International Journal of Clinical Pharmacology and Therapeutics
 Vol. 39 – No. 7/2001 (279-283)


The “Dorian Gray Syndrome”:

psychodynamic need for hair growth
restorers and other “fountains of youth”

B. Brosig (1), J. Kupfer (2), V. Niemeier (1) and U. Gieler (1)

(1) Clinic for Psychosomatics and Psychotherapy, and
(2) Department of Medical Psychology, Center for Psychosomatic Medicine,
Justus Liebig University, Gießen, Germany

Key words:
life-style medication
Dorian Gray Syndrome
androgenetic alopecia
male pattern baldness


The psychic-dynamic factors underlying the hypochondriac disorder involving an obsessive preoccupation with physical attractiveness (dysmorphophobia) and the treatment possibilities for some manifestations of this syndrome have been examined.
This psychosomatic illness frequently leads to the taking of finasteride, a medication that halts the balding process in cases of androgenetic alopecia or even stimulates renewed hair growth. The nosological demarcation of the disorder requires the differential diagnosis of depressive, hypochondriac and delusionary disorders.
The psychodynamics involved, as deduced from 2 case studies, takes the form of an expansion of the patients’ reductionist perspective, characterized by an emphasis on external types extending to a psychogenetic attitude with regression into narcissistic fixation. The authors seek eternal youth which is a “leitmotif” of the disorder, and they apply the term “Dorian Gray Syndrome” after Oscar Wilde’s novel. The treatment recommended is a course of intensive psychotherapy; often the topic of “life-style medication” must be introduced before the specific narcissistic conflicts behind the current symptoms can be treated.


“Life-style medication” has recently become fashionable, not least because it holds out the promise that, with no great effort, one can get ever closer to the ideal of so called beauty. This goal is in accord with the life- style of a society characterized by the cult of youth and a longing for physical perfection (operative notions for this include “fit for fun”, “the fun society”, “the experience society”). Balding is generally associated with ageing; consequently, the desire to prolong a youthful appearance inevitably leads to demands for effective treatment (see [Rushton1999]).
We chose the concept “Dorian Gray Syndrome” [Brosig et al. 2000] to underscore the latent wish of patients to be able to “swim against the current”, as it were, in order to stay eternally young. The name of the syndrome derives from the title of a novel by Oscar Wilde (The Picture of Dorian Gray, 1890; edition consulted 1994), in which the protagonist Dorian Gray sells his soul to the devil so as not to have to physically experience the ageing process. In the book, it is Dorian’s portrait, not his body that ages. The portrait becomes increasingly bloated and ravaged because of his dissipated life-style. As a consequence, the titular hero can see how he would look if he himself were exposed to this mode of living and the attendant ageing process. At the same time, the novel’s motif of the selfportrait is coupled with the encoded suggestion of the mirror and is thereby transformed into an association with the self-love of the narcissist. The highly compact story by this writer and “dandy” (see text insert: “TheDisciple”), brings both of the elements – artificiality and self-regard – that constitute a narcissistic attitude together in poetic compression. In the clinical picture of the disorder which is now referred to as the Dorian Gray Syndrome, one finds that this is characterized diagnostically by symptoms of body dysmorphic hypochondriac imbalance, social phobia coupled with narcissistic regression, and denial of any personality-structuring process of growth to maturity (Table 1). Two brief case vignettes drawn from our psychodermatological work (see [Brosig et al. 2000]) serve to illustrate the psychodynamic concept we are putting forward.

The Disciple
(by Oscar Wilde)

When Narcissus died the pool of his pleasure changed from a cup of sweet wa ters into a cup of salt tears, and the Oreads came weeping through the wood land that they might sing to the pool and give it comfort. And when they saw that the pool had changed from a cup of sweet waters into a cup of salt tears, they loosended the green tresses of their hair and cried to the pool and said, “We do not wonder that you should mourn in this manner for Narcissus, so beautiful was he.” “But was Narcissus beautiful?” said the pool. “Who should know that better than you?” answered the Oreads. “Us did he ever pass by, but you he sought for, and would lie on your banks and look down at you, and in the mirror of your waters he would mirror his own beauty.” And the pool an swered, “but I loved Narcissus be cause, as he lay on my banks and looked down at me, in the mirror of his eyes I saw ever my own beauty mirrored.

Table 1.

Diagnostic criteria for the Dorian Gray Syndrome.
  1. Excessive preoccupation with the outward appearance (body dysmorphic disorder)
  2. Imaginary or minimal defects in externalmorphology causing embarrassment and social reclusiveness (narcissistic regression)
  3. Strong desire to preserve youthfulness in order not to grow older (“swimming against the current of time”, and denial of the maturation process)
  4. along with excessive worry about external appearance

Case vignette 1

A 34-year-old male patient presented at a der matology clinic showing obvious signs of distress due to hair loss. Medical examination revealed that his hair growth and thickness was well within the normal range of variation for his age (Stage I according to Hamilton).
The patient reported that he first noticed that the hair on his head was thinning and shedding more pronouncedly after he got married. Other com plaints expressed included disturbed sleep and reduced drive, fatigue, listlessness and a lack of “joie de vivre”.

