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Body Dysmorphic Disorder and a Prosthesis
Case Reports Body Dysmorphic Disorder and a Prosthesis ERIK ROSKES, M.D.
B
ody dysmorphic disorder (BDD) is an illness characterized by “a preoccupation with a defect in appearance” that is “either imagined, or, if a slight physical anomaly is present, markedly excessive,” according to DSM-IV. This illness has recently begun to receive increased attention (see, for example, Phillips,1,2 Phillips et al.,3,4 and Hollander et al.5). A MEDLINE literature review focusing on BDD (and variants thereof) and prosthesis revealed only one report6 of delusional monosymptomatic hypochondriasis (which would be diagnosed under DSM-IV as delusional disorder, somatic type) in which the focus of the disorder was an artifice (dentures). This article reports a case of BDD, without evidence of psychosis, in which the focus of the preoccupation is a prosthesis (eye). The case raises the question of the prevalence of body dysmorphic disorder in otherwise premorbidly psychiatrically healthy individuals who receive a prosthesis.
Case Report
Mr. M.. is a 27-year-old African American man referred to me in forensic consultation. Six years prior to the referral, he was a bystander in a shooting resulting in the loss of his right eye and the subsequent placement of a prosthesis. MRI at the time of the event revealed no brain injury, and a psychiatric consultation was not obtained. Before the injury, he was a successful college student-athlete, and he had no psychiatric history. After receiving his prosthesis, he lost his stereoscopic vision, and he had difficulty concentrating on his academic tasks because of eye strain. Mr. M.. is an only child in a high-achieving family. Both parents had Master’s-level education, and the expectation of the family was that he would be an academic success. During the initial year after the injury, Mr. M.. made an attempt to return Received November 6, 1998; revised January 8, 1999; accepted February 26, 1999. From the University of Maryland School of Medicine, Baltimore, MD. Address correspondence and reprint requests to Dr. Roskes, University of Maryland School of Medicine, 22 South Greene Street, Box 291, Baltimore, MD 21201; email: [email protected] Copyright 䉷 1999 The Academy of Psychosomatic Medicine.
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to college but was unable to do so. He reported that his inability to perform at school was related to the difficulty he had adjusting mentally and physically to life with one eye. About 1 year after the injury, at the time of the trial of his assailant, he became profoundly depressed and was hospitalized voluntarily for 2 days. However, he signed himself out of the hospital and did not follow up with outpatient treatment. His diagnosis at that time was major depression and posttraumatic stress disorder (PTSD). Body dysmorphic disorder was not diagnosed at the time of his hospitalization. Mr. M.. reported that after his injury, he began to view himself as “ugly” and as “half a man.” He developed excessive concern over the appearance of his prosthesis. He described feeling unease and discomfort with himself after this trauma and said “I can’t even stand to look at myself.” He became convinced that people around him could easily identify his prosthetic eye and began wearing glasses to hide it. He is reluctant to take off his glasses, and he never removes the prosthesis in the presence of others. He felt that his prosthesis directly interfered with his ability to be successful and indicated that his discomfort related to his overall self-concept as well as his external appearance. I was called to see him after he became involved with the law. He had started a business, and, in his mind, the success of the business was indicative of his success as a person and was a way of overcoming his perceived “ugliness.” He described the business as “my monument to those who felt I was washed up, who felt sorry for me. It made me somebody that nobody thought I could be.” When the business began to fail, his initial response was again to become severely depressed, feeling that the failure of his business meant that he, too, was a failure. He took to bed and stayed there for several weeks. He then decided he would do “whatever it took” (including helping drug dealers) to save the business. This led to an arrest and my consultation. During the interview, I observed Mr. M.. closely. I was unable to discern which eye was the prosthesis until he tapped it with his fingernail. Mr. M.. reported that he had been told this by many people, and he interpreted these reports as indications that “People just don’t understand—you can’t see everything with the naked eye.” Mr. M.. had fairly severe depressive pathology, but there was no evidence of psychosis, formal thought disorder, or ongoing PTSD symptomatology. My diagnoses included major depressive disorder, recurrent, severe PTSD by history; and body dysmorphic disorder. Because of the nature of the forensic consultation, I was not in a position to render treatment, though my suggestions included both psychopharmacologic and psychotherapeutic interventions. Psychosomatics 40:5, September-October 1999
