CASE
“I will not show my mouth”: a case report of a young female patient with body dysmorphic disorder
Madhurima Ghosh, Krishan Kumar1, Rajiv Gupta2, Surender Kumar3
Senior Resident, 1Assistant Professor, 2Professor and Head, 3Junior Resident, Department of Psychiatry, Pt BD Sharma PGIMS, Rohtak, Haryana, India
Abstract
Body dysmorphic disorder (BDD) is clinically distinct from obsessive-compulsive disorder, eating disorders, and depression. In clinical settings, BDD usually goes unrecognised and undiagnosed. There is a preoccupation with either an ‘‘imagined’’ defect in one’s appearance or markedly excessive concern over a slight physical anomaly. The most common preoccupations are with the nose, skin, hair, eyes, eyelids, mouth, lips, jaw, and chin. We report a case of body dysmorphophobia in an adult female presenting with severe depression with suicidal ideation. She improved on selective serotonin reuptake inhibitor, and exposure and response prevention and cognitive behaviour therapy. Patients with BDD do not consult mental health professionals primarily. Rather, they seek treatment by general practitioners, dermatologists, dentists, and plastic surgeons. It is necessary that more clinicians are informed about the disorder.
Ghosh M, Kumar K, Gupta R, Kumar S. “I will not show my mouth”: a case report of a young female patient with body dysmorphic disorder. Dysphrenia. 2014;5:138-40.
Keywords: Somatoform Disorders. Obsessive-Compulsive Disorder. Suicide. Depression. Serotonin Uptake Inhibitors.
Correspondence: keshusony@rediffmail.com
Received on 28 December 2013. Accepted on 11 February 2014.
Introduction
Body dysmorphic disorder (BDD) was first described more than 100 years ago by Enrique Morselli, an Italian psychiatrist (1891) by using the term “dysmorphophobia”, defined as the fear of having a deformity.[1] The American Psychiatric Association classified BDD as a distinct somatoform disorder in 1987.[2] BDD has received particular attention in the media and in clinical research over the past ten years. BDD is an increasingly recognised somatoform disorder, clinically distinct from obsessive-compulsive disorder (OCD), eating disorders, and depression. However, BDD usually goes unrecognised and undiagnosed in clinical settings. It is important to recognise and accurately diagnose BDD because this often secret illness may be debilitating. Patients with BDD are preoccupied with a perceived physical defect, and this disrupts their lives by causing them considerable social distress and occupational dysfunction. They may seek care for their perceived defects from many subspecialties, including dermatology,[3] cosmetic surgery,[4] dentistry,[5] psychiatry, and family medicine. Sachan et al.[6] conclude that it is vitally important that dentists/orthodontists create adequate awareness of this condition, and identify its characteristics and symptomatology to allow for referral for diagnosis and appropriate management. These patients often want cosmetic and aesthetic procedures, which have become more affordable and available than ever before. However, cosmetic procedures rarely improve the symptoms of patients with BDD, and often add to their psychic distress; therefore, considering the presence of this disorder before performing aesthetic procedures has been recommended. Furthermore, numerous reports have documented patients with BDD committing violent acts toward physicians who perform procedures on them.[7]
BDD is defined as a preoccupation with either an ‘‘imagined’’ defect in one’s appearance or where there is a slight physical anomaly, then the person’s concern is markedly excessive. The preoccupation is associated with many time consuming rituals such as mirror gazing or constant comparing.[8] BDD is sometimes considered a “female disorder” because the symptoms involve appearance. However, BDD appears as common or nearly as common in males as in females. The gender ratio appears to be in the range of 1:1 to 3:2 (female:male), although it has varied in different studies.[9] BDD appears to have more similarities than differences in males and females, but some gender differences have been found.[9-11] BDD usually begins during early adolescence, although treatment seeking for BDD is delayed an average of approximately 11 years after illness onset.[12]
The most common preoccupations are with the nose, skin, hair, eyes, eyelids, mouth, lips, jaw, and chin. However, any part of the body may be involved and the preoccupation is frequently focused on several body parts. Complaints typically involve perceived or slight flaws on the face, the size of body features (too small or too big), hair thinning, acne, asymmetry or lack of proportion. Sometimes, the complaint is extremely vague; it may amount to no more than the patient feeling generally ugly. Shame results from the anticipation of negative reactions from others. BDD is associated with poor self-esteem, impaired functioning, such as lowered overall academic performance and excessive school absences due to self-consciousness, embarrassment, and avoidance. Such patients have a poor quality of life, are socially isolated, depressed, and at high risk of committing suicide. Lifetime rates of suicide ideation range from 58% to 78%,[12] with adolescents having even higher rates (81%).There is evidence for the benefit of cognitive behaviour therapy (CBT), exposure and response prevention (ERP) therapy, and selective serotonin reuptake inhibitors (SSRIs) in high doses.
