Body dysmorphic disorder

Etiological factors and treatment challenges in an adolescent male with body dysmorphic disorder: A case report

There are very few existing reports in adolescents about the clinical presentation and treatment challenges associated with body dysmorphic disorder coexisting with suicidal behaviour. This case report describes a 13-year old male with body dysmorphic disorder, who was completely convinced that his belief related to the disorder is true (delusional belief) and therefore had no insight into his condition. His preoccupation with the shape of his nose progressed significantly over a 2-year period to the extent that he wore a surgical mask on a daily basis to camouflage the perceived defect. The distress due to the persistent preoccupation and intrusive thinking became so severe that he started to experience suicidal ideation and attempted suicide twice with no harm sustained. This case report focuses on three treatment challenges faced by the treating team: the need of continued treatment with pharmacotherapy and psychotherapy following a cosmetic procedure, the impact of the mother’s preoccupation with her physical appearance on the recovery of the young person, and the management of suicidality. We have also highlighted the probable causative factors of the development of the illness in this patient which are consistent with the established aetiology of body dysmorphic disorder.

Body dysmorphic disorder in a sample of cosmetic surgery applicants

Body dysmorphic disorder (B.D.D.) consists of a preoccupation with an imagined or slight physical defect. This study is the first European report on prevalence and several clinical and functional characteristics of patients with B.D.D. in a cosmetic surgery setting. Comparisons with defect- and severity-matched subjects without B.D.D. were also performed.

Case report of body dysmorphic disorder in a suicidal patient

Few reports exist about the treatment of body dysmorphic disorder (BDD) in patients who are suicidal. This case report describes a 19-year-old male with BDD who had delusional-intensity beliefs about facial disfigurement that had gradually intensified over a 2-year period. However, he was initially misdiagnosed with depression partly because he was admitted immediately after a suicide attempt that was associated with depressive symptoms and social withdrawal, symptoms that subsequently proved to be secondary to his BDD. The symptoms resolved completely and his social functioning returned to normal after 8 weeks of inpatient treatment with fluoxetine and cognitive behavioral therapy. This report is a reminder that suicidal behavior and ideation can have many causes; to avoid misdiagnosis and inappropriate treatment, clinicians should consider other possibilities before assuming that suicidal behavior or ideation is the direct result of depression. We discuss the many changes in the understanding and diagnostic classification of BDD since it was first reported by Enrico Morselli in 1886.

Case report of body dysmorphic disorder in a suicidal patient

Few reports exist about the treatment of body dysmorphic disorder (BDD) in patients who are suicidal. This case report describes a 19-year-old male with BDD who had delusional-intensity beliefs about facial disfigurement that had gradually intensified over a 2-year period. However, he was initially misdiagnosed with depression partly because he was admitted immediately after a suicide attempt that was associated with depressive symptoms and social withdrawal, symptoms that subsequently proved to be secondary to his BDD. The symptoms resolved completely and his social functioning returned to normal after 8 weeks of inpatient treatment with fluoxetine and cognitive behavioral therapy. This report is a reminder that suicidal behavior and ideation can have many causes; to avoid misdiagnosis and inappropriate treatment, clinicians should consider other possibilities before assuming that suicidal behavior or ideation is the direct result of depression. We discuss the many changes in the understanding and diagnostic classification of BDD since it was first reported by Enrico Morselli in 1886.

Screening for Body Dysmorphic Disorder in a Dermatology Outpatient Setting at a Tertiary Care Centre

Context:

A distressing pre-occupation with an imagined or slight defect in appearance with a marked negative effect on the patient's life is the core symptom of body dysmorphic disorder (BDD).

Aim:

To screen the patients attending a dermatology clinic at a tertiary care centre for BDD using the BDD-dermatology version (DV) questionnaire.

Settings and Design:

This cross-sectional study enrolled 245 consecutive patients from the dermatology outpatients clinic.

Methods:

The demographic details were collected and the DV of BDD screening questionnaire was administered. A 5-point Likert scale was used for objective scoring of the stated concern and patients who scored ≥3 were excluded from the study.

Statistical Analysis Used:

The results were statistically analysed. Differences between the groups were investigated by Chi-square analysis for categorical variables, and Fisher exact test wherever required.

Results:

A total of 177 patients completed the study, and of these, eight patients screened positive for BDD. The rate of BDD in patients presenting with cosmetic complaints was 7.5% and in those with general dermatology, complaints were 2.1%, with no significant difference between the two groups (P = 0.156). Facial flaws (62.5%) were the most common concern followed by body asymmetry (25%).

Conclusion:

The rates of BDD found in this study are comparable but at a lower rate than that reported in literature data.

Do mental health and self-concept associate with rhinoplasty requests?