Patient history

The tramdriver had been married to a colleague for 5 years and they had a two-year-old son. After the death of his father, a trades man, in 1988 the patient, from the age of 3, lived with his mother after his parents became divorced. The patient describes himself as a “white-haired boy”, showered with love as an only child and who received “everything he wanted”.
His fear of receding hair led to him constantly check his appearance. He was used to examining closely what he called his “disfigurement” in the mirror before commencing pronounced grooming behavior (persistent combing). The mood of depression was accompanied by neglect of friends and acquaintances in favor of a narrow fixation on his relationship with his wife. Typical comments were

I look ugly, my hair’s thin, other people make jokes about the way I look, even women draw my attention to it; I look so old. I can’t bear to look at my self in the mirror and keep trying to comb my hair so it looks right, but to no avail. My wife, who has cut my hair ever since we have been married, makes jokes and disparaging remarks about my ‘thin patches’ whilst she is doing it. My wife would like me to take finasteride, too”.

The patient expressed considerable expectations regarding the effects of the new medication and hoped that it would make him more acceptable socially and more attractive to his wife. He is currently in the preliminary phase of motivation training for a course of psychotherapy. The patient’s statements allow reconstruction of the following psychodynamic situation. Conflicts arising out of the new state of being married are warded off. In the process of his denial of maturity, which is probably linked to the relinquishing of libidinal aspects of the self (as it were: “active (sex) life”), he develops a reductionist view of the process of maturation involving a preoccupation with growing older (and less attractive) and leading to a narcissistic retreat into himself, to the point where, like a pubescent teenager, he can think of only outward attractiveness. The narcissistic sense of injury at growing older (the “cult of youth”) is counteracted by “rejuvenating measures” under the illusory impression that the “stream of time” can be turned back. This creates an outwardly ideal and ostensibly impregnable shell, a mantle of timelessness (“Dorian Gray” or “Michael Jackson”condition).

Psychodynamic evaluation

The defensive mechanisms involved are overwhelmingly narcissistic and to some extent designed to forestall any polymorphousperverse inclination. The symptom of body dysmorphic imbalance, like other symptoms of an almost delusionary nature (see Table 2), presents itself initially in the form of psychic stabilization.

Table 2. Differential diagnosis or co-morbidity.

  1. body dysmorphic disorder
  2. other disorders of somatization
  3. depressive disorders
  4. compulsive illnesses
  5. delusional disorders
  6. attacks or conditions of fear and panic (social phobias)
  7. schizophrenic psychoses

Case vignette 2

A 44-year-old female patient attended a psychotherapeutic polyclinic complaining of chronic low spirits with adynamia and sleeplessness as well as a sense of inner vacancy. She was seeking psychotherapeutic aid on the advice of her dermatologist who had noticed her constant and excessive preoccupation with her hair. She often spent half an hour in the morning at her mirror, was plagued by a fear of increasing loss of hair, a fear which lacked any dermatological basis. She maintained that she was unable banish the thought that her hair was thinning and that she would
soon have a bald patch. She insisted on treatment with finasteride. She could be motivated during the outpatient visits, to undergo a psychodynamic course of therapy.
In the course of the 6-week treatment as an inpatient, it became clear that the symptoms had began after the patient had undergone termination of a pregnancy. She had felt that she could not trust herself, at her age, to bear the stress of pregnancy and to care for a baby. On the one hand, she claimed that she wanted a child; on the other, that she was not capable of giving birth to a child. It is clear from this history that she associated pregnancy and motherhood with physical energy and the “youthfulness”. After the abortion, the above mentioned symptoms appeared, along with depressive and hypochondriac features and the “fear of hair loss”.


The intelligent patient, at the time of this investigation, still looks youthful and attractive despite being in the 24th year of her marriage. She had been very happy after getting married and has 2 children, aged 24 and 29 years of age, who are making their own way in life. Although she is relieved at no longer having to care for her children, she is also sad, and feels that there is a gap in her life. She is also under the impression that her husband is no longer interested in her, sexually and otherwise. During her childhood, she often had the sense of not being wanted. She claimed that her parents spent more time working on the farm than caring for their children; and, caught between older and younger siblings, she felt like “an expendable extra”. Subsequently, however, and not least because of her physical attractiveness, she received more attention and she regards this development as a compensation for her dreary childhood. She felt particularly proud of her beautiful hair, which she always took good care of.
Analyzed psychodynamically, the conflict associated with the pregnancy is marked by the patient’s regression to narcissistic stages of psychic development with an intensive preoccupation with her hair (in Germany this would be termed a “Sissy of Austria” condition). This caused her to deflect her fear of losing the charm of a young woman towards an obsessive preoccupation with losing her (beautiful and feminine) hair. At the same time, as a compromise, this intensive preoccupation with hair-loss is associated with the symptoms of pregnancy. Is she not pregnant all the time?
Once these aspects are interpreted for her and subsequently worked through, her compulsive thoughts gradually faded and she was able to make new plans for her life. With her husband’s support, she was able to open a florist’s shop.

