Case presentation - Body

Dysmorphic Disorder with

psychotic features
Dr Halit Ibrahimi, M.D.
Resident in Psychiatry, 4th year
Clinical University Centre of Kosova, Prishtina
PATIENT HISTORY
A 17 years old female came to the Emergency Unit
of Psychiatric Clinic, associated from her parents,
with complaints about her appearance, depressive
mood, anorexia, insomnia, aggressive behavior
within family (especially towards her mother). We
learned that patient’s problems began four years
ago. From the beginning of illness, patient began to
neglect school and almost every other activity; her
grades became worst every day. In the beginning,
she was preoccupied with her height (At the time,
she used to say: “If I grow up just for another cm, I
will commit suicide”).
PATIENT HISTORY
She began treatment from a local psychologist,
who visited her at her house. As result of this
treatment, vanished patient’s preoccupation with
her height (now she is happy to be tall “like a
photo model”), but she began to be preoccupied
with her nose and her eyes (Quotation: “As a
result of a medical treatment – because of an
eyelid irritation caused by excessive use of make-
up - I lost eyes shining. Before this, I had the most
beautiful eyes in town. I want to operate my nose,
because it is very ugly. I want to have a nose like
Angelina Jolie, and after the operation, I will go to
the U.S. to become photo model”).
PATIENT HISTORY
In the last 12 months or so, the patient was treated
by a psychiatrist, who prescribed her
antipsychotic treatment (Risperidone), but
because she refused to take it, parents put it in her
food. In the near past, the patient manifested a
physical aggressive behavior toward her parents,
especially her mother, saying to her that she is to
blame for the patient’s nose, because she
inherited its form from her (mother). Lately, she
doesn’t manifest physical aggressive behavior
(only verbal), and she began to read religious
books and pray to God to help her operate the
nose.
PATIENT HISTORY

In the last month or so, the patient began a diet, eating

mostly unhealthy foods (chips, wafers), saying that she
became overweight and must loose weight in order to be
a photo model. Parents confirm the fact that she really
began to gain weight.
We must note that patient showed a special relationship
with her father (who is schizophrenic, under medication,
like two other of his siblings), who is very permissive to
her.
There are no other significant data from her life
anamnesis. She has one sibling (brother) with whom she
has ‘normal relationship’.
PHYSICAL EXAMINATION
The patient is 183 cm high, weights 56 kg, her
nose is lightly wider than normal in the middle.
LABORATORY EVALUATION AND
DIAGNOSTIC PROCEDURES
 Blood and urine analysis were within normal values, CT of brain
and EEG shows no pathological findings.
 Psychological examination: “The patient has been evaluated
using the test House, Tree-Person and Stories, from
observations and interviewing her…
Conclusion: The patient manifests a symptomatology of
progressive psychotic process; it is possible that she suffers
from some kind of personality, or affective disorder… But, we
must know that in adolescence there can be some psychotic
symptoms, but if the patient is offered an adequate support, it is
possible to strength its ego structure. One possible mean of
intervention can be supportive psychotherapy, focused in the
ego structure. The patient must be under psychiatric
monitoring”. (Vjollca Berisha, clinic psychologist).
HOSPITAL COURSE
From the beginning of hospitalization, the patient was anxious,
claiming that she is not sick and has no need to be treated. She
repeatedly asked to be dismissed from hospital. She manifested
bizarre behavior, e.g. she kept her lips like she was to whistle, an
excessive imitation of VIP posture. She accepted company of a
chronic schizophrenic patient, twice older than her, holding hands
with him and behaving like a couple. When asked, she said that
she liked him. The patient manifested childish behavior, with
naïve demands and became very easily frustrated, if others didn’t
fulfill her demands. In the beginning she was treated with
Risperidone alone (from initial doses to 4 mg a day), but from the
4th day of hospitalization till the dismissal from hospital, she took
Fluoxetine, too (20 mg a day, in the morning). Often she used to
put excessive make-up. She took part passively in ward activities.
OUTCOME
The patient was dismissed from hospital with the diagnosis of:
Body Dysmorphic Disorder (DSM-IV-TR) with psychotic features.
These are diagnostic criteria for Body Dismorphic Disorder
according to DSM-IV-TR:

 Preoccupation with an imagined defect in appearance. If a slight

physical anomaly is present, the person's concern is markedly
excessive.
 The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
 The preoccupation is not better accounted for by another mental
disorder (e.g., dissatisfaction with body shape and size in anorexia
nervosa).
QUESTIONS
 What do you think about the diagnosis, is it
correct?
 What about the patients father influence in the
course of disease and treatment?
 Do you think that the course of illness is going
toward an psychotic disorder?
Thank you for your time and
attention!

Prishtina, October 8th, 2009