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6.1 Enrico Morselli

The Italian physician, psychiatrist, and anthropologist Enrico Agostino Morselli was born in Modena on 17 July 1852 and died in Genova on 13 February 1929. Therefore, he was a contemporary of turn-of-the-century alienists such as Valentin Magnan (1835–1916), Hippolyte Bernheim (1840–1919), Emil Kraepelin (1856–1926), Sigmund Freud (1856–1939), and Pierre Janet (1859–1947).

Morselli graduated doctor of medicine, in 1874, worked in several mental hospitals (Reggio Emilia, Florence, Macerata, Turin, Genoa), held positions at the medical faculty of Turin, and became a full professor of psychiatry at the university of Genoa in 1889. In Florence, he worked with Paolo Mantegazza, a famous physiognomist. That training probably contributed to the subsequent interest in physical anthropology and body shape.

In 1875, Carlo Livi, Augusto Tamburini, and Enrico Morselli founded, in Reggio Emilia, the Rivista sperimentale di freniatria e di medicina legale in relazione con l’antropologia e le scienze giuridiche e sociali (Experimental review of psychiatry and legal medicine in relation with anthropology and legal and social sciences), a scientific journal that is still getting published.

Morselli was importantly influenced by positivism of the nineteenth century, with its emphasis on the positive knowledge, imposed on the mind by experience and grounded on verified data. In 1881, he founded and edited the Rivista di filosofia scientifica (Review of scientific philosophy), destined to become the official organ of Italian positivism.

Furthermore, Morselli introduced some reforms to renew and humanize the Italian mental asylums but, on the other hand, some of his writings seem to support eugenics and pseudoscientific views about the classification of human populations into discrete racial categories.

As a curious scientist, Morselli was interested in exploring unusual phenomena such as hypnosis and mediumism, and he used photography to document the actions of the famous medium Eusapia Paladino and tackle the problem of subjectivity or objectivity of apparitions during spiritual séances [1].

As regards hypnotism, he embraced Bernheim’s (école de Nancy) psychological interpretation based on the concept of suggestion, rather than Charcot’s (école de la Salpêtrière) neurological vision. Unlike Charcot, Bernheim assumed that suggestion was the key to all hypnotic phenomena, and the hypnotic state was not a neurosis [2].

In 1926, 3 years before dying, Morselli published La psicanalisi. Studii ed appunti critici (The psychoanalysis, studies, and critical notes). In spite of some doubts and critical remarks that the author raised from a medical point of view, these two volumes were one of the first attempts to introduce Sigmund Freud’s theory into the Italian culture [3].

Morselli wrote many articles and books on clinical and forensic psychiatry, experimental psychology, sociology, and anthropology. However, in the history of psychiatry, he is known primarily for having coined the word dysmorphophobia in the last years of the nineteenth century.

6.2 Birth of the Neologism Dysmorphophobia

On April 1891, Enrico Morselli published, in the Bollettino della Regia Accademia Medica di Genova, an article with the title ‘Sulla Dismorfofobia e sulla Tafefobia due forme non per anco descritte di Pazzia con idee fisse’ (Fig. 6.1) [4]. Some authors incorrectly reported 1886 as the publication date of that seminal paper [5, p. 257].

Fig. 6.1
figure 1

First and last pages of Morselli’s article on taphephobia and dysmorphophobia [4]

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In his article, Morselli created ‘due denominazioni nuove’ (two neologisms): ‘tafefobia’ and ‘dismorfofobia’. The word tafefobia (in English ‘taphephobia’) was invented to indicate the abnormal fear of being buried alive. It is derived from the Greek τάφος (grave) and φόβος (flight, fear, anxiety, concern, horror). The other neologism, dismorfofobia (in English ‘dysmorphophobia’), was coined to describe a condition in which a person is tortured by the preoccupation with some imagined or negligible defects in his/her physical appearance. It is derived from the Greek δύσμορφος (misshapen) and φόβος.

In his paper, Morselli did not attach more importance to dysmorphophobia than to taphephobia.

