History
A 26-year-old woman presents saying she needs referral to a plastic surgeon as her nose is too large. She feels that people constantly comment on her nose, behind her back. She feels her facial disfigurement has prevented her from developing positive relationships as she lacks confidence and never believes friends when they try to reassure her that her nose is fine. She rarely goes out as she is convinced that everyone stares at her and talks about her. She recently gave up her job as she was constantly late because it took her so long to apply her makeup to hide the disfigurement. She was also reluctant to move from the office to a receptionist role as she did not want to have to see people.
Mental state examination
Her appearance is healthy and there is no discernible abnormality with her nose. It is neither extreme in shape nor size. The woman presents as affable and communicative. She is however inclined to hide her face and especially her nose by using a leaflet even though she is wearing a floppy hat which covers most of her face. Her eye contact is variable. She appears somewhat nervous and her speech is rapid but only when she is talking about her nose. She does not describe herself as low in mood and does not appear depressed. She does not have active self-harm ideation and there is no evidence of psychosis.
Questions
•What is the diagnosis?
ANSWER 34
This woman has body dysmorphic disorder (BDD). She is preoccupied with a defect in her appearance that is imagined. For it to be a disorder it must lead to impairment in social or occupational functioning, and cause significant distress. The individual’s symptoms must not be better accounted for by another disorder, for example, thinking they are fat in the context of an eating disorder, or a depressive delusion. The defect is not recognized by other people. This dislike of the defect is more than the usual negative feelings that most people have about the way they look from time to time, as it significantly impacts on functioning, especially socially. The beliefs usually represent overvalued ideas, although occasionally when insight is absent the beliefs may be delusional in quality. In this case it is important to explore co-morbidities. Co-morbidity with other psychiatric disorders is common with three quarters of people with BDD, in that they may have either major depressive disorder, social phobia or obsessive-compulsive disorder at some point. It has been suggested that individuals with BDD are more likely to have avoidant personality disorder or dependent personality disorder which conforms to the introverted, shy and neurotic traits usually found in individuals with the disorder. Body dysmorphic disorder is sometimes called dysmorphophobia and is one of the hypochondriacal disorders.
Common symptoms of body dysmorphic disorder
There are preoccupations and ruminations about a perceived defect in appearance, which sometimes leads to obsessive or compulsive behaviours. Such behaviours might include regular checking of the relevant body part or checking in the mirror, intense avoidance of mirrors or images of themselves, attempts to hide the area of concern with make up and clothing and prolonged grooming. All of these would be to an intense degree. Some will withdraw from family or social life, becoming intensely self-conscious and often develop low self-esteem. If these aspects intensify the self-consciousness becomes paranoia that others are commenting on them, and the low mood and low self-esteem graduates to depression and ideas of self-harm. The person may seek regular reassurance from those close to them, regularly comparing themselves to others. Relationships and work can suffer, and it may lead to major depression, generalized anxiety, alcohol or drug abuse.
Many individuals with BDD repeatedly seek treatment from doctors as they attempt to correct the perceived ‘disfigurement’. Initial surgery is unlikely to help as the patient is rarely satisfied given that their concerns do not relate to genuine abnormal features. The overvalued ideas about disfigurement often remain or subtly alter, leading to ongoing or additional concerns. They usually accept psychiatric or psychological help reluctantly. It is a difficult disorder to treat. Psychodynamic approaches to therapy have not proven to be effective, but there has been some success with cognitive behaviour therapy (CBT). Selective serotonin reuptake inhibitors may help if there is a strong depressive component or features of OCD, but it would ideally be used alongside CBT.
• BDD is a difficult disorder to treat and psychological treatments are usually reluctantly accepted.
• Cognitive behaviour therapy is the treatment of choice.
KEY POINTS
History
A 38-year-old woman presents to the emergency department having taken an overdose some 6 hours ago. She is refusing to give consent for her blood to be taken for tests. She is also shouting ‘you’re not going to pump my stomach’. You are told that the psychiatrist should be called so he can put her on a Section 5 (2) of the Mental Health Act (MHA) to enable you to take bloods and enforce treatment.
She took the overdose after finding out that her husband of 15 years is leaving her. The overdose was impulsive. She wrote no note. She has three children who were in the house at the time of the overdose. She is adamant that there is no point in living, given she has been betrayed by her husband. She is sure her family will look after her children. You look up a handbook describing the Mental Health Act which outlines the main sections as shown in the box below.
Questions
•What is the role of the psychiatrist in this case?
•What are the key issues that need clarification?
• Section 2 – An assessment order which allows compulsory detention for 28 days.
• Section 3 – A treatment order which allows detention for 6 months.
• Section 4 – An order than can be applied by a single clinician to admit a patient while arrangements are made for further assessment. Detention is for up to 72 hours.
• Section 5(2) – An order that allows detention of existing in-patients for 72 hours.
Main sections of the Mental Health Act