Case: Boy with a big face
J, a handsome-looking boy, is 16 years old and is in the second grade of junior high school. He has been away from school for more than a year because he hates his better face.
When he entered the ward, his expression was shy and worried.
When he walked, he covered his face with his hands, and always slipped and hurried past.
He answered the doctor’s question in a low voice, and spoke very little.
In the ward, he often appeared restless.
The doctor asked him, “Why come to hospital?
“He replied that it was because he didn’t like his face and disliked his own face.
However, in the eyes of the doctor, he did not see what he called “big face”.
In the past, he did not like his father very much, and rarely took the initiative to communicate with his father.
Some things that must be said are also conveyed through the mother.
He didn’t like that his father always loved drinking, and Xinjiang was often drunk.
And do not like father and mother quarrel and lose their temper.
This hostile feeling towards his father has been more prominent since his onset.
Before he was hospitalized, he had not lived with his parents for a long time. He always lived at his grandmother’s house. Even so, he had less communication with his grandmother.
The relationship with my mother is a bit better, but I also speak to my mother when I need her to do things for him.
The MMPI test results at admission were: D72, Pd71, Si64.
The two-point front end is 24.
Neurosis may be 92.
Strangely, he didn’t stay in the ward for a long time, and he began to get acquainted with several girls of the same age who were hospitalized at the same time. When he was with them, he was particularly excited, had many words, and had a loud voice.
Within 20 days of hospitalization, he began to fall in love with a girl five years older than him, and the patient was suffering from obsessive-compulsive disorder.
Seeing everyone else’s eyes were straight and intent.
There is no usual shyness at all.
Although people made it clear that he couldn’t fall in love with him, he was still the same and was extremely distressed.
For a long time after the girl was discharged from the hospital, he was distressed by the incident.
Later, the matter subsided, but the hospital stay took four or fifty days.
After the girl was discharged from the hospital, he was concerned about his “face” again. He asked for a “thinning face cream”. Without the doctor’s consent, he bought a “thinning face cream” to apply.With a bottle, if it doesn’t work, I don’t think about “face” anymore.
In order to ease their father-son relationship, the doctor did a lot of work for him.
Asked his father to come to accompany him, and did such a job for a month, but he just couldn’t figure it out.
A few days before his father was ready to accompany him, he called many times, asking his grandma not to let his father come, and threatened that if his father came, he would no longer cooperate with the treatment.
At the insistence of the doctor, his father came to the ward and came with his mother, allowing his mother to play a buffer role in it.
The moment he saw his father, he was like a mouse afraid of cats, hiding, avoiding, and hiding in the entertainment room to watch TV.
It was the doctor who just dragged him to meet his father, and reluctantly said hello to his father.
Thereafter, according to the doctor’s plan, his mother left, and the father was alone with him, and later they were actually better.
But there are still problems.
In a flash, he had been hospitalized for two months, and his thoughts of “face” remained unshakable.
The doctor decided to announce to him the date of discharge and use a time-limited method to promote a “change” in his mind.
During this short period of time, his heart was more turbulent. After being hospitalized for so long, his “face” problem was still not completely solved, and he had to make the last effort.He proposed to the doctor to reshape his “face”, and the doctor agreed to “consult” the cosmetic department.
The result was that the doctor there said that there was nothing wrong with his face.
If the result of the plastic surgery is not satisfactory to him, the doctors there will take a “lawsuit” and they do not agree to plastic surgery for him.
He also said that he had not reached adulthood, and even they agreed to achieve plastic surgery, and they had to be over 20 years old. After returning from the plastic surgery consultation, he thought for two hours, and then came to the doctor’s office to tell the doctor his decisionNo plastic surgery, decided to go home and study hard.
After entering high school, let’s talk.
He seemed happy and suddenly relaxed, and I knew he was making a big decision.
I encouraged him to say that as a “man”, you should be able to take responsibility for your decisions.
You have to sign an agreement with your parents. You can tell them what you want from your parents, and ask them to gradually stop arguing at home.
But make a commitment to your parents.
What he promised was this: 1. After returning home, he immediately started school and followed closely his previous class.
(Before he got sick, he was the best student in the year group. He always took the first test, and his learning ability should not be a problem.) 2. He no longer paid attention to the “face” problem, at least before he was admitted to high school. 3. After he went back.Living with parents, no longer fled to grandma’s house, but only occasionally visited the grandma’s house.
The parents promised him: 1. Provide convenience for his studies, his father no longer cares about staying up and wasting electricity while studying, and 2. his parents no longer quarrel in front of him.
3. The parents promised that when he still needs plastic surgery when he is an adult, he will save some money for him to use at that time.
(This is a trick to slow down).
During the more than ten days of further discharge, the doctor’s requirements for him were: 1. Try loudly and calmly communicate with his father and doctor, including other adults in the ward; 2. Self-taught for more than 6 hours a day to adapt toThe need to go to school after home, 3, can not do both, can not be discharged.
People in several areas have promised to honor the content of these agreements.
In the following days, he became happy, and he communicated with each other as frankly as an adult man.
Study hard every day.
Interaction with father and doctor is more natural than before.
He left the ward and was hospitalized for 72 days.
I hope he can grow up healthy.
The doctor hopes to get good news of his continuous improvement.
The patient, just discharged, has not received follow-up news.
About the patient’s treatment summary: 1. The patient’s poor cognition, that is, he cannot learn without doing a good job of the “face”, and cannot do what normal people do.