Case Reports Discussion The primary differential diagnostic issue in this case was the role of the legal context as a source of secondary gain. The focus of my role as a forensic consultant was on the issue of sentencing, limiting the question to some extent. In my opinion, Mr. M. was not malingering his symptoms nor his distress, but it is a possibility that cannot be excluded on the basis of the above data alone. It is my opinion that his high level of premorbid functioning argued against significant personality pathology. Other considerations in this case are the role of confounding Axis I diagnoses. For instance, his concern with the appearance of the prosthesis could be ascribed to a general negativism within a major depressive disorder. One could ascribe his description of the prosthesis as the source of his feelings of worthlessness and hopelessness to a defensive projection of these painful feelings to the prosthesis. However, although the patient was suffering from a recurrent major depression at the time of my evaluation, he appeared also to be suffering from symptoms consistent with BDD. Also, his history argues for a separate diagnosis of BDD, because he continued to suffer with the concern even in the absence of severe depressive symptoms (as was the case during the initial, successful years of his business). Finally, comorbidity is common in BDD, with major depression reportedly carrying an 80% lifetime prevalence rate in individuals with BDD.4 Alternatively, the concern about the prosthesis could be viewed as a form of criterion B-4 for PTSD (“intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event”). This raises the question, which DSM-IV does not address directly, of the role of trauma in the development of BDD. Although it is possible that the current case could be interpreted as a manifestation of PTSD, it is my belief that this diagnosis cannot explain this patient. Although clearly having suffered from PTSD in the time immediately
after his traumatic eye injury, he did not continue to have acute PTSD symptoms after the final disposition of his assailant about 1 year after his injury. During my interview, he did not appear to meet criteria even for one of the symptom clusters within the PTSD classification. The diagnosis of BDD is supported by Mr. M.’s reported high levels of distress regarding the prosthetic eye. He repeatedly described his business as an extension of himself, and he blamed all of his failures on the “ugliness” of the prosthesis. When his initially successful business began to fail, he started engaging in inappropriate and illegal methods to shore up his projection of his feelings of hopelessness and worthlessness into the prosthesis by attempting to maintain his “successful” business, thereby maintaining the image of himself as a successful person. Although suffering from concurrent major depression and having a history of PTSD, as noted above, these diagnoses do not suffice to explain the distress related to the prosthesis. This is the first reported case of BDD in which the focus is a prosthesis. Unfortunately, because of the nature of the consultation, no information as to treatment responsiveness can be provided. However, there is no a priori reason to believe that the illness would respond any differently than in a typical case. Future research should focus on 1) the prevalence of BDD in individuals with prostheses; 2) comparisons of prevalence rates of BDD in individuals with prostheses caused by trauma vs. those resulting from other causes; and 3) examining the clinical characteristics and course of prosthesis-related BDD to BDD in the absence of prostheses. This case should stimulate psychiatrists working with patients who have prostheses to evaluate for prosthesis-specific concerns, even in cases in which the prosthetic device appears invisible. The author thanks Mark Ehrenreich, M.D., and Christine Skotzko, M.D., for their helpful comments during the preparation of this article.
