Syndrome of dysmorphomania: a simple desire to be attractive or psychiatric disorder?

Remembering himself in adolescence, few will argue that at that time he was completely satisfied with his appearance, did not envy more attractive friends and loved his mirror image. In the overwhelming majority of cases, everything was accurate to the "contrary". In principle, excessive self-criticism in terms of appearance is characteristic of adolescents, but if it goes beyond certain limits and is brought to the fore, it is already a question of a mental disorder whose name is dysmorphomania.

A little bit about the very concept of "dysmorphomania"

The term "dysmorphomania" is known in psychiatry since the end of the XIX century. The word itself consists of 3 parts, which in translation from the ancient Greek signify:

• "Dis" is a negative prefix, in this case indicating a certain disorder, a pathological process, a disorder,
• "Morph" - appearance, appearance, face,
• "Mania" is a passion, a fixation on some idea, a painful conviction in something.

Hence we conclude that dysmorphomania is a painful conviction in its physical unattractiveness.

Sometimes "dysmorphomania" is confused with "dysmorphophobia" (the word "phobia" means fear, fear of something). The latter means undue concern about a defect (sometimes greatly exaggerated) or a feature of one's body. Curved nose and pimples on the face, narrow lips and slanted eyes, "wheel" legs and full thighs, lack of waist and "bear paw" - this is only an incomplete list of defects and "ugly" features that teenagers find themselves.

In this case, a guy or a girl is fixated not only on his defect. They are pathologically afraid of condemnation from the side, attentive glances, peer glances and quiet conversations behind their backs. To teenagers with difmorphophobia it seems that everyone is looking at them, noticing ugly shortcomings and then discussing this issue with others.

If the idea of a physical defect arises situationally and does not absorb the adolescent entirely, causing serious difficulties with socialization, it is rather not about dysmorphophobia in the literal sense of the word, but about transistor dysmorphophobic phenomena (rudimentary dysmorphophobia) peculiar to adolescence. But if the idea of a physical defect is brought to the fore, interfering with the normal life, development and entry of a teenager into society, one has to talk about an easy disorder of the psyche.

Dimorphomania is a deeper phenomenon when feelings about the appearance go to the level of delirium. Those. There may not be a physical defect in general, it may be almost invisible from the side, or the most attractive features are taken for ugliness (for example, a large breasts of a teenage girl).

The idea of a defect in appearance becomes the central idea that determines the further behavior and life of the adolescent. This is not just fear, but a painful conviction of a defect that needs to be eradicated in any way. This condition is practically not amenable to correction due to the absence of criticism from the patient.

It can be said that dysmorphophobia and dysmorphomania are two stages of the same mental disorder, manifested in increased attention to one's appearance. But on the other hand, from the point of view of psychiatry, dysmorphophobia refers to neurosis-like states, while dysmorphomania is a psychotic disorder. And not always dysmorphophobia develops into a deeper frustration. So these are two different kinds of one mental pathology.

The syndrome of dysmorphomania itself can have different manifestations:

• in the form of a reaction that is characteristic of adolescence, but is enhanced by a psychopathic personality or acute accentuation of character,
• as a temporary reversible disorder of the psyche (reactive dysmorphomania),
• dysmorphomania, which occurs during adolescence, under the influence of psychogenic and endogenous factors of a susceptible personality accentuation (endoreactive teenage dysmorphomania), which with age passes or becomes less significant,
• Dysmorphomania in the form of an isolated symptom characteristic of some types of schizophrenia.
• a syndrome of anorexia nervosa as one of the variants of dysmorphomania with a delusional idea of excess weight and the need to fight it with all sorts of methods, even to the detriment of health.

Also distinguish cosmetic dysmorphomania (obsession with physical deficiency) and perfumery (a painful idea of the presence of an unpleasant body odor).

But in whatever form is observed dysmorphomania in the patient, it will have the same symptoms as with other varieties of this mental pathology.

[1], [2]

Epidemiology

Studies on the epidemiology of the pathological process suggest that this syndrome is more typical for adolescent and early adolescence. The majority of patients are young people between the ages of 12-13 and 20 years. And among the girls this pathology is more common than among the boys. 

