Psychiatry · Year 3 · from Psychiatry
Case 2: Body Dysmorphic Disorder
Patient Demographics
- Age: 22 years old
- Sex: Male
- Occupation: College senior (struggling to complete degree)
Chief Complaint
"My nose is deformed. I can't go out in public because everyone stares at it."
History of Present Illness
The patient presents with a 4-year preoccupation with perceived flaws in his appearance, specifically his nose, which he believes is "grotesquely large and asymmetrical." He spends 4-5 hours daily examining his nose in mirrors, taking photographs from different angles, and comparing his nose to others. He has consulted with 3 different plastic surgeons, all of whom told him his nose appears normal and declined to perform surgery. He has avoided attending classes in person for the past year, completing coursework online when possible, and failing courses that required in-person attendance. He avoids social situations, canceled plans to attend his best friend's wedding, and has not dated in 3 years because he believes no one could be attracted to him. When he must go out, he wears a hat pulled low and keeps his head down. He frequently asks his roommate for reassurance that his nose "doesn't look too bad today." He has researched surgical options overseas and is considering traveling abroad for rhinoplasty against medical advice.
Mental Status Examination
Appearance: Young man with objectively normal facial features including nose, appears uncomfortable being observed, turns face away from examiner
Behavior: Repeatedly touches nose, avoids direct eye contact, positions head to minimize examiner's view of his face
Speech: Normal rate and volume
Mood: "Hopeless about my appearance"
Affect: Anxious, dysphoric, ashamed
Thought Process: Linear but repetitive (returns to nose)
Thought Content:
- Preoccupation with perceived nose defect (not noticeable to examiner)
- Overvalued ideas about appearance (believes flaw is obvious to everyone)
- Referential thinking (believes others notice and judge his nose)
- Denies suicidal ideation currently but reports passive thoughts in past
- No homicidal ideation
Perceptions: No hallucinations
Cognition: Alert, oriented, intact
Insight: Poor - convinced appearance concerns are valid despite contrary evidence
Judgment: Impaired - considering unnecessary surgery abroad
Psychiatric Workup
Screening Tools:
- BDD-YBOCS (Yale-Brown OC Scale modified for BDD): 34 (severe)
- BDD Questionnaire (BDDQ): Positive screen
- PHQ-9: 18 (moderate-severe depression)
- Suicidal ideation screen: History of passive SI, currently denies
Diagnosis
Body Dysmorphic Disorder with Absent Insight/Delusional Beliefs (F45.22)
DSM-5 Criteria:
- Preoccupation with perceived defects in appearance not observable or appearing slight to others - present (nose appears normal)
- Repetitive behaviors in response to appearance concerns:
- Mirror checking - present
- Excessive grooming - present
- Reassurance seeking - present
- Comparing appearance to others - present
- Causes clinically significant distress or impairment - present (avoidance, academic failure)
- Not better explained by an eating disorder (no weight/shape concerns)
Insight specifier: Absent insight/delusional beliefs - completely convinced appearance beliefs are true
High-Risk Features:
- BDD has high suicide rates (suicidal ideation in 80%, attempts in 25%)
- Insight is poor (delusional variant)
- Considering surgery against medical advice
Treatment Plan
Pharmacotherapy:
- Start fluoxetine 20 mg daily
- Titrate to 60-80 mg (high doses needed for BDD, similar to OCD)
- May require doses up to 80 mg or switch to clomipramine
- If delusional insight, may augment with antipsychotic
Psychotherapy:
- CBT adapted for BDD
- Cognitive restructuring targeting appearance beliefs
- Exposure and response prevention:
- Exposure to avoided situations (going out without camouflage)
- Response prevention (limit mirror checking, no reassurance seeking)
- Perceptual retraining (reduce selective attention to perceived flaw)
ERP Targets:
- Reduce mirror checking to 2 brief checks daily (set timer)
- Eliminate reassurance-seeking from roommate
- Gradually increase time in public without camouflage (hat, positioning)
- Attend one in-person activity weekly
Safety:
- Assess suicide risk at each visit
- Safety plan in place
- Family involvement for monitoring
Address Cosmetic Surgery:
- Psychoeducation: Cosmetic surgery does NOT help BDD and often worsens symptoms
- Patients typically become preoccupied with surgical result or shift focus to new "flaw"
- Strongly advise against surgery; document discussion
Follow-up:
- Weekly visits initially
- BDD-YBOCS monitoring
- Suicide risk assessment ongoing