Alle varie forme sintomatiche assunte dalla Pazzia con idee fisse e il cui carattere fondamentale consiste nella fobia che le accompagna, sono da aggiungerne, secondo le mie osservazioni di questi ultimi anni, due non ancora descritte da alcun alienista o, per lo meno, poco conosciute. Esse sarebbero la dismorfofobia e la tafefobia, due denominazioni nuove che io mi permetto di proporre per la prima volta, ma che sono costrutte secondo le norme generalmente adottate dai migliori trattatisti [4, p. 110].

According to some observations I made in the last few years, two new varieties should be added to the various forms of Insanity with fixed ideas, whose essential feature is the phobia that underlies them. They are still undescribed or, at least, not very well-known. Dysmorphophobia and taphephobia are the two new terms I take the liberty of putting forward, following the lexical rules usually adopted by outstanding writers of treatises.

In an interesting historical review, Berrios remarks that sometimes the creation of the neologism dysmorphophobia was mistakenly attributed to the famous German alienist Emil Kraepelin [6]. For example, in 1962, the French psychiatrist Cyrille Koupernik—who named dysmorphophobia ‘psychose de la laideur’ (ugliness psychosis)—indicated Kraepelin as the minter of the new expression [7, p. 321].

In fact, Kraepelin never named the new syndrome in the first three editions of his classic handbook Psychiatrie. Ein Lehrbuch für Studierende und Ärzte (Psychiatry. A manual for students and physicians) [8,9,10]. He introduced the term Dysmorphophobie in the German language only in the 1915 edition [11] (p. 1861, line 15), without citing Morselli’s work (Fig. 6.2).

Fig. 6.2
figure 2

In 1915, the word Dysmorphophobie appears in an Emil Kraepelin’s book [11]

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6.3 Morselli’s Concept of Dysmorphophobia

In 1885, Morselli published the first volume of his Manuale di semejotica di malattie mentali (Handbook of semiotics of mental disorders), mainly devoted to the anthropological and physiological evaluation of the patients [12]. Nine years later, the second volume appeared in which the author underlined the uncertainties of the neuropathological explanations of mental symptoms and gave great significance to the psychological aspects, particularly to the role of the emotions [13]. The paper on dysmorphophobia and taphephobia was written between these two phases. It introduced two new words and, above all, investigated a psychopathological concept.

In the 1891 article, Morselli did not present clinical vignettes of patients with dysmorphophobia. He probably collected his sample of persons with that enigmatic symptom—the fear of deformity—during the 1880s, mainly in his private practice [6]. But how many patients with dysmorphophobia did he see?

Katharine Phillips, in her excellent book The broken mirror, wrote that ‘In the late 1800s, Morselli saw 78 patients with Body Dysmorphic Disorder (BDD)’ [14, p. 20]. This figure appears exaggeratedly high. In fact, Morselli spoke, in his article, of 78 cases, but he referred to the total number of cases of Insanity with fixed ideas he had seen in his private practice. The list of symptoms he observed included:

  • First, agoraphobia (fear of open spaces), acrophobia (fear of heights), aichmophobia (fear of pointed objects), belonephobia (fear of needles and pins), claustrophobia (fear of narrow spaces and tunnels), dysmorphophobia (fear of deformity), hyalophobia (fear of fragments of glass that might be present in foods), mysophobia or rhypophobia (fear of dirt), taphephobia (fear of apparent death and premature entombment);

  • Secondly, the clinical pictures that the German psychiatrist Rudolf Gottfried Arndt (1835–1900) called questioning paranoias such as arithmomania (number madness) and onomatomania (name madness);

  • Thirdly, the irresistible need to act in some singular manner such as coprolalia (outburst of obscene words), dipsomania (craving for alcohol), kleptomania (urge for stealing), oniomania (compulsion to buy), pyromania (impulse to start fires);

  • And to finish, the antivivisectionist insanity (obsessional preoccupation with the suffering of animals subjected to experiments in scientific laboratories) first described by the French psychiatrist Valentin Magnan (1835–1916).

Generalmente queste sindromi psicopatiche si attribuiscono alla influenza ereditaria e si considerano come psicosi degenerative: esse, cioè, per la maggioranza degli alienisti, sono forme della psicosi degli ereditarii (Morel). Ma io ho da qualche anno insistito sul fatto, da me osservato e confermato, che non tutte le pazzie con idee fisse, incoercibili ed impulsive, sono indizio o stigmata psichica di degenerazione. Avendo ormai raccolto nella mia clientela privata circa ottanta casi di questa singolare condizione psicopatica (più esattamente settantotto), posso riaffermare quanto dissi fino dal 1882 al Congresso Medico di Modena: che, cioè, in un certo numero di casi non è possibile scoprire il benché menomo indizio di eredità psico- o neuro-patica, ma solo uno stato neurastenico qualche volta transitorio [4, p. 115].

