Question

CASE STUDY:

                                          “THE CARPENTER”


Chris is a shy, anxious-looking, 31-year old carpenter who has been hospitalized after making suicide attempt by putting his head in a plastic bag. He asks to meet with the psychiatrist in a darkened room. He is wearing a baseball cap pulled down over his forehead and partially covering his eyes. Looking down at the floor, Chris says he has no friends, has just been fired from his job, and was recently rejected by his girlfriend. When the psychiatrist asks Chris to elaborate, he replies, “It’s really hard to talk about this, Doctor. I don’t know if I can. It’s too embarrassing. Well, I guess I should tell you…after all, I’m in the hospital because of it. It’s my nose.” “Your nose?” the psychiatrist asks. “Yes, these huge pockmarks on my nose. They’re grotesque! I look like a monster. I’m as ugly as the Elephant Man! These marks on my nose are all I can think about. I’ve thought about them every day for the past 15 years. I even have nightmares abut them. And I think that everyone can see them and that they laugh at me because of them. That’s why I wear this hat all the time. And that’s why I couldn’t talk to you in a bright room…you’d see how ugly I am.”

The psychiatrist couldn’t see the huge pockmarks that Chris was referring to, even when she later met him in a brightly lit room. Chris is, in fact, a handsome man with normal-appearing facial pores. The psychiatrist says, “I see no ugly pockmarks. Is it possible that your view of your appearance is distorted, that may be the pockmarks are just normal-looking facial pores?” “That’s a hard question to answer,” Chris replies. “I’ve pretty much kept this preoccupation a secret because it’s so embarrassing. I’m afraid people with think I’m vain. But I’ve told a few people about it, and they’ve tried to convince me that the pores really aren’t visible. Sometimes I sort of believe them. I think I probably am distorting and that they’re not so bad. Then I look in the mirror and see that they’re huge and ugly, and I’m convinced that people laugh at them. Then no one can talk me out of it. When people try to, I think they just feel sorry for me and that they’re trying to make me feel better. This has affected me in a lot of ways, Doctor,” Chris adds. “It may be hard for you to believe, but this problem has ruined my life. All I can think about is my face. I spend hours a day looking at the marks in the mirror. But I just can’t resist. I started missing more and more work, and I stopped going out with my friends and my girlfriend. I got so anxious when people looked at me that I started staying in the house most of the time. Sometimes when I did go out, I went through red lights so I wouldn’t have to sit at the light where people might be staring at me. The hat helped a little but it didn’t cover all the marks. I tried covering them with makeup for awhile, but I thought people could see the makeup so that didn’t really help. The only time I really felt comfortable was when I wore my nephew’s Batman mask on Halloween. Then no one could see the marks. I missed so much work that I was fired. My girlfriend stuck it out with me for a long time, but she finally couldn’t take it anymore. One thing that was really hard for her was that I started asking her about 50 times a day whether I looked okay and whether she could see the marks. I think that was the last straw. If I had a choice, I’d rather have cancer. It must be less painful. This is like an arrow through my heart.”

Chris went on to discuss the fact that he had seen a dermatologist to request a plastic surgery procedure, but was refused the procedure because, “the dermatologist said there was nothing there.” He finally convinced another dermatologist to do the procedure but thought it did not help. Eventually he felt so desperate over the supposed marks that he made two suicide attempts. His most recent attempt occurred after he looked in the mirror and was horrified by what he saw. He told the psychiatrist, “I saw how awful I looked, and I thought, I’m not sure it’s worth it to go on living if I have to look like this and think about this all the time.” His first suicide attempt had also led to hospitalization; Chris was so ashamed of his concern and thought it wouldn’t be taken seriously, that he kept it secret and told the staff only that he was depressed.


List what you would diagnose for each of the 5 axes and a brief explanation of why:



AXIS I: _________________________________

Explain your reason for this specific choice:



AXIS II: _________________________________

Explain your reason for this specific choice:



AXIS III: _________________________________

Explain your reason for this specific choice:



AXIS IV: _________________________________

Explain your reason for this specific choice:



AXIS V: _________________________________



DSM-5 Diagnosis (write diagnosis in format of DSM-5 as well):

Answer 1

AXIS I: Body Dismorphic Disorder

Chris is preoccupied with an imagined defect in his appearance. And this preoccupation has clearly caused him significant distress and impairment with daily. Even to the point of driving him to suicide, so Chris has a fairly severe case of Body Dysmorphic Disorder.

He shows a lot of behaviours which support the diagnosis of BDD for e.g. his checking behaviors (mirror checking), camouflaging behaviors (wearing a hat and makeup), and avoidance behaviors (going through red traffic lights, not allowing people in close proximity, etc.)

AXIS II: Although Chris does show some symptoms of Avoidant Personality Disorder since he has no close friends, he avoids activities which involve being with close proximity to others, and constantly feels like he is unappealing to others. But without any knowledge of his childhood behaviour history, it is difficult to diagnose this. Since, all these symptoms currently seem to be manifestations of BDD only.

AXIS III: No medical or neurological condition seems associated with Chris's BDD problem

AXIS IV : Chris faced recent psychological stressors both in professional and personal life, i.e. Getting fired from job and rejection from girlfriend

AXIS V : At the time of his interview, Chris's level of functioning is very low (around 1-20 GAF). Since apart from having significant functioning problems in personal, social as well as work life, he has attempted suicide two times. He is still at a danger of harming himself because of a recent serious suicide attempt.

DSM-5 Diagnosis

F45.22 Body Dysmorphic Disorder

F60.6 Avoidant Personality Disorder

V 62.2 Occupational Problems

V 61.1 Partner Relational Problems

(DSM -5 diagnosis will also include score from assessment of functioning, but otherwise Chris shows very low levels of functioning because of recent suicide attempt and significant distress in personal and professional life. Chris must be administered the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in order to determine this score.)