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Letter to the Editor

A Case of Body Dysmorphic Disorder by Proxy

Ajay Kumar Bakhla, MD; Sinha Prakriti, MPhil; and Patnaik Ashok Kumar, MD, DPM

Published: August 23, 2012

A Case of Body Dysmorphic Disorder by Proxy

To the Editor: Body dysmorphic disorder (BDD) is characterized by preoccupation with an imagined defect in appearance of self. We present and discuss the case of a 28-year-old woman with a preoccupation regarding perceived deformities of appearance for her daughter as well as for herself. A PubMed search of BDD and dysmorphophobia by proxy yielded only 5 such reports1-4; the current report extends the boundaries of "self" in the psychopathology of BDD.


Case report. Ms A, a 28-year-old woman, presented 6 months before the time of this report with an illness of 10 years’ duration with repetitive thoughts and preoccupation related to short stature and facial deformity. She was repeatedly checking the mirror and seeking assurance about her presumed facial deformity and height. Her appetite and sleep were reduced, and she had preferred staying at home because of doubts that people were looking at her and mocking her ugliness.

After she was married, she was critical of the attributes of her husband and felt that his face was disproportionately big. With the fear that her baby would also share her physical ugliness, she even attempted an abortion, though unsuccessful. Since the birth of her daughter, she indulged in frequent checking and assurance seeking for her daughter’s assumed deformity of face. She used to feel guilty for passing along ugliness to her daughter, and thoughts of strangling her own child troubled her repeatedly, which led her to avoid the child while alone.

There was no family history of any significant psychiatric or medical illness, and her general physical examinations revealed no abnormalities. Her score on the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS)5 was 32 for self and 30 for her daughter; the overall Clinical Global Impressions-Severity of Illness scale6 score was 5, indicating severe symptoms and functioning mainly with assistance. On the 17-item Hamilton Depression Rating Scale (HDRS17),7 her score was 38. She received tablet venlafaxine 150 mg/d and trifluoperazine 10 mg/d as well as cognitive-behavioral therapy. After 12 weeks, her BDD-YBOCS scores were 12 for self and 6 for her daughter. Her overall Clinical Global Impressions Improvement scale6 score was 2 (much improved), and her HDRS17 score was 12; her distress had improved, but mild dysmorphic ideas for self persisted.


The patient had characteristic preoccupation and distress with an imagined defect in appearance of self. She had apprehensions of passing along ugliness to her baby, and the attempted abortion indicates the extent and intensity of her dysmorphic symptoms, which continued for herself and her daughter.

The possible psychopathological explanation of proxy manifestation may be due to (1) a variant of BDD, (2) severity of BDD, and (3) association of depression. Josephson and Hollander2 reported 2 cases of proxy BDD and suggested that BDD criteria should be expanded as "appearance obsessions" in others. In this and previous cases,1,2 the proxy component appeared later in the course of illness of established BDD and also improved earlier with treatment, suggesting proxy manifestation may be due to extension of the BDD itself, in terms of severity, and not a variant of BDD. Associated depression may also be confounding to psychopathology.

This case illustrates that the idea of self-ugliness in BDD may extend beyond self as proxy manifestation.


1. Atiullah N, Phillips KA. Fatal body dysmorphic disorder by proxy. J Clin Psychiatry. 2001;62(3):204-205. PubMed doi:10.4088/JCP.v62n0312a

2. Josephson SC, Hollander E. Body dysmorphic disorder by proxy. J Clin Psychiatry. 1997;58(2):86-87. PubMed doi:10.4088/JCP.v58n0206c

3. Godden D. Body dysmorphic disorder by proxy. Br J Oral Maxillofac Surg. 1999;37(4):331. PubMed

4. Laugharne R, Upex T, Palazidou E. Dysmorphophobia by proxy. J R Soc Med. 1998;91(5):266. PubMed

5. Phillips KA, Hollander E, Rasmussen SA, et al. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull. 1997;33(1):17-22. PubMed

6. National Institute of Mental Health. Clinical Global Impressions (CGI) scale. Psychopharmacol Bull. 1985;21:839-843.

7. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23(1):56-62. PubMed doi:10.1136/jnnp.23.1.56

Ajay Kumar Bakhla, MD

Sinha Prakriti, MPhil

Patnaik Ashok Kumar, MD, DPM

Author affiliations: Departments of Psychiatry (Drs Bakhla and Kumar) and Psychology (Ms Prakriti), Tata Motors Hospital, Jamshedpur, Jharkhand, India.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Published online: August 23, 2012.

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