelenting self-criticism for things done, decisions made 17. Anxiety about, and avoidance of, specific reminders of the event Deeper Clinical Diagnoses Related to Trauma All experiences are intrinsically individual, what one person finds traumatic another may not. Below is a classic definition and timeline of reactions to trauma. It may help the reader to think of PIPs as physical injuries or malfunctioning organs whose presence is perceived as highly threatening to physical safety. I have included this more complex view of trauma to illustrate the complex nature of the possible outcomes of the PIP event. I conducted a quick survey on one PIP support page and the response revealed the women were all suffering one or more of the symptoms that lead to a diagnosis below. I accept this is not a strictly valid or reliable psychometric test however it provided a powerful look at the psychological issues the women are struggling with. If the trauma did not involve an experience so intense as to warrant a diagnosis such as Acute Stress Disorder then an Adjustment Disorder may be diagnosed. The predominant symptoms which characterize an Adjustment Disorder can be depressed mood, anxiety, disturbance of conduct e.g., confrontational attitude, reckless driving, or other maladaptive reactions e.g., physical complaints, work or academic inhibition, social withdrawal. By its definition, an Adjustment Disorder cannot last longer than 6 months, unless the precipitating experience is on-going or has on going consequences. If, however, the precipitating experience involved actual or threatened death or physical injury; the symptoms have elements of dissociation, re-experiencing avoidance of reminders of the experience, and anxiety; and the symptoms persist for several days

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and cause a serious impairment in normal daily functioning, a diagnosis of Acute Stress Disorder (ASD) may be made. All of the above diagnoses, of course, depend on specific symptoms that must be evaluated by a qualified clinician.

Maladaptive Coping Strategies Maladaptive coping strategies because they serve either to push out of awareness any memory of the traumatic event, or to give you a false sense of accomplishment. Unfortunately, such strategies serve no purpose in helping you integrate the trauma into your sense of self. Rememberan event is traumatic because it disrupts your previously secure sense of self. Consider that wild animals live with a sharp awareness of perpetual danger, yet most people live with a normalised sense of safety and security to the point of not understanding their basic vulnerability and fragmented sense of self. So when something disastrous happens, the psychological damage from the shattering of ones illusions about life and identity may be more problematic than any physical damage. Treatments for traumatic events The clinical treatment can take a variety of approaches: The treatment should provide a sense of safety, both as a protection from maladaptive coping strategies and as an acceptance of your thoughts and feelings as non-threatening; resolve the troubling aspects of the memories of the traumatic experience; and integrate positive growth into a victims lifestyle. I am suggesting that the PIP scare is a stressful experience that challenges both physical and psychological resources of the patient and delay in suitable treatment only increases the severity, breadth and complexity of the issues they face. Future issues MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com

There has never been a health scare of this nature or scale before therefore it is difficult to gather evidence from previous events. However there is a great deal of evidence regarding long term issues around trauma an via mastectomy research we can extrapolate the long term psychological effects of breast removal. It is important to remember regarding mastectomies that the woman has the breasts removed as the option for physical safety, there is usually not another add-on option as with PIP remove and replace. The psychological effect of this is that the woman retains more control; there inevitability of loss is balanced by the sense of removal of the threat and a healthy life. This document will highlight two issues that this document will address however this is for the sake of brevity and should not be taken as a complete examination of future problems. The first is in regard to the nature of the process, the women undertook medical advice regarding the procedure. To discover this trusted source was acting in error has profound effects on the victim. Victims may have strong feelings of guilt and shame, a strong sense of personally taking responsibility for making such a bad decision. This could influence other medical decisions later in life not only for them but for their children, grandparents and other family members. They now cannot trust the medical institutions we rely upon or their own abilities to make positive decisions regarding medical procedures. Other emotions may include vulnerability, fear of criticism, and anxiety about been seen as a vain fool, shallow or frivolous with their health. The if only sense of frustration is also a common thread, with victims still agonizing over how things could have been different if they had only been able to predict the future or extended themselves just a little further. The consequences of a failure of the doctor-patient relationship are powerful and real, a sense of trust in one of our most important and well regarded services is being broken. When the news regarding a serious error is revealed, whether the fault lies via the surgeon, practise or through a third party, the patient is likely to experience a great sense of betrayal. Patients trust their doctor to inform them

