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==Overveiw==
__NOTOC__
[[Palpitations]] are one of the most common complains of patients when visiting a physician.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref>  The causes of [[palpitations]] can range from benign (most common) to life-threatening conditions if not managed properly.<ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref> [[Palpitations]] are described differently by each patient, usually as an uncomfortable awareness of rapid, pounding heart beats, but also described as flip-flopping of the chest, rapid fluttering in the chest or pounding in the neck.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref>  The diagnosis is made by a detailed history, physical examination and a surface 12-lead [[EKG]].  The management of [[palpitations]] consists in treating the underlying cause.
{{CMG}}; {{AE}} {{Alonso}}
 
Infobox goes here
 
<nowiki>{{SI}}</nowiki>
 
'''''Synonyms and keywords:'''''
 
== Overview ==
'''Body dysmorphic disorder (BDD)''' is a mental disorder that involves a disturbed [[body image]]. It is generally diagnosed in those who are extremely critical of their physique or self-image, despite the fact there may be no noticeable disfigurement or defect.
 
Most people wish they could change or improve some aspect of their physical appearance, but people suffering from BDD, generally considered of normal appearance, believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation at their appearance. They tend to be very secretive and reluctant to seek help because they are afraid others will think them vanity|vain or they may feel too embarrassed to do so.
 
Ironically, BDD is often misunderstood as a vanity driven obsession, whereas it is quite the opposite; people with BDD believe themselves to be irrevocably ugly or defective.
 
BDD combines obsessive and compulsive aspects, which links it to the [[Obsessive-Compulsive Disorder|OCD]] spectrum disorders among psychologists. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high [[suicide]] rate among all mental disorders.  
 
A German study has shown that 1-2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (''Psychological Medicine'', vol 36, p 877). Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. The prevalence of BDD is equal in men and women, and causes chronic social [[anxiety]] for those suffering from the disorder[http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./].
 
Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with [[Clinical depression]] and three times as high as those with [[bipolar disorder]]<ref>http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280</ref>. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery<ref>http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html</ref>.
 
==Historical Perspective==
BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "'''Dysmorphophobia'''". BDD was first recorded/formally recognized in 1997 as a disorder in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]]; however, in 1987 it was first truly recognized by the [[American Psychiatric Association]].  
 
In his practice, [[Sigmund Freud|Freud]] eventually had a patient who would today be diagnosed with the disorder; Russian [[aristocrat]] [[Sergei Pankejeff]], nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.
 
==Classification==
 
==Pathophysiology==
BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others.
 
An absolute cause of body dysmorphic disorder is unknown. However research shows that a number of factors may be involved and that they can occur in combination, including:
 
'''A chemical imbalance in the brain.''' An insufficient level of [[serotonin]], one of the brain's [[neurotransmitter]]s involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary.
   
'''Obsessive-compulsive disorder.''' BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over their life. A history of, or [[gene]]tic predisposition to, OCD may make people more susceptible to BDD.
 
'''Generalized anxiety disorder.''' Body dysmorphic disorder may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD.


==Causes==
==Causes==
===Life-Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.


*[[Acute coronary syndrome ]]
==Differentiating type page name here from other Diseases==
*[[Malignant hypertension]]
*[[Myocardial infarction ]]
*[[Third degree AV block]]
*[[Ventricular arrhythmia]]


===Common Causes===
== Epidemiology and Demographics ==
''According to Dr Katharine Phillips (2004) :''


==Focused Initial Rapid Evaluation==
Although large [[epidemiology|epidemiologic]] surveys of BDD's prevalence have not been done, studies to date indicate that BDD is relatively common in both nonclinical and clinical settings (Phillips & Castle, 2002). Studies in community samples have reported current rates of 0.7% and 1.1%, and studies in nonclinical student samples have reported rates of 2.2%, 4%, and 13% (Phillips & Castle, 2002). A study in a general inpatient setting found that 13% of patients had BDD (Grant, Won Kim, Crow, 2001). Studies in outpatient settings have reported rates of 8%-37% in patients with OCD, 11%-13% in social phobia, 26% in trichotillomania, 8% in major depression, and 14%-42% in atypical major depression (Phillips & Castle, 2002). In one study of atypical depression, BDD was more than twice as common as OCD (Phillips, Nierenberg, Brendel et al 1996), and in another (Perugi, Akiskal, Lattanzi et al, 1998) it was more common than many other disorders, including OCD, social phobia, simple phobia, generalized anxiety disorder, [[bulimia nervosa]], and substance abuse or dependence. In a [[dermatology]] setting, 12% of patients screened positive for BDD, and in [[cosmetic surgery]] settings, rates of 6%-15% have been reported (Phillips & Castle, 2002).
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.