References
1. Phillips KA: Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 1991; 148:1138–1149 2. Phillips KA: Body dysmorphic disorder: diagnosis and treatment of imagined ugliness. J Clin Psychiatry 1996; 57(suppl 8):61–65 3. Phillips KA, McElroy SL, Keck PE, et al: Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150:302–308 4. Phillips KA, McElroy SL, Hudson JI, et al: Body dysmorphic dis-
Psychosomatics 40:5, September-October 1999
order: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? J Clin Psychiatry 1995; 56(suppl 4):41–51 5. Hollander E, Cohen LJ, Simeon D: Body dysmorphic disorder. Psychiatric Annals 1993; 23:359–364 6. Mack PJ: Hairy dentures: a monosymptomatic hypochondriacal psychosis. Br Dent J 1985; 158:50–51
437
B
ody dysmorphic disorder (BDD) is an illness characterized by “a preoccupation with a defect in appearance” that is “either imagined, or, if a slight physical anomaly is present, markedly excessive,” according to DSM-IV. This illness has recently begun to receive increased attention (see, for example, Phillips,1,2 Phillips et al.,3,4 and Hollander et al.5). A MEDLINE literature review focusing on BDD (and variants thereof) and prosthesis revealed only one report6 of delusional monosymptomatic hypochondriasis (which would be diagnosed under DSM-IV as delusional disorder, somatic type) in which the focus of the disorder was an artifice (dentures). This article reports a case of BDD, without evidence of psychosis, in which the focus of the preoccupation is a prosthesis (eye). The case raises the question of the prevalence of body dysmorphic disorder in otherwise premorbidly psychiatrically healthy individuals who receive a prosthesis.
Case Report
Mr. M.. is a 27-year-old African American man referred to me in forensic consultation. Six years prior to the referral, he was a bystander in a shooting resulting in the loss of his right eye and the subsequent placement of a prosthesis. MRI at the time of the event revealed no brain injury, and a psychiatric consultation was not obtained. Before the injury, he was a successful college student-athlete, and he had no psychiatric history. After receiving his prosthesis, he lost his stereoscopic vision, and he had difficulty concentrating on his academic tasks because of eye strain. Mr. M.. is an only child in a high-achieving family. Both parents had Master’s-level education, and the expectation of the family was that he would be an academic success. During the initial year after the injury, Mr. M.. made an attempt to return Received November 6, 1998; revised January 8, 1999; accepted February 26, 1999. From the University of Maryland School of Medicine, Baltimore, MD. Address correspondence and reprint requests to Dr. Roskes, University of Maryland School of Medicine, 22 South Greene Street, Box 291, Baltimore, MD 21201; email: [email protected] Copyright 䉷 1999 The Academy of Psychosomatic Medicine.
436
to college but was unable to do so. He reported that his inability to perform at school was related to the difficulty he had adjusting mentally and physically to life with one eye. About 1 year after the injury, at the time of the trial of his assailant, he became profoundly depressed and was hospitalized voluntarily for 2 days. However, he signed himself out of the hospital and did not follow up with outpatient treatment. His diagnosis at that time was major depression and posttraumatic stress disorder (PTSD). Body dysmorphic disorder was not diagnosed at the time of his hospitalization. Mr. M.. reported that after his injury, he began to view himself as “ugly” and as “half a man.” He developed excessive concern over the appearance of his prosthesis. He described feeling unease and discomfort with himself after this trauma and said “I can’t even stand to look at myself.” He became convinced that people around him could easily identify his prosthetic eye and began wearing glasses to hide it. He is reluctant to take off his glasses, and he never removes the prosthesis in the presence of others. He felt that his prosthesis directly interfered with his ability to be successful and indicated that his discomfort related to his overall self-concept as well as his external appearance. I was called to see him after he became involved with the law. He had started a business, and, in his mind, the success of the business was indicative of his success as a person and was a way of overcoming his perceived “ugliness.” He described the business as “my monument to those who felt I was washed up, who felt sorry for me. It made me somebody that nobody thought I could be.” When the business began to fail, his initial response was again to become severely depressed, feeling that the failure of his business meant that he, too, was a failure. He took to bed and stayed there for several weeks. He then decided he would do “whatever it took” (including helping drug dealers) to save the business. This led to an arrest and my consultation. During the interview, I observed Mr. M.. closely. I was unable to discern which eye was the prosthesis until he tapped it with his fingernail. Mr. M.. reported that he had been told this by many people, and he interpreted these reports as indications that “People just don’t understand—you can’t see everything with the naked eye.” Mr. M.. had fairly severe depressive pathology, but there was no evidence of psychosis, formal thought disorder, or ongoing PTSD symptomatology. My diagnoses included major depressive disorder, recurrent, severe PTSD by history; and body dysmorphic disorder. Because of the nature of the forensic consultation, I was not in a position to render treatment, though my suggestions included both psychopharmacologic and psychotherapeutic interventions. Psychosomatics 40:5, September-October 1999
