MIAMI BEACH Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.
In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.
Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.
Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.
Take before and after photographs, and have the patient sign a written contract, she added.
"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.
If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.
Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:
▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.
Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."
▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.
"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.
Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.
▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.
▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."
Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.