==Complete Diagnostic Approach==
BDD is underdiagnosed, however. Two studies of inpatients (Phillips, McElroy, Keck et al, 1993, and Grant, Won Kim, Crow, 2001), as well as studies in general outpatients (Zimmerman & Mattia, 1998) and depressed outpatients (Phillips, Nierenberg, Brendel et al 1996), systematically assessed a series of patients for the presence of BDD and then determined whether clinicians had made the diagnosis in the clinical record. All four studies found that BDD was missed by the clinician in every case in which it was present. Thus, underdiagnosis of BDD appears common.
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="Thavendiranathan-2009">{{Cite journal  | last1 = Thavendiranathan | first1 = P. | last2 = Bagai | first2 = A. | last3 = Khoo | first3 = C. | last4 = Dorian | first4 = P. | last5 = Choudhry | first5 = NK. | title = Does this patient with palpitations have a cardiac arrhythmia? | journal = JAMA | volume = 302 | issue = 19 | pages = 2135-43 | month = Nov | year = 2009 | doi = 10.1001/jama.2009.1673 | PMID = 19920238 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date =  | accessdate = 25 April 2014 }}</ref>


<span style="font-size:85%"> '''Abbreviations:''' '''AF:''' Atrial fibrillation; '''AVRT:''' AV reentry tachycardia; '''AVNRT:''' AV nodal reentry tachycardia; '''BP:''' Blood pressure; '''CBC:''' Complete blood count; '''ECG:''' Electrocardiogram; '''TSH:''' Thyroid stimulationg hormone; '''TTE:''' Transthorasic echocardiography; '''VT:''' Ventricular tachycardia; '''WPW:''' Wolff-Parkinson-White syndrome </span>
== Risk Factors ==


