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

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The “Dorian Gray Syndrome”:

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

*Revised and expanded paper, first published as:
Brosig, B., Kupfer, J., Niemeier, V. Gieler, U. (2001) The Dorian Gray Syndrome. Hair Growth Restorers and other „Fountains of Youth”. I. J. Clin. Pharmacol. Ther . 39 , 279-283.


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

(1) Klinik für Psychosomatik und Psychotherapie, Centre for Psychosomatic Medicine, Justus Liebig University Giessen (Chair: Prof. Dr. Ch. Reimer)
(2) Dept. of Medical Psychology, Centre for Psychosomatic Medicine Justus Liebig University Giessen (Chair: Prof. Dr. D. Beckmann)



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




Abstract

The present study deals with the psychodynamics underlying a hypochondriac disorder involving the obsessive preoccupation with physical attractiveness: dysmorphophobia. This frequently leads to the taking of Finasteride, a medication that halts the balding process in cases of androgenetic alopecia or stimulates renewed hair growth. The nosological demarcation of the disorder requires the differential diagnosis of depressive, hypochondriac and delusionial disorders.

The psychodynamic involved, as deduced from two case studies, takes the form of an expansion of the patients' reductionist perspective, characterized by an emphasis on external morphe along with a regression to narcissistic fixations. The authors take the desire for eternal youth as the ‘leitmotif' of the disorder, and coin 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.

Introduction

Life-style medication” has become a fashionable drug recently, not least because it holds out the promise that, with no great effort, one can get ever closer to the ideal of a normative beauty. This goal accords 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 Rushton 1999)

We chose the concept of “Dorian-Gray-Syndrome” (Brosig 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, instead of his body, it is Dorian's portrait that ages, becoming 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 self-portrait is coupled with the motive of the mirror, discussed as a decisive clinical concept in psychoanalysis, and is thereby transformed into an association with the self-love of the narcissist. A highly condensed story by the writer and dandy (see text insert) Oscar Wilde brings together in poetic compression both of the elements – artificiality and self-regard – that constitute a narcissistic attitude.

If one returns to the clinical picture of the disorder itself, we have defined as the Dorian-Gray-Syndrome, one finds that this is characterized diagnostically by symptoms (Table 1) of dysmorphophobia, coupled with narcissistic regression, and denial of any personality-structuring process of growth to maturity, which is close to the dynamics involved in perversion. Two brief case vignettes drawn from psychodermatological work (see Brosig et al. 2000) serve to illustrate the psychodynamic concept we are arguing for.


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. Along with excessive worry about one's external appearance there is a strong desire to preserve one's youthfulness in order not to grow older – as it were, swimming against the current of time (denial of the maturation process).

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 complaints expressed included disturbed sleep and reduced drive, fatigue, listlessness and a lack of “joie de vivre”.

Anamnesis

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 has great expectations regarding the new medication, hoping it will 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 surrounding the progression and generativity arising out of the new state of being married are warded off. In the process of his denial of maturity, which is of course often linked to the relinquishing of libidinal aspects of the self (as it were: “active (sex) life”), he develops a reductionist view of this 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 little else but outward beauty. The narcissistic sense of injury at growing older (the “cult of youth”) is counteracted by “rejuvenating measures” under the illusory impression that he can turn back the stream of time.

This creates an outwardly ideal and ostensibly impregnable shell, a mantle of timelessness (“Dorian Gray” or “Michael Jackson” condition).

Psychodynamically , the defensive mechanisms involved are overwhelmingly narcissistic and to some extent are also designed to forestall any polymorphous-perverse inclination. The symptom of body dysmorphic imbalance, like other symptoms of an almost delusionary nature (see Table 2), presents itself at first as a 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. perversion

Case vignette 2

A 44-year-old female patient visits a psychotherapeutic polyclinic complaining of chronic low spirits with adynamia and sleeplessness as well as a sense of inner vacancy. Her reason for seeking psychotherapeutic aid is the advice given her by a dermatologist who has found her constant preoccupation with her hair to be excessive. She often spends half an hour in the morning at her mirror, plagued by a fear of increasing loss of hair , a fear, however, that lacks any dermatological basis in fact. But she maintains that she cannot banish the thought that her hair is thinning and that she will soon have a bald patch. She insists on treatment with Finasteride. She is able to be motivated by outpatient consultation to undergo a psychodynamically oriented course of therapy.

