LETTERS TO THE EDITORS
Serotonin, Psilocybin, and Body Dysmorphic Disorder: A Case Report
Editors:
Body dysmorphic disorder, preoccupation with an imag-
ined defect in appearance or excessive concern with a slight
physical anomaly, has been successfully treated recently with
selective serotonin reuptake inhibitor (SSRI) medication, I, 2
which has led to the proposition of a possible serotonergic ba-
sis for this disorder. I, 2 Further evidence of this theory comes
from reports of exacerbation of body dysmorphic disorder
during tryptophan depletion" and use of the 5-hydroxytrypta-
mine (5-HT) antagonist cyproheptadine.' In support of this
theory, we present a case in which body dysmorphic symp-
toms were qualitatively altered with the ingestion of psilocy-
bin, a potent serotonergic agent" in a patient who later re-
sponded to the SSRI fluoxetine.
Mr. A, a 27-year-old white man, presented with symptoms of
body dysmorphic disorder, reflecting preoccupation with per-
ceived 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, mainly because he had
suffered social avoidance and depressive symptoms as a result
of his feeling of ugliness since the age of 16. He had been able
to complete 2 years of tertiary education, but he had with-
drawn from his studies because of his worsening symptoms.
Mr. A had an extensive history of visits to plastic surgeons and
dermatologists for treatment of his thin cheeks and other fa-
cial preoccupations (e.g., prominent chin, facial scarring), al-
though his appearance was normal. He also spent up to 4 hours
per day checking his appearance in the minor. He did not ap-
pear to have primary depression, as indicated by the absence
of vegetative signs and a score of 5 on the Hamilton Rating
Scale for Depression, but there was evidence of ritualistic be-
havior, such as spending many hours in front of the minor, de-
spite the fact that this caused him further distress. He had been
variously treated with the benzodiazepines diazepam (20
mg/d) , temazepam (30 mg/day), oxazepam (60 mg/day), and
flunitrazepam (l.5 mg/day) with some success (flunitrazepam)
in the reduction of his social anxiety but no reduction in his
aesthetic preoccupation. He was unable to tolerate the antide-
pressants nortriptyline and doxepin because of severe anti-
cholinergic side effects. Mr. A not infrequently used other
drugs in an attempt to relieve his symptoms and reported that
the intensity of his somatic distress increased with the use of
marijuana but improved markedly on several occasions when
he had ingested psilocybe fungi. Mr. A reported that he had
looked in the minor under the influence of the latter psy-
chotomimetic agent on three separate occasions and noted
that his appearance on these occasions had "changed" and
that he no longer looked deformed, He suggested that subse-
quent to these experiences he was no longer certain that his
deformity was "real" and that this was one of the reasons he
agreed to a trial of fluoxetine, a potent serotonergic antide-
188
pressant, reported to be effective in the treatment of depres-
sion and obsessive-compulsive disorder. Three weeks after
commencing fluoxetine treatment, 40 rug/day, Mr. A reported
a significant reduction of his concern with his appearance and
minor-checking behavior and was able to resume his social
activities and tertiary study. He continued fluoxetine therapy
for 18 months, and his condition remained stable. There was
no family history of psychiatric illness.
A disturbance in the 5-HT neurotransmitter system has been
implicated in a range of disorders, including schizophrenia.s-"
eating disorders," panic disorder," and obsessive-compulsive
disorder.'? The present case adds to the literature, suggesting
that body dysmorphic disorder, which appears to be closely re-
lated to obsessive-compulsive disorder" may be tied to a dis-
ruption in the serotonergic system. The qualitative effects of
marijuana, a possible 5-HT antagonist, II and psilocybin in a pa-
tient who responded to fluoxetine seem rather intriguing, be-
cause psilocybin compounds psilocybin and psilocin are
closely related to serotonin biogenetically and the psy-
chotropic effects of these substances, which include gross
changes in body image, have been linked to their affinity for the
5-HT neurotransmitter system.v It is now believed that psy-
chotomimetic agents such as lysergic acid diethylamide (LSD)
and psilocybin produce their effects by serving as 5-HT2 ago-
nists at postsynaptic 5-HT2 receptors." Strassman," for in-
stance, reported that drugs that affect the serotonergic neuro-
transmitter system, such as allopurinol and fluoxetine, may
cause a decreased sensitivity to the hallucinogens psilocybin
and LSD, which suggests a possible overlap of fluoxetine and
psilocybin in tenus of specific serotonergic effect. It is inter-
esting to note that some success has also been reported with
psychedelic agents in the treatment of other 5-HT relevant dis-
orders, such as depression.v
KARL R. HANES, PHD
Cognitive Neuropsychiatry Research Unit
Mental Health Research Institute
Parkville, Victoria, Australia
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