Invisible to See
by David Elpern MD
June 21, 2001
The patient is a 22-year-old woman who presented for treatment of
acne. She had seen another dermatologist for about a year and had
been prescribed various
topical therapies as well as doxycycline and minocycline. Both of
the latter made her light-headed, so she stopped taking them. She
states that she hates her skin and is very self-conscious. She won't
let her boyfriend rub acne medications on her back; she doesn't want
anyone touching her back.
closer questioning, she expresses humiliation with her body. She is
embarrassed because she is short and feels that she is fat. She goes
to the gym and looks at the thin women exercising and wishes she could
be anorexic but says she wouldn't "hurt myself."
mother has told her she is on the heavy side and to just accept it.
patient has been on birth control pills (Demulen) since age 14 to
regulate her menses, which were infrequent and painful.
This shows a neat, attractive, well-groomed, articulate woman. She
does not appear clinically depressed. She is 5 foot tall and weighs
115 lbs. She has scattered small erythematous papules, few in number,
on the forehead, cheeks and chin. Similar small lesions are also present
on the upper back and upper chest. The lesions are monomorphous. They
can be seen in good light and with magnification, but are barely noticeable
Mild inflammatory acne with possible Body Dysmorphic Disorder (BDD).
I have seen patients like improve after Accutane, but realize that
the disorder is much more complicated. I am aware of the literature
linking Accutane with depression, but have found that most patients
who are depressed about their skin do better emotionally with this
medication. In addition, I will pursue a psychiatric opinion, since
a cognitive behavioral or psychopharmacologic approach may be more
appropriate if the patient is willing to pursue this avenue.
Definition: Body Dysmorphic Syndrome, BDD, is a distressing or impairing
preoccupation with a nonexistent or slight defect in appearance. Importantly,
the individual's rating of the body feature (skin) does not fit with
that of an objective observer, who may not see anything unattractive
or unusual about the feature, or who may note some minimal problem
(i.e., mild acne on the skin). The preoccupation causes distress or
impairment in social, occupational, or other important areas of functioning
that severely interferes with the individual's existence.
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