Dysmorphomania syndrome: a simple desire to be attractive or a mental disorder?

Remembering themselves as teenagers, few people can claim that at that time they were completely satisfied with their appearance, did not envy more attractive friends and loved their mirror image. In the overwhelming majority of cases, everything was exactly the opposite. In principle, excessive self-criticism in terms of appearance is typical for teenagers, but if it goes beyond certain limits and comes to the forefront, we are already talking about a mental disorder called dysmorphomania.

A little about the concept of "dysmorphomania"

The term "dysmorphomania" has been known in psychiatry since the end of the 19th century. The word itself consists of 3 parts, which, translated from ancient Greek, mean:

• "dis" is a negative prefix, in this case indicating some violation, pathological process, disorder,
• "morph" - appearance, exterior, face,
• "mania" - passion, fixation on some idea, morbid conviction in something.

From this we conclude that dysmorphophobia is a morbid conviction of one’s physical unattractiveness.

Sometimes "dysmorphomania" is confused with "dysmorphophobia" (the word "phobia" means fear, dread of something). The latter means excessive concern about some defect (sometimes greatly exaggerated) or feature of one's body. A crooked nose and pimples on the face, narrow lips and slanted eyes, "bow" legs and full hips, no waist and "bear paw" - this is only an incomplete list of defects and "ugly" features that teenagers find in themselves.

At the same time, the boy or girl is fixated not only on their defect. They are pathologically afraid of condemnation from others, attentive glances, peers' glances and quiet conversations behind their backs. Teenagers with dimorphophobia feel like everyone is looking at them, noticing their ugly flaws and then discussing this issue with others.

If the idea of a physical defect arises situationally and does not completely absorb the teenager, causing serious difficulties with socialization, we are talking not about dysmorphophobia in the literal sense of the word, but about transient dysmorphophobic phenomena (rudimentary dysmorphophobia), characteristic of adolescence. But if the idea of a physical defect comes to the forefront, interfering with the normal life, development and entry of the teenager into society, we have to talk about a mild mental disorder.

Dimorphomania is a deeper phenomenon, when experiences about appearance reach the level of delirium. That is, there may be no physical defect at all, it may be almost unnoticeable from the outside, or the most attractive features are taken for ugliness (for example, large breasts in a teenage girl).

The idea of having a defect in appearance becomes the central idea that determines the teenager's future behavior and life. This is no longer just fear, but a painful conviction of having a defect that must be eradicated by any means necessary. This condition is practically impossible to correct due to the lack of criticism from the patient.

It can be said that dysmorphophobia and dysmorphomania are two stages of the same mental disorder, which manifests itself in increased attention to one's appearance. But on the other hand, from the point of view of psychiatry, dysmorphophobia refers to neurosis-like conditions, while dysmorphophobia is a psychotic disorder. And dysmorphophobia does not always develop into a deeper disorder. This means that these are two different types of the same mental pathology.

Dysmorphophobia syndrome itself can have various manifestations:

• in the form of a reaction typical of adolescence, but intensified by a psychopathic personality or acute accentuations of character,
• as a temporary reversible mental disorder (reactive dysmorphomania),
• dysmorphomania that occurs in adolescence, under the influence of psychogenic and endogenous factors of sensitive accentuation of personality (endoreactive adolescent dysmorphomania), which passes or becomes less significant with age,
• dysmorphomania as an isolated symptom characteristic of some types of schizophrenia.
• nervous anorexia syndrome as one of the variants of dysmorphomania with a delusional idea of excess weight and the need to fight it by all possible methods, even to the detriment of health.

There is also cosmetic dysmorphomania (an obsessive idea of a physical defect) and perfume dysmorphomania (a painful idea of the presence of an unpleasant body odor).

But no matter what form of dysmorphomania a patient experiences, it will have the same symptoms as other types of this mental pathology.

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Epidemiology

Studies on the epidemiology of the pathological process indicate that this syndrome is more typical for adolescence and early youth. Most patients are young people aged 12-13 to 20 years. Moreover, this pathology is more common among girls than among boys.

In some cases, the pathology may develop late and manifest itself in adulthood, when adult uncles and aunts run to a cosmetologist demanding mandatory surgical correction of appearance without any apparent serious reason.

Causes dysmorphomanias

Psychological factors are a common cause of dissatisfaction with one's appearance, which in some cases develops into mental disorders such as dysmorphomania or dysmorphophobia.