These psychopathic syndromes are usually attributed to hereditary factors and are regarded as degenerative psychoses: in other words, for most alienists they are forms of Morel’s hereditary psychoses. However, for some years, I have insisted upon the fact I have observed and confirmed, that not all varieties of insanity with fixed, uncontrollable and impulsive ideas are the sign or the psychic stigma of degeneration. I have now collected, among my private clients, nearly eighty cases of this particular psychopathic condition (seventy-eight, to be precise), and I can confirm what I said ever since 1882 at the Medical Congress of Modena: namely that, in a certain number of cases, it is impossible to detect the minimum sign of a psycho- or neuro-pathic inheritance, but only a neurasthenic state, sometimes temporary.

The above passage shows that Morselli contrasted in his article the causal theory of degeneration developed by Bénédict Augustin Morel (1809–1873) and, later, by Valentin Magnan (1835–1916). That deterministic model dominated European psychiatry for some decades, particularly in France. It regarded many mental disorders—such as delusional and obsessional states—as inherited degenerative illnesses with an inexorable negative outcome. On the contrary, Morselli considered dysmorphophobia, at least in some cases, as an acquired state of neurasthenia which may be transitory. Furthermore, he underlined the psychological aspects of insanity with fixed ideas and, in the last lines of his article, he used the word unconscious:

lo stato psichico che la caratterizza, sia esso una rappresentazione, o un sentimento, o una tendenza, irrompe dal fondo dell’incosciente, e portandosi con somma vivacità nel campo appercettivo giunge a dominare nella coscienza e ne inibisce l’ingresso ad ogni altro stato psichico che si trovi con esso in antagonismo [4, p. 119].

the typical psychic state of the insanity with fixed ideas—representation, or feeling, or tendency—breaks with great vivacity from the depths of the unconscious into the apperceptive field, dominates the consciousness and prevents the entry into it of any other antagonist psychic state.

As regards taxonomy, generally speaking, an alienist of the late nineteenth century could consider a clinical phenomenon as an alteration of a cognitive, emotional, or volitional faculty (e.g. fixed ideas, fears, impulses). Otherwise, he could classify a psychopathological symptom on the basis of its content (e.g. anorexia nervosa, hypochondria) [6, 15].

Morselli defined dysmorphophobia primarily by the content of the complaint: disliking some parts of the physical body. As Berrios and Kan marked, in doing so the author founded ‘a narrow view of dysmorphophobia’ as a distinct mental disorder [6, p.1]. In addition, he attached much more importance to the ideational component of dysmorphophobia (fixed idea of deformity) than to the emotional (fear, anxiety, shame) and volitional (avoidant behaviours, compulsive checking) elements.

As to the second part of the neologism, Morselli used the term phobia in a broad sense that was very common in the nineteenth century and included obsessive thoughts [15]. He always regarded dysmorphophobia as a form of ‘vera pazzia del dubbio’ (true madness of doubts) with ‘idee fisse che moltissime volte danno origine ad azioni coatte’ (fixed ideas that very often give rise to compulsive actions) [13, p. 441].

In the 1891 article, he wrote:

Il dismorfofobico è, infatti, un vero infelice: egli, in mezzo alle sue occupazioni, ai discorsi, alla lettura, durante il pranzo, ovunque insomma e a tutte le ore del giorno, è incolto dal dubbio di una deformità, che possa essersi sviluppata nel suo corpo e a sua insaputa: teme di avere o di potere avere la fronte depressa e schiacciata, il naso ridicolo, le gambe torte, ecc. e però si guarda ripetutamente allo specchio, si frega la fronte, si misura la lunghezza del naso, esamina le più piccole macchie della pelle, o investiga su se stesso le proporzioni del tronco e la direzione delle membra, e solo dopo un certo tempo, convincendosi del contrario, si libera dallo stato penoso in cui l’accesso lo ha posto [16, p. 111]

