CASE: Self-surgery
Dr. T (a pseudonym), a middle-aged male surgeon, arrives in the emergency department (ED) by ambulance after vomiting and losing consciousness at his office. Paramedics place him on an involuntary psychiatric hold, which is permitted in California, after learning that he had been performing surgery on himself.
Dr. T has developed medical complications after attempting to repair his own umbilical hernia. He states that the hernia resulted from weakened periumbilical abdominal muscles after multiple abdominal liposuctions, during which he inserted a cannula through the umbilicus. Dr. T initially repaired the hernia 4 months ago, but the wound margins had dehisced. He had performed the procedure at his ambulatory care surgical suite with help from his surgical assistant. Dr. T says he has performed many procedures on himself, including abdominal and chest liposuction, dermal filler injections, and skin laser resurfacing to improve perceived blemishes and remove hair. These procedures often resulted in poor cosmetic outcomes.
The authors’ observations
Clinical interviews confirmed that Dr. T met DSM-IV-TR criteria for BDD (Table 1).1 He is excessively preoccupied with perceived physical defects, which cause clinically significant distress, and this preoccupation is not better accounted for by another mental disorder.
Although Dr. T denied any psychotic symptoms during clinical interviews and Mini-Mental State Exam assessment, a reported 77% of BDD patients meet criteria for delusional disorder, somatic type (Table 2).1,2 Both disorders can be diagnosed concurrently if a patient meets criteria for both disorders.1 Phillips et al3 have suggested that delusional and non-delusional BDD may constitute the same disorder, spanning a continuum of insight. This hypothesis is supported by reports that selective serotonin reuptake inhibitors (SSRIs) work equally well for both BDD variants.4
Table 1
DSM-IV-TR criteria for body dysmorphic disorder
| A. | Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive |
| B. | The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning |
| C. | The preoccupation is not better accounted for by another mental disorder (eg, dissatisfaction with body shape and size in anorexia nervosa) |
| Source: Reference 1 | |
Table 2
DSM-IV-TR criteria for delusional disorder
| A. | Nonbizarre delusions (ie, involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month’s duration |
| B. | Criterion A for schizophrenia has never been met |
| C. | Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre |
| D. | If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods |
| E. | The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition |
| Somatic Type: This subtype applies when the central theme of the delusion involves bodily functions or sensations. Somatic delusions can occur in several forms. Most common are the person’s conviction that he or she emits a foul odor from the skin, mouth, rectum, or vagina; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are definitely (contrary to all evidence) misshapen or ugly; or that parts of the body (eg, the large intestine) are not functioning | |
| Source: Reference 1 | |
HISTORY: Accomplishment, anxiety
When we ask Dr. T why he operated on himself, he replies that he did not have time to go to another surgeon. He disagrees when we suggest that he feared that his privacy and professional reputation might be compromised. Dr. T states, “Doctors with walking pneumonia prescribe pills for themselves; this is the same in principle” and “There is no law against operating on oneself.” When we ask if he regrets his actions, he says “I was just overconfident. I did them under local anesthesia and I have a high pain tolerance.” He denies enjoying the pain. He reports that his friends and significant other consider him “courageous” for operating on himself. He denies further plans to perform surgery on himself.
Dr. T has no history of psychiatric hospitalizations or suicide attempts. He has a history of “situational anxiety” and over 3 years his general practitioner prescribed unknown dosages of sertraline, alprazolam, and propranolol, but he did not take these medications regularly and denies taking any other medications. Except for impaired judgment, his mental status exam is within normal limits. He has no other medical problems. He denies alcohol or illicit drug use or a desire to harm himself or others. Dr. T states that as a younger man he was an accomplished athlete and is now an avid body builder who exercises daily and is proud of the intensity and rigor of his workouts.