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Risk factors

Risk factors for the development of pathology in this case are divided into:

• shortcomings of family upbringing: insulting the child (ugly, moron, etc.), inadequate attitude to sexual characteristics (statements like "it's indecent to have big breasts"), parents' fixation on the topic of the body. And even funny names (my bunny, mommy's teddy bear), if they are based on physical characteristics (for example, the child has protruding ears or is prone to obesity), can lead to an incorrect assessment of one's external attractiveness.
• ridicule and criticism from others, especially peers. More than half of the patients admitted that they were periodically or constantly subjected to ridicule at school or kindergarten. Children are cruel in this regard, and often make fun of the slightest physical defects in others.

Both of these factors, in the presence of some physical defect, biological causes and/or acute personality accentuations, can lead to the development of a persistent pathological mental state, which is dysmorphomania.

There is an assumption that the problem of dysmorphophobes and dysmorphomaniacs is also that they perceive their appearance with some distortions as a result of disturbances in the perception and processing of visual information. That is, they do not see exactly what is actually there.

But the environmental hypothesis reasonably explains why the pathology tends to increase the number of patients. The propaganda in the media of the idea that everything in a person should be beautiful with inflated demands for the ideal of beauty in women and men leads to the fact that most teenagers see their image as far from ideal, which negatively affects self-esteem and the still fragile psyche.

The desire for a healthy lifestyle and body beauty is generally a positive phenomenon, but it is important to understand that not everything comes down to external beauty, which, unfortunately, is not available to everyone. And not only to understand, but also to convey this to the younger generation.

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Pathogenesis

The pathogenesis of dysmorphomania as a mental disorder is based on the idea of its dependence on biological factors and nosological affiliation. That is, not every teenager concerned about their appearance is considered mentally ill. To make the appropriate diagnosis, it is not enough for the patient to have harsh criticism of their appearance. There must be a certain predisposition for simple self-criticism to develop into a pathological conviction of their unattractiveness and even inferiority.

As for biological factors, patients with dysmorphophobia have been found to have a reduced level of serotonin, which is one of the main neurotransmitters. The second and more accurate name for serotonin is the pleasure hormone. Its deficiency leads to a depressed state, which, with the assistance of some internal and external factors, can provoke the development of various mental disorders.

A certain hereditary predisposition is indicated by the fact that this diagnosis is also found among the closest relatives of patients with dysmorphomania. However, this is only a fifth of the total number of those studied, so it is incorrect to draw certain conclusions from these results.

According to some scientists, certain anomalies of the brain (individual parts of it) can also provoke the development of dysmorphophobia syndrome. Although this hypothesis still remains unconfirmed.

Most often, dysmorphomania is diagnosed in people with individual personality accentuations. In such patients, some character traits stand out against the background of others. People with accentuations of the dysthymic, emotional (sensitive), stuck, anxious and schizoid types are prone to developing dysmorphomania.

And although character accentuations are not mental disorders, they may well become the basis for the development of mental pathologies, especially if the trigger is improper upbringing in the family and ridicule from peers in childhood and adolescence.

Dysmorphomania is often one of the symptoms of another fairly common mental pathology – schizophrenia. Usually, this phenomenon is observed in patients with a sluggish form of schizophrenia. But there are often cases when dysmorphomania syndrome begins to manifest itself during a protracted period of adolescent relapsing schizophrenia.

Symptoms dysmorphomanias

Obvious dissatisfaction with one's appearance, especially if there are certain reasons for it, does not yet indicate a mental disorder called dysmorphophobia. It makes sense to talk about the development of dysmorphophobia only when the idea of a physical defect becomes constant and prevailing. At the same time, certain deviations in the teenager's behavior are observed: he avoids unfamiliar companies and entertainment events among peers, despite his interest, refuses to speak in public, although in the circle of friends and acquaintances he feels quite "in his element".

The development of dysmorphomania is indicated by a triad of indicative symptoms:

• An obsessive belief in the presence of a physical defect. In this case, the basis for it may be some minor defect in appearance, or the absence of one, or the most attractive feature (most often a girl's gorgeous breasts or a boy's large penis, which attract the attention of others) may act as a physical defect.

The idea of a physical defect in dysmorphophobia overshadows all other thoughts and determines the actions of the patient.

• The idea of attitude is based on the belief that others pay attention only to the patient's physical disability, and their attitude towards him is built precisely on condemnation and hostility.
• Depressive mood. The patient is constantly in a depressed state, absorbed in thoughts about his "ugliness" and ways to correct it.

