Let’s talk about Body Dysmorphic Disorder briefly. So here’s an example. “A 25-year-old single
man spends hours everyday looking into the mirror. He is convinced that a scar above his lip
makes him look unattractive. He stopped going out with friends and now works from home because
he’s so concerned about the scar that he believes he is grotesque and can’t go out into public.
So he comes in to the doctor’s office asking for help to conceal his scar. On inspection, the
doctor finds the scar is barely even visible and there is really no intervention that would be
ethically recommended but the man says that regardless he wants a referral to a plastic surgeon."
So body dysmorphic disorder is really a preoccupation with body parts that are perceived by
an individual somehow being flawed and patients will often perceive themselves as being grotesque.
It’s extreme self-consciousness. It can lead to isolation and excessive focus on body image
with staring in the mirror for hours and during the day and it can also lead to multiple and very
expensive plastic surgery visits. Body dysmorphic disorder is imagined ugliness and it was first
described over 100 years ago. It tends to affect females more than males, more common in
unmarried people and it’s an illness of youth so usually late teens or early 20’s are affected.
About 90% of people actually have a co-existing depressive disorder, 70% will have anxiety
and about a third of people may have a psychotic disorder. So here are the diagnostic criteria.
You’re looking for a patient who believes that they have a facial deformity, asymmetry of
something on their body but they’re too ashamed to present for treatment. They frequently check
and groom themselves, they may try to compensate for an imagined anomaly and complications
will often lead to social isolation. So, our man who is seeking out a plastic surgeon to correct a
barely visible scar, that sounds like body dysmorphic disorder. Well, how would you go about
treating this disorder? Surgeries and dermatologic procedures are routinely unsuccessful
because once they are done, the patient just finds something else to ruminate about. Antidepressants
like SSRIs can be helpful in patients especially for those who have a comorbid depression, which
we know does go hand in hand with body dysmorphic disorder. Now let’s talk about pain. So, what
are pain disorders? Well, they are prolonged severe discomfort without any adequate medical
explanation. Pain often coexists with a medical condition but is not directly caused by it and
patients often have a history of multiple visits to their doctors and this can be acute under 6
months or it can be chronic. Females tend to be more affected and usually it comes on around
age 30 to 50 and there is an increased incidence in first degree relatives. There’s also increased
incidence in blue-collar workers, people who are susceptible to incurring injuries and patients
have a very high incidence of comorbidities like depression, anxiety and also substance abuse.
When it comes to pain, it’s imperative that you first rule out any organic or general medical
cause of the pain. The differential diagnosis beyond that will include hypochondriasis and also
malingering. Note that analgesics are actually not helpful unless there’s a physical or medical
problem contributing to pain. When it’s a pain disorder from a psychiatric standpoint, analgesics
won’t help and in fact patients will only become dependent on them and they’re already at high
risk for substance abuse. You might try treating with an SSRI or maybe a nerve block. Biofeedback
has been found to be very helpful as has hypnosis and psychotherapy is also a great way to help
your patient better understand and manage their pain through other techniques like mindfulness.