APRIL 2015 DELHI PSYCHIATRY JOURNAL Vol. 18 No.

Case Report

Body Dysmorphic Disorder in Orthodontic

Practice – an unusual case report
Harpreet Grewal,1 Navneet Kaur Bhatia,2 Pranav Sapawat,3 M.S. Bhatia4
Department of Dentistry1,3 and Psychiatry4, University College of Medical Sciences &
Guru Teg Bahadur Hospital, Dilshad Garden, Delhi-110095
Department of Orthodontics2, Santosh Dental College & Hospital, Ghaziabad, U.P.
Contact: Harpreet Grewal. E-mail:hrprtgrwl@gmail.com

Introduction braces removed thrice, he got up from the dental

Body Dysmorphic Disorder (BDD) is defined
as a preoccupation with an imagined or slight defect
in appearance leading to significant distress or
impairment in important areas of functioning.1 These
patients usually present to facial cosmetic surgery
settings for correction of their perceived defects.2
In a study in patients attending cosmetic surgery or
dermatology department, 7 to 12 % had BDD.3 The
exact prevalence of BDD in other clinical settings
is not known. BDD has replaced previous terms
e.g. Dysmorphophobia, 4 dysmorphic syndrome, 5
hypochondriacal paranoia,6 obsession with shame
of the body.7
These patients often request multiple surgeries
to correct slight or nonexistent defects, and reported
high levels of dissatisfaction with their postoperative
results, despite a technically successful procedure.8,9
We report a peculiar case, which after correction
of orthodontic problem refuses to get braces
removed.
Case Report
Mr R, a 21 years old patient studying in a
college presented to dental outpatient department
for malaligned teeth (Fig1). On dental examination,
the patient was having dental class III malocclusion
with reverse overjet of 3 mm and mesiopalatally
rotated maxillary central incisors. Patient was
treated with fixed edgewise appliance therapy (Fig
2) and duration of treatment was 2 years.
Subsequently, the patient was unwilling to get braces
removed on the pretext that wearing braces gives
him confidence and good looks. On trying to get the
Delhi Psychiatry Journal 2015; 18:(1) © Delhi Psychiatric Society
chair and walked out of the dental operatory. Further,
on revisit he was referred to psychiatry outpatient
department for detailed evaluation.
On history, there were beliefs about his personal
appearance, mainly related to nose and teeth,
although no abnormality could be elicited. The history
was not suggestive of major depression, obsessive
compulsive disorder, generalized or social anxiety
disorder, drug dependence, head injury, seizure
disorder, chronic medical illness or any treatment.
Past and family history was also negative for
psychiatric disorder, chronic medical illness and drug
dependence. On mental state examination, general
appearance and psychomotor activity were normal.
Perception did not reveal any abnormality. The
higher mental functions including memory, abstraction
and intelligence were normal. Mood was appropriate
and normal. There was no lability. Thinking revealed
persistent fear about reoccurrence of malalignment
on removal of braces. There was no suicidal ideation.
The patient was diagnosed as suffering from body
dysmorphic disorder. He was counselled and put on
Fluoxetine 20mg daily after breakfast and olanzapine
5 mg at night. He started improving after 3 weeks
and was fully recovered in 2 months. On slight
persuasion, he agreed and got his orthodontic braces
removed.
Discussion
Body dysmorphic disorder is common in clinical
practice but often goes unrecognized. Psychiatric
comorbidities9-12 in form of major depression, severe
anxiety disorders (OCD, generalized anxiety
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DELHI PSYCHIATRY JOURNAL Vol. 18 No. 1
disorder, panic, social anxiety disorder), substance
abuse, sleep disorders, bulimia, suicidal tendencies
etc are common with BDD and it results in severe
impairment in all spheres of life. In the present case,
there was no psychiatric comorbidity. The present
patient was peculiar that he had image distortion at
the time of presentation and after orthodontic
treatment, he refused to stop after the treatment
inspite of being told about the harmful effects of
wearing braces for long term.
BDD has also been labelled as Obsessive Com-
Fig 1. Before treatment
Fig 2. After treatment
pulsive Spectrum Disorder (OCSD) and Affective
Spectrum Disorder. Pharmacotherapy in form of
SSRIs (Fluoxetine, fluovoxamine, citalopram)10-14
and antipsychotics15 are found to be effective in the
216 Delhi Psychiatry Journal 2015; 18:(1) © Delhi Psychiatric Society
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treatment of BDD in addition to Behaviour therapy
and Cognitive Behaviour Therapy (CBT)16 but in
the present case, only pharmacotherapy in form of
SSRI (Fluoxetine) and atypical antipsychotic
(olanzapine) was used to which the patient
responded.
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DELHI PSYCHIATRY JOURNAL Vol. 18 No. 1
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