We report a case of body dysmorphophobia in an adult female presenting with severe depression with suicidal ideation.
Case summary
A 20-year-old unmarried female educated up to Xth class presented with a severe depressive episode with suicidal ideation for a period of about two months. On interview, she revealed that she felt worthless as her body was excessively thin, and her teeth were ‘dirty’ and protruded. She was firm in her belief about her misshapen teeth and too skinny appearance which began about six months back when she took admission in a co-education college for a course in Junior Basic Teachers. It had actually started when one of her male classmates commented on her slim figure. Since then she started comparing her body with other girls. She spent hours thinking about her skinny body and started wearing loose clothes in order to hide her body contour. Though her friends assured her she had a perfect figure, patient was not convinced and kept on asking her friends repeatedly about her thin built. She worried that no boy would ever like to marry her. At around the same time, few classmates made fun of a teacher who had big incisor teeth that were protruded outside the lips. Since then patient started to believe that her teeth were also misshapen and were matter of joke. Though patient’s incisor teeth were slightly bigger and protruded than rest of the pairs, this neither concerned her nor was ever pointed out by anyone before. But from now onwards, this added to her despair and she could not just resist of being preoccupied with her looks. She started talking covering her mouth with her hand or clothing. She would check her teeth in the mirror for several times daily and carried a small pocket mirror. She would notice the built and teeth of other girls in her college and neighbourhood, and would compare herself to them. She started repeatedly asking her family members whether she looked ugly due to her teeth and would not be pacified by their reassurances. Instead she started avoiding meeting new people, or going out. Even if she went out, she preferred to speak less. She would not participate in class discussions and not open her mouth even when asked a question in the class despite knowing the answer. She remained preoccupied with the thoughts of her teeth and built for most of the times. She had limited control over her thoughts and almost remained engrossed for about half a day. During extreme preoccupations, she would fear of rejection from friends and experience bodily uneasiness, palpitations, and sweating lasting for few minutes. Though at times she considered this to be excessive, trying to deviate her mind but failed invariably. She requested several times to her father to take her to a dentist but he refused by saying that nothing was wrong with her.
Gradually, she stopped going to college and became totally housebound because she was extremely ashamed of her looks. She spent almost the entire day in her bedroom, stopped watching her favourite television shows, or doing household works. Sometimes, she would cry helplessly. She also started to consider her life useless and thought of ending her life. She gathered some pesticides from the store though couldn’t have enough courage to consume them. Being guilty of her intensions, she disclosed this to her mother. Consequent to this, she was brought to the outdoor of our psychiatry department. At admission, her mood was depressed and her drive reduced. She cried often and reported anhedonia, hopelessness and loss of interest, and suicide ideation.
Up to ten times a day, she went to the washroom to check her teeth. She did not interact with other patients and would always keep comparing with their teeth. She was constantly preoccupied with thoughts about it.
The girl was the eldest daughter of a lower middle socioeconomic family. No particular problems in family interaction could be assessed and there was no family history for psychiatric disorders. She was described by her parents as being ambitious at school and a little reserved and shy towards her peers, with good inter-personal relationships with others. She had no previous sexual experience.
