107

3. Body dysmorphic disorder. G. E. Berrios, The History of Mental Symptoms (Cambridge

University Press, 1996), 276-81.
4. Birtchnell, S. A., ’Dysmorphophobia - a centenary discussion’, British Journal of Psychiatry, cliii
(suppl. 2) (1998), 41-3.
5. Jerome, L., ’A study of the perception of body image in patients requesting cosmetic
rhinoplasty’, M.Sc. Thesis, University of Manchester, 1980.
6. Thomas, C. S. and Goldberg, D. P. ’Appearance, body image and distress in facial dysmor-
phophobia’, Acta Psychiatr. Scand., xcii (1995), 231-6.
7. Jerome, L., ’Perception of body image’, Canadian Journal of Psychiatry, xxxviii (1993), 630-1.
8. Jerome, L., ’Body dysmorphic disorder: symptom or syndrome’, American Journal of Psychiatry,
cli (1994), 460-1.
9. Phillips, K. A., McElroy, S. L., Keck, P. E., Pope, H. G. and Hudson, J. I., ’Body dysmorphic
disorder: 30 cases of imagined ugliness’, American Journal of Psychiatry, cl
(1993), 302-8.

Classic Text No. 45

Dysmorphophobia and taphephobia:

two hitherto undescribed forms of Insanity
with fixed ideas

A note by the general member,

Prof. ENRICO MORSELLI

As the result of some observations I have made in recent years, I propose to

add two new and previously undescribed varieties to the various forms of
insanity with fixed ideas, whose underlying phenomenology is essentially
phobic. The two new terms I would like to put forward, following the
nomenclature currently accepted by leading clinicians, are dysmorphophobia
and taphephobia.
The first condition consists of the sudden appearance and fixation in the
consciousness of the idea of one’s own deformity; the individual fears that he
has become deformed (dysmorphos) or might become deformed, and
experiences at this thought a feeling of an inexpressible ansieta (anxiety). The
second condition, taphephobia, consists of the sick person’s being plagued, at
his approach to the time of his own death, by a fear of the possibility of being
buried alive (taphe, grave), this fear becoming the source of a terribly

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distressing anguish. It necessary for me to give a very detailed

is not
description of these two forms of rudimentary paranoia I have discovered
new
and named, since in so doing I would only be repeating descriptions that
have long been available among the many and varied forms of paranoia in
books and the [111] most important journals of psychiatry;’ instead, I shall
limit myself to making some general comments on the conditions.
The ideas of being ugly and of being buried whilst in a state of apparent
death are not, in themselves, morbid; in fact, they occur to many people in
perfect mental health, awakening however only the emotions normally felt
when these two possibilities are contemplated. But, when one of these ideas
occupies someone’s attention repeatedly on the same day, and aggressively
and persistently returns to monopolize his attention, refusing to remit by any
conscious effort; and when in particular the emotion accompanying it
becomes one of fear, distress, anxiety and anguish, compelling the individual
to modify his behaviour and to act in a pre-determined and fixed way, then
the psychological phenomena have gone beyond the bounds of normal, and
may validly be considered to have entered the realm of psychopathology.
The dysmorphophobic, indeed, is a veritably unhappy individual, who in
the midst of his daily affairs, in conversations, while reading, at table, in fact
anywhere and at any hour of the day, is suddenly overcome by the fear of
some deformity that might have developed in his body without his noticing
it. He fears having or developing a compressed, flattened forehead, a
ridiculous nose, crooked legs, etc., so that he constantly peers in the mirror,
feels his forehead, measures the length of his nose, examines the tiniest
defects in his skin, or measures the proportions of his trunk and the straightness
of his limbs, and only after a certain period of time, having convinced himself
that this has not happened, is able to free himself from the state of pain and
anguish the attack put him in. But should no mirror be at hand, [ 112] or
should he be prevented from quieting his doubts in some way or other by
means of some mechanism or movements of the most outlandish kinds, as

might a rhypophobic who cannot get water to wash himself, the attack does
not end very quickly, but may reach a very painful intensity, even to the point
of weeping and desperation.
The taphephobic, too, is an unhappy person, his every day, his every hour
being tormented by the sudden occurence of the idea of being buried alive,
that is, in the state of not being truly dead. He has heard or read terrible
stories of people being buried in a state of apparent death, and he fears that
the same might happen to him. This condition is accompanied by a distress

a
The latest literature of importance, in my opinion, regarding this subject, which was first made
known in Italy by my late, lamented assistant Dr Buccola ( Riv. sperim. di Freniatria, 1881), may be
read in: R. Amdt, Lehrbuch der Psychiatrie, 1883; R. von Krafft-Ebing, Lehrbuch der Psychiatrie,
4th edn, 1890; V. Magnan, in Progrès médical passim; E. Kraepelin, Compendium der Psychiatrie, 2nd
edn, 1887; Schüle, Psichiatrica clinica [3rd German edn], Italian trans. 1890; as well as in many
monographs and articles in the specialist journals.