SUMMARY

Considering the increasing tendency towards cosmetic rhinoplasty and conflicting data in this regard, and in order to assess the role of mental health and self-concept in rhinoplasty patients, this study was performed at Taleghani Hospital in Tehran during 2003-2004. This was a case-control study of 52 rhinoplasty patients admitted to the ear, nose and throat (ENT) and oral and maxillofacial surgery (OMFS) wards of Taleghani Hospital and 52 control subjects who were matched according to age, gender, marital status, economic state, education level and occupation with the former group. Data were gathered using the 'General Health Questionnaire-28' and 'Roger's Self-Concept questionnaire', and then were analysed by t, Pearson, Chi-square and Fisher's exact tests. The comparison of mental health (including the total score and the scores of subscales for depression, anxiety, somatic complaints, and social incompatibility) and self-concept between rhinoplasty patients and the control group has not been shown to be statistically different. It seems that there is no relationship between mental health, self-concept and the decision to undergo rhinoplasty. However, more elaborate studies are needed to bring the demographic, sociocultural and psychological factors into consideration.

Issues in the pharmacological treatment of obsessive-compulsive disorder

AIMS

Obsessive-compulsive disorder (OCD) preferentially responds to a class of antidepressants called serotonin reuptake inhibitors (SRI). This review discusses certain issues unique to pharmacological treatment of OCD: choice of SRI, dose and duration of treatment, options after first failed SRI trial and treatment of SRI non-responders.

METHODS

We performed a MEDLINE search for pharmacotherapy studies published until December 2006. In addition, the reference sections of major articles, and reviews were also screened. We also considered clinical guidelines and narrative reviews in writing this review.

RESULTS

The SRIs are equally effective in treating OCD. Meta-analyses suggest that clomipramine may be superior to other SRIs. OCD tends to respond to higher doses of SRIs than that used to treat depression. Response to treatment is usually delayed and may take up to 8-12 weeks. Atypical antipsychotics are the only proven augmenting agents in SRI non-responders. Cognitive behaviour therapy (CBT) is an effective treatment strategy in treating OCD and possibly has a role in treating SRI non-responders.

DISCUSSION

Side effect profile and drug-drug interactions largely determine the choice of SRI. Those who fail to respond to one SRI trial may well respond to another SRI trial. Clomipramine is recommended if 2-3 trials of SRIs fail to produce response. Atypical antipsychotics are the first-line augmenting agents in SRI non-responders. CBT should be considered in all patients with OCD and is a potential option in SRI non-responders.

CONCLUSION

OCD is a chronic and debilitating disorder. In responders, SRIs have to be continued in the same doses (if possible) for a minimum of 1-2 years and may be lifelong in those with persistent symptoms and in those with multiple relapses. CBT has to be offered in combination with SRIs wherever facilities for CBT exist.

A sociodemographic, phenomenological, and long-term follow-up study of patients with body dysmorphic disorder in Brazil

OBJECTIVE

The main characteristic of body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance in a normal-appearing person or an excessive preoccupation with appearance in a person with a small physical defect. In this non-controlled study, our objective was to describe the socio-demographic, phenomenological, and long-term outcome features of a Brazilian sample of patients with BDD.

METHODS

We performed a chart-review of the 166 patients who attended the Obsessions, Compulsions, and Impulsions Subprogram of the Institute of Psychiatry of the Federal University of Rio de Janeiro, Brazil, during the period between 1998 and 2005.

RESULTS

Twenty patients (12%) had clinically significant BDD. This sample was characterized by a predominance of female (n = 11; 55%), single or divorced (n = 18; 90%), and economically unproductive patients (n = 17; 85%). We found an average of 2.5 current imagined defects per patient. The most frequently reported body parts of excessive concern were the overall appearance, size or shape of the face (n = 7; 35%), the skin (n = 6; 30%), the hair (n = 6; 30%), the nose (n = 5; 25%), and the body build and weight (n = 5; 25%). Most individuals exhibited a chronic condition (n = 13; 65%) and kept the same concerns during the course of the disorder (n = 12; 60%). All patients displayed compulsive behaviors, including recurrent mirror checking (n = 14; 70%), camouflaging (n = 13; 65%), reassurance seeking by means of repetitive questioning of others (n = 9; 45%), and excessive use of cosmetics (n = 7; 35%). Two patients reported "do-it-yourself" surgeries. Seven patients had current suicidal ideation (35%). Six patients (30%) showed no insight over their dysmorphic beliefs. Fifteen patients (95%) exhibited psychiatric comorbidities, mostly obsessive-compulsive disorder (OCD) (n = 14, 70%) and major depressive disorder (n = 11; 55%). The majority of patients were treated naturalistically with serotonin reuptake inhibitors (n = 15; 75%), either solo or in association with antipsychotics (n = 10; 50%). Nevertheless, only 5 (25%) responded favorably to treatment during the long-term follow-up (CGI < or = 2).

CONCLUSIONS

BDD is a severe disorder that is frequently associated with other psychiatric conditions and responds poorly to treatment in the naturalistic setting. No significant trans-cultural variations were identified in the comparison between Brazilian, North American, and European samples.

Body dysmorphic disorder in adult orthodontic patients

INTRODUCTION

Body image plays an important role for patients seeking orthodontic treatment. It affects how patients feel about their physical appearance and, in extreme cases, can lead to subjective fears of ugliness. When there is a physical defect that, although within normal limits, seems far more noticeable to the patient, this may be diagnosed as body dysmorphic disorder (BDD). This interview-based study was designed to assess BDD in adults attending the Orthodontic Department at the Eastman Dental Hospital in London for their initial consultations for orthodontic treatment and also in the general public.