The patient stayed four weeks at inpatient care. She improved on fluoxetine 60 mg/day, and ERP and CBT.
Discussion
Patients with BDD do not consult mental health professionals primarily because of the somatic explanation of their concerns. Rather, they seek treatment by general practitioners, dermatologists, dentists, and plastic surgeons, resulting in low prevalence in clinical psychiatric populations. To date, there has been little research concerning BDD.
Along with BDD, this patient in the case report suffered from typical comorbid features, namely severe depressive episode (the tenth edition of the International Classification of Diseases and Related Health Problems, ICD-10: F32.2), associated rituals, and social avoidance. According to the literature, depression is the most frequently related psychiatric disorder. Between 60% and 94% of patients with BDD have a lifetime diagnosis of depression.[13] Most individuals with BDD perform ritualistic behaviours related to their dysmorphophobic beliefs that resemble OCD compulsions. Between six per cent and 30% fulfill the diagnostic criteria for a concurrent OCD.[8,13,14] Virtually always, BDD results in social impairment, in particular avoidance of social interactions. Available studies show a percentage for social phobia in BDD patients varying between ten per cent and 43%.[8,13,15]
The dysmorphophobic symptoms were treated successfully with ERP. The girl’s social and occupational functioning had improved distinctly. Several studies published in recent years report that up to 70% of patients with BDD benefit from systematic exposure to avoided situations and prevention of anxiety-reducing behaviours.[16] There is growing evidence that BDD symptoms, as well as comorbid depression, respond preferentially to SSRIs. Nehra et al.[17] reported effective treatment of BDD symptoms with CBT.
The case report shows that it is possible to obtain a satisfying outcome if BDD is diagnosed early and treated appropriately. Complications such as being housebound or suicide attempts, which occur in up to 25%, can thereby be avoided. Therefore, it is necessary that more clinicians are informed about the disorder. More scientific data are needed concerning epidemiology, aetiology, and treatment strategies.
Source of support: Nil. Declaration of interest: None.
References
1. Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. New York, NY: Oxford University Press; 2005.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 2002.
3. Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detection and treatment in a surgical dermatology practice. Dermatol Surg. 2004;30:1391-9.
4. Sarwer DB, Whitaker LA, Pertschuk MJ, Wadden TA. Body image concerns of reconstructive surgery patients: an underrecognized problem. Ann PlastSurg. 1998;40:403-7.
5. Herren C, Armentrout T, Higgins M. Body dysmorphic disorder: diagnosis and treatment. Gen Dent. 2003;51:164-6.
6. Sachan A, Chaturvedi TP, Adit. Body dysmorphic disorder: a new concern for dentists. Dysphrenia. 2012;3:134-6.
7. Cotterill JA. Body dysmorphic disorder. DermatolClin. 1996;14:457-63.
8. Phillips KA, McElroy SL, Keck PE Jr, Pope HG Jr, Hudson JI. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry. 1993;150:302-8.
9. Phillips KA, Menard W, Fay C. Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatry. 2006;47:77-87.
10. Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J NervMent Dis. 1997;185:570-7.
11. Perugi G, Akiskal HS, Giannotti D, Frare F, Di Vaio S, Cassano GB. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J NervMent Dis. 1997;185:578-82.
12. Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Res. 2006;141:305-14.
13. Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry. 1996;169:196-201.
14. Phillips KA, McElroy SL, Keck PE Jr, Hudson JI, Pope HG Jr. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull. 1994;30:179-86.
15. Hollander E, Cohen LJ, Simeon D. Body dysmorphic disorder. Psychiatr Ann. 1993;23:359-64.
16. Gomez-Perez JC, Marks IM, Gutierrez-Fisac JL. Dysmorphophobia: clinical features and outcome with behavior therapy. European Psychiatry. 1994;9:229-35.
17. Nehra DK, Bathla JC, Kumar P, Kumar V. Psychological management of body dysmorphic disorder. Dysphrenia. 2012;3:183-6.
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.