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even more vivid and acute than that of the one described above, since the
possibility this patient fears, being further off in the future, he feels powerless
to avoid or prevent, especially since at that moment he would be
unconscious, or, even if he were conscious, he would be unable to move
himself, or by any sign or action or word to inform the people that he was
not yet dead, but still alive. The taphephobic’s only way to prevent being
buried alive is to prescribe minutely and in advance every detail of his own
burial, and like the rhypophobic before the sink or the dysmorphophobic
before the mirror, he will dictate a will, and then later, not content with it,
write a second one, and a third one, and a fourth one, etc. In the wills there
will be very precise instructions regarding the patient’s burial: the number of
hours that will have to intervene after his state of apparent death; beside him
a bell must be placed, and food and water; some special electric device will
be installed; the coffin will be constructed in such a fashion as not to impede
the circulation of fresh air, or the lid will be easy to open, etc., etc. Copies of
these instructions will be placed by the taphephobic around his house, or
given to different people, and the precautions taken will never seem to be
excessive, nor indeed even adequate; and therefore there will always be new
fears, new anguish, and succeeding attacks of taphephobia. With each new
attack, the patient will rush anxiously to get his will, re-read it over and over
again, gradually calm down, put the will away, but then take it out and open
it again, and as long as this state of anxiety persists, he will be unable [ 113]
to think or do anything else. Incidentally, I once had a typical case of this
singular phobia in a young woman whose brother happened to be suffering
from a very remarkable form of ’metaphysical insanity’.
We have here, then, syndromes comparable with other similar forms of
insanity with fixed ideas, in which the essential character of the disturbance,
so to speak, remains constant, even though the symptomatic manifestations

vary according to the specific form the predominating ideas, emotions, or

impulses take. Indeed, the richness of our ideas, emotions and volitions is
mirrored in the multiplicity of forms in which this psychosis manifests itself,
and which Arndt quite rightly named ’rudimentary paranoia’. Dysmorpho-
phobia and taphephobia should from now on take their places alongside agora-
phobia (fear of open spaces), claustrophobia (fear of closed spaces), acrophobia
(fear of heights), and other phobias of location;b alongside rhypophobia or
mysophobia (fear of dirt), belonephobia (fear of needles), aichmophobia (fear of
pointed instruments);’ and finally alongside arithmo-mania (number

bA so far undescribed variety of claustrophobia or clitrophobia (Raggi) consists in the anxiety some
people experience on travelling by railroad through covered passages or tunnels; this could also be
called cryptophobia (from crypte, cave). I have seen two classical examples of this condition.
c
Of these insanities characterized by a fear of contact I have seen a variety not yet recorded in
the literature, as far as I am aware. This is the fear of pieces of glass that might be present in foods,
especially soups, or in dnnks. The neologism would be hyalophobia (from hyalos, glass).

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madness) and onomatomania (name madness) and other such metaphysical

insanities, or, as Arndt would say, ’questioning paranoias’.d I will pass over
here the [ 114] various disorders in which an emotive idea becomes a violent
impulse which overpowers the will of the sick person and compels him to act
in some specific manner (kleptomania, pyromania, coprolalia, dipsomania,
oneomania or the compulsion to buy, homicidal and suicidal impulses, etc.,
etc.) which would take a long time even to list, the number of possible and
conceivable varieties being as numerous as the various bizarre, criminal,
perverted, or ridiculous acts the human mind can imagine, and feel itself
irresistibly compelled to put into practice.&dquo; I will, however, mention the anti-
vivisectionist furore first described by Magnan, since in sharing beliefs and
sentiments present in the population of sane individuals it has a great affinity
with taphephobia. A love of animals and concern for the suffering that
physiologists inflict on them in their experiments are not in themselves
pathological; they become so when this love of animals and preoccupation
with what happens to them in scientific laboratories coalesce to dominate the
whole sentimental sphere in the form of a painful anxiety, and prevent the
enraged animal-lover from thinking of anything else. Similarly in the case of
the taphephobic: that there have been cases, and that examples exist, of
apparent death and premature burial is a common idea, and it is only right
that both the authorities on their part, and individual citizens on theirs, feel
concerned about the matter and try their best to stop or prevent any
repetition of it. But in the taphephobic this concern is constantly present at
every moment, at every hour; it is accompanied by an incredible sense of
anxiety, and compels the sufferer, as has been said above, to uniform and
continually repeated acts which satisfy his consciousness and quiet his mind
for the moment, but soon after, sometimes in just half an hour, already seem
insufficient, so that the fear and anxiety return with the same intensity as
before.
We can observe in both the dysmorphophobic and the taphephobic all the
signs [115] alienists have assigned to rudimentary paranoia, and of which
Magnan provided the following summary:

d
The most interesting example I have seen of metaphysical insanity is the one of a lady who,
every time she had to defecate, was attacked by the anxious fear of committing an indecent act, and
would ask herself why God had given human beings such a strange method of elimination.
e
The best description and classification of these psychoses is given by Magnan and his school:
see Legrain, Du délire chez les dégénérés (Paris, 1886).

