An Aberrant Presentation of Delusional Body Dysmorphic Disorder - Importance of Early Psychiatry Liaison

Sir,

Body dysmorphic disorder (BDD) is often under recognized and characterized by a chronic course and poor outcomes.[1] Given its predilection for presentation in medical or surgical settings, clinicians across the board should recognize BDD early to ensure appropriate interventions and avoid ineffective and potentially risky procedures often demanded by these patients.[2] Mr. A, 30-year-old unmarried male, presented to the orthopedic department with complaints of being “too short.” Having previously undergone Ilizarov surgical limb lengthening in both the legs for same complaints, he currently demanded “one more surgery immediately” despite being explained the potential risks. At this point, the patient was referred to psychiatric services for evaluation. Upon interviewing, Mr. A revealed that he had always felt unappealing because of his “short stature” since school days. He would often avoid social gatherings for this reason. Researching on methods to enhance his height became his preoccupation and while doing so, he stumbled on the Ilizarov procedure. To increase the chances of success, he chose to undergo the surgery at Russia. However, the surgery was “unsuccessful” and he also developed postoperative complications and required prolonged hospitalization. Yet, he was adamant on having repeated surgery and was not ready to consider any argument to the contrary. This rigid and inflexible belief about his perceived defect suggested a delusion. The BDD-Yale Brown Obsessive Compulsive Scale score was 28 indicating “severe” body image-related obsessions and compulsions.[3] Due to hostile attitudes toward the treating team and lack of insight, involving him in the therapeutic process was challenging.

This case highlights the unique challenges involved in initiating the therapeutic process among patients with BDD. The prior negative interactions with health-care providers and lack of insight were major hurdles in establishing a therapeutic alliance. Patients with BDD rarely present to psychiatric services as they are convinced about the “true” nature of their presumed deformity.[4] It is important to note that in the present case, the patient presented to psychiatric services after a delay of more than 10 years. Remaining undiagnosed and facing dissatisfaction with cosmetic procedures can worsen the symptoms of BDD and heighten the risk of self-harm.[5] In such scenarios, there is a need to initiate psychiatric treatment early and this may require extensive negotiations with patients. Such negotiations and psychoeducation are currently underway in the present case. To conclude, physicians and surgeons who are commonly the first contact medical personnel should be aware of the aberrant presentations of the disorder to initiate liaison with psychiatric services at the earliest, to prevent poor physical and psychiatric outcomes.