Mr A, is a 27-year old Caucasian man who presented with preoccupation with perceived
emaciated and gaunt cheeks, although his appearance seemed unremarkable. Mr A was an
unemployed single man, who had never married. He reports that he had never engaged in a
significant romantic relationship, due mainly to the fact that he had suffered social
avoidance and depressive symptoms as a result of his feeling of ugliness, since the age of
sixteen. He had been able to complete two years of college, but had withdrawn from his
studies due to his worsening symptoms. Mr A had a long history of visits to plastic surgeons
and dermatologists for treatment of his thin cheeks, and other facial preoccupations (e.g.
prominent chin, facial scarring), although his appearance was normal.
He also spent up to four hours per day checking his appearance in the mirror. He did not
appear to have primary depression, as indicated by the absence of vegetative signs and a
score of 5 on the Hamilton Depression Rating Scale, but there was evidence of ritualistic
behavior, such as spending many hours in front of the mirror, despite the fact that this
caused him further distress. He had been variously treated with the benzodiazepines Valium
(20 mg/d), Restoril (30 mg/d), Serax (60 mg/d) and Rohypnol (1.5 mg/d), with some success
in the reduction of his social anxiety, but no reduction in his facial preoccupation. He was
unable to tolerate the antidepressants Pamelor and Aponal, due to severe anticholinergic
side-effects (e.g. dry mouth, blurred vision, dizziness, rapid heart rate, constipation).