A 'Secret Disorder' Yields to Serotonin Reuptake Inhibitors

Article excerpt

A strange and poorly understood ailment is disrupting the lives of an undeterminable number of Americans. Called body dysmorphic disorder, or BDD, it causes rather ordinary-looking people to perceive themselves as hideously disfigured.

"The symptoms consist of a preoccupation with an imagined defect in appearance," Katharine Phillips, director of the BDD and body image clinic at McLean Hospital, Belmont, Mass., told Drug Topics. "If the person has a slight defect, he obsesses excessively over it.

"Essentially, these people look normal," she continued. "When they walk into my office, I generally cannot figure out what their obsessions are about."

Yet, those plagued with BDD spend most of their time agonizing over the grotesque physical flaws they plainly believe they have. The fixations cause a tremendous amount of distress, often interfering with a patient's ability to carry out daily activities. Sometimes, long hours are devoted to "corrective" grooming rituals.

While some patients manage to function "pretty well," Phillips said, others are "not functioning at all. They've dropped out of high school or college because of this. They can't work. We have a fair number of patients on disability because of their BDD."

Sufferers can become housebound and "very socially isolated," the physician pointed out. "Some go out only at night, when no one can see them," she said. "One woman stayed in her house for six years. When she did go out, she covered her face with bandages so no one could see it. Meanwhile, she's a pretty woman." It can be a very serious disorder, Phillips noted. "In severe cases, it can even lead to suicide."

Little is known about the disorder. Phillips, who is immersed in a number of BDD-related research projects, has interviewed 100 patients with the ailment. Her work indicates that it appears to affect an equal number of men and women and that it usually starts in adolescence, pursuing patients on a chronic basis year after year. "I've seen people from age 16 through age 80," Phillips said. Her oldest patient had been troubled by BDD since her youth. GRADUAL ONSET: The physician has discovered that patients' obsessions primarily involve the face or head. "The most common preoccupations," she remarked, "are with the skin, hair, and nose." Most of those interviewed by Phillips said the illness had a gradual onset. "Certain people say it started pretty suddenly, occasionally, but not always, after someone made a comment about their appearance" Phillips said.

It is impossible to figure out what percentage of the population is affected by BDD. "Any estimate would be a guess, I think," Phillips said. One problem is that patients often seek help from dermatologists and plastic surgeons, rather than psychiatrists. While other types of physicians may suspect that "something psychiatric is going on, they don't necessarily make the diagnosis of a psychiatric disorder," she said.

Also, BDD "tends to be a secret disorder," Phillips said. "Patients are generally very embarrassed and ashamed of their preoccupation. They don't want to talk about it."

Nobody knows what mysterious process is at work in BDD, but symptoms improve when patients are treated with drugs that increase serotonin levels in the brain. One of Phillips' patients has done well on clomipramine (Anafranil, Ciba-Geigy Corp.). Approved for the treatment of obsessive compulsive disorder (OCD), it is a tricyclic antidepressant with a powerful ability to block serotonin reuptake. Its effects on norepinephrine are modest.

Phillips' patient says that "when he drops his medication dosage, which he sometimes does because of side effects, the holes in his teeth come back," Phillips related. "When he goes up on his dose, they go away. That makes me think he is seeing something that, when he's on medication, he doesn't see; something we wouldn't see."

The other drug Phillips frequently prescribes for BDD patients is fluoxetine (Prozac, Eli Lilly & Co. …