{{familytree/start}}
== Screening ==
{{familytree | | | | | | | | A01 | | | | |A01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Characterize the symptoms:'''<br>
❑ '''Duration'''
: ❑ Short lasting: spontaneous termination<br>
: ❑ Long lasting: need appropriate tratment for controlling the symptoms<br>
❑ '''Frequency'''
: ❑ Daily<br>
: ❑ Weekly<br>
: ❑ Monthly<br>
: ❑ Yearly<br>
❑ '''Onset'''
: ❑ Sudden (suggestive of [[SVT]] of [[VT]])<br>
: ❑ Gradual (suggestive of [[axiety]] of excerise induced [[sinus tachycardia]])<br>
❑ '''Type of palpitations'''<br>
: ❑ Flip-flopping of the chest (suggestive of [[extrasystole]])<br>
: ❑ Rapid fluttering of the chest (suggestive of [[tachycardia]])<br>
: ❑ Pounding in the neck (suggestive of [[AVRT]] and [[AVNRT]])<br>
: ❑ Pulsation palpitations (suggestive of [[structural heart disease]])<br>
: ❑ Anxiety-related palpitations<br>
❑ '''Prodrome'''
: ❑ [[Chest pain]]<br>
: ❑ Dizziness<br>
: ❑ [[Syncope]]<br>
: ❑ [[Dyspnea]]<br>
: ❑ [[Vertigo]]<br>
: ❑ [[Fatige]]<br>
❑ '''Position'''
: ❑ After standing up straight (suggestive of [[orthostatic hypotension]] or [[AVNRT]])
: ❑ Pounding sensation while lying in bed (suggestive of [[AVNRT]])
</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | Z01 | | | | | | |Z01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Search for associated symptoms and circumstances'''<br>
❑ Sudden changes of posture (suggestive of [[Orthostatic hypotension|intolerance to orthostasis]] or [[AVNRT]])<br>
❑ [[Syncope]] (suggestive of [[SVT]] or [[stuctural heart disease]])<br>
❑ [[Angina]], [[dyspnea]], [[fatige]] (suggestive of [[stuctural heart disease]] or [[ischemic heart disease]])<br>
❑ Polyuria (suggestive of [[AF]])<br>
❑ Rapid regular pulse in the neck (suggestive of [[AVNRT]])<br>
</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | B01 | | | | | |B01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Inquire about drug that can cause palpitations:'''<br>
❑ Sympathicomimetic agent pump inhalers (asthmatic patients)<br>
❑ [[Vasodilators]]<br>
❑ [[Anticholinergics]]<br>
❑ [[Hydralazine]]<br>
❑ Whithdrawl of [[beta-blockers]]<br>
❑ [[Alcohol]]<br>
❑ [[Cocaine]]<br>
❑ [[Heroin]]<br>
❑ [[Amphetamines]]<br>
❑ [[Caffeine]]<br>
❑ [[Nicotine]]<br>
❑ [[Cannabis]]<br>
❑ Synthetic drugs<br>
❑ Weight reaction drugs<br>
</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Obtain a detailed past medical hystory:'''<br>
❑ Prevous episodes of palpitations<br>
: ❑ First episode: young age (suggestive of [[AVRT]])<br>
: ❑ Number of episodes<br>
: ❑ Time since last episode<br>
: ❑ Circumstances of past episodes<br>
❑ [[Cardiac arrhythmia]]<br>
❑ [[Structural heart disease]]<br>
: ❑ [[Hypertrophic cardiomyopathy]]<br>
: ❑ [[Valvular disease]]<br>
: ❑ [[Congenital heart disease]]<br>
: ❑ [[Cardiomegaly]]<br>
❑ [[Systemic diseases]]<br>
: ❑ [[Hyperthyroidism]]<br>
: ❑ [[Pheochromocytoma]]<br>
❑ History of [[panic attacks]]<br>
❑ History of [[depression]]<br>
❑ Family history of [[arhythmias]] and [[structural heart disease]]<br>
</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | D01 | | | | | |D01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Examine the patient:'''<br>
'''Vitals'''<br>
❑ [[Pulse]]<br>
: ❑ [[Rhythm]]<br>
:: ❑ Regular (suggestive of [[AVRT]], [[AVNRT]], [[atrial flutter]] or [[VT]])<br>
:: ❑ Irregular (suggestive of [[extrasystole]], [[AF]] or [[atrial flutter]])<br>
: ❑ [[Rate]]<br>
:: ❑ [[Tachycardia]]<br>
::: ❑ Over the estimated maximum for the patient's age (suggestive of [[SVT]] or [[VT]])<br>
::: ❑ Under the estimated maximum for the patient's age (suggestive of [[anxiety]] or [[panic attack]])<br>
:: ❑ [[Bradycardia]] (suggestive of [[sinus bradycardia]], [[second degree AV block]] and [[third degree AV block]])
: ❑ Pulse deficit (suggestive of [[AF]])
❑ [[Blood pressure]]<br>
: ❑ [[Orthostatic hypotension]] (Fall in [[Blood pressure|systolic BP]] ≥ 20 mmHg and/or in [[Blood pressure|diastolic BP]] of at least ≥ 10 mmHg between the [[supine]] and sitting [[BP]] reading)<br>
: ❑ [[Hypertension]]<br>
❑ [[Temperature]]<br>
: ❑ [[Fever]] (suggestive of [[infection]])<br>
❑ [[Respiratory rate]]<br>
'''Face'''<br>
❑ [[Exophthalmos]] (sugestive of [[hyperthyroidism]])<br>
'''Neck'''<br>
❑ [[Goirter]] (suggestive of [[hypherthyroidism]])<br>
❑ [[Jugular venous pulse]]: [[cannon A wave]] (suggestive of [[Atrioventricular dissociation|AV dissociation]])<br>
'''Skin'''<br>
❑ Hot and sweaty (suggestive of [[hyperthyroidism]])
'''Hair'''<br>
❑ Thin (suggestive of [[hyperthyroidism]])
'''Respiratory'''<br>
❑ [[Rales]] (suggestive of [[heart failure]])<br>
'''Cardiovascular'''<br>
❑ [[Murmurs]] (suggestive of [[valve disease]])<br>
: ❑ Associated with [[Heart sounds|midsystolic click]] (suggestive of [[mitral valve prolapse]])<br>
: ❑ [[Heart murmur|Holosystolic murmur]] in the left sternal border that increases with valsalva (suggestive of [[hypertrophic obstructive cardiomyopathy]])<br>
❑ Displaced [[apex beat]] (suggestive of [[cardiomegaly]]<br>
❑ [[S3]] (suggestive of [[cardiac heart failure]])<br>
'''Neurologic'''<br>
❑ [[Tremors]] (suggestive of [[panic attacks]] or [[Hyperthyroidism]])<br>
</div>}}
{{familytree | | | | | | | | |!| | | | | | }}
{{familytree | | | | | | | | E01 | | | | | |E01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Order labs and tests:'''<br>
❑ [[ECG]]<br>
: ❑ Determine if the rythm is regular or irregular
: ❑ Assess the p wave and QRS morphology
: ❑ Search for short PR intervals and delta waves (suggstive of [[WPW]])
: ❑ Search for deep septal Q waves in I, V4 to V6 and signs of [[left ventricular hypertrophy]] (suggestive of [[hypertrophic obstructive cardiomyopathy]])
: ❑ Presence of more negative than 0.04 ms p wave in V1 (suggestive of [[AF]])
: ❑ Presence of prior myocardial infaction Q waves (suggestive of [[VT]])
: ❑ Presence of aberrant T wave with prolonged QT segment (suggestive of [[Long-QT syndrome]])
: ❑ Normal [[ECG]] (suggestive of [[anxiety]] or [[panic attack]])
❑ [[CBC]] (to rule out [[anemia]] or [[infection]])<br>
❑ [[Electrolyte disturbances|Electrolytes]] (to rule out [[hypokalemia]] and [[hypomagnesemia]])<br>
❑ [[TSH]] (to rule out [[hyperthyroidism]])<br>
❑ [[Blood sugar|Glucose level]] <br>
❑ [[Cardiac enzymes]] (to rule out [[MI]])<br>
----
'''Order imaging studies'''<br>
❑ [[TTE]] (to rule out [[structural heart disease]])<br>
</div>}}
{{familytree | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | Y01 | | | | | |Y01='''Does the patient has [[EKG]] findings or [[TTE]] findings suggestive of a cardiac cause for the palpitations?'''}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| |}}
{{familytree | | | | F01 | | | | | | | F02 | | | F01='''Yes''' | F02='''No'''}}
{{familytree | | | | |!| | | | | | | | |!| | | | | |}}
{{familytree | | | | X01 | | | | | | | X02 | | | |X01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient has [[EKG]] findings of an arrhythmia?'''</div>|X02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient has history signs of a psychiatric disorder?'''</div>}}
{{familytree | |,|-|-|^|-|-|.| | | |,|-|^|-|.| | |}}
{{familytree | W01 | | | | W02 | | W03 | | W04 | | |W01='''Yes'''|W02='''No'''|W03='''Yes'''|W04='''No'''}}
{{familytree | |!| | | | | |!| | | |!| | | |!| | | | | | }}
{{familytree | G01 | | | | G02 | | G03 | | |!| | | | | G01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Arrhythmia'''<br>
❑ [[Extrasystole]]<br>
❑ [[SVT]]<br>
: ❑ Sinus tachycardia<br>
: ❑ Atrial fibrillation<br>
: ❑ Atrial flutter<br>
: ❑ AVNRT<br>
: ❑ AVRT<br>
: ❑ Focal atrial tachycardia<br>
: ❑ Nonparocymal juntional tachycardia<br>
: ❑ Multifocal atrial tachycardia<br>
❑ [[VT]]
: ❑ Long-QT syndorme<br>
: ❑ Torsades de pointes<br>
❑ [[Bradyarrhythmias]]
: ❑ Sick sinus syndrome<br>
❑ [[Wolff-Parkinson-White syndrome]]<br>
</div>|G02=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Nonarrhythmic cardiac cause'''<br>
❑ Atrial septal defect<br>
❑ Ventricular septal defect<br>
❑ Cardiomyopathy<br>
❑ Congestive heart failure<br>
❑ Congenital heart disease<br>
❑ Mitral valve prolapse<br>
❑ Paricarditis<br>
❑ Valvular disease<br>
: ❑ Aortic stenosis<br>
: ❑ Aortic regurgitation<br>
</div>|G03=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Psychiatric cause'''<br>
❑ Anxiety<br>
❑ Panic attack<br>
❑ Depression<br>
❑ Somatization<br>
</div>}}
{{familytree | | | | | | | | | | | | | | | | U01 | | | U01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the patient has history of taking drugs or madications that can cause palpitations?'''</div>}}
{{familytree | | | | | | | | | | |,|-|-|-|-|v|'| | | |}}
{{familytree | | | | | | | | | | H01 | | | H02 | | | |H01='''Yes'''|H02='''No'''}}
{{familytree | | | | | | | | | | |!| | | | |!| | | | |}}
{{familytree | | | | | | | | | | I01 | | | I02 | | | |I01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Drugs or medication intake'''<br>
❑ Alcohol<br>
❑ Caffeine<br>
❑ Medications<br>
: ❑ Sympathicomimetic agents<br>
: ❑ Vasodialators<br>
: ❑ Anticolinergics agents<br>
: ❑ Hydralazine<br>
: ❑ Withdrawal of beta-blockers<br>
: ❑ Beta-agonists<br>
: ❑ Digitalis
❑ Recreational drugs<br>
: ❑ Cocaine<br>
: ❑ Heroine<br>
: ❑ Cannabis<br>
❑ Nicotine
</div>|I02=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Systemic disease'''<br>
❑ Anemia<br>
❑ Electrolyte disturbances<br>
❑ Fever<br>
❑ Hyperthyroidism<br>
❑ Hypoglycemia<br>
❑ Hypovolemia<br>
❑ Pheochromocytoma<br>
❑ Pulmonary disease<br>
❑ Vasovagal syndrome<br>
</div>}}
{{familytree/end}}


