A 26-year-old woman comes to the office requesting referral for breast surgery. She says, "I feel disgusted with how my breasts look," and she describes numerous cosmetic aspects of her breasts that she finds troubling, including their asymmetry, shape, and small size. The patient says she has stopped going out with her friends because everyone stares at her breasts. She spends 1-2 hours every morning trying on different outfits to "hide" her chest and has ordered multiple custom bras to make her breasts appear more symmetric. The patient has no history of medical or psychiatric conditions and takes no medications. Vital signs are within normal limits. On physical examination, the breasts appear normal in symmetry, shape, and size. There are no palpable breast lumps or axillary lymphadenopathy. The patient says, "I really think cosmetic surgery would help me feel normal again." Which of the following is the most appropriate initial response to this patient's concerns?

Question

A 26-year-old woman comes to the office requesting referral for breast surgery.  She says, "I feel disgusted with how my breasts look," and she describes numerous cosmetic aspects of her breasts that she finds troubling, including their asymmetry, shape, and small size.  The patient says she has stopped going out with her friends because everyone stares at her breasts.  She spends 1-2 hours every morning trying on different outfits to "hide" her chest and has ordered multiple custom bras to make her breasts appear more symmetric.  The patient has no history of medical or psychiatric conditions and takes no medications.  Vital signs are within normal limits.  On physical examination, the breasts appear normal in symmetry, shape, and size.  There are no palpable breast lumps or axillary lymphadenopathy.  The patient says, "I really think cosmetic surgery would help me feel normal again."  Which of the following is the most appropriate initial response to this patient's concerns?

Quizplus · Accepted Answer

11ec25c8_d7ab_08fb_bc81_5709ccfdaf29_MD0003_00 This patient's excessive preoccupation with perceived defects in her breast shape, size, and symmetry is consistent with body dysmorphic disorder (BDD). Patients with BDD typically engage in time-consuming behaviors to conceal the perceived defect and frequently become socially isolated due to fears that others will see and reject them because of their "deformity." Most patients have minimal to no insight into their true condition (BDD) and seek surgical and dermatologic treatments to correct their perceived flaws. However, surgery should be discouraged because patients are rarely satisfied with the results and BDD symptoms may worsen following the operation, leading to additional, inappropriate cosmetic procedures. Responding to a patient with BDD who requests surgery requires engaging the patient and trying to build rapport before discussing the recommendation to avoid surgery. The most appropriate initial response would be to acknowledge the patient's distress and focus on the impairment it causes without validating or dismissing the patient's beliefs about appearance. In this patient, acknowledging how her time-consuming appearance concerns have negatively impacted her social life can help establish a therapeutic alliance and lay the foundation for educating her about BDD and treatment options. (Choice A) Reassuring the patient that her breasts are normal when she does not believe that they are will likely be seen as dismissive and invalidating, leading to a deterioration in rapport. It is better to focus on the distress and the impairment that BDD causes, rather than disputing a patient's perceived flaws. (Choices B and E) Surgery should be discouraged in patients with BDD, and these statements imply that pursuing surgery is a reasonable treatment option. A better initial approach is to acknowledge how appearance concerns have caused suffering, followed by educating the patient about BDD and the reasons for avoiding surgery. (Choice D) Although patients with BDD who undergo surgery are rarely satisfied with the outcome, this response is likely to frustrate the patient at this point. This comment would be more appropriate after establishing rapport and educating the patient about BDD. Educational objective: Body dysmorphic disorder (BDD) involves excessive preoccupation with perceived appearance flaws and is often accompanied by poor insight and a request for surgical procedures. The initial approach should focus on the suffering and impaired functioning without challenging the patient's beliefs about appearance. Once rapport is established, the patient should be educated about BDD and its treatment. References: Body dysmorphic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25150563) New perspectives in the treatment of body dysmorphic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29636904)

A 26-Year-Old Woman Comes to the Office Requesting Referral for Breast