Currently, controversy is raging in the state of Florida about a bill which restricts underage minors from having permanent sex-change operations even with the consent of an adult. In these days of ‘everything is new’ including transgender issues, research into the annals of psychiatry show that body dysmorphia was studied as far back as Freud and is frequently associated with deep seated depressive issues. Before we start agreeing to slice and dice, some insight into research that has already been done would be very useful.

Indian J Psychiatry. 2006 Oct-Dec; 48(4): 260–262.

doi: 10.4103/0019-5545.31561

PMCID: PMC2915600

PMID: 20703349

Body dysmorphic disorder, dysmorphophobia or delusional disorder—somatic subtype?

V.K. Aravind* and V.D. Krishnaram**

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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.

Keywords: Body dysmorphic disorder, change of face appearance, delusional disorder, somatic type

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Body dysmorphic disorder (BDD) previously known as ‘dysmorphophobia’ is defined as a preoccupation with an imagined defect in one’s physical appearance. The preoccupation is associated with many time-consuming rituals such as mirror gazing or constant comparing.1 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.2

In 1886, Morselli described dysmorphophobia. Dysmorphophobia 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.3

There is frequent comorbidity in BDD, especially in depression, social phobia, and obsessive–compulsive disorder (OCD) and delusional disorder.4 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.5

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 infestations by insects, worms and foreign bodies, emitting a foul odour (halitosis) or of being ugly.6,mirror%20gazing%20or%20constant%20comparing.