The dysmorphophobic, indeed, is a really miserable individual; in the middle of his daily affairs, while talking, while reading, during meals, in short everywhere and at any time, he is suddenly caught by the doubt of some deformity, that might have developed in his body without his knowing it: he is afraid he has, or he might develop a squashed and flattened forehead, a ridiculous nose, bandy legs, etc., so he looks at himself in the mirror repeatedly, feels his forehead, measures the length of his nose, scrutinizes the smallest specks in his skin, or inspects the proportions of his trunk and the straightness of his limbs, and only after a period of time, he can to be reassured and free himself from the painful state the attack put him in.

Three years after, in the second volume of the Manuale di semejotica, Morselli mentioned dysmorphophobia only once, in the section ‘Il linguaggio dell’alienato’ (The language of the alienated person). He catalogued this disorder among the ‘Idee morbose’ (morbid ideas), in the general cluster ‘Rappresentazioni verbali di idee fisse, incoercibili e coartanti’ (Verbal representations of fixed, invincible, and compulsive ideas).

In particular, the author classified dysmorphophobia in the subgroup ‘Ipotesi egoistiche per lo più relative alla conservazione e integrità dell’io personale e ai suoi rapporti col mondo esterno’ (egoistic hypotheses that mainly concern the preservation of the subject and his relationships with the external world) [13, p. 440].

Morselli placed dysmorphophobia among insanities with fixed ideas and highlighted the obsessional features of that clinical picture. He observed that persons suffering from dysmorphophobia showed all the symptoms contemporary alienists used to describe for the insanity with fixed ideas, a condition that Rudolf Gottfried Arndt (1835–1900) also called ‘paranoia rudimentaria’ (rudimentary—or partial or primitive—paranoia) [17, p. 534].

Morselli reported in his article (Fig. 6.3) a summary of the main signs of this group of insanities, according to the school of Jacques Joseph Valentin Magnan (1835–1916). It is possible to find the original schema in a French book published in 1886 by Paul Maurice Legrain (1860–1939) [18, p. 70]. It is exactly alike.

Fig. 6.3
figure 3

Summary of the main signs of insanity with fixed ideas or rudimentary paranoia. From E. Morselli, 1891 (p. 115)

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The concept of insanity with fixed ideas was widely shared in those years.

Gabriele Buccola (1854–1885) was a brilliant psychiatrist who worked with Morselli in Turin from 1881 to 1885 when he prematurely died. He defined the fixed ideas as ‘mental representations that arise and persist in the consciousness in a coercive way and that German alienists call by a very expressive word, Zwangsvorstellungen’ [19, p. 155]. Buccola included under that label phobias, obsessions, impulsions, and delusions.

A classification arranges together phenomena that are like and separates those which appear unlike. Subsequently, nosology studies linkages among different diagnostic categories of a taxonomy. So Morselli explored similarities and differences between dysmorphophobia and other mental disorders.

He noted that some patients with dysmorphophobia were first aware of the absurdity of their ideas but later and gradually lost this critical ability and developed a distinctly recognizable delusion.

Furthermore, he indicated the affinities with certain melancholic and hypochondriacal states but affirmed that the emotional disturbance of dysmorphophobia comes in bouts and is not a stable mood alteration. Fig. 6.4 graphically schematizes the relationships among dysmorphophobia, delusional, hypochondriacal, and melancholic states according to Morselli’s way of thinking.

As regards eating disorders, neither Lasègue’s anorexie histérique [20] nor Gull’s anorexia nervosa [21] was mentioned by Morselli in his article on dysmorphophobia. As a matter of fact, Gull and Lasègue did never report in their clinical vignettes the presence of a body image disturbance. The first medical description of a severe body uneasiness associated with eating disordered behaviours appeared 12 years after Morselli’s work (see Chap. 1 of the present book). In 1903, Pierre Janet described the case of Nadia, a girl with anorexic symptoms due to the obsession of body shame (‘obsession de la honte du corps’) [22, pp. 33–40].

Fig. 6.4
figure 4

Relationships among dysmorphophobia, delusional, hypochondriacal, and melancholic states according to Enrico Morselli’s thought, 1891

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6.4 Use of the Term Dysmorphophobia After Morselli

For some decades, the medical literature on dysmorphophobia was poor and scattered, and the new word appeared only in a small number of European publications, mostly of anecdotal nature [5].

