Società Italiana di Tricologia
Giornale Italiano di Tricologia
Dysmorphophobia (Or the “non-ailment”) Andrea Marliani MD Firenze Summary We are coming up against an increasing number of patients who are convinced that they have alopecia when they have no real pathology whatsoever! Clinically, it is now classed as “dysmorphophobia”. These patients are generally intelligent and often hold a position of responsibility in society but as soon as hair is mentioned they can act very irrationally. In terms of psychological disorders, dysmorphophobia often leads to depression. This depression may, in itself, be a cause of chronic effluvium; and this will aggravate the depressive state. It is always difficult to find the right way to treat patients with dysmorphophobia. Patients are often irascible or aggressive and may be suicidal. Suicide, or attempted suicide, in these patients is a growing cause for alarm. It is like a silent epidemic. I am of the opinion that the best mode of treatment to adopt is to prescribe a selective inhibitor for the reabsorption of serotonin. These patients nearly always refuse pharmacological therapy. It is therefore necessary to come to a compromise, perhaps by prescribing a very low dosage. Most patients will experience some relief. At this point, patients will be much more likely to accept a higher dosage of the medicine. The doctor must never say that the problem is non-existent. The focus of the problem has been altered. It is like playing a game of chess. Our first move must always be to agree with the patient, so that we will be able to win the game.
In dermatology, and especially in trichology, we are encountering an increasing number of patients who are convinced that they have alopecia, or some serious skin ailment, when (in actual fact) they have no real pathology whatsoever! 20 years ago, we would have said it was a simple fixation. Clinically, it is now classed as “dysmorphophobia”. This was first described over 100 years ago, in 1886, by Enrico Morselli, an Italian psychiatrist, who defined it as: an “obsession about an imaginary defect in one’s external appearance”. The Americans refer to “Body Dysmorphic Disorder”. Patients with these symptoms are generally intelligent, from the middle or upper classes, with a high level of education and social status and often hold a position of responsibility in society. But as soon as hair is mentioned, they change completely: their eyes widen; they look nonplussed; and they seem to become irrational. Dismorphophobia should be thought of as a form of schizoid depression entailing a loss in the perception of one’s body as a unified whole. It usually makes its first appearance during adolescence. It may continue, becoming chronic, or it may not reappear until middle-age, or even later. 28