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Generally, these psychopathic syndromes are considered to be degenerative

psychoses and are attributed to the influence of heredity; for the majority of
alienists, then, they are examples of Morel’s ’hereditary psychoses’. But for
some years now, I have insisted upon the fact, which I have been able to
confirm through observation, that not all forms of insanity with fixed ideas of
an irrepressible and impulsive kind are clear indications or the ’psychic

stigmata’ of degeneration. Having now collected amongst my private clients

nearly eighty cases of this singular psychopathic condition (78 to be precise),
I can reaffirm the point I first made at the Medical Congress of Modena in
1882, namely that in a certain number of such cases it is impossible to find
the slightest indication of a psychopathic or neuropathic inheritance, but only
a state of neurasthenia, which may sometimes be transitory.
Now it is true to say that the mental disturbance which characterizes
rudimentary paranoia develops from a constitutionally psychopathic base, to
which one may justly, with Benedikt, give the name of psychasthenia;
however, just as there are psychasthenias due to congenital, inherited
unhealthiness or weakness of the brain, so too there are psychasthenias due
to accidental, acquired nervous exhaustion. And this is why we sometimes
see develop - even in the absence of any sort of nervous or psychopathic

heredity - an insanity with fixed ideas, a pathological fear of contact, a

compulsive disorder, in fact any type of rudimentary paranoia, at the time of
puberty or in pregnancy, or during the puerperium or lactation, or at the
menopause, or even following sexual excitement, or finally during
convalescence from serious acute diseases, especially of the infective variety.
Of these neurasthenic forms [116] I have collected various examples, and I
can say that almost all of them can be subsumed under so-called
’metaphysical insanity’. In one of these patients, in fact, there was typical
taphephobia.
In my ’Essay on the classification of mental diseases’,f neurasthenic
insanity figures amongst the paraphrenias of the second sub-group, that is,
amongst the constitutional psychopathies, and more specifically in the
section of psychopathies based on a simple neuropathic constitution. I would
like to draw my colleagues’ attention to the affinity recorded here for the first
time between rudimentary paranoia of the imaginary and impulsive kind,
periodic insanity, and epileptic insanity; for as is usual with Italian scientific
publications, my essay on the taxonomy of mental diseases was better
received abroad than in Italy, and I witness my idea becoming more and

fFirst published in 1883 (Turin: Roux) in booklet form; repeated as an appendix to my

Manualedi Semeiottica delle Malattie mentali, Vol. I (Milan, 1885).

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112

more accepted that many of the mental disturbances that occur in periodic
forms have an analogy and an affinity (I do not mean an identity) with
epilepsy. In any case, I would like to state firmly that I never intended
neurasthenia to be seen as a pathological condition exclusively acquired or
transient; it is sufficient to have had even a limited experience as a
neuropathologist to know that it can be a truly constitutional condition, with
an inherited base and a degenerative predisposition. It follows (and this is

very important in practice) that contrary to what many alienists write and
think, rudimentary paranoia can be totally cured, whilst in other instances,
when it is due to a weakness or to an anomalous development of the
personality, it will persist all through life, manifesting itself in the most varied
forms. In this clinical concept of rudimentary paranoia are reconciled two
opposite nosological tendencies. I recall in this regard that Kraepelin, in
defining it as ’neurasthenic insanity’, seems to consider it purely and
exclusively as a pathological alteration of the [117] ’neuro-psychic
functions’.9 But Magnan and others declare it to be a form of ’degenerative
psychosis’, while Krafft-Ebing, who is evidently trying to reconcile both
ideas, describes it in the group of ’asthenic neuropsychoses’ as ’a form of
psychological degeneration with a neurasthenic basis’.’ There can be no
doubt that in this area of psychiatric nosography, too, the truth lies between
the two extremes, that is, we must admit that rudimentary paranoias may be
caused in different ways, either by the one mechanism or by the other.
Another fact needs to be remembered here which is often forgotten: in the
forms of this psychosis that are truly neurasthenic, unlike in degenerative
forms, the clinical picture is constant and uniform. The neurasthenic always
feels the same anxious timidness, the same doubt he experienced in his first
attack, and he goes on feeling it from the onset of his condition until its end.
He is solely and exclusively an agoraphobic, a taphephobic, a dysmor-
phophobic, a claustrophobic, etc. In the degenerate, by contrast, we meet the
most curious succession of doubts, each one of which dominates the
consciousness of the patient for a certain period of time, and then yields to a
second, and then a third, etc. Thus I have seen cases in which the most
varied forms of insanity with fixed ideas succeeded one another: first a period
of typical rhypophobia, then one of typical metaphysical insanity, then a
more or less accentuated phase of the form of doubt of action that we call
abulia, and finally for two or four months a characteristic taphephobia. This
succession of dissimilar doubts gives such an individual a strong amenity with
sufferers from periodic insanity; this fact alone, by the way, would indicate
the degenerative or hereditary nature of the psychopathic state, even if there
were no reliable information concerning the sick person’s family history.

