A 17-year-old male student is uncooperative for his required annual physical. Though he is willing to give adequate history, he is unwilling to disrobe for the physical examination. You notice that he avoids eye contact and appears flushed when you address him for questions. He is wearing four layers of clothing, despite the warm spring weather. Hesitantly, he tells you he hates his “puny” body and does not want anyone to look at it. He says he feels “unmanly” and is on a special diet to “bulk up”. He spends hours checking himself and “grooming” in front of the mirror. He admits that he is preoccupied by his body image and he is always comparing his body to other peers.
Which of the following would be the most likely diagnosis for this patient?
Correct Answer B:
Dysmorphic disorder is characterized by preoccupation with an imagined defect or excessive concern of appearance. Preoccupation is marked by distress or impairment in social functioning.
A. Though the patient is preoccupied with the size of his body, the preoccupation is not limited to fear of “fatness.” The patient is on a special diet in order to “bulk up” or gain weight.
C. Though rituals are commonly seen in BDD, the rituals are limited to preoccupation with the imagined defect.
D. Preoccupation with primary or secondary sexual defects is characteristic of gender identity disorder. However, this individual appears to desire being “more manly” in his appearance and does not express desire to be more like the opposite sex.
E. In both disorders there is fear of rejection and humiliation; however, it is clear that this patient’s fear of humiliation is limited to his imaged body defect.
A 25-year-old female comes to your office requesting a referral to an otolaryngologist for surgery on her nose. She states that her nose is too large and that “something must be done.” She has already seen multiple family physicians, as well as several otolaryngologists. She is 168 cm (66 in) tall and weighs 64 kg (141 lb). A physical examination is normal, and even though she initially resists a nasal examination, it also is normal. The size of her nose is normal.
Which one of the following is the most likely cause of this patient’s concern about her nose?
Correct Answer D:
Body dysmorphic disorder is an increasingly recognized somatoform disorder that is clinically distinct from obsessive compulsive disorder, eating disorders, and depression. Patients have a preoccupation with imagined defects in appearance, which causes emotional stress. Body dysmorphic disorder may coexist with anorexia nervosa, atypical depression, obsessive-compulsive disorder, and social anxiety. Cosmetic surgery is often sought. SSRIs and behavior modification may help, but cosmetic procedures are rarely helpful.
An 88-year-old white female nursing-home resident with a primary diagnosis of Alzheimer’s disease develops a pattern of behavioral symptoms consisting of significant physical and verbal aggression toward staff and other residents on at least three occasions. In addition, she has experienced hallucinations that have been very stressful to her. After secondary causes have been excluded, you decide to treat her abnormal behavior pharmacologically.
Which one of the following would be the most appropriate choice?
Secondary causes of behavioral symptoms includes adverse medication effects, metabolic causes, infections, dehydration, pain, delirium, fecal impaction, and injury. Appropriate first-line pharmacologic treatment of nursing home residents who have severe behavioral symptoms with psychotic features, such as hallucinations and delusions that are causing distress, consists of atypical antipsychotics such as risperidone. The other choices listed are not atypical antipsychotics.
Over the past year, a 27-year-old female has had marked feelings of anxiety, tension and irritability during the week preceding most menstrual cycles, accompanied by extreme fatigue and insomnia. She has regularly missed several days of work each month because of fatigue. She has no previous history of any health or mental problems, and within a few days of the onset of her period she is back to normal.
Which one of the following is true concerning this condition?
Women with premenstrual dysphoric disorder (PMDD) experience a cluster of mood, cognitive, and physical symptoms that recur in the luteal phase of the menstrual cycle and remit in the follicular phase. Multiple rigorously conducted, placebo-controlled, randomized trials have consistently shown the value of SSRIs, especially if administered during the luteal phase of the menstrual cycle. Among women whose mothers have been affected by PMS, 70% have PMS themselves, compared with 37% of women whose mothers have not been affected. Because many patients with PMDD do not have depressive symptoms, this disorder should not be considered as simply a depressive variant. Some studies have shown that symptoms actually worsen with administration of oral contraceptive pills. Because of the potential for drug dependence, high-potency benzodiazepines such as alprazolam should be used only as second-line drug therapy if an optimal response is not achieved with an SSRI.
Difficult patients include those who make repeated visits without apparent medical benefit, those who do not seem to want to get well, those who engage in power struggles, and those who focus on issues seemingly unrelated to medical care.
Which one of the following strategies is recommended for managing such patients?
One of the best suggestions for better management of these patients is to schedule regular follow-up visits at 2- to 3 week intervals, especially if high dependency needs are suspected.
→ Ignoring the problem (choice A) or exporting it to another physician (choice B) does not make the difficulty disappear.
→ Accusing the patient of being problematic (choice C) may provoke patient anger and counter-blaming. Telling the patient that there is nothing wrong or that there is nothing you can do for him or her may trigger persistent attempts to prove that a problem exists.
→ Attempts to solve problems with psychopharmacology (choice E), unless carefully introduced and targeted to a specific diagnosis, may also prove problematic.
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