Disorders of Body Image

Abstract

General adult psychiatrists commonly encounter patients with unusual attitudes to their bodies, often in connection with eating disorders. The condition of body dysmorphic disorder (BDD)—in which the patient is preoccupied with an imagined or exaggerated aspect of the appearance—is more rarely seen, especially in the National Health Service, where more severe mental illnesses get priority. When we do see patients with this condition, they tend to be difficult to help. Sometimes the referral comes from a general practitioner who wishes to know whether a patient's request for cosmetic surgery is appropriate. For all who deal with such patients, Castle and Phillips' short book is packed with clinically useful information. Whilst the title suggests that the book addresses all disorders of body image, the focus is on BDD. This is fair enough since there are already many texts on eating disorders; only one chapter deals specifically with eating disorders, although basic-science chapters include information on anorexia nervosa, bulimia nervosa and obesity. The book also offers clinically relevant chapters on body image in general psychiatric disorders and body image disorders in childhood. However, the editors are particular authorities on BDD and in three chapters they provide an account of its diagnosis and management. As well as a general account of the epidemiology, diagnosis, clinical features and management of BDD, there are detailed descriptions of psychopharmacological and cognitive—behavioural treatments. The clinical chapters are preceded by accounts of basic research in body image. Neurological and anthropological evidence is supplemented by a fascinating chapter on the brain physiology of disgust as an emotion. Beyond psychiatry, it seems that as many as 7-16% of patients seen by cosmetic surgeons and dermatologists have BDD; and, whereas most individuals who have cosmetic surgery perceive their body image to have improved, some 80% of patients with BDD are dissatisfied with the results of treatment. The more detailed chapters on treatment of BDD are clearly relevant for psychiatrists and psychologists treating the condition. The chapter on cognitive—behavioural treatment requires some knowledge of specific methods (e.g. downward arrow technique) but this