Therapeutic strategy

In treating the Dorian Gray Syndrome, it is of prime im portance to establish a climate of trust in the doctor/patient relationship. Finasteride (see Table 3) may be administered in order to facilitate contact with patients, to meet their expectations, and in the longer term (case study examples) to motivate them to undergo psychotherapy. If a depressive condition is conspicuous, the recommended treatment is a selective serotonin reuptake inhibitor (SSRI, such as flovoxamine or clomipramine), either alone or in combination with pimocide in order to optimize the effect of SSRI treatment in parallel with psychotherapeutic treatment on the psychic disorder (see Table 4, taken from [Phil lips 2000]).

Table 3.


Active ingredients: 4-azasteroid, which inhibits human-type II 5-a- reductase
and blocks the peripheral conversion of testosterone into the androgen
dihydrotestosterone (DHT). Review in [Kaufman et al. 1998].
Side effects:
  1. diminished libido
  2. reduced volume of ejaculate
  3. erectile dysfunction
  4. increase in mammary tissue

Table 4.

Treatment strategies for Dorian Gray Syndrome.
  1. psychodynamic therapy with properly motivated patients
  2. serious cases with chronic body dysmorphic disorder should additionally
    receive medication with psycho active drugs
  3. psychotherapy should be intensive (if necessary, in patient or high-frequency
    outpatient therapy
    ) because chronic cases are common
  4. cognitive-behavioral methods [Phillips 2000] are recommended as an alternative to psychodynamic approaches to treatment


Since the study of Christopher Lasch[1979], narcissism has been understood as a culturally specific, temporal phenomenon. In the guise of the Dorian Gray Syndrome, it is combined with an over-emphasis on external morphology and a fetish obsession with youthfulness. This expresses itself in the denial of the ageing process, in reactive measures against the normal structuring aspects of maturation and in the attendant effects on the individual’s life [Colarusso 1999]. We have chosen the term “Dorian Gray Syndrome” to describe the narcissistic triad of body dysmorphic disorder, self-regard and denial of maturity (hence of mortality [Csef 1987]). This syndrome, also known in the dermatology literature as the “Thersites syndrome” (in Homer’s Odyssey, Thersites was the ugliest warrior in the Greek army), reflects in its very name the pathology of alienation from self [Lacan 1966].
Today, men as well as women can develop a fetish obsession with some part of the body, thereby subjecting physical aspects, eroticism and thus sexuality to the normative processes of a materialist esthetic. The body dysmorphic disorder that is often revealed in the course of clinical examination can be regarded as a symptom situated somewhere along the scale between hypochondria, depression, compulsive disorder and a delusional illness. After clarification of motivation, treatment involves the decisive implementation of intensive psychotherapy, if necessary, combined with antidepressive and neuroleptic medication. The “life-style” medication finasteride can, under certain conditions, be administered to help stabilize the doctor/patient relationship and, in the initial phase of consultation, to improve the patient’s motivation to submit to intensive psychotherapy.


Brosig B, 2000
Das Dorian-Gray-Syndrom. Haarwuchsmittel und andere “Jungbrunnen”. Vortrag zum
Thema “Life style-Drogen” der Sektion Klinische Pharmakologie an der Akademie für ärztliche Fortbildung und Weiterbildung der Landesärztekammer Hessen, Bad Nauheim, 29.4.2000

Brosig B, Kupfer J, Niemeier V, Gieler U 2000

Urticaria and the re call of a sexual trauma. Dermatol Psychosom 1: 72-75

Colarusso CA, 1999
The development of time-sense in middle adult hood. Psychoanal Q 68: 52-83

Cotterill JA, 1996
Body dysmorphic disorder. Dermatol Clin 14: 457-463

Csef H, 1987
Tod und Neurose. Angst, Todestrieb, Objektverlust und Narzißmus auf dem Hintergrund humaner Todeserfahrung. Fortschr Neurol Psychiatrie 55: 164-173

Kaufman KD, Olsen EA, Whit ing D, Savin R, De Villez R, Bergfeld W, Price VH, Van-Neste D, Rob erts JL, Hordinsky M, Shapira J, Binkowitz B, Gormley GJ, 1998
Finasteride in the treat ment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol 39: 578-589

Lasch C, 1979
The culture of narcissism. American life in an age of diminishing expectations. Norton, New York

Lacan J, 1966

Le stage du miroir comme formateur de la fonction du Je. In: Lacan J (eds) Ecrits. Edition du Seuil, Paris

Phillips KA, 2000

Body dysmorphic disorder: Diagnostic controversies and treatment challenges. Bull Menninger Clin 64: 18-35

Rushton DH, 1999
Androgenetic alopecia in men: the scale of the problem and prospects for treatment. Int J Clin Pract 53: 50-53

Stangier U, Gieler U 1997

Somatoforme Störungen in der Dermatologie. Psychotherapie 2: 91-101

Wilde O, 1994

The Picture of Dorian Gray. Penguin Popular Classics, Harmondsworth