The belief in one's physical unattractiveness due to certain characteristics of the body can develop in several directions:

• Dissatisfaction with one's appearance in general
• Dissatisfaction with certain facial features or body characteristics
• Exaggeration of a physical defect (its appearance and significance)
• The idea of having an imaginary defect in appearance
• Painful thoughts that the patient's body is prone to spreading unpleasant odors, such as the smell of sweat or urine, bad breath due to illness or tooth decay, etc.

All these moments are also characteristic of dysmorphophobia, but the experiences are accompanied by criticism from the patient about painful thoughts, despite the fact that a person is often unable to overcome his fears on his own. Thoughts about a physical defect are an important, but not decisive moment in the life and actions of a teenager, he does not immerse himself in experiences entirely, depriving himself of the joys of life.

With dysmorphophobia, all these moments are experienced much more deeply, absorbing all thoughts and desires of a person. The obsessive idea takes on the character of delirium in the absence of criticism from the patient. Themes of painful experiences during the disease may remain unchanged, or move from one idea to another as the pathological process develops (at first, the patient thinks that he has narrow lips, then he abandons this idea and begins to worry about body odor, “protruding” ears, etc.).

The idea of a physical defect is joined by the idea of correcting it by any means necessary. At the same time, in a conversation with a psychiatrist, such patients carefully hide both thoughts about physical deformity and the desire to correct it, but they are happy to share their ideas and wishes with a cosmetologist and surgeon.

Showing amazing ingenuity and persistence, dosmorphomaniacs often manage to convince others of their physical defect. Having obtained consent for surgery from parents and doctors, they still do not calm down. Having corrected one "defect", they will certainly discover another and will actively seek to correct it.

There are frequent cases when dysmorphomaniacs try to correct their "shortcomings" on their own, going on strict diets, inventing grueling physical exercise plans, and even injuring themselves (cutting their ears and noses, filing down protruding teeth, etc.). If they fail to correct the "terrible defect", they are inclined to dare to commit suicide.

Dysmorphomania syndrome may develop gradually or arise suddenly. The first signs of a possible mental disorder, along with the symptoms described above, may include:

• Limiting contacts with people who, in the patient’s opinion, dislike his appearance and any defects in it.
• Changing your hairstyle to hide any defects on your head.
• Withdrawn in communication with close people, unwillingness to discuss issues of appearance.
• Wearing shapeless, loose or too tight clothing, supposedly to hide figure flaws.
• Increased desire to take care of the body (very frequent shaving and eyebrow correction, unreasonable resort to cosmetics).
• Frequent palpation of the area of the body where the patient believes there is a physical defect.
• An obsessive desire to go on a diet or exercise without an emphasis on self-improvement.
• Avoiding walks in daylight.
• Reluctance to participate in social events.
• Taking medications without a doctor's prescription and no apparent reason.
• Increased anxiety, irritability.
• Problems with learning, loss of attention.
• Obsession with one's thoughts and experiences.
• Thoughts that others treat them badly because of a certain physical disability, which the patient may share with loved ones.
• Cold attitude towards loved ones.
• Inadequate reaction to the troubles and joys of others due to concentration on one's own experiences.

But the main signs that help to make a diagnosis of "dysmorphomania" are:

• increased interest in their reflection in the mirror (patients try to see the “defect” in their appearance, choose a pose in which, in their opinion, the defect is less noticeable, think about all possible methods of correction and the desired result),
• a categorical refusal to be photographed, so as not to perpetuate one's deformity and because of the conviction that in a photo the "defect" will be more clearly visible to others.

At the first stage of the disease, dysmorphomania may be almost unnoticeable to others. Patients tend to hide their feelings, look in the mirror often, but only when they think that no one sees it, and explain their refusal to take photos and videos by a bad mood or unpreparedness for filming (not dressed for the occasion, no appropriate makeup, bags under the eyes, I don’t look good today, etc.).

But when painful experiences intensify and symptoms become permanent, plus they are joined by an obsession with correcting the deficiency by any means and methods, it becomes increasingly difficult to hide the disease.

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Complications and consequences

As we can see from the above, dysmorphomania is a disease that is dangerous not so much for those around you as for the patient himself. The lack of appropriate treatment contributes to the aggravation of the pathological condition, which leads to complications such as prolonged depression, nervous breakdowns, a tendency to inflict injuries on oneself in order to correct an imaginary defect, and suicidal impulses.

The desire to correct figure flaws by any means leads to serious health problems. Refusal to eat or long-term strict diets lead to problems with the digestive system. A striking example of the severe consequences of dysmorphomania is anorexia.

