The authors’ observations
This case involves challenging ethical, legal, and countertransference issues. One of the first dilemmas the treatment team encountered was the decision to continue the involuntary hold for observation and assessment. The ED physician and psychiatric resident were faced with telling a fellow physician that he had to remain in the hospital despite his adamant desire to leave. Dr. T’s articulate arguments against staying in the hospital were addressed in order to deliver needed medical treatment. The psychiatric, surgical, and internal medicine teams discussed these countertransference concerns extensively during Dr. T’s hospitalization.
Clearly, Dr. T demonstrated poor judgment by operating on himself, and we aimed to ensure that he received appropriate psychiatric follow-up, but it could not be mandated. After intense and strongly debated ethical and legal discussions with the hospital’s ethicists and risk management team, we determined that we could not file a report with the state medical board because there was no evidence of incompetence, malpractice, or imminent risk to patients. A detailed description of these discussions is omitted from this article to preserve Dr. T’s confidentiality. However, Dr. T will have to disclose and explain the involuntary psychiatric hold on his next medical license renewal.
Our decision was influenced by Phillips,13 who found that although patients with BDD may have minimal insight into their illness, “their judgment remains intact in areas unrelated to their body image problem. Attention span and memory are well preserved, and physical and neurologic examinations are normal.” Although Dr. T meets criteria for BDD, mental illness in physicians is not synonymous with impairment.19
BDD treatment options
With medications and psychotherapy, patients with BDD generally have a good prognosis. A recent meta-analysis found that SSRIs and cognitive-behavioral therapy are effective treatments for BDD.20 In general, higher doses of SSRIs are needed to treat BDD compared with depression. Other medications with evidence of efficacy for BDD include the serotonin norepinephrine reuptake inhibitor venlafaxine21 and the anticonvulsant levetiracetam.22 However, clinicians often don’t have the opportunity to try these approaches because BDD patients are difficult to engage in treatment, as is evident in Dr. T’s case. Innovative approaches that combine practical and evidence-based strategies have been manualized.23 These approaches can help clinicians engage BDD patients in treatment and recognize underlying issues of distorted body image.
Related Resources
- BDD Central. www.bddcentral.com.
- Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. New York, NY: Oxford University Press; 2005.
Drug Brand Names
- Alprazolam • Xanax
- Levetiracetam • Keppra
- Propranolol • Inderal
- Sertraline • Zoloft
- Venlafaxine • Effexor
Disclosure
Dr. Rapaport receives grant/research support from the National Institute of Mental Health and the National Center for Complementary and Alternative Medicine and is a consultant for Affectis Pharmaceuticals, Methylation Sciences, PAX Pharmaceuticals, and Johnson and Johnson Pharmaceuticals.
Drs. Rafin and Pimstone report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgement
The authors wish to thank Dr. Kristine Andrade for editorial assistance. We also wish to thank the Institutional Review Board at Cedars-Sinai Medical Center for its review and approval of this case report, and Dr. T for his consent to publish it.