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both good and bad news and to offer the best possible option, post PIP is appears clear to many women that this has not happened. Untreated emotional issues with particular regard to PSTD Untreated PTSD can have devastating, far-reaching consequences for sufferers' functioning and relationships, their families, and for society. Symptoms in women with PTSD who are pregnant include having other emotional problems, poor health behaviours, and memory problems. Babies who are born to mothers who suffer from this illness during pregnancy are more likely to experience a change in at least one chemical in their body that predisposes the baby to develop PTSD later in life. Individuals who suffer from PSTD are at risk of having more medical problems, as well as trouble reproducing. Emotionally, PTSD sufferers may struggle more to achieve as good an outcome from mental-health treatment as that of people with other emotional problems.

Economically, PTSD can have significant consequences as well. Traumatic reactions are responsible for difficulties at work, higher rates of absenteeism and lowering of productivity. They are more likely to lead to an increased up take of doctors appointments, medication such as sleeping tablets and lowering of social interactions. Substance abuse and its subsequent costs increase and reliance on social services and disability support for conditions such as depression also increase.

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References Aesthetic Surgery and Quality of Life Before and Four Months Postoperatively, Journal of the Long-Term Effects of Medical Implants , Chahraoui K et al, 2006, 51 (3): 207210 Body Image Concerns of Breast Augmentation Patients, Sarwer DB, et al 2003, Plastic Reconstructive Surgery 112 Cosmetic surgery, gender and culture, Fraser, Suzanne, 2003, Palgrave Characteristics of a Population of Women with Breast Implants Compared with Women Seeking other Types of Plastic Surgery, Brinton L, Brown S, Colton T, Burich M, Lubin J, 2000, Plastic Reconstructive Surgery 105 (3): 919927 Effect of Breast Augmentation Mammoplasty on Self-esteem and Sexuality: A Quantitative Analysis, Figueroa-Haas CL, 2007, Plastic Surgery Nursing 27 (Mar): 1636 MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com

Mortality and Suicide Among Danish Women with Cosmetic Breast Implants. Jacobsen PH, 2004, Archives of Internal Medicine, 164 Medical Mistakes: A Workshop on Personal Perspectives, Richard T. Pensona, Sasha S. Svendsena, Bruce A. Chabnera, Thomas J. Lynch Jr.a and Wendy Levinsonb Nakedness, gender, and religious meaning, Margaret R. Miles, Carnal Knowing: Female Nakedness and Religious Meaning in the Christian West (Vintage. 1989) 169-185 Psychological implications of mastectomy, Colette Ray, British Journal of Social and Clinical Psychology, Volume 16, Issue 4, pages 373377, November 1977 Psychological Problems Derived from Mastectomy: A Qualitative Study, Jos Manuel Garca Arroyo, Mara Luisa Domnguez Lpez, International Journal of Surgical Oncology, Volume 2011 Plastic surgery: Beauty or beast? Melissa Dittmann, American Psychological Association, September 2005, Vol 36, No. 8

Social Desirability, Psychological Symptoms, and Perceived Health in Burn Injured Patients, Mimmie Willebrand, Bjorn Wikehult, Lisa Ekselius The Effect of Breast Cancer Treatments on Sexuality In Premenopausal Female Cancer Survivors, Ramona E. Chase, RN, MSN, University of Pennsylvania School of Nursing The Efficacy of Breast Augmentation: Breast Size Increase, Patient Satisfaction, and Psychological Effects, Young VL et al, 1994, Plastic Reconstructive Surgery 94 (Dec): 958969 Venus Envy: A History of Cosmetic Surgery, Haiken, Elizabeth, 1997, Johns Hopkins University Press Womens Psychosocial Outcomes of Breast Augmentation with Silicone gel-filled implants: a 2-year Prospective Study, Cash TF et al, 2002, Plastic Reconstructive Surgery 109 (May): 21122121. MBA Rooms: London & Leeds: +447875036885, +44845 901 1819 www.markbradleyassociates.com