The authors’ observations
Dr. T does not meet DSM-IV-TR criteria for a current mood or anxiety disorder; however, he has taken medications for what he described as “situational anxiety.” This pattern is consistent with data suggesting that BDD patients feel an unusually high degree of stress in their lives.5 Crerand et al6 found that >60% of BDD patients had a lifetime history of an anxiety disorder.
Dr. T’s history highlights traits often observed in patients with BDD. As is common in men with BDD, he follows a rigorous exercise regimen.7 He also was a competitive athlete, and hypercompetitiveness has significant positive correlation with BDD symptoms.8 He is preoccupied with excessive body hair, which is more prevalent in men than in women with BDD.9 Dr. T’s work required a keen sense of aesthetics, and it has been observed that individuals with BDD have increased aesthetic sensitivity.10,11
Although many individuals with BDD struggle socially and financially, some BDD patients are successful and quite accomplished. In a study of 156 Pakistani medical students, 5.8% met criteria for BDD.12 In The broken mirror,13 BDD expert Dr. Katharine Phillips describes caring for many high-functioning health care professionals who suffer from BDD, yet “they provide their patients with superb care … many with this disorder are productive, some are very high achievers.”
EVALUATION: Bad scars
Dr. T has multiple surgical scars on his chest and abdomen (Photo), ecchymoses, and tenderness on palpation. His vital signs are within normal limits and he is otherwise medically healthy. Notable laboratory findings include elevated white blood cell count and platelets, and decreased hemoglobin.
A CT scan shows a large hematoma over the anterior abdominal wall extending toward the flanks with extensive subcutaneous emphysema. The peritoneum is intact. These findings raise the medical team’s concern about possible infection and vascular instability. The involuntary psychiatric hold for observation is continued after evaluation in the ED.
Photo Dr. T’s chest and abdomen during presentation to the ED
Note the asymmetry of the nipples and scarring from prior self-surgeries
The authors’ observations
There is a disconnect between Dr. T’s perception of his physical attributes and the treatment team’s observations. He perceives himself as marred by physical defects, while the treatment team sees him as a handsome and attractive person— excluding his scars from self-surgery.
Patients with BDD frequently are concerned about perceived physical defects that objective observers would consider slight or not noticeable. Three-quarters of individuals with BDD seek surgery or other medical treatment for their perceived physical flaws.4 Many patients minimize their BDD symptoms and their distress when talking with health care professionals.14 Approximately 20% of cosmetic surgery patients report ongoing psychiatric treatment at the time of surgery.15 Eighty-four percent of cosmetic surgeons state they have refused to operate on a patient because of BDD.16 However, it may be difficult for surgeons to distinguish a “perfectionist” from a patient with BDD.17 Even “positive” cosmetic surgery outcomes do not ameliorate BDD symptoms because most patients develop new areas of concern. In a small study of patients with minimal defects who requested cosmetic surgery, surgery did not reduce symptoms of BDD, disability, or psychiatric comorbidity in 6 out of 7 patients at 5-year follow up.18
Specialized medical equipment, such as surgical instruments and dermabrasion or laser hair removal devices, can be purchased on the Internet, which may increase the likelihood of individuals attempting procedures on themselves. Veale14 published a retrospective case series of patients who were turned down or unable to afford cosmetic surgery who performed self-surgery. These efforts did not lead to the desired effect, and patients continued to be plagued by their original concerns as well as self-inflicted scarring and damage.
Dr. T had the training and resources to perform cosmetic procedures on himself. Unfortunately, these efforts led to disfigurement. Phillips13 states that although self-surgery appears infrequently, it reflects the severe emotional pain and desperation felt by some patients with BDD. Self-surgery is associated with an increased rate of serious suicide attempts.14 Carefully monitor any BDD patient for suicidal ideation, intent, or plans.
TREATMENT: Refuses follow-up
Dr. T is admitted to the medical service and stabilized with IV fluids and antibiotics. The consultation-liaison service followed him during hospitalization. Because repeated interviews do not uncover grave disability or an imminent danger to himself or others, the involuntary psychiatric hold is discontinued. Dr. T declines psychiatric follow-up care, but says he would consider seeing a mental health professional in the future.