Body dysmorphic disorder: Borderline category between neurosis and psychosis
Mr. S is a 27-year-old male from middle socio-economic status. The patient was referred to psychiatry outpatient department from the plastic surgery department for clearance for rhinoplasty surgery. Patient was interviewed in detail and his history dated back to 17 years of age when he was in his final year of schooling. He started noticing pimples and acne on his face, which embarrassed him to face his peers. He observed that few of the acne cleared, but few on the face left black marks and those on the nose turned into comedones. Most of them cleared with the treatment from a dermatologist. But the patient's concern with the healed scars on the face and nose started increasing and he started becoming preoccupied with them. He felt embarrassed to face his classmates and would feel shy to face the public or relatives visiting his house.\nThe patient adopted measures like covering his nose with his hands while speaking to others or while listening to the lectures in the class so as to hide the marks. Over a period of time, he started developing rituals such as repeatedly watching his nose in the mirror, frequently washing his face after he returns back home from outside, applying powder over the nose to cover up the imagined area of scars on the nose, and trying to reshape his nose on his own using a stone, which resulted in bleeding and worsening of the condition.\nThe patient developed anxiety in social situations because of his referential thinking involving his imagined ugly appearance. He also developed misinterpretations of other people's behavior and comments linking them to his facial disfigurement. He spent enormous amount of time and money in reshaping his nose, at times resorting to stealing money from home. He developed depressed mood, death wishes, and suicidal thoughts as a result of lack of improvement with treatment from various doctors. Patient had frequent change of jobs giving the reason as his inability to cope up with works involving social contact as a result of his ugly nose. He also started attributing his failures in academics and professional life to the imagined deformity in the nose. The patient did have recurrent suicidal ideation secondary to preoccupation with imagined deformity and occupational dysfunction, but there was no active attempt.\nThe patient did have history of stammering since childhood, which exacerbated after his social anxiety increased. He has a history of alcohol and tobacco abuse. He is the first among his five siblings. His mother used to be very critical of his appearance from his childhood. There is family history of stammering, but there was no other significant mental illness in the family. He had difficult temperament from his childhood, although adequate information could not be got.\nAt the time of presentation to us, the patient had non pervasive sad mood, decreased concentration in his work, significant social anxiety, and avoidance of social situations due to referential thinking, stammering, strong beliefs that his nose is ugly and deformed (amounting to delusional level) with absent insight, and he attributed all his failures to the physical problem. There was significant impairment in social, occupational, and academic functioning. There were obsessions related to contamination and compulsive washing, checking, and obsessive images, blasphemous thoughts, and sexual obsessions.\nThe patient was diagnosed to have BDD-delusional variant with obsessive compulsive disorder mixed type, social anxiety disorder, dysthymia with mild depressive episode without somatic complaints, and stammering, according to DSM-IV criteria.