In some cases, the pathology may have a later development and manifest itself in adulthood, when adult uncles and aunts run to a cosmetologist with the requirement of mandatory surgical correction of appearance without apparent serious cause.

Causes of the dysmorphomania

A frequent cause of discontent with their appearance, which in some cases develops into mental disorders such as dysmorphomania or dysmorphophobia, are psychological factors.

[3]

Risk factors

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

• shortcomings of family education: insult to the child (a freak, a moron, etc.), inadequate attitude towards sexual characteristics (statements such as "it is indecent to have a big breast"), parents' obsession with bodily topics. And even comic names (my bunny, mother bear), if they have soil under them in the form of physical features (for example, a child's ears protruding or he is inclined to fullness), can lead to an incorrect evaluation of his 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 in this regard are cruel, and often laugh at the slightest physical deficiencies in others.

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

There is an assumption that the problem of dysmorphophobia and dysmorphomania is also that they perceive their appearance with some distortions as a result of impaired perception and processing of visual information. Those. They see not quite what it really is

But the hypothesis of the environment reasonably explains why pathology tends to increase the number of patients. Propaganda in the media of the idea that in a person everything should be beautiful with overstated requirements for the ideal of beauty for women and men leads to the fact that most teenagers see their image as far from ideal, which negatively affects self-esteem and not yet strengthened psyche .

The desire for a healthy lifestyle and beauty of the body as a whole is a positive phenomenon, but it must be understood that not everything is reduced to external beauty, available, alas, not to everyone. And not only to understand, but also to bring it to the younger generation.

[4], [5],

Pathogenesis

The pathogenesis of dysmorphomania as a mental disorder is based on the idea of its dependence on biological factors and nosological affiliation. Those. Not every teenager, worried about his appearance, is considered mentally ill. To make the appropriate diagnosis, there is not enough hard criticism for your appearance on the part of the patient. There must be some predisposition to the fact that simple self-criticism has developed into a pathological conviction of its unattractiveness and even inferiority.

As for biological factors, in patients with dysmorphomania, a lower serotonin level, which is one of the main neurotransmitters, was revealed as a result of the studies. The second and more accurate name for serotonin is the pleasure hormone. Its deficiency leads to a depressed state, which, with the help of some internal and external factors, can provoke the development of various mental disorders.

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

To provoke the development of dysmorphomanic syndrome, according to some scientists, some brain anomalies (some of its areas) may also occur. 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 from the background of others. People with accentuations of dysthymic, emotional (sensitive), stuck, anxious and schizoid type tend to develop dysmorphomania.

And although character accentuations are not mental disorders, they can well become the basis for the development of pathologies of the psyche, especially if the triggering is incorrect parenting and mockery of peers in childhood and adolescence.

Often, dysmorphomania is one of the symptoms of another fairly common mental pathology - schizophrenia. Usually, this phenomenon is observed in patients with a slow type of schizophrenia. But there are cases when the dysmorphomanic syndrome begins to appear during a long period of adolescent recurrent schizophrenia.

Symptoms of the dysmorphomania

The apparent dissatisfaction with his appearance, especially if there are definite reasons, does not yet speak of a mental disorder called dysmorphomania. Even about the development of dysmorphophobia, it makes sense to speak only when the idea of a physical defect becomes permanent and prevalent. In this case, there are certain deviations in the behavior of the adolescent: he avoids unfamiliar companies and recreational activities in the circle of peers, despite his interest refuses to speak publicly, although in the circle of friends and acquaintances feels quite "at ease."

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

• Obsessive belief in the presence of physical deficiency. In this case, the soil for it can serve as a slight defect in appearance, and lack thereof, or as a physical defect is the most attractive feature (most often the chic breasts of a girl or the large size of the penis in the boy, attracting extraneous views).

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

• The idea of a relationship based on the conviction that others pay attention only to the physical defect of the patient, and their attitude towards him is built on condemnation and dislike.
• Depressive mood. The patient is constantly in a depressed state, absorbed in his thoughts about his "ugliness" and how to correct it.

Conviction of its physical unattractiveness due to certain features of the body can develop in several ways:

• Dissatisfaction with his appearance as a whole
• Dissatisfaction with certain facial features or features of the figure
• Exaggeration of physical defect (its appearance and significance)
• The idea of an imaginary appearance defect
• Painful thoughts that the patient's body tends to spread unpleasant odors, such as the smell of sweat or urine, smell from the mouth due to illness or damage to the teeth, etc.

All these moments are inherent for dysmorphophobia, but the experiences are accompanied by criticism from the patient about painful thoughts, despite the fact that people often can not overcome their fears independently. Thoughts about physical deficiency are important, but not decisive in a teenager's life and deeds, he does not immerse himself in experiences entirely, depriving himself of the joys of life.

With dysmorphophobia, all these moments are experienced much deeper, absorbing all the thoughts and desires of a person. The obsession acquires the character of delirium in the absence of criticism from the patient. The themes of painful experiences during the illness can remain unchanged, or move from one idea to another as the pathological process develops (at first the patient seems to have narrow lips, then he throws this idea and begins to worry about the smell of the body, "sticking out" the ears and etc.).

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

Showing amazing ingenuity and perseverance, do-morpomans often manage to convince others of their physical shortcomings. After agreeing to an operation on the part of parents and doctors, they still do not calm down. Having corrected one "defect", they will necessarily find another and will actively seek its correction.

There are often cases when dysmorphomanians try to correct their "shortcomings" on their own, sitting on rigid diets, devising schemes of exhausting physical exercises and even injuring themselves (pruning ears and nose, cutting out bulging teeth, etc.). If the "terrible defect" can not be remedied by them, they tend to dare to commit suicide.

The syndrome of dysmorphomania can have a gradual development or arise suddenly. The first signs of a possible mental disorder, along with the above symptoms can be considered:

• Limitation of contacts with people who, in the patient's opinion, are hostile to his appearance and the defects in it.
• Change the hairstyle in order to hide with her help the defects on her head.
• Closeness in communicating with close people, unwillingness to discuss matters of appearance.
•  Wearing a shapeless or loose garment, ostensibly to conceal the flaws of the figure.
• Increased desire to care for the body (very frequent shaving and eyebrow correction, causeless resort to cosmetics).
• Frequent palpation of a site of a body on which, according to the patient, there is a physical defect.
• An obsessive desire to sit on a diet or exercise without the emphasis on self-development.
• Refusal to walk in the daylight.
• Unwillingness to participate in public events.
• Drug use without prescribing a doctor and for obvious reasons.
• Increased anxiety, irritability.
• Problems with study, worsening of attention.
• Focus on your thoughts and feelings.
• Thoughts that others are bad for them due to a certain physical defect, which the patient can share with relatives.
• Cold attitude towards close people.
• Inadequate response to the ills and joys of others due to the focus on their experiences.

But the main signs that help diagnose "dysmorphomania" are:

• heightened interest in their reflection in the mirror (patients try to see the "defect" in their appearance, pick up a pose in which they think the defect is less noticeable, consider all possible ways of correction and the desired result)
• categorical refusal to be photographed in order not to perpetuate their ugliness and because of the conviction that the photo "defect" will be more clearly visible to others.

At the first stage of the disease, dysmorphomania can be almost invisible to others. Patients tend to hide their experiences, often look in the mirror, but only when they think that no one sees this, the refusal of photos and videos is explained by a bad mood or unavailability for shooting (not dressed for occasion, there is no appropriate make-up, "bags" under eyes, today I look bad, etc.).

But when painful experiences intensify and the symptoms become permanent, plus the obsession for correcting the defect is supplemented by any means and means, it is becoming increasingly difficult to conceal the disease.

[6], [7]

Complications and consequences

As we see from the above, dysmorphomania is a disease that is dangerous not so much for others as for the patient himself. The lack of suitable treatment contributes to the aggravation of the pathological condition, which leads to such complications as prolonged depression, nervous breakdowns, propensity to injure themselves to correct an imaginary defect, suicidal gusts.

The desire to correct the flaws of the figure by any means leads to serious health problems. Refusing to eat or staying for a long time on strict diets leads to problems with the digestive system. A striking example of the severe consequences of dysmorphomania is anorexia.

