“I hate my juicy lips. People, they stare at me, especially on the train, making fun of my hideous, juicy lips.” Steven’s story led him to spend hundreds of dollars a month on beauty products to improve the look of his supposed juicy lips and miss work due to the inability to bear the “disgusted stares” on the train. We met him in the dermatology clinic while he was asking for a “potion” that would cure his “diseased lips.” Meeting Steven makes us to rethink the initial possibility that these feelings could merely apply to anyone and are representative of society’s quest for beauty, supported by the multibillionaire dollar cosmetic industry. All people, in fact, do spend time and resources on beauty enhancing measures, and at times, have been unhappy with some aspect of their appearance. The scientific literature gives us evidence of our innate ability to easily extrapolate information from a person’s face to make an evaluative assessment. However, it also shows that many different aspects of culture, history, and personality can reshape our biologic perceptions, revealing to us a dynamic process of aesthetic appreciation that can range from normal appearance concerns to abnormal disorders of self-perception. Body dysmorphic disorder (BDD) is a disorder of self-perception; it is the impairing preoccupation with a nonexistent or minimal flaw in appearance. It is the obsession with perfection. These patients complain of misshapen, disfigured, and grotesque body parts, supposed deformities that make them feel intolerably ugly. BDD is a relatively common yet under-recognized disorder. People with BDD compare themselves to others, hide body parts, and have impaired functioning in society. When severe, this disorder can destroy a person’s life. Although it has been described for centuries, it has only more recently come to the attention of the medical community.

BDD is not just a reflection of modern society’s preoccupation with appearance. A description of this disorder was initially documented in 1891 by the Italian psychiatrist Enrico Morselli. He named it dysmorphophobia, derived from the Greek word dysmorphia, meaning ugliness, specifically of the face [1]. Jerome [2] translated Morselli’s classic article describing dysmorphophobia, in which he wrote:

As the result of some observations I have made in recent years, I propose to add two new and previously undescribed varieties to the various forms of insanity with fixed ideas, whose underlying phenomenology is essentially phobic. The two new terms I would like to put forth, following the nomenclature currently accepted by leading clinicians, are dysmorphophobia and taphephobia.

The first condition consists of the sudden appearance and fixation in the consciousness of the idea of one’s own deformity; the individual fears that he has become deformed (dysmorphos) or might become deformed, and experiences at this thought a feeling of an inexpressible disaster… The ideas of being ugly are not, in themselves, morbid; in fact, they occur to many people in perfect mental health, awakening however only the emotions normally felt when this possibility is contemplated.

But, when one of these ideas occupies someone’s attention repeatedly on the same day, and aggressively and persistently returns to monopolise his attention, refusing to remit by any conscious effort; and when in particular the emotion accompanying it becomes one of fear, distress, anxiety, and anguish, compelling the individual to modify his behaviour and to act in a pre-determined and fixed way, then the psychological phenomena has gone beyond the bounds of normal, and may validly be considered to have entered the realm of psychopathology.

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. He 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 with rituals or movements of the most outlandish kinds, the way a rhypophobic who cannot get water to wash himself might, the attack does not end very quickly, but may reach a very painful intensity, even to the point of weeping and desperation.

In this excerpt, Morselli’s description of dysmorphophobia is not simply characterized by one’s fear of having a physical defect, as the suffix “phobia” might suggest. Rather, it describes an individual who displays polarization of attention, charged with an emotion that focuses on a particular aspect of the body [3]. It is the development of obsessive thoughts about one’s appearance and engagement in compulsive behaviors, such as excessive mirror checking, to the extent that it interferes with daily functioning.

Years later, in 1903, the next major historical reference to dysmorphophobia was made by the French psychiatrist Pierre Janet [4]. He described a married woman who was housebound for five years due to the preoccupation with the belief that she had a moustache. She avoided engaging with her neighbors out of fear that she would be ridiculed for her “hairy face” and imagined them shouting at her, “Hairy, hairy!” This obviously caused her severe distress and significantly impaired her social functioning. In this same account, Janet also described the first possible use of behavioral therapy in treating these patients. He noted “[she underwent] treatment dictated by her husband under our instruction” that “consisted of motivational and attention exercises to combat her shyness” [5].

Like Morselli, Janet classified dysmorphophobia to belong to a large class of syndromes similar to obsessive-compulsive disorder, and he called it l’obsession de la hontu du corps or obsession with shame of the body. He regarded this disorder to be “common, invariably overlooked” and one that “evoked extreme shame,” as individuals feared being viewed as ugly and ridiculed. His sentiments remain valid today in that BDD is prevalent but continues to be an under-recognized condition [6].

Another notable historical figure who is credited with describing dysmorphophobia is Emil Kraepelin. Kraepelin, a German psychiatrist and regarded by many as the founder of modern psychiatry, believed that biological and genetic disorders were the primary causes of mental illnesses. He recognized dysmorphophobia as a psychiatric disorder and included it in the eighth edition of his textbook, published in four volumes between 1909 and 1915. Kraepelin [7] stated, “some patients cannot rid themselves of the thought of having something conspicuous or ridiculous on their bodies, arousing the attention or ridicule of passers-by with the strangely shaped nose, crooked legs or a repellent odor.” Though Kraepelin used Morselli’s term dysmorphophobia in naming this disorder, he did not mention Morselli himself. Therefore, some references [8] actually acknowledge Kraepelin for recognizing this disorder. Regardless, similar to Morselli and Janet, Kraepelin classified dysmorphophobia to be an obsessive neurosis [9], describing it as one of the obsessive-compulsive neuroses in his textbook.

Perhaps one of the best-known cases in the history of BDD and psychoanalysis is a patient of Sigmund Freud, who went by the pseudonym “Wolf Man.” He was later known to be Sergei Pankejeff, a wealthy Russian aristocrat who acquired his name “Wolf Man” from a dream he had as a child. In his later life, Pankejeff began showing symptoms of BDD [10]. He became fixated with his nose, which led him to repeatedly seek out the opinions and treatments of physicians for “blackheads, swellings, wounds from picking pimples, and imaginary scars” [11]. At one point, he complained that his nose had been injured due to a dermatologist’s ill-advised use of electrolysis, leaving him with a scar or a hole in his nose. According to Ruth Mack Brunswick, his psychoanalyst at the time, “nothing whatsoever was visible on the small, snub, typically Russian nose of the patient.” Pankejeff realized that though the injury was all too noticeable to him, his reaction to it was abnormal. Therefore, having exhausted all his dermatological resources, he reconsidered help through psychoanalyses. By the time that Pankejeff came to Brunswick for evaluation, he was significantly distraught. Gardiner [12] published Brunswick’s report in The Wolf Man, and in it she explained: