Body dysmorphic disorder in the dermatology patient
Section snippets
Clinical picture
The patient with body dysmorphic disorder (BDD) has a firm belief that some aspect of his or her appearance is ugly, abnormal, or deformed.[1], [2], [3], [4], [5] This may be an obsessional worry or a frank delusion. Should there be an abnormality, it will be essentially imperceptible to the observer, yet it will virtually take over the patient’s life.2 The patient is consumed by feelings of shame and guilt, constantly worrying as to whether or not the problem is visible, whether everyone is
Epidemiology
Although it may occur in childhood, the onset of BDD is most common in adolescence, a time when the patient is coming to terms with body changes and when the opinion of coevals is crucial to the sense of well-being.[3], [8] Though present, the concern may not be acknowledged by the patient for a decade or more due to embarrassment and shame. Studies suggest that the gender incidence is equal, but clinical experience would suggest that there is a second peak in postmenopausal women.
Many studies
Etiology
What we know of the underlying causes of BDD can be viewed from two perspectives— developmentally and neuropsychiatrically. Developmentally, the way that one feels about oneself —one’s body image and one’s level of self-esteem—are generated very early in life, and for these to be realistic, the sense of touch is crucial.10 The love and caring of parents is transmitted to the infant primarily through parental touch. The infant, to whom parental love and caring are transmitted throughout infancy
Evaluation and diagnosis
It is important to remember that, were the patient able to accept the possibility of a psychiatric problem, the patient would not be in the dermatology office but rather that of the psychiatrist.
Appropriate questionnaires have been developed that patients can answer independently.17 These are clearly essential for large studies, but in the office, if one takes a careful history, if one is empathic, and if one asks open-ended questions, one can learn a great deal of diagnostic information from
Treatment
As noted earlier, were the patient emotionally ready to seek psychiatric help, that is the help that the patient would be seeking. For most of those who present to the dermatologist, such a suggestion is experienced initially as an insult, arousing only anger, even rage, and hostility. The goal of the dermatologist, then, is to reach a point where the symptoms can be viewed more realistically by the patient, and the possibility of psychiatric referral or a psychotropic drug be discussed.
Prognosis
BDD is a serious and potentially fatal psychiatric disorder, with physical—often dermatologic—features; yet, the diagnosis is often missed by psychiatrists because the physical symptoms conceal the psychiatric and by nonpsychiatric physicians because the psychiatric symptoms are not recognized. Untreated, the prognosis is poor. The condition is chronic and lifelong. Major depression, severe anxiety disorders, or personality disorders are part of the picture; 24-28% of patients are reported to
Conclusions
After a period of 3 to 4 months symptom free on a SSRI, attempts can be made to taper the drug, and although many patients will remain symptom free sometimes for months, recurrences are extremely common. These too, however, will usually respond to treatment. With regard to psychiatric referral, the therapeutic relationship and perhaps the feelings of dependency that have arisen and permitted the patient to accept dermatologic treatment sometimes stand in the way of referral to a psychiatrist,
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