g
h
Kraepelin, Comp. d. Psychiat., 2nd edn (Leipzig, 1887), 374f.
Krafft-Ebing, Lehrb. d. psychiat., 3rd edn (Stuttgart, 1888), 509-22.

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[118] I can also not omit here a consideration of the relationship between
the rudimentary paranoias on the one hand, and the true and proper
paranoias on the other. I do not believe that an absolute division between the
two -types can be made the way some writers have pretended to be able to,
basing this in particular on the patient’s awareness of the abnormality of the
phenomena he is experiencing. I have observed some cases of insanity with
fixed ideas in which the patient was at first aware of the strangeness,
absurdity, and morbidity of his ideas, or of his anxieties, but later lost this
consciousness little by little, so that the irrepressible idea no longer seemed
either strange or morbid. In fact I have collected indubitable cases of primary
paranoia that set in towards puberty with the symptom of obsessive ideas,
ideas that then later became the nucleus of a clearly recognizable persecutory
paranoid psychosis.’
We must also accurately distinguish the anxiety state, which characterizes a
phobia, from the one that accompanies depressive or melancholic psycho-
neuroses. This distinction is especially difficult in the case of dysmorphophobia,
which apparently has many affinities with certain hypochondriacal states, and
also in that of taphephobia, which at a first sight may be confused with the
fear of death, thanatophobia, which so often distresses the melancholic
patient. However, the differential diagnosis can be made from the fact that
the emotional disturbance of the phobias comes in ’attacks’, and does not
depend on a constant alteration of mood, and that the disturbance never
precedes the appearance of the obsessive ideas either of deformity or of the
future possibility of being buried alive. Furthermore, the hypochondriac and
the melancholic have no awareness of the morbidity of their condition, or if
they do have it at first, they lose it as their disease progresses. Lastly, we must
remember that in dysmorphophobic and taphephobic cases we are not
dealing at all with hallucinatory disorders. [119] Naturally I leave aside here
the other clinical features upon which I hold it useless to dwell; but in order
to explain my idea better, I would emphasize that the dysmorphophobic
stands in the same relationship to the hypochondriac, in his compulsion to
examine the physical condition of his body, and the taphephobic to the
melancholic, in his fear of death, as the rhypophobic to the person suffering
from a delusion of poisoning.
With regard to the pathogenesis of these conditions, it is becoming more
and more evident to me that it must be situated in the context of the
psychological laws of association, or better, in the context of the classification
of psychic states, to which I have made reference in one of my previous
articles.’ The latest studies on hypnotism, and the speculations of several

’
English and American alienists, of late accepting ideas coming from the German and Italian
schools, now refer to phobic insanity with the term ’abortive monomania’: see E.C. Spitzke,
Insanity, its Classification, Diagnosis and Treatment (New York, 1883), 311.
’
Morselli, ’Paranoia rudimentale impulsiva’, Riv. sperim. di Freniatria e Medicina legale, 1886.

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114

distinguished psychologists (Ribot, Paulhan, Pierre Janet, Wm. James, etc.)

are leading us to the idea that the personality may be a synthetic system of
ideas and impulses. Insanity in all its forms must be regarded as an
anomalous organization or as a disintegration of the psychological and
physiological elements that make up the personality: of this I hope to be able
to give a demonstration in my future writings. Indeed, it is especially in
insanity with fixed ideas that we see the morbid disassociation of such
elements: the psychic state that characterize this form of insanity - whether it
be of ideation, or of sentiment, or of impulse - breaks forth from the depths
of the unconscious, and moving with vehemence and great force into the
perceptive field, manages to dominate the consciousness, and to inhibit the
entry into it of any other psychological state that might stand in opposition
to it.
Genoa, April 1891.

k
In the second volume of my Manuale di Semeiottica delle Malattie mentali (in press), and in a
Trattato clinico di Psichiatria on which I have been working for several years.

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