24-year-old male comes to you with the chief complaint that his nose is too big to the point of being hideous. He has been avoiding contact with others and has left his studies.
The patient states that his nose is a constant embarrassment to him and he would like it surgically reduced. He tells the physician that three previous plastic surgeons had all refused to operate on him because they said his nose was fine, but the patient states that “they just didn’t want such a difficult case”. You observe that the patient’s nose is of normal size and shape.
What do you think?
This is a typical manifestation of body dysmorphic disorder (also know as dysmorphophobia), that is an extreme feeling of dislike or concern about some aspect of the appearence in spite of a normal or nearly normal shape The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of this individuals are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder.
Complications: As the presentation of this patient, social withdrawal is common, and patients may be unable to work or to sustain relationships with others. Suicidal ideation is common, and completed suicide may occur.
Treatment: As this patients are loath to consider their pathologic concerns per se, they rarely stay in treatment. Both fluoxetine and clomipramine are effective in reducing the intensity of the patientsâ€™ concerns, and there is some preliminary evidence for the effectiveness of behavior therapy.
So, what you don’t like about yourself?
Jon Mikel IÃ±arritu, M.D.