It is a kind of bad cognition.
2. The doctor has the right to “do not open the pot,” the principle of requiring the patient to face whatever they are facing, encourage the patient to grow, and promote the socialization of the patient.
Including him while in hospital, fell in love with a girl 5 years older than him.
The doctor did not criticize him, but expressed understanding.
And guide him to get a correct view of love, and fade away his past mystery of the opposite sex.
Although this process took nearly 40 days, it was worth it to the doctor.
Requires to interact with his father and ask patients not to evade. Although it is very difficult, it still partially solves the problems between their father and son, and makes a good start.
Explain to him that his son agreed with his father and became a man.
On the 20th day after admission, he wrote in his diary that he loved to speak and made friends more than when he was just hospitalized.
On the day of discharge, he also took the initiative to go to a girl patient who had been discharged to say goodbye to her.
3. Encourage the patient to interact with others and trust others, and point out to him that not communicating with the doctor is “empathy”, which is to transplant the usual attitude towards the father to the doctor.
Therefore, in the process of treatment, stubbornly resist the help of the doctor.
4. Time-limited treatment.
At the end of the extended treatment period, tell the patient the approximate date of discharge and accelerate the patient’s inner change.
Make patients “responsible” for lack of progress in treatment.
Force the patient to make the right choice at the fork. 5. Strengthen psychological treatment.
The total time of psychotherapy is about 40 times / half an hour.
These psychological treatments will change the patient’s ideological understanding, the role of psychological maturity mechanism, and even its long-term effects will easily occur after discharge.
During the treatment, the patient had fewer words and asked the patient to keep a diary. His diary was very detailed and rich in content. He basically obtained the required materials.
The patient rarely spoke to the doctor in language, but he kept a diary for the doctor.
This behavioral characteristic of patients is worth thinking about and is an interesting phenomenon.
6, using flexible, comprehensive treatment.
Medication, pre-hospitalization, chlorpromazine 75 mg / day, orally.
In the first 20 days of treatment, the patient wrote in his diary that he was in a better mood than before and was able to communicate with others (referring to those girls).
One month after hospitalization, the combined use of Vestone was started at a maximum dose of 3 mg / day, hoping to have an impact on the pathological understanding of patients’ stubborn body image disorders.
In the end, a valid score cannot be given yet.
But the doctor decided to stick with the app.
Discharge medication: clomipramine 50 mg / day, Vestone 2 mg / day.
Discussion on body image disorder: 1. Body image disorder is named as physical deformity disorder in DSM-IV, also known as Ugly Syndrome.
From the characteristics of the disease, it should belong to the scope of suspected neurosis.
It is also characterized by neurotic conflict.
Like the patient mentioned earlier, he has had conflicts with his father for a long time. He does not like his father’s drinking and vulgarity.
He doesn’t agree with his father’s male character, speaks and acts like a little girl.
Study pressure is high, always want to win the battle.
Never be reconciled to the second, school is always ranked first in class performance.
During the hospital stay, I fell in love with a female patient who was 5 years older than myself. Just 16 years old, I had to engage in a subject, and I was extremely distressed about this matter.
This also shows that in adolescence, he has a longing for sex.
Therefore, beauty reflects the psychological needs of the time.
2, the pathological understanding of body image disorders, most people believe that it is the concept of overpriced.
However, some people think that it is a paranoid disorder, and it is difficult for many patients to shake this kind of thinking in clinical practice.
Some people believe that the pathological understanding of body image disorder is a “spectrum”, from the overpriced concept that can be solved by reasoning to the delusion that cannot be solved by reasoning.
Clinically, people can indeed see that some patients’ ideas can be loosened or even disappeared.
They may return to their pre-ill levels, or they may have only a few ideas, but they can do normal things, social functions are not affected too much, or all pathological concepts have disappeared.
But some are very stubborn and cannot be shaken at all.
A book in the United States records a patient’s obsessive attention to the face for 15 years, and continues to pay attention.
Seriously affected his quality of life.
Many patients put this awareness of the disease into action and require plastic surgery.
3. The formation of such suspected overpriced concepts or delusions is, of course, related to the patient’s personality before illness, and may be introverted and suspected personality qualities.
The little patient mentioned earlier is an extremely introverted person: introverted, at school and at home, showing a lack of talk, bad communication, and not actively revealing his inner thoughts.
At home, he had not communicated with his father for a long time, and only used very few words to answer his father’s inquiries.
Although it is better to associate with a mother than with a father, it is also insufficient.
Very strong in learning.
Learn until late at night.Don’t delay a bit.
Even knowledge of the liberal arts must be recited many times.
4. The focus of psychotherapy should be: (1) Reduce excessive attention to body image and accept that your body and appearance are healthy and normal.
Encourage patients’ hobbies and social interactions.
(2) Eliminate neurotic conflicts and reduce social stress.
Exploring the psychological roots of the onset, including fear, inappropriateness, rejection or abuse, and sexual depression.
Relieve the adverse factors of family disease.
(3) Encourage socialization of patients and promote social interactions among patients.
Express your inner experience with more words, rather than express your psychological needs with this “narrative disorder”.
(4) The patient’s “secondary obesity” is lifted, and the patient is required to take responsibility for his own affairs.
(5) Reward patients for social participation.
5. Drug treatment of body image disorders: At present, it is uncertain about the role of drug treatment.
There have been claims of antidepressants and well-known antipsychotics.
It is intended to improve the patient’s depression, anxiety, and pathological understanding of body image.