==Treatment==
== Natural History, Complications, and Prognosis==
The management of palpitations will be directed to the specific undelying cuase.  If the etiology can be determined and low risk, portentialy curative treatments are availabe, that should be the first choise of management.  For benign arrhythmias, such as extrasystole, lifestyle changes may be sufficient to prevent future episodes.  For patiens in whom no clear disease has been established, advise should be made for them to avoid possible triggers for palpitations as caffeine, alcohol, nicotine, recreational drugs.<ref name="pmid21697315">{{cite journal| author=Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L et al.| title=Management of patients with palpitations: a position paper from the European Heart Rhythm Association. | journal=Europace | year= 2011 | volume= 13 | issue= 7 | pages= 920-34 | pmid=21697315 | doi=10.1093/europace/eur130 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21697315  }} </ref><ref name="Zimetbaum-1998">{{Cite journal  | last1 = Zimetbaum | first1 = P. | last2 = Josephson | first2 = ME. | title = Evaluation of patients with palpitations. | journal = N Engl J Med | volume = 338 | issue = 19 | pages = 1369-73 | month = May | year = 1998 | doi = 10.1056/NEJM199805073381907 | PMID = 9571258 }}</ref><ref name="har">{{Cite web  | last =  | first =  | title = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | url = http://scholar.harvard.edu/files/barkoudah/files/management_of_palpitations.pdf | publisher =  | date =  | accessdate = 16 April 2014 }}</ref><ref name="Abbott-2005">{{Cite journal  | last1 = Abbott | first1 = AV. | title = Diagnostic approach to palpitations. | journal = Am Fam Physician | volume = 71 | issue = 4 | pages = 743-50 | month = Feb | year = 2005 | doi =  | PMID = 15742913 }}</ref><ref name="turner">{{Cite web  | last =  | first =  | title = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | url = http://www.turner-white.com/pdf/hp_jan03_methods.pdf | publisher =  | date = | accessdate = 25 April 2014 }}</ref>


