Body Dysmorphic Disorder, Dysmorphophobia or Delusional Disorder-Somatic Subtype?
Aravind, V., Krishnaram, V., Indian Journal of Psychiatry
Byline: V. Aravind, V. Krishnaram
Excessive concern about the appearance of one's body is the hallmark of body dysmorphic disorder (BDD). A case with recurrent intrusive preoccupation and concern about the appearance of the face, ritualistic behaviours associated with this preoccupation, resulting in social and interpersonal difficulties is presented. The difficulty to draw a discrete boundary between BDD and a delusional disorder of somatic type is highlighted.
Body dysmorphic disorder (BDD) previously known as 'dysmorphophobia' is defined as a preoccupation with an imagined defect in one's physical appearance. The preoccupa-tion is associated with many time-consuming rituals such as mirror gazing or constant comparing. One of Freud's patients who was subsequently analysed by Brunswick was known as the 'Wolfman' and he was preoccupied with imagined defects on his nose.
In 1886, Morselli described dysmorphophobia. Dysmorpho-phobia by proxy was reported by R. Laugharne in 1997-the patient was preoccupied not with her own appearance but how her potential offspring might look.
There is frequent comorbidity in BDD, especially in depression, social phobia, and obsessive-compulsive disorder (OCD) and delusional disorder. Beliefs about defects in appearance usually carry strong personal meanings and implications. A belief that his nose was too big caused one patient to feel that he would end up alone, unloved and that he might look like a crook. Also, such patients are likely to display delusions of reference, believing that people around them notice their defect and evaluate them negatively or humiliate them as a consequence of their ugliness.
A further aspect of BDD is time-consuming behaviours adopted by sufferers to examine the defect repeatedly or to disguise or improve it. Examples include gazing into the mirror to compare particular features with those of others; and some other features such as excessive grooming, which can be quite deleterious especially where the skin is concerned, camouflaging the defect with clothes or make-up, dieting and pursing dermatological treatment or cosmetic surgery.
Delusional disorder comprises a heterogeneous group of disorders of unknown aetiology whose hallmark and chief features are the presence of a single delusional system. Major modes of presentation of somatic delusional disorder, 'mono-symptomatic hypochondrical psychosis' are those of infesta-tions by insects, worms and foreign bodies, emitting a foul odour (halitosis) or of being ugly.
A 37-year-old well-educated male from the middle socio-economic class was presented with a belief that his face was changing into one of an 'eunuch' with a perceived emphasis on his face, lips, ears and his voice in articulation and also people commenting him as eunuch (number nine)-nine is a social-cultural term given to an eunuch. The total duration of his illness was 7 years. The illness probably started in 1997, while he was at his workplace, talking with his customers. He suddenly started feeling that his customers were referring and talking about him as an'eunuch' by stressing on the words 'nine' boldly and repeatedly. As days passed, he was excessively preoccupied with his face changing into 'eunuch'-like appearance. Change of face into that of 'eunuch' was noticed by other people and his own family members-wife, mother and others-with an impact of mostly avoiding him. He felt that they noticed his 'eunuch' face with disgust and shame. He could not continue his job and resigned it as he was observed by each and every person around him pointing out purposefully to him with words nine and similar numbers. He felt shameful to leave his home, to mingle with others and to have social interaction. He felt uneasy and was preoccupied with his imagined eunuch facial appearance.
During the course of his illness he became more pre-occupied, suspicious and started spending a great deal of time in front of the mirror. …