Case Reports Discussion The primary differential diagnostic issue in this case was the role of the legal context as a source of secondary gain. The focus of my role as a forensic consultant was on the issue of sentencing, limiting the question to some extent. In my opinion, Mr. M. was not malingering his symptoms nor his distress, but it is a possibility that cannot be excluded on the basis of the above data alone. It is my opinion that his high level of premorbid functioning argued against significant personality pathology. Other considerations in this case are the role of confounding Axis I diagnoses. For instance, his concern with the appearance of the prosthesis could be ascribed to a general negativism within a major depressive disorder. One could ascribe his description of the prosthesis as the source of his feelings of worthlessness and hopelessness to a defensive projection of these painful feelings to the prosthesis. However, although the patient was suffering from a recurrent major depression at the time of my evaluation, he appeared also to be suffering from symptoms consistent with BDD. Also, his history argues for a separate diagnosis of BDD, because he continued to suffer with the concern even in the absence of severe depressive symptoms (as was the case during the initial, successful years of his business). Finally, comorbidity is common in BDD, with major depression reportedly carrying an 80% lifetime prevalence rate in individuals with BDD.4 Alternatively, the concern about the prosthesis could be viewed as a form of criterion B-4 for PTSD (“intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event”). This raises the question, which DSM-IV does not address directly, of the role of trauma in the development of BDD. Although it is possible that the current case could be interpreted as a manifestation of PTSD, it is my belief that this diagnosis cannot explain this patient. Although clearly having suffered from PTSD in the time immediately
after his traumatic eye injury, he did not continue to have acute PTSD symptoms after the final disposition of his assailant about 1 year after his injury. During my interview, he did not appear to meet criteria even for one of the symptom clusters within the PTSD classification. The diagnosis of BDD is supported by Mr. M.’s reported high levels of distress regarding the prosthetic eye. He repeatedly described his business as an extension of himself, and he blamed all of his failures on the “ugliness” of the prosthesis. When his initially successful business began to fail, he started engaging in inappropriate and illegal methods to shore up his projection of his feelings of hopelessness and worthlessness into the prosthesis by attempting to maintain his “successful” business, thereby maintaining the image of himself as a successful person. Although suffering from concurrent major depression and having a history of PTSD, as noted above, these diagnoses do not suffice to explain the distress related to the prosthesis. This is the first reported case of BDD in which the focus is a prosthesis. Unfortunately, because of the nature of the consultation, no information as to treatment responsiveness can be provided. However, there is no a priori reason to believe that the illness would respond any differently than in a typical case. Future research should focus on 1) the prevalence of BDD in individuals with prostheses; 2) comparisons of prevalence rates of BDD in individuals with prostheses caused by trauma vs. those resulting from other causes; and 3) examining the clinical characteristics and course of prosthesis-related BDD to BDD in the absence of prostheses. This case should stimulate psychiatrists working with patients who have prostheses to evaluate for prosthesis-specific concerns, even in cases in which the prosthetic device appears invisible. The author thanks Mark Ehrenreich, M.D., and Christine Skotzko, M.D., for their helpful comments during the preparation of this article.
References
1. Phillips KA: Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 1991; 148:1138–1149 2. Phillips KA: Body dysmorphic disorder: diagnosis and treatment of imagined ugliness. J Clin Psychiatry 1996; 57(suppl 8):61–65 3. Phillips KA, McElroy SL, Keck PE, et al: Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150:302–308 4. Phillips KA, McElroy SL, Hudson JI, et al: Body dysmorphic dis-
Psychosomatics 40:5, September-October 1999
order: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? J Clin Psychiatry 1995; 56(suppl 4):41–51 5. Hollander E, Cohen LJ, Simeon D: Body dysmorphic disorder. Psychiatric Annals 1993; 23:359–364 6. Mack PJ: Hairy dentures: a monosymptomatic hypochondriacal psychosis. Br Dent J 1985; 158:50–51
437