== Diagnosis ==


{{familytree/start}}
=== Symptoms ===
{{familytree | | | | | | | | | A01 | | | | | | | | | | |A01='''Determine the cause of the palpitations'''}}
*Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
{{familytree | | | | |,|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | }}
*Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home.
{{familytree | | | | B01 | | | | | | | | | B02 | | | | | | |B01=<div style="float: left; text-align: left; width: 08em; padding:1em;">'''Cardiac cause'''</div>|B02='''Extracardiac cause'''}}
*Compulsive skin-touching, especially to measure or feel the perceived defect.
{{familytree | |,|-|-|^|-|-|.| | | |,|-|-|-|+|-|-|-|.| | | |}}
*Reassurance-seeking from loved ones.
{{familytree | C01 | | | | C02 | | C03 | | C04 | | C05 | | | |C01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Arrhythmia'''<br>
*Social withdrawal and co-morbid depression.
[[Premature ventricular contraction]]<br>
*Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble.
: ❑ Isolated [[extrasystole]] don't need further treatment
*Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc.
: ❑ [[Ablation therapy]] is used for recurrent episodes
*Obsession with [[plastic surgery]] or multiple plastic surgeries with little satisfactory results for the patient.
: <span style="font-size:85%">[[Premature ventricular contraction|Click here for a complete management]]</span>
*In obscure cases patients have performed plastic surgery on themselves, including [[liposuction]] and various implants with disastrous results.
[[SVT]]<br>
 