The injuries that dysmorphomaniacs inflict on themselves in order to independently correct an imaginary defect can be life-threatening, causing bleeding or the development of malignant tumor processes. What is worth only trimming excessively protruding, in the opinion of the patients, body parts or cutting off "ugly" moles!

Obsessive thoughts about one's unattractiveness push everything else into the background. The patient may abandon studies or work, focusing only on "correcting" one's appearance, which will lead to a deterioration in academic performance at school, the impossibility of obtaining further education in secondary specialized and higher educational institutions, demotion at work, or even dismissal from the enterprise.

Dysmorphomania also has a negative impact on a person's socialization in society. Such patients tend to be withdrawn, avoid communication, and, ultimately, may lose friends and remain lonely for life.

Diagnostics dysmorphomanias

When diagnosing many mental disorders, the main difficulty is that patients are in no hurry to admit that they are sick, try to hide the symptoms of the disease, and behave in a way that is not typical for them.

The same masking of the disease is observed in dysmorphomanic syndrome. Patients do not want to share their experiences with doctors and loved ones, only aggravating the problem. But the diagnosis of dysmorphomania is carried out only on the basis of anamnesis, study of the patient's complaints and information received from his relatives.

Since everything is shrouded in mystery, and the symptoms of the disease are carefully hidden, all hope lies with those who live with the patient in the same apartment and have more opportunities for communication. Relatives should be alerted by the coldness and hostility in the teenager's communication with them, as well as unusual isolation and unwillingness to communicate with peers.

Observations of a teenager with dysmorphophobia allow us to identify two features of their behavior that indicate this pathology:

• "mirror symptom" of A. Delmas, which can have 2 manifestations:
  • regular careful examination of one's reflection in order to examine one's "defect" in more detail and find ways to disguise or correct it,
  • unwillingness to look in the mirror at all, so as not to see once again these “terrible physical defects” that haunt the patient,
• "the photograph symptom" described by M.V. Korkina, when a person refuses to be photographed (including for documents), inventing various excuses not to do so. The real reason for such reluctance to take a photo is the conviction that the photo will only highlight physical defects. In addition, the photo will remain a painful reminder of the "ugliness" for a long time.

Another indicative factor in diagnosing dysmorphomania is the teenager’s depressive mood due to internal experiences about his appearance, as well as the conviction expressed in a fit of emotion that others treat him with hostility, looking at a physical defect that already worries the teenager.

Dysmorphomania is also indicated by increased conversations about cosmetic methods of appearance correction, discussions of the problem of an “existing” physical defect and methods of correcting it with relatives, which occurs if the patient decides to undergo surgery, but parental consent is required.

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Differential diagnosis

Dysmorphomania and dysmorphophobia are mental disorders with similar symptoms, but if the latter is quite easily corrected in special sessions with a psychotherapist and psychologist, then with dysmorphomania everything is not so simple. That is why it is important to differentiate these conditions from each other, based on the fact that with dysmorphomania syndrome, the idea of a physical defect becomes overvalued, absorbing all the patient's thoughts and determining all his actions. This idea is not criticized by the patient, since he himself is not aware of his mental problem.

At the same time, with dysmorphophobia, physical deformity is only an obsession that exists in parallel with others and does not change the teenager's behavior completely. And even if the patient cannot cope with his fears on his own, this is not a reason for the lack of self-criticism.

Transient dysmorphophobic disorders in adolescence can also appear in completely healthy young people. But they are transient, tied to a certain psychotraumatic situation, have some basis in the form of a minor physical defect that the teenager exaggerates. Such disorders do not completely absorb the teenager and do not radically change his behavior. The changes concern only some moments related to shyness.

Differential diagnostics are also carried out in other directions. Thus, dysmorphomania with characteristic delusional ideas of physical deformity can be one of the psychotic symptoms characteristic of the progressive (paranoid, delusional) form of schizophrenia. In this case, it is observed within the framework of the polymorphic syndrome in paroxysmal schizophrenia, hallucinatory and depressive-paranoid syndromes.

Dysmorphomania syndrome is very often diagnosed against the background of sluggish schizophrenia, which, due to the lack of expression of symptoms, can go unnoticed for a long time. In 30% of cases of such a diagnosis, dysmorphomania is noted within the framework of a neurosis-like type of sluggish schizophrenia, which is characterized by fears and obsessive ideas. And the idea of a physical defect fits these concepts perfectly.

