[Body dysmorphic disorder and psychosis. Case reports and discussion]

The diagnosis of patients who have a preoccupation about physical ugliness is not easy. Many diagnoses can be made. Body dysmorphic disorder (BDD) is defined as a preoccupation with an imaginary defect in physical appearance. What seems difficult in this diagnosis is to make the difference between the psychotic and the non-psychotic form of the disorder. If the patient becomes delusional, we have to make the diagnosis of delusional disorder, somatic subtype. Sometimes it is not easy to make the difference between the delusional and non-delusional form of the illness. A good example is the so-called "olfactory reference syndrome" (ORS), which involves the persistent preoccupation with one's body odour. To make it more difficult, the preoccupation with one's appearance can be seen in many other disorders, such as schizophrenia, or major depressive disorders. We present three cases of dysmorphophobic patients, to discuss their diagnosis and show how we have to be careful about this delusional versus non-delusional difference.

The first case is a young man, aged 20 year, who exhibits the typical picture of an ORS. He has probable olfactory hallucinations. He had good response to a treatment combining escitalopram 15mg and risperidone 1mg. The second case had a first appearance of BDD, but he had auditive hallucinations and the evolution showed a pattern more typical of schizophrenia, paranoid subtype. He responded initially to citalopram 20mg and ripseridone 2mg. Sleepy with risperidone, it was shifted to amisulpiride 200mg. After five years, it was possible to stop the amisulpiride, but we had to maintain it to avoid a relapse. The third case is typical of schizophrenia, with a pseudo neurotic aspect, and its course was terrible, with poor response to all neuroleptic therapy, including clozapine.

These three cases are typical of a feature rarely reported in the literature: the delusional aspect of a dysmorphophobic concern. The literature mainly focuses on the more anxious pattern, and so emphasises the treatment with serotoninergic antidepressants. Our cases demonstrate a gradation in the delusional and psychotic aspect. The first case is dubitatively psychotic, the second is an "ambulatory" schizophrenia with a good response to treatment, the third a very destructive disease. In our cases, some features showed in the typical BDD are also present. We question the obsessive compulsive aspect of the disorder, which was present in our three cases. This supports the fact that the dysmorphophobic feature could be considered more like a symptom than a disorder itself. It reminds us to be always looking for the delusional features of a disorder so as to give the appropriate treatment.