Only in the course of the six weeks of ward treatment does it becomes clear that the symptoms began after the patient underwent termination of a pregnancy . She felt that she could no longer trust herself at her age to bear the stress of a pregnancy and having to care for a baby. On the one hand, she says, she wanted a child; on the other, she didn't feel she was up to giving birth to one. It is clear from this that she associates pregnancy and motherhood with physical energy and the freshness of youth . After the abortion, the above-mentioned symptoms appear, along with depressive and hypochondriac features and the “fear of hair loss”.

Anamnesis

This intelligent patient still looks youthful and attractive despite having been married for 24 years. She was initially very happy after getting married; two children, now 20 and 19 years of age, have flown the coop and have gone their own way. 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. Her parents, she claims, spent more time working on the farm than caring for their children; caught between older and younger siblings, she felt like “an expendable extra”. Subsequently, however, and not least because of her physical attractiveness, she became quite popular; and this, she thinks, was compensation for her often dreary childhood. She felt particularly proud of her beautiful hair, which she always took good care of.

Psychodynamically , then, 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 hairdo (in German terms, this would be a “Sisy of Austria” condition). This causes her to deflect her fear of losing a young woman's charms onto an obsessive preoccupation with losing her (beautiful feminine) hair. At the same time, as a compromise-formation, this intensive preoccupation with hair-loss reflects also a common symptom of pregnancy. Isn't she pregnant all the time? Once this is interpreted for her and subsequently worked through, her compulsive thoughts gradually fade away and she is able to make new plans for her life. With her husband's support, she opens a florist's shop.

Therapeutic strategy

In treating the Dorian Gray Syndrome, it is of prime importance 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, derived from [Phillips 2000]).

Table 3.

Finasteride.

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; and
  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, ward based or high-frequency treatment) as chronificized conditions are frequently encountered.
  4. cognitive-behavioral methods [Phillips 2000] are recommended as an alternative to psychodynamic approaches to treatment

Discussion

Ever since Christopher Lasch's conceptual work (1979), narcissism has been understood as a culturally specific temporal phenomenon of our era. In the guise of the Dorian-Gray-Syndrome, it is combined with an over-emphasis on external morphe and with a fetishization of youthfulness, leading to a denial of the ageing process, understood as a psychic defence against the normal structuring aspects of maturation and the realization of basic “facts of life” (Colarusso 1999).
For the narcissistic triad of body dysmorphic disorder, narcissistic regression with exaggerated self-regard and denial of maturity (hence of mortality; Csef 1987) we have chosen the term “Dorian-Gray-Syndrome”.
This syndrome, also known in the literature of dermatology as the “Thersites Syndrome” (in Homer's Odyssey , Thersites was the ugliest warrior in the Greek army), reflects in its very name the aspect of alienation from Self (Lacan 1966).
Not only women but also men are nowadays gripped by the fetishization of the body, which subjects physicality, eroticism and thus sexuality to the normative processes of a materialist aesthetic. The body dysmorphic disorder that is often revealed in the course of clinical examination can be seen as only one symptom that is situated somewhere along the scale of hypochondria, depression, obsessive-compulsive disorder, perversion (Euler et a. 2003) and delusion.Treatment requires, after clarification of motivation, the decisive implementation of intensive psychotherapy, if necessary combined with antidepressive and neuroleptic medication. The “life-style” medication such as 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.

References



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

Euler S, Brähler E, Brosig B., 2003:
Das Dorian-Gray-Syndrom als „ethnische Störung“ der Spätmoderne. Psychosozial 26 :73-89.

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



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