Injuries that the dysmorphomania do to themselves to correct an imaginary deficiency can be life-threatening, causing bleeding or the development of malignant tumor processes. That only it is necessary to undercut unnecessarily bulging, according to patients, parts of the body or cutting "ugly" moles!

Obsessive thoughts about their unattractiveness brings everything else to the background. The patient can abandon his studies or work, doing only "correction" of his appearance, which will lead to deterioration of school performance, the impossibility of obtaining further education in secondary special and higher educational institutions, demotion at work or even dismissal from the enterprise.

Dysmorphomania negatively affects the socialization of man in society. Such patients tend to be withdrawn, avoid communication, and, in the end, may lose friends and remain lonely for life.

Diagnostics of the dysmorphomania

When diagnosing many mental disorders, the main difficulty is that patients do not rush to recognize themselves as sick, try to hide the symptoms of the disease, behave in an unusual manner for them.

The same disguise of the disease is also observed with 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, the study of patient complaints and information received from his relatives.

Because everything is covered in mystery, and the symptomatology of the disease is carefully hidden, all the hope for those who live with the patient in one apartment and has more opportunities for communication. Closer should be alerted by the coldness and dislike of the adolescent's communication with them, as well as the unusual isolation and reluctance to communicate with peers.

Observations of a teenager with dysmorphomania make it possible to distinguish two features of their behavior that indicate precisely this pathology:

• "A symptom of a mirror" by A. Delm, who can have 2 manifestations:
  • regular careful examination of their reflection in order to more closely consider their "defect" and find ways to disguise it or correct it,
  • unwillingness to look in the mirror at all, to once again not see these "terrible physical defects" that do not give the patient a rest,
• "A symptom of photography", described by M.V. Korkina, when a person refuses to be photographed (including photos on documents), inventing various pretexts not to do so. The true reason for this reluctance to take photos is the conviction that photography will only emphasize physical defects. In addition, the photo will remain a painful reminder of "ugliness" for a long time.

Indicative in terms of diagnosing dysmorphomania is the depressed mood of a teenager because of inner feelings about his appearance, as well as the conviction expressed in a fit of feelings that others treat him with dislike, looking at the physical defect that is already disturbing to the adolescent.

Dysmorphomania is indicated by frequent conversations on the topic of cosmetology methods of appearance correction, discussion of the problem of the "available" physical defect and methods of its correction with relatives, which takes place if the patient decides to perform a surgical operation, but the consent of the parents is required.

[8], [9]

Differential diagnosis

Dysmorphomania and dysmorphophobia are mental disorders with similar symptoms, but if the second one is fairly easily amenable to special treatment with a psychotherapist and a psychologist, then dysmorphomania is not so simple. That is why it is important to differentiate these states among themselves, relying on the fact that in the syndrome of dysmorphomania the idea of physical deficiency becomes overvalued, absorbing all the patient's thoughts and defining all his actions. This idea is not criticized by the patient, because he himself does not realize his mental problem.

At the same time, with dysmorphophobia, physical ugliness is only an obsession that exists in parallel with others, and does not change the adolescent's behavior to the fullest. And even if the patient can not cope with his own fears, this is not an excuse for lack of self-criticism.

Transistor dysmorphophobic disorders in adolescence can also appear in quite healthy young people. But they are transitory in nature, tied to a certain psychotraumatic situation, have some basis in the form of a slight physical defect, which the teenager exaggerates. Such disorders do not completely absorb the adolescent and do not radically change his behavior. The changes concern only some of the moments associated with shyness.

Differential diagnosis is also carried out in other directions. So, dysmorphomania with the characteristic delusions of physical malformation can be one of the psychotic symptoms characteristic of the progredited (paranoid, delirious) form of schizophrenia. In this case, it is observed within the framework of polymorphic syndrome with paroxysmal schizophrenia, halyatsatorno-and depressivno-paranoidnyh syndromes.

The syndrome of dysmorphomania is very often diagnosed against a background of sluggish schizophrenia, which can be overlooked for a long time due to the lack of expression of symptoms. In 30% of cases of this diagnosis, dysmorphomania is noted in the neurosis-like type of sluggish schizophrenia, which is characterized by fears and obsessions. And the idea of a physical defect can not be better suited to these concepts.

Dysmorphomania in the context of schizophrenia is characterized by the pretentiousness or absurdity of the invented methods of correcting deficiencies in the appearance of patients who exhibit considerable "awareness" in this matter, sometimes reaching insanity.

Endoreactive teenage dysmorphomania in many ways resembles the same pathology in case of sluggish schizophrenia, especially in the first stage. The basis for this disorder is the accentuation of the person (usually a sensitive and schizoid type) and a minor physical defect, and the trigger is a kind of psychotraumatic situation that is of particular importance to the individual.

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

Treatment of the dysmorphomania

Difficulties in diagnosing and treating dysmorphomania are also in bringing a patient to a doctor. Patients flatly refuse to visit a psychologist or psychiatrist, considering themselves mentally healthy. Despite the fact that they are ready to go to the plastic surgeon even a thousand times, spending huge sums on correction of minor or imaginary flaws in appearance.

Sociable and friendly with cosmetologist adolescents at a reception with a therapist behave differently. They become withdrawn, do not want to talk about the problem, hide their experiences, not realizing the need for treatment, because they, according to the patients themselves, are not sick, but simply seek to take care of their appearance, bringing it closer to the ideal.

With a timely recognized disease and effective psychotherapy, the attacks of the disease appear less and less (they pass by themselves) or disappear altogether. The main goal of the first psychotherapeutic classes is to accept yourself as you are, to reconcile with your real or perceived lack. And only when this goal is achieved, the doctor goes on to discuss the appropriateness and various possibilities for correcting the "defects" of the appearance that are safe for the patient.

But before going to sessions of psychotherapy, the doctor prescribes a course of drugs that correct the oppressed state of patients. These drugs include tranquilizers and antidepressants. In this case, compulsory preparations are considered obligatory, which have a beneficial effect on the work of the brain, the central nervous system, and the whole organism.

What can not be done with dysmorphology, is to support the painful idea of the need for cosmetic surgery. Surgical intervention in this case not only does not solve the problem of mental disorder, but also aggravates it. The patient will never be satisfied with the result by one hundred percent, he will look for more and more new defects in his appearance, whipping up the obsession about ugliness and resorting to other plastic operations. At some point, he may break and injure himself or commit suicide.

If the syndrome of dysmorphomania 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 in most cases is performed on an outpatient basis. Hospitalization is resorted to only in extreme cases, when there is a danger that the patient can harm himself. This is possible with severe depression, suicidal tendencies, attempts to change the appearance yourself without the help of doctors.

Prevention

Since even in the presence of an endogenous (internal) factor for triggering the disease process, the action of a subjective psychogenic trigger is often required, the main measures for the prevention of dysmorphomania are the proper education of the child in the family and the timely elimination of existing defects in the appearance of the child until they have developed into a psychiatric problem.

The formation of normal self-esteem will help to prevent an inferiority complex inherent in hypochondriacs, especially if there is a certain physical defect. In no case should you resort to offensive remarks about children, even if these comments are made by parents as a joke and are not intended to offend the baby. Expressions such as "mother's fatty" or "and to whom you are such a lop-eared" may adversely affect a child's self-esteem.

If there is a physical defect, it is inadmissible to focus on the child's attention on him, to remind him of different reasons. On the contrary, you need to do everything necessary to save the baby from flaws in appearance or at least make them less noticeable.

Educators, teachers, medical personnel should also be attentive to children with physical defects, avoiding caustic remarks and preventing teasing from other guys, which are the strongest trigger in the development of dysmorphomania. It is necessary at all forces to help the child to love himself as he is with all his shortcomings, not allowing thoughts of a physical defect to prevail over the rest.

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Forecast

The prognosis of dysmorphophobia and dysmorphomania is most often considered positive. Very rarely the disease becomes chronic. Usually effective treatment quickly stops seizures of excessive care for their appearance, returning the teenager the joy of communicating with peers.

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