A 38-year-old man comes to the office stating that "my skin is being eaten away by flesh-eating bacteria." He has repeatedly used a stiff brush to apply antibacterial soap and disinfectant to the skin he insists is infected. The patient describes a progression of itching and redness followed by intense, burning pain at infected sites that spreads almost daily to new body areas. The patient systematically inspects his skin twice a day and records detailed descriptions of the affected areas. He is able to fall asleep at night but awakens sometimes to scratch his skin. He works as an accountant and has had a stable job performance. Current medications include a multivitamin and acetaminophen as needed. He drinks alcohol socially and does not use tobacco or illicit drugs.
Temperature is 36.5 C (97.7 F), blood pressure is 122/76 mm Hg, and pulse is 62/min. Physical examination reveals scattered lesions on his extremities that appear to have been caused by intense, abrasive scrubbing. The remainder of the physical examination is unremarkable.
Which of the following is the patient's most likely psychiatric diagnosis?

Question

A 38-year-old man comes to the office stating that "my skin is being eaten away by flesh-eating bacteria."  He has repeatedly used a stiff brush to apply antibacterial soap and disinfectant to the skin he insists is infected.  The patient describes a progression of itching and redness followed by intense, burning pain at infected sites that spreads almost daily to new body areas.  The patient systematically inspects his skin twice a day and records detailed descriptions of the affected areas.  He is able to fall asleep at night but awakens sometimes to scratch his skin.  He works as an accountant and has had a stable job performance.  Current medications include a multivitamin and acetaminophen as needed.  He drinks alcohol socially and does not use tobacco or illicit drugs.
Temperature is 36.5 C (97.7 F), blood pressure is 122/76 mm Hg, and pulse is 62/min.  Physical examination reveals scattered lesions on his extremities that appear to have been caused by intense, abrasive scrubbing.  The remainder of the physical examination is unremarkable.
Which of the following is the patient's most likely psychiatric diagnosis?

Quizplus · Accepted Answer

11ec193a_98aa_2e05_853d_5fcf2fbfaf43_MD0002_00 This patient's false, fixed belief that his skin is being eaten by flesh-eating bacteria is consistent with delusional disorder, somatic type. Patients with delusional disorder have fixed delusions without prominent hallucinations or other symptoms of psychosis. Their behavior may not be obviously odd or bizarre, and their functioning unrelated to their delusions may appear normal. Common themes in the somatic type include concern about infestation, deformity, foul body odor, or halitosis. Patients with this disorder typically have no insight into their condition and are more likely to see a dermatologist or primary care physician than a psychiatrist. Treatment involves antipsychotic medications, psychotherapy, and regular appointments to monitor the patient's course. (Choice A) Body dysmorphic disorder is an obsessive-compulsive-related disorder that involves preoccupation with perceived ugliness and defects in appearance. This patient has fixed false beliefs about skin infestation rather than concerns regarding appearance flaws, making delusional disorder the appropriate diagnosis. (Choice C) Patients with illness anxiety disorder fear having a serious undiagnosed medical illness, but they are not delusional and can acknowledge the possibility that they do not have the feared illness. In addition, patients with illness anxiety disorder have few if any somatic symptoms, unlike this patient who experiences severe itching and burning. (Choice D) Obsessive-compulsive disorder involves time-consuming obsessions (eg, intrusive thoughts, urges, images) and compulsions (eg, repetitive behaviors) and are typically not delusional. This patient's obsessive concern with being infected with flesh-eating bacteria and resultant checking behaviors revolve around his somatic delusion. (Choice E) Patients with somatic symptom disorder typically have excessive anxiety about multiple physical symptoms but are not delusional. Educational objective: Patients with delusional disorder, somatic type, typically seek care from primary care providers and dermatologists rather than psychiatrists. The disorder is characterized by fixed delusions that something is wrong with their body; patients' functioning is otherwise intact with no other prominent symptoms of psychosis. __________ References: Delusional disorders--are they simply paranoid schizophrenia? (http://www.ncbi.nlm.nih.gov/pubmed/21078814) A systematic review on the pharmacological treatment of delusional disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27811554)

A 38-Year-Old Man Comes to the Office Stating That "My