Dysmorphomania in the context of schizophrenia is characterized by the pretentiousness or absurdity of the invented methods of correcting the flaws in the appearance of patients, who demonstrate considerable “awareness” in this matter, sometimes reaching the point of insanity.

Endoreactive adolescent dysmorphomania is in many ways reminiscent of the same pathology in sluggish schizophrenia, especially in the first stage. The basis for this disorder is the accentuation of personality (usually sensitive and schizoid type) and a minor physical defect, and the trigger is a certain psychotraumatic situation that has special significance for the individual.

The ideas of correcting a physical defect are quite logical and adequate. There is no complete detachment from society, in some situations the particularly significant idea of a "defect" in appearance briefly gives way to other thoughts, and the teenager can freely communicate with peers.

Treatment dysmorphomanias

The difficulties of diagnosing and treating dysmorphomania also lie in bringing the patient to the doctor. Patients flatly refuse to visit a psychologist or psychiatrist, considering themselves mentally healthy. At the same time, they are ready to visit a plastic surgeon at least a thousand times, spending huge amounts of money on correcting minor or imaginary flaws in their appearance.

Teenagers who are sociable and friendly with the cosmetologist behave differently at the psychotherapist's appointment. They become withdrawn, do not want to talk about the problem, hide their experiences, not realizing the need for treatment, because, in the patients' opinion, they are not sick, but simply strive to take care of their appearance, bringing it closer to the ideal.

If the disease is recognized in time and psychotherapy is effective, attacks of the disease appear less and less (and pass on their own) or disappear altogether. The main goal of the first psychotherapeutic sessions is to accept yourself as you are, to come to terms with your real or imaginary shortcomings. And only when this goal is achieved, the doctor moves on to discussing the appropriateness and various possibilities for correcting the "defects" of appearance that are safe for the patient.

But before starting psychotherapy sessions, the doctor prescribes a course of drugs that correct the depressed state of patients. Such drugs include tranquilizers and antidepressants. In this case, general strengthening drugs that have a beneficial effect on the functioning of the brain, central nervous system and the entire body are also considered mandatory.

What you can't do with dysmorphomania is to support the morbid idea of the need for cosmetic surgery. Surgical intervention in this case not only does not solve the problem of mental disorder, but also worsens it. The patient will never be completely satisfied with the result, he will look for more and more defects in his appearance, spurring on the obsession with ugliness and resorting to other plastic surgeries. At some point, he may break down and injure himself or commit suicide.

If dysmorphomania syndrome is a symptom of schizophrenia, then treatment is prescribed taking into account the underlying disease. Psychotherapeutic methods without this will be useless.

Treatment of dysmorphomania is in most cases carried out on an outpatient basis. Hospitalization is resorted to only in extreme cases, when there is a danger that the patient may harm himself. This is possible with severe depression, suicidal tendencies, attempts to change appearance independently without the help of doctors.

Prevention

Since even in the presence of an endogenous (internal) factor, the action of a subjective psychogenic trigger is often required to initiate the disease process, the main measures for preventing dysmorphomania are considered to be the correct upbringing of the child in the family and the timely elimination of existing defects in the child’s appearance before they develop into a psychiatric problem.

Forming a normal self-esteem will help prevent an inferiority complex, which is typical for suspicious children, especially if there is some physical defect. In no case should you resort to offensive remarks towards children, even if these remarks are made by parents as a joke and are not intended to offend the child. Expressions like "mommy's fat boy" or "who did you take after with such lop-ears" can negatively affect the child's self-esteem.

If there is a physical defect, it is unacceptable to focus the child's attention on it, to remind him of it on various occasions. On the contrary, it is necessary to do everything necessary to rid the child of the flaws in appearance or at least make them less noticeable.

Caregivers, teachers, and medical personnel should also be attentive to children with physical defects, avoiding caustic remarks and preventing teasing from other children, which is the strongest trigger for the development of dysmorphophobia. It is necessary to help the child by all means to love himself as he is with all his shortcomings, not allowing thoughts about a physical defect to prevail over others.

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Forecast

The prognosis for dysmorphophobia and dysmorphomania is usually considered positive. Very rarely, the disease becomes chronic. Usually, effective treatment quickly stops attacks of excessive concern about one's appearance, returning the teenager to the joy of communicating with peers.

In schizophrenia accompanied by dysmorphomania syndrome, the prognosis is not so pleasant, since everything depends on the possibilities and results of treatment of the underlying disease.