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To the Editor: Little is known about the causes and pathophysiology of body dysmorphic disorder. We report two cases of body dysmorphic disorder that followed a medical illness and suggest that the latter might play an active role as a trigger in the pathogenesis of the disorder.
Arnold was a 17-year-old boy who came to us with severe body dysmorphic disorder that had lasted 2 years. He had no psychiatric history until he developed Bell’s palsy at the age of 15, after which he became socially isolated and self-absorbed, complaining of severe facial/skin deformities, despite resolution of the palsy. He spent long hours examining his face and picking at real or perceived lesions and discolorations. His symptoms were so severe that he attempted suicide and was hospitalized. Subsequently, he was referred to our clinic.
Mr. A was a 22-year-old man who came to our clinic with severe symptoms of body dysmorphic disorder related to his skin. His symptoms started immediately after he developed ulcerative colitis 18 months earlier. He believed that his skin was excessively dry and deformed and that people were commenting about his appearance. He spent hours checking his skin in the mirror. Mr. A became socially withdrawn, quit his job, and was homebound. Of interest, he reported a similar episode of body dysmorphic disorder when he was 16. This earlier illness resolved spontaneously after 6 months.
These cases suggest that a range of physical illnesses may act as a stimulus for the development and/or exacerbation of body dysmorphic disorder. To our knowledge, there is no literature connecting body dysmorphic disorder to a medical condition. However, there is a recent report (1) describing a similar link between a medical illness (malignancies) and obsessive-compulsive disorder (OCD). The latter has many features similar to body dysmorphic disorder, such as obsessive thoughts and repetitive behavior. Moreover, both disorders appear to preferentially respond to selective serotonin reuptake inhibitors, which suggests a common serotonin dysfunction (2). This neurochemical dysfunction might have been triggered by the inflammatory process in our patients. One possible pathophysiological mechanism for a biochemical link between these medical illnesses and the onset of body dysmorphic disorder or OCD may be through cytokines, which have been shown to be activated in inflammatory diseases and cancer and have been suggested to suppress serotonin synthesis (3). This report raises an interesting question about biological factors in the onset of body dysmorphic disorder. Further investigation to illuminate these factors is suggested.
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