Demanding Dental Patients Versus Those with a Psychiatric Disorder: Part I

Have you ever had a patient you just could not seem to satisfy? No matter what you did, the work did not meet their expectations? There is a difference between a simply “demanding” patient and one who has a true psychological disorder. In part one of this series, I am going to discuss some key differences between these two types of patients.

Somatoform disorders are the third most frequently diagnosed mental disorders, with up to 2 percent of the population displaying signs and symptoms of body dysmorphic disorder. BDD is the preoccupation with an imagined or exaggerated defect in physical appearance.¹ If the defect or problem is real, the patient's concern or focus on the defect is excessive.

The cause of the disease is unknown, but researchers suggest it may be used to avoid responsibility for other predicaments in their life by playing the role of a suffering patient, or to reduce some type of self-blame. The symptoms they experience are very real to them, but they are psychological oral health issues rather than physiological in nature. Because of the nature of the disease, general dentists, orthodontists and oral/maxillofacial surgeons are often the first clinicians to encounter patients with this disorder.

What is BDD?

There are three criteria psychiatrists and psychologists generally use to diagnose BDD²:

• The person is preoccupied with an imagined defect in appearance or concern over a symptom, or the perceived imperfection is exaggerated.
• This preoccupation is affecting other family, social or occupational areas of functioning.
• The preoccupation is not better accounted for by another mental disorder.

Symptoms of the disease include:

• The complaints are specific to one part of their appearance, with 86 percent of patients with BDD mentioning some aspect of their face.³
• The preoccupation represents some type of personal inadequacy (e.g. “If it wasn’t for these crooked, yellow, protruding teeth, I could get a job, date, etc.”).
• They exhibit perfectionist thinking.
• There is a history of dissatisfaction with cosmetic procedures. The patient has visited multiple dentists, often over a long period of time, none of whom could solve their problem.
• After treating the problem, there is/has been no improvement in symptoms or restorative results.
• The patient may appear anxious or despondent, cover their mouth when speaking or avoid eye contact.
• The patient attempts to dictate diagnosis and control treatment.
• There is a precipitating event – “This has been going on ever since …”
• The patient needs to find the “right person” who can “fix” the problem.
• The patient may have other mental disorders such as obsessive-compulsive disorder.

Recognizing a patient with BDD

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There are several key signs to look out for during the interview process that may suggest that the patient has BDD. These include:

• The history is plausible, but the symptoms do not match the clinical findings.
• If the problem is cosmetic, such as restorative work, they may be unable to pinpoint the exact problem. They just know it “isn’t right.”
• They do not want you to contact the dentists or physicians who were unable to fix their problem in the past, or will refuse to provide names or details of past treatment.
• You are their “only hope” to get the problem solved correctly.
• They believe the problem is physical, not psychological.
• They cry during the interview.

More severe situations that may arise when diagnosing or treating a patient with BDD include:

• The problems and symptoms they present seem to defy a cure.
• Even the most well-designed and -executed treatment plan will not satisfy them or eliminate/mitigate the problem, and your treatment and interventions may make it worse.
• They will often demand their money back or threaten to report you to the dental board.

It is very easy to get caught up in the patient's dilemma; after all, we all want to help and do what we can to solve their problem and alleviate their pain. However, it is important to trust your instincts if you sense that something is not right. Though you may be tempted to begin treatment when meeting with this type of patient, I’d recommend not doing so, as you will never fully satisfy their expectations. It is important for you to sit down with the patient and discuss your concerns. If the situation presents itself, refer them to a psychiatrist for a definitive diagnosis.   

The second part of this series will discuss this demanding patient, how to differentiate them from one with a potential somatoform disorder, and steps you can take to understand their true concerns and desires. By doing so, you will achieve clinical success and patient satisfaction.

(Click this link for more dentistry articles by Dr. Bob Winter.)

Bob Winter, D.D.S., Spear Faculty and Contributing Author

References

1. Brodine, A. H., & Hartshorn, M. A. Recognition and management of somatoform disorders.The Journal of Prosthetic Dentistry 2004; 91,3:268-273.
2. Polo, M. Body dysmorphic disorder: A screening guide for orthodontists. American Journal of Orthodontics and Dentofacial Orthopedics 2011;139:170-3. 
3. Hepburn, S. & Cunningham, S. Body dysmorphic disorder in adult orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics 130.5 (2006): 569-574.