METHODS

A total of 70 members of the general public and 40 patients, all over 18 years of age, were assessed. The BDD modification of the Yale-Brown obsessive compulsive scale was used for diagnosis of BDD.

RESULTS

BDD was diagnosed in 2 members of the general public (2.86%) and 3 patients (7.5%).

CONCLUSIONS

It is important to have an understanding of body image and to be able to identify orthodontic patients who have BDD. These patients are rarely satisfied with the results of treatment, and it is therefore important to recognize them to avoid unnecessary treatment and to refer them for appropriate management.

Pharmacotherapy for body dysmorphic disorder: treatment received and illness severity

BACKGROUND

Research on pharmacotherapy received by individuals with body dysmorphic disorder (BDD), a relatively common and impairing disorder, is very limited.

METHODS

We examined past and current pharmacotherapy received by 151 individuals with BDD who were recruited from diverse sources.

RESULTS

72.9% of subjects had received psychotropic medication. The most common type ever received was an SRI (65.6%), followed by non-SRI antidepressants (41.1%) and benzodiazepines (27.2%). Subjects with greater lifetime impairment due to BDD were more likely to have received pharmacotherapy, and subjects with lifetime OCD or greater lifetime impairment due to BDD were more likely to have received an SRI specifically. Subjects revealed their BDD symptoms to only 41.0% of pharmacotherapists. Only 12.9% of SRI trials were considered optimal for BDD, and an additional 21.5% were considered minimally adequate. SRI trials that were considered optimal or at least minimally adequate for BDD were associated with greater improvement in BDD and less severe current BDD symptoms than non-optimal or inadequate SRI trials.

CONCLUSIONS

A high proportion of individuals with BDD receive pharmacotherapy, primarily SRIs, although most SRI trials appear inadequate for BDD. SRI treatment that was considered adequate was associated with greater improvement in BDD and less severe BDD symptoms.

Obsessive-compulsive disorders and dermatologic disease

Obsessive-compulsive disorder and obsessive-compulsive spectrum disorders are often associated with dermatologic manifestations. The phenomenology is discussed and possible animal models explored. Treatment involves both pharmacotherapy and cognitive behavior therapy. Many of these patients experience considerable shame over their behavior and may be reluctant to acknowledge the existence of a psychiatric disorder. The dermatologist's approach to this patient is discussed.

Pathophysiology of obsessive–compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by repetitive intrusive thoughts and compulsive time-consuming behaviors classified into three to five distinct symptom dimensions including: (1) aggressive/somatic obsessions with checking compulsions; (2) contamination concerns with washing compulsions; (3) symmetry obsessions with counting/ordering compulsions; (4) hoarding obsessions with collecting compulsions; and (5) sexual/religious concerns. Phenomenologically, OCD could be thought of as the irruption of internal signals centered on the erroneous perception that "something is wrong" in a specific situation. This generates severe anxiety, leading to recurrent behaviors aimed at reducing the emotional tension. In this paper, we examine how the abnormalities in brain activity reported in OCD can be interpreted in the light of physiology after consideration of various approaches (phenomenology, neuropsychology, neuroimmunology and neuroimagery) that contribute to proposing the central role of several cortical and subcortical regions, especially the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), the dorsolateral prefrontal cortex (DLPC), the head of the caudate nucleus and the thalamus. The OFC is involved in the significance attributed to the consequences of action, thereby subserving decision-making, whereas the ACC is particularly activated in situations in which there are conflicting options and a high likelihood of making an error. The DLPC plays a critical part in the cognitive processing of relevant information. This cortical information is then integrated by the caudate nucleus, which controls behavioral programs. A dysfunction of these networks at one or several stages will result in the emergence and maintenance of repetitive thoughts and characteristic OCD behavior.

Cognitive-behavior therapy for self-injurious skin picking. A case series

Self-injurious skin picking is characterized by repetitive, ritualistic, or impulsive skin picking that leads to tissue damage and causes significant distress or impairment in daily functioning. Little is known about effective behavioral or cognitive-behavioral treatments for self-injurious skin picking. As described by Azrin and colleagues, habit reversal is a promising behavioral treatment for modifying nervous habits or tics. To the authors' knowledge, only one case series currently exists in the literature that shows self-injurious skin picking, in the absence of an underlying dermatological condition or without psychiatric comorbidity, can be successfully treated with habit reversal. In the current article, the authors describe the implementation and outcome of cognitive-behavior therapy for three patients with severe self-injurious skin picking, two of which had psychiatric comorbidity.

The significance of the concept of obsessive-compulsive spectrum disorder to the treatment of chronic nonmalignant pain

The concept of an obsessive-compulsive spectrum of disorders has become useful. This article reviews what has been learned about these conditions (especially in the last few years), and how this information may be helpful to clinicians and researchers who work with patients with chronic nonmalignant pain.