DYSMORPHOPHOBIA (?body odor)

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I have a young female patient (30) who complains of a ten year history of 
body odor without hyperhidrosis.  She is healthy except for "fatigue" and 
has no discernable odor to me or my assistant raising the probability of 
a psychiatric component.  Any one had this type of case?

Jay Barnett, MD
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Sounds like a monosymptomatic delusion. I had a patient with delusion of body
odor do well on Orap a few years ago [same as delusions of parasitosis], but
my current favorite is Risperdal {Janssen, risperidone} 1-2 mg hs - works as
well as Orap but less sedating and less likely to cause dystonic reactions.

KC Smith MD FRCPC
Niagara Falls ON 
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 I think we 
all see these types of cases and it's a question of dysmorphophobia, which is 
more of a description of the behavior than a psychiatric diagnosis. I tend to 
treat them like I do my patients with mild delusions of parasitosis , which is 
to say I humor them to a point and give them something that is either supportive 
treatment or placebo as the situation dictates. I generally don't give them 
pimozide (which would be unwarranted in a dysmorphophobic patient). If they seem 
to have emotional problems they need to talk about I would consider sending them 
for counselling or psychiatric referral, but probably most of these folks won't 
take you up on that unless they really want to anyway. 

Mark Naylor, M.D.
Fleishaker Assistant Professor for Dermatology Research
Center for Molecular Medicine
University of Oklahoma Health Sciences Center
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Why would you say pimozide would be "unwarranted" in dysmorphophobia? In my
view dysmorphophobia is a type of monosymptomatic delusion. This can be very
disabling, and can lead patients to do or avoid doing things which can result
in considerable financial, social and even physical harm. Pimozide works, and
it is quite safe and effective, in particular at the low doses these folks
tend to need [eg. 1-3 mg hs]. Risperdal can be used if pimozide is poorly
tolerated.

KC Smith MD FRCPC
Niagara Falls ON
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I agree that if someone is truly delusional in the sense that they are 
psychotic, then pimozide or other neuroleptics are indicated. If the delusion of 
parasitosis is really a "pseudodelusion" that is, just a gullible person who has 
been led to believe for one reason or another that microscopic insects or 
something like that is responsible for their atopic dermatitis, then I don't 
think these drugs are the appropriate treatment. The key test is whether they 
are truly delusional or simply misled in what they believe. If they are 
describing pink insects with their mother's face, then you could probably assume 
you are dealing with a real delusion. 

Most of the people that I see that believe they are infested with insects are in 
the latter category and are not truly delusional. Pimozide for these folks only 
exposes them to acute dystonic reactions and eventually, tardive dyskinesia 
which is much worse since it is generally a permanent neurologic sequelae. Most 
of the people that I see that have mild symptomatology of dysmorphophobia have 
some self-image problems or maybe are diagnosably neurotic, but are definitely 
not psychotic. For that reason, I wouldn't use pimozide unless it was a very 
severe case, and even then, only for a limited time (a few months). 

Respectfully,
Mark Naylor, M.D.
Fleishaker Assistant Professor for Dermatology Research
Center for Molecular Medicine
University of Oklahoma Health Sciences Center
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For what my opinion is worth (about 2 cents on this issue) I would tend 
to agree with K. Smith: the vast majority of patients I have encountered 
to date clearly fit my, and my psychiatric consultants, definitions of 
psychosis. Indeed, the last two successive patients I dealt with were 
both emergently admitted to our psych unit for suicidal ideation driven 
by their conviction that these "bugs" were attacking their flesh. Digging 
deep ulcers in the skin goes beyond simple neurosis in my opinion. By the 
way, the two people I have heard speak on this who are very insightful 
are Caroline Koblenzer and John Koo, both with derm/psych training. Keep 
an eye out for them.

Mark Ling, M.D., Ph.D.
Emory University Department of Dermatology
Clinical Pharmacology Unit
Atlanta, GA
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