: [[Sinus tachycardia]]<br>
===Location of imagined defects===
:: ❑ Usually there is no need for treatment
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:
:: <span style="font-size:85%">[[Sinus tachycardia#Medical Therapy|Click here for a complete management]]</span>
{{col-begin}}
: [[Atrial fibrillation resident survival guide|Atrial fibrillation]]<br>
{{col-break}}
:: ❑ Unstable: [[Cardioversion|electrical cardioversion]]<br>
*skin (73%)
:: ❑ Paroxymal: no treatment, schedule controls<br>
*hair (56%)
:: ❑ Persistent: [[Heart rate|Rate]] control + [[Anticoagulant|anticoagulation therapy]]<br>
*nose (37%)
:: ❑ Recurrent: [[Heart rate|Rate]] control + [[Anticoagulant|anticoagulation therapy]] + antiarrhythmic drugs<br>
*weight (22%)
:: ❑ Permanent: [[Heart rate|Rate]] control + [[Anticoagulant|anticoagulation therapy]]<br>
*stomach (22%)
:: <span style="font-size:85%">[[Atrial fibrillation resident survival guide|Click here for a complete management]]</span>
*breasts/chest/nipples (21%)
: [[Atrial flutter resident survival guide|Atrial flutter]]<br>
*eyes (20%)
:: ❑ Ustable: [[Cardioversion|electrical cardioversion]]<br>
*thighs (20%)
:: ❑ Stable: [[Heart rate|Rate]] control<br>
*teeth (20%)
:: <span style="font-size:85%">[[Atrial flutter resident survival guide|Click here for a complete management]]</span>
*legs (overall) (18%)
: [[AVNRT]]<br>
*body build / bone structure (16%)
:: ❑ Poorly tolerated [[heart rate]]: [[cardioversion]]<br>
*ugly face (general) (14%)
:: ❑ [[Trendelenburg position]] and [[vagal maneuvers]] could terminate the rythm<br>
*lips (12%)
:: ❑ [[Adenosine]] is the first line treatment<br>
*buttocks (12%)
:: ❑ [[Cardioversion]] is the most effective long term therapy<br>
*chin (11%)
:: <span style="font-size:85%">[[AV nodal reentrant tachycardia|Click here for a complete management]]</span>
*fingers
: [[AVRT]]<br>
*eyebrows (11%)
:: ❑ Orthodromic AVRT: vagal maneuvers or adenosine<br>
 
:: ❑ Antidromic AVRT: procainamide (avoid AV node blockers)<br>
''source: '''The Broken Mirror''', Katharine A Philips, Oxford University Press, 2005 ed, p56 ''
: [[Atrial tachycardia|Focal atrial tachycardia]]<br>
 
:: ❑ Correct the undelying cause<br>
People with BDD often have more than one area of concern.
:: ❑ [[Adenosine]] + [[vagal maneuvers]] are the first line treatment<br>
 
:: ❑ Ustable: [[Cardioversion|Electrical cardioversion]]<br>
==The Disabling Effects of BDD==
:: <span style="font-size:85%">[[Atrial tachycardia|Click here for a complete management]]</span>
BDD can be anywhere from slightly to severely debilitating. It can make normal employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners of sufferers of BDD may also become involved and suffer greatly, sometimes losing their loved one to [[suicide]].
: Nonparocymal juntional tachycardia<br>
 
: Multifocal atrial tachycardia<br>
==Prognosis==
[[VT]]
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist unless treated.
: [[Long QT syndorme]]<br>
 
:: ❑ Beta-blockers<br>
== Treatment ==
:: ❑ Electrolyte repletion<br>
Typically the [[psychodynamic]] approach to therapy does not seem to be effective in battling BDD while in some patients it may even be countereffective.
:: <span style="font-size:85%">[[Long-OT syndrome|Click here for a complete management]]</span>
 
: [[Torsades de pointes]]<br>
CBT ([[Cognitive Behavioral Therapy]]) coupled with [[exposure therapy]] has been shown effective in the treatment of BDD. Low levels or insufficient use of serotonin in the brain has been implicated with the disorder and so [[SSRI]] drugs are commonly used, and with some success, in the treatment of Body Dysmorphic Disorder. Drug treatment will sometimes also include the use of an [[anxiolytic]].
:: ❑ Withdrawl of drugs that may cause the [[arrhythmia]]<br>
 
:: ❑ Correction of [[electrolyte disturbance]]<br>
BDD tends to be chronic; current information suggests that symptoms do not subside, but rather worsen through time. Indeed in most patients, the symptoms and concerns diversify and social contacts may further deteriorate. As so, treatment should be initiated as early as possible following the diagnoses.
:: ❑ Pacing<br>
:: <span style="font-size:85%">[[Torsades de pointes|Click here for a complete management]]</span>
[[Bradyarrhythmias]]
: Sick sinus syndrome<br>
[[Wolff-Parkinson-White syndrome]]<br>
:: ❑ Unstable: [[Cardioversion|Electrical cardioversion]]<br>
:: ❑ Orthodromic AVRT: vagal maneuvers or adenosine<br>
:: ❑ Antidromic AVRT: procainamide (avoid AV node blockers)<br>
:: <span style="font-size:85%">[[Wolff-Parkinson-White syndrome resident survival guide|Click here for a complete management]]</span>
</div>|C02=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Nonarrhythmic cardiac cause'''<br>
[[Atrial septal defect]]<br>
: ❑ Surgical closure<br>
: <span style="font-size:85%">[[Atrial septal defect|Click here for a complete management]]</span>
[[Ventricular septal defect]]<br>
: ❑ Srgical closure: depends on the age of the patient and size of the defect<br>
: <span style="font-size:85%">[[Ventricular septal defect|Click here for a complete management]]</span>
[[Cardiomyopathy]]<br>
: ❑ Depends on the type of cardiomyopathy, directed towards symptom relief<br>
: ❑ Includes: [[BP]] control, [[heart rate]] control, implanted devices, ablation therapy<br>
: <span style="font-size:85%">[[Cardiomyopathy|Click here for a complete management]]</span>
[[Congestive heart failure]]<br>
: [[Acute heart failure resident survival guide|Acute heart feilure]]<br>
:: ❑ Hypertensive with no volume overload: [[ACE inhibitos]] + [[Beta-blockers]]<br>
:: ❑ Hypertensive with volume overload: [[diuretics]]
:: ❑ Hypotensive with volume overload: IV [[inotrope]] + [[diuretics]] (monitor [[BP]])
:: ❑ Hypotensive with no volume overload: IV [[inotrope]]
: <span style="font-size:85%">[[Acute heart failure resident survival guide|Click here for a complete management]]</span>
: [[Chronic heart failure resident survival guide|Chronic heart feilure]]<br>
:: ❑ Fluid retention: [[diuretics]]
:: ❑ No fluid retension: [[ACE inhibitors]] + [[Beta-blockers]]<br>
: <span style="font-size:85%">[[Chronic heart failure resident survival guide|Click here for a complete management]]</span>
❑ Congenital heart disease<br>
❑ Mitral valve prolapse<br>
❑ Paricarditis<br>
❑ Valvular disease<br>
: ❑ Aortic stenosis<br>
: ❑ Aortic regurgitation<br>
</div>|C03=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Psychiatric cause'''<br>
❑ Anxiety<br>
❑ Panic attack<br>
❑ Depression<br>
❑ Somatization<br>
</div>|C04=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Drugs or medication intake'''<br>
❑ Alcohol<br>
❑ Caffeine<br>
❑ Medications<br>
: ❑ Sympathicomimetic agents<br>
: ❑ Vasodialators<br>
: ❑ Anticolinergics agents<br>
: ❑ Hydralazine<br>
: ❑ Withdrawal of beta-blockers<br>
: ❑ Beta-agonists<br>
: ❑ Digitalis
❑ Recreational drugs<br>
: ❑ Cocaine<br>
: ❑ Heroine<br>
: ❑ Cannabis<br>
❑ Nicotine
</div>|C05=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Systemic disease'''<br>
❑ Anemia<br>
❑ Electrolyte disturbances<br>
❑ Fever<br>
❑ Hyperthyroidism<br>
❑ Hypoglycemia<br>
❑ Hypovolemia<br>
❑ Pheochromocytoma<br>
❑ Pulmonary disease<br>
❑ Vasovagal syndrome<br>
</div>}}
{{familytree/end}}


==References==
==References==
{{Reflist|2}}
{{reflist|2}}
 
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[[Category:Up-To-Date]]
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Latest revision as of 01:53, 14 October 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

Infobox goes here

{{SI}}

Synonyms and keywords:

Overview

Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed body image. It is generally diagnosed in those who are extremely critical of their physique or self-image, despite the fact there may be no noticeable disfigurement or defect.

