A 23-year-old woman comes to the office due to skin concerns. The patient states, "I have pockmarks on my nose from having acne as a teenager." She has tried high-dose retinol creams and skin-resurfacing procedures with no improvement. The patient applies concealer to her nose every morning and has been late to work multiple times due to her routine. She touches up her makeup throughout the day and is concerned that her supervisor has started to notice her frequent trips to the bathroom. Vital signs are within normal limits. Skin examination shows pores of minimal size, if any, on the nose and forehead; no acne or scarring is visible. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate statement?

Question

A 23-year-old woman comes to the office due to skin concerns.  The patient states, "I have pockmarks on my nose from having acne as a teenager."  She has tried high-dose retinol creams and skin-resurfacing procedures with no improvement.  The patient applies concealer to her nose every morning and has been late to work multiple times due to her routine.  She touches up her makeup throughout the day and is concerned that her supervisor has started to notice her frequent trips to the bathroom.  Vital signs are within normal limits.  Skin examination shows pores of minimal size, if any, on the nose and forehead; no acne or scarring is visible.  The remainder of the examination shows no abnormalities.  Which of the following is the most appropriate statement?

Quizplus · Accepted Answer

11ec25c8_d7ac_688d_bc81_73fd60cd6f2f_MD0003_00 This patient's excessive preoccupation with a slight or nonexistent defect in physical appearance (ie, belief that her nose is scarred from acne) is consistent with body dysmorphic disorder (BDD). In response to appearance concerns, patients with BDD engage in time-consuming behaviors, such as this patient repeatedly examining her appearance in the mirror and reapplying makeup to conceal her perceived defects. Patients with BDD typically have limited insight into their condition and therefore require a sensitive and tactful assessment approach. The physician should acknowledge their distress and avoid referring to perceived defects as "imagined" or arguing with them about their appearance. Physicians should empathize with patients' efforts to cope with their condition and determine their level of insight by gently exploring their perceptions of how others see them. In BDD, insight can range from fair to good (patient acknowledges beliefs about appearance are possibly or probably not true) to poor to absent (patient thinks beliefs about appearance are probably or definitely true). (Choice A) Patients with BDD are rarely reassured when told that their appearance is normal. They may feel that such statements minimize or ignore their concerns. (Choice B) This statement both validates the patient's concerns (by normalizing preoccupations about nasal skin) and inquires about past treatments, making it seem as if the physician agrees that something is wrong with her appearance. This approach may inadvertently reinforce her concerns. (Choice C) Applying only moisturizer and sunscreen does not address the underlying issue of BDD, so this recommendation is unlikely to be helpful to the patient. It is also misleading to describe the patient's skin as irritated when examination shows no abnormalities. (Choice E) This statement directly challenges the patient's perception of her appearance, which is likely counterproductive to developing a collaborative physician-patient relationship. Educational objective: Body dysmorphic disorder is characterized by preoccupation with slight to nonexistent appearance flaws and related repetitive behaviors such as checking, comparing with others, and camouflaging the perceived defect. Assessment requires a sensitive approach that acknowledges patients' distress and explores the level of their insight while avoiding direct confrontation or referring to perceived defects as "imagined." References: New perspectives in the treatment of body dysmorphic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29636904) Recent advances in understanding and managing body dysmorphic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28729345)

A 23-Year-Old Woman Comes to the Office Due to Skin