Dysmorphophobia (Sometimes Called Monosymptomatic Hypochondriasis)
Dysmorphophobia
The fears and avoidance of most social phobics are different from those of people with dysmorphophobia, whose problem may also drive them into avoiding social situations and living the life of a recluse. Dysmorphophobia describes persistent complaints of some defect in a specific part of the body that is not noticeable to others; occasionally several parts of the body are involved. Sometimes the idea is so fixed that it amounts to a delusion (a firmly fixed false belief), and some people may exhibit other features of schizophrenia, suggesting that the primary problem is one of schizophrenia rather than something more akin to phobia. In other people, there is no evidence of schizophrenic disorder or other anxiety psychosis phenomena when observed over several years. Dysmorphophobics have no disturbance of body image as a whole, unlike people with anorexia nervosa who perceive themselves as overweight even while they are starving themselves (sometimes to death), or transsexuals who feel that their body is of the wrong sex and who may seek operations or medications to change their physical gender.
In contrast to social anxiety, dysmorphophobics do not think that their anxiety,is silly, nor do they feel much better when away from the social situations that they avoid; they are more preoccupied with a specific aspect of their body. Some cases of dysmorphophobia, however, are intermediate. Although exposure treatment (explained in Chapter 10) can be helpful for dysmorphophobics who avoid social situations, in our experience they usually refuse it; when they do accept treatment, improvement tends to be slow.
Dysmorphobia usually first occurs in young adult life; many dysmorphophobics have always been shy. Their complaint may center on their fears that their body, limbs, penis, breasts, or parts of their face or body are misshapen or too large or small, or their fears of bad odors coming from their sweat or breath, or from their genitals or rectum. Sufferers worry that others comment adversely about their appearance or smell, and so they avoid company. They will try to conceal the body part about which they are selfconscious and may be unable to look others in the eye. Some avoid looking in a mirror because they become so upset by what they think they see, or wash themselves zealously to remove odor that in fact is imperceptible to anyone else.
Many dysmorphophobics ask plastic surgeons to correct the imagined stigma, but even after cosmetic surgery the generalized anxiety disorder remains. Problems other than the specific bodily preoccupation also persist afterwards. Among patients in one study who had a rhinoplasty (nose operation) 15 years earlier, more among those who had been operated on for strictly cosmetic reasons were severely neurotic or schizophrenic than among those who had operations for disease or injury. Depression, too, is common. In a dermatology clinic depression was more common among dysmorphophobics complaining of too little or too much hair or of skin blemishes than it was among patients with psoriasis or normal control subjects.
Just how Dysmorphobia fits together with the disorders of Social Phobia, schizophrenia, and sometimes depression remains unclear. Treatment is difficult and trials of behavior therapy and antipsychotic and antidepressant medication are warranted based on present knowledge and experience.