In 1905, the Italian psychiatrist Eugenio Tanzi described in his treatise on mental disorders [23] three beautiful young women suffering from dysmorphophobia. He cited Morselli’s work and, like Morselli, regarded this clinical picture as a fixed idea, using the term phobia in the old broad sense that included obsessional thoughts.

However, it is not without interest that Tanzi considered this clinical picture as ‘the teratological chapter of pathophobia’ (p. 508), highlighting the relationship with hypochondria. In Tanzi’s book, dysmorphophobia was classified as one of the possible psychic symptoms of neurasthenia, defined as ‘a persistent state of valetudinary, without definite objective abnormalities’ (p. 497). Valetudinarian is a person whose chief concern is his/her physical health and, indeed, also in dysmorphophobia the body is the central focus of the obsessional thoughts.

In 1909, Robertson and MacKenzie translated Tanzi’s textbook and the word ‘dysmorphophobia’ appeared in the English language [24, p. 150]. A century later Laurence Jerome provided the first readily available English translation of Morselli’s classic paper. It appeared in the journal History of Psychiatry with the title ‘Dysmorphophobia and taphephobia: two hitherto undescribed forms of insanity with fixed ideas’ [16].

In 1915, Emil Kraepelin mentioned, very briefly, some patients who were obsessed by the idea they had a strange nose, or had bandy legs, or smelt bad and, consequently, attracted attention and became an object of derision. Like Morselli, Kraepelin considered ‘Dysmorphophobie’ as a ‘Zwangsneurose’ (obsessive-compulsive neurosis) and described this condition together with ‘Ereuthophobie’ (a nagging fear of blushing) [11, pp. 1860–1861].

In the tenth edition of the International Classification of Diseases (ICD-10), dysmorphophobia is not a specific diagnostic category, but the term still appears to indicate a variant of the hypochondriacal disorder (F45.2) or—when it has delusional features—one of the other persistent delusional disorders (F22.8) [25].

As regards the Diagnostic and Statistical Manual of Mental Disorders (DSM), the term dysmorphophobia was not used in the first two editions [26, 27].

On the contrary, in the DSM-III [28], the word dysmorphophobia occurred in the residual category atypical somatoform disorder (300.70). The ‘atypical’ designation was similar to the ‘Not Otherwise Specified’ category used in the subsequent editions of the diagnostic manual. Four lines described the clinical picture:

An example of cases that can be classified here include those of individuals who are preoccupied with some imagined defect in physical appearance that is out of proportion to any actual physical abnormality that may exist. This syndrome has sometimes been termed ‘Dysmorphophobia’ (p. 252).

Seven years after, in 1987, the revised edition DSM-III-R [29] introduced the expressions delusional disorder somatic type (297.10) and body dysmorphic disorder (BDD) (300.70) to indicate two distinct psychiatric diagnostic categories (see Chap. 5 of the present book). BDD was included in the group of somatoform disorders together with hypochondriasis. Dysmorphophobia was officially replaced by the new terms.

However, the old word did not disappear (Fig. 6.5).

Fig. 6.5
figure 5

PubMed articles with a title that contains the word dysmorphophobia

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6.5 Final Note

In 1891, Morselli coined an Italian neologism that is still being used, ‘dismorfofobia’ (English: dysmorphophobia; French: dysmorphophobie; German: Dysmorphophobie or Körperdysmorphophobie; Spanish: dismorfofobia). Morselli applied the concept of phobia in its broad pre-Freudian sense that did not distinguish phobias from obsessions. He considered dysmorphophobia as an insanity with fixed ideas, a group of mental disorders that included phobias, obsessions, compulsive behaviours, and delusional thoughts. To construct this new diagnostic category, he attached more clinical importance to the content of the symptom (imagined or negligible imperfections in body appearance) and its cognitive component (obsessional or, sometimes, delusional ideas) than to the associated emotions (anxiety, shame). As to aetiology and prognosis, Morselli refused the concept of dysmorphophobia as a degenerative (inherited) illness and sustained that, at least in some cases, it may be an acquired and transitory state of neurasthenia.