(Or the “non-ailment”)
Andrea Marliani MD
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 “dismorphophobia”. 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.
Today’s lifestyles have led to an increase in the frequency, and gravity, of these symptoms. It has gone from being a problem for a small number of individuals to an illness in many. Stereotype images portrayed in the media aggravate the situation. Many young people feel they cannot “come up to scratch” and that they are inadequate.
This “defect” causes significant emotional stress and can lead to social isolation, unhappiness, and a loss of social relationships. These patients become obsessed with their problem, as they perceive it, and develop ritualistic, repetitive and obsessive behavioural traits. They are always looking in a mirror, or combing their hair; and they repeatedly ask friends, family and doctors for reassurance. In terms of psychological disorders, dismorphophobia often leads to depression. This depression may, in itself, be a cause of chronic effluvium; and this will, in turn, aggravate the depressive state.
In addition to the repetitive, ritualistic behaviour, loneliness and lack of social relationships, the anamnesis may also point to an obsessive family, or stressful friends.
In terms of awareness, patients vary a lot. They may be perfectly aware of what the problem really is, completely unaware, or they may be at any stage in between. And their awareness may vary over time.
Dismorphophobia, this dermatological non-ailment, may extend to disorders in perception and sensitivity. Patients may complain of pain, burning, or itching in the “affected” area, when there is no skin pathology at all. Patients may even become delirious. At this point, you should think you are dealing with mono-symptomatic, hypochondrial schizoid psychosis.
It is always difficult to find the right way to treat patients with dismorphophobia. It is always a lengthy process, needing tact and patience, because 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. These patients need constant reassurance: they telephone frequently; and they often seek out a whole series of other specialists, and are never satisfied with the treatment and advice they are given.
If the medical doctor has no experience in this field, s/he may be severely perturbed by these patients; when, for instance, the patient complains of being bald but clearly is not so. Doctors may end up making serious errors of judgement, perhaps prescribing more treatment than is necessary or, alternatively, underrating the seriousness of the matter for the patient.
So what should we do if we are faced with patients who are convinced they are bald when they clearly are not? Patients who may have already consulted other doctors, and who are already taking finisteride, using minoxidil or undergoing any one, or all, of a series of other therapies?
Psychological and behavioural therapies have proved to be disappointing! One reason for this is that these patients refuse the treatment because they are convinced that they do not need it.
I am of the opinion that the best mode of treatment to adopt is to prescribe a selective inhibitor for the reabsorption of serotonin. This should be prescribed for a long period of time, and at a higher dosage than is given to counteract depression. 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 in terms of anxiety levels, severity of depression and obsession, and in their need to behave ritualistically. At this point, patients will be much more likely to accept a higher dosage of the medicine; and they will then make further advances on their way to recovery.
But to win round these patients, and to enable them to agree to even the lowest level of medication, initially, it is often necessary to take a deft approach. The doctor needs to listen to the patients’ description of their problems carefully. S/he must be in no way judgmental, and must never, never say that the problem is non-existent, or imaginary. The doctor must help patients to feel accepted, and must show verbal and non-verbal proof of his/her sympathy. Should the doctor deny the existence of the problem, the patient would simply make a run for it, and turn to yet another specialist. The doctor needs to acknowledge the patient’s view of the situation, however with some reservation … Along the lines of: “It is true that you are losing your hair, but …”.
The follow-up will depend on the patient’s personality. Perhaps: “Let’s try to find a solution together … It is important for you to feel less stressed because anxiety increases hair loss … So we should try to bring your anxiety level down …” This way, the patient may well accept pharmacological treatment for his/her hair loss. The focus of the problem has been altered. In this type of chess game, it is important that the first move is always providing validation to the patient, in order to be able to help them.