(Editorial) Reflections Beyond the Mirror Navigating Body Dysmorphic Disorders After Rhinoplasty

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Author(s): Prof. M. Mustehsan, Dr. Salman Bajwa

Pages: 1-2 |


Mental turmoil, exacerbated by post-operative stress, can complicate follow-up visits. Patients may suffer disproportionate distress, fail to acknowledge objective evidence and have unrealistic expectations and illogical concerns. Unconscious compensatory behaviors become more apparent.

These patients may exhibit features of multiple disorders. Abundant literature has primed us to diagnose these patients with body dysmorphic disorder (‘I cannot see because of my bumped nose). Differentials to consider include somatic symptom disorder (‘it feels weird breathing through my new nose’), anxiety disorder (‘I avoid gatherings out of concern for my weak nose’), and adjustment disorder (‘I cannot break the news to my family’). Such patients may acquire a variety of maladaptive defense mechanisms (unconscious processes used by the ego to decrease internal stress). Neurotic maladaptive defenses provide short-term relief, but harm long-term relations. These include controlling (‘I just need you to look deeper with a probe.’) and intellectualization (‘I know that a perfectly natural result is impossible.’).Immature defenses include blocking (‘I cannot concentrate on my work’) and somatization. Projection, a pathologic defense, can present as paranoid delusions (‘Everyone keeps looking inside my nose’).

Reflecting on these patients led us to develop a concise interview framework (acronym PULVERISE). It is appropriate for a spectrum of disorders and applies elements of various psychotherapies (supportive, cognitive behavioral and motivational):

  1. Prerequisite- time. Openly acknowledge that the patient’s concerns deserve and demand time and attention. Progress may be incremental, and require multiple consultations.
  2. Patiently Probe, and take Pauses. Resist the ‘righting reflex’. Pauses help patients feel unhurried, even if visits are kept short, and gives surgeons time to consider.
  3. Understand and List concerns. Having a list helps organize what may be runaway conversations.
  4. Validate concerns and respond to them, e.g., ‘It is not easy to adjust to (specific changes).It is human to be concerned about one’s appearance. A few other patients have had similar concerns, but I am concerned how it is affecting your (function).’
  5. Empower patients by conveying hope and supporting autonomy, e.g., Moving forward, I am confident we can overcome these concerns.’
  6. Reflect on the concerns, their influence on behaviors, and how to address them. This takes time.
  7. Individual reflection conserves time and allows ideas to incubate. Provide patients with a written task, e.g., to reflect on their concerns, and how they would like to see them resolved. This helps organize their thoughts, and produces a tool valuable in future visits.
  8. Summarize the meeting and encourage Strategies. Summaries help bring order. Promote anticipation/preparation, humor, and suppression-these mature defense mechanisms help control mental stress. Mindfulness and peer-support have important roles.
  9. Establish Expectations and deliver accurate Empathy. Expectations inform goals which can define progress. The surgeon’s own expectations are important. At the very least, one’s expectations should be that the seriously afflicted patient will eventually agree to seek expert psychotherapy.

An early referral decision is advisable for controlling patients or those showing transference. This approach remains valid in our current experience.