Most people wish they could change or improve some aspect of their physical appearance, but people suffering from BDD, generally considered of normal appearance, believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation at their appearance. They tend to be very secretive and reluctant to seek help because they are afraid others will think them vanity|vain or they may feel too embarrassed to do so.

Ironically, BDD is often misunderstood as a vanity driven obsession, whereas it is quite the opposite; people with BDD believe themselves to be irrevocably ugly or defective.

BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders among psychologists. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

A German study has shown that 1-2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (Psychological Medicine, vol 36, p 877). Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. The prevalence of BDD is equal in men and women, and causes chronic social anxiety for those suffering from the disorder[3].

Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with Clinical depression and three times as high as those with bipolar disorder[1]. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery[2].

Historical Perspective

BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first recorded/formally recognized in 1997 as a disorder in the DSM; however, in 1987 it was first truly recognized by the American Psychiatric Association.

In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; Russian aristocrat Sergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

Classification

Pathophysiology

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others.

An absolute cause of body dysmorphic disorder is unknown. However research shows that a number of factors may be involved and that they can occur in combination, including:

A chemical imbalance in the brain. An insufficient level of serotonin, one of the brain's neurotransmitters involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary.

Obsessive-compulsive disorder. BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over their life. A history of, or genetic predisposition to, OCD may make people more susceptible to BDD.

Generalized anxiety disorder. Body dysmorphic disorder may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD.

Causes

Differentiating type page name here from other Diseases

Epidemiology and Demographics

According to Dr Katharine Phillips (2004) :

Although large epidemiologic surveys of BDD's prevalence have not been done, studies to date indicate that BDD is relatively common in both nonclinical and clinical settings (Phillips & Castle, 2002). Studies in community samples have reported current rates of 0.7% and 1.1%, and studies in nonclinical student samples have reported rates of 2.2%, 4%, and 13% (Phillips & Castle, 2002). A study in a general inpatient setting found that 13% of patients had BDD (Grant, Won Kim, Crow, 2001). Studies in outpatient settings have reported rates of 8%-37% in patients with OCD, 11%-13% in social phobia, 26% in trichotillomania, 8% in major depression, and 14%-42% in atypical major depression (Phillips & Castle, 2002). In one study of atypical depression, BDD was more than twice as common as OCD (Phillips, Nierenberg, Brendel et al 1996), and in another (Perugi, Akiskal, Lattanzi et al, 1998) it was more common than many other disorders, including OCD, social phobia, simple phobia, generalized anxiety disorder, bulimia nervosa, and substance abuse or dependence. In a dermatology setting, 12% of patients screened positive for BDD, and in cosmetic surgery settings, rates of 6%-15% have been reported (Phillips & Castle, 2002).

BDD is underdiagnosed, however. Two studies of inpatients (Phillips, McElroy, Keck et al, 1993, and Grant, Won Kim, Crow, 2001), as well as studies in general outpatients (Zimmerman & Mattia, 1998) and depressed outpatients (Phillips, Nierenberg, Brendel et al 1996), systematically assessed a series of patients for the presence of BDD and then determined whether clinicians had made the diagnosis in the clinical record. All four studies found that BDD was missed by the clinician in every case in which it was present. Thus, underdiagnosis of BDD appears common.

Risk Factors

Screening

Natural History, Complications, and Prognosis

Diagnosis

Symptoms

  • Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
  • Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home.
  • Compulsive skin-touching, especially to measure or feel the perceived defect.
  • Reassurance-seeking from loved ones.
  • Social withdrawal and co-morbid depression.
  • Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble.
  • Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc.
  • Obsession with plastic surgery or multiple plastic surgeries with little satisfactory results for the patient.
  • In obscure cases patients have performed plastic surgery on themselves, including liposuction and various implants with disastrous results.

Location of imagined defects

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:

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