He first told his mother that he was concerned with the small size of his private parts in October 2015. She brought him to see the neighbourhood doctor who told him that his penis was of normal size for an Asian man. In spite of the doctor’s medical and professional reassurance and the strong emotional support provided by his mother and girlfriend, he remained unconvinced and continued to harp on the smallness of his penis.

Meanwhile, he was also stressed by his school work. In Jan 2016, he complained to his mother that his life was boring and meaningless. He added that the only thing stopping him from suicide was the love of his family.

On the 3rd of March 2016, he did not return home after school. At around 8.30pm, he went to a housing block near the Bedok bus interchange to jump to his death. In his suicide note, he apologised to his girlfriend and his family for killing himself. He said that “it was not due to the stress of examination but it was more about his physical development” and “he still knew that there was something wrong with his body parts”.

This JC student could have been suffering from a condition known as Body Dysmorphic Disorder (BDD). BDD is a psychological condition affecting certain vulnerable individuals to the extent that they are excessively preoccupied with an imagined defect in appearance. BDD is a hidden disorder and its incidence is unknown. The best estimate might be 1% of the population and the prevalence rate in dermatology clinic is 6% and cosmetic surgery clinic is 15%.

Sufferers may be concerned with a lack of symmetry with their body, something that is too big or swollen or too small, or basically out of proportion with regards to the rest of the body.

In a study of 30 individuals with BDD by Dr KA Philips et al (published in American Journal Of Psychiatry 1993), the location of the imagined defects included hair (63%), nose (50%), skin (50%), eyes (27%), breasts (10%) and penis (7%). About a third (29% of these 30 cases) had attempted suicide at least once. BDD usually begins in adolescence, but many sufferers leave it for years before seeking help and when they do seek help eventually, they often present their problems with other symptoms such as depression or social phobia and do not reveal their real concerns.

Many sufferers have repeatedly sought treatment with dermatologists or cosmetic surgeons before finally accepting psychiatric help. Treatment can improve the outcome of the illness for most sufferers. Many BDD patients can recover with adequate treatment Others may function reasonably well for a time and then suffer relapses. Some may remain chronically ill. BDD is dangerous and there is a high rate of suicide.

From my clinical experience, BDD is usually accompanied by secondary depression characterised by low mood, slow movement. slow thought process, self-blame and negative thoughts, insomnia, poor appetite, lack of concentration, loss of interest in hobbies and suicidal thoughts or even attempts.

In the case of this JC student, as a result of his preoccupation with the small size of his penis, he had also become depressed, complaining that life was boring and meaningless. People were quick to criticise the lack of adequate sexual education in Singapore because it is easy to directly believe this is a sex problem due to his misconception about the size of his penis. However, the fact that he has sought help from doctors and it has been clinically proven that there is nothing wrong with him shows that his problem is beyond that of a sexual one.

While the incidence of BDD is not clear, causative factors to consider in BDD include environmental factors, such as society’s emphasis on appearance, individual factors, such as traumatic life events (teasing from peers and rejection), and the triggers could include stressors in life and emotional events such as relationship breakups. A genetic predisposition might play a part too; thus a combination of all this factors could very likely lead to BDD.

Because of its association with depression and hence suicide, early diagnosis and intervention is crucial in the management of BDD. Once diagnosed, medication (in the form of anti-depressants and anti-psychotics) together with intensive individual psychotherapy can bring about a full recovery.

BDDs are usually the result of a chemical imbalance in the brain which is not objectively detectable through routine investigatory procedures such as blood tests, x-rays or brain scans. Hence, being aware of the symptoms of BDD is important in order to prevent tragedies like this case from happening.