Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis by Christine Montross

before?” He paused again to think. “Maybe eight.”
    Eddie’s thoughts about his skin and hair not only consumed his mind, they also interfered with the most basic aspects of his life. His girlfriend of many years had left him, fed up with the ways in which his preoccupations with his appearance affected their lives. In addition to the hours Eddie spent each day in front of the mirror, he also canceled plans to go out at the last minute, fearful that he was so hideous-looking that strangers would ridicule him on the street or that in a different light his new girlfriend would finally see him realistically and break up with him on the spot. He would ask her—sometimes hundreds of times a day—how his skin and hair looked. No matter how reassuring her comments were, he remained unconvinced that he was anything other than grotesquely disfigured.
    To make matters worse, Eddie was ashamed of his inability to change either his outlook or his behavior. “Some people think I’m really vain,” he said softly. “But people who are vain think they are beautiful and
like
to look at themselves.” He paused. “I hate looking in the mirror, but I have to try to fix how horrible I look.”
    Though Eddie’s symptoms sound remarkable, the fact is that in terms of the demographics of mental illness his affliction is as common as schizophrenia, anorexia, or bipolar disorder, plaguing one out of every fifty to a hundred people. Descriptions of the disorder can be found even in centuries-old case reports with a range of evocative names, like “imagined ugliness” and “dysmorphophobia,” but the crux of the symptoms is the same: a preoccupation with an imagined defect in one’s appearance or excessive concern about a slight physical anomaly. Today we call this illness body dysmorphic disorder (BDD).
    Descriptions of patients who would today be diagnosed with BDD periodically surface in the psychiatric literature of the nineteenth and twentieth centuries.
The Oxford English Dictionary
dates the word “dysmorphophobia”
(from the Greek
dysmorpho-,
meaning “misshapen or deformed,” and
-phobia,
meaning “fear”)
to 1891. The first use of the term is attributed to the Italian psychiatrist Enrico Morselli, who gave his article the enticing title “Dysmorphophobia and Taphephobia.” The fear of being deformed, alongside the fear of being buried alive. The triumphant subtitle of Morselli’s article reads like an exploration of the new world: “Two Hitherto Undescribed Forms of Insanity with Fixed Ideas.” Morselli writes, “The dysmorphophobic, indeed, is a veritably unhappy individual, who in the midst of his daily affairs, in conversations, while reading, at table, in fact anywhere and at any hour of the day, is suddenly overcome by the fear of some deformity that might have developed in his body without his noticing it.”
    Like Bethlem’s Charles Harold Wrigley in 1890, the patients whom Morselli describes are indistinguishable from those I see more than a century later. He writes that the dysmorphophobe “fears having or developing a compressed, flattened forehead, a ridiculous nose, crooked legs, etc., so that he constantly peers in the mirror, feels his forehead, measures the length of his nose, examines the tiniest defects in his skin, or measures the proportions of his trunk and the straightness of his limbs, and only after a certain period of time, having convinced himself that this has not happened, is able to free himself from the state of pain and anguish the attack put him in. But should no mirror be at hand, or should he be prevented from quieting his doubts in some way or other by means of some mechanism or movements of the most outlandish kinds, . . . the attack does not end very quickly, but may reach a very painful intensity, even to the point of weeping and desperation.”
    Indeed, patients with BDD, both current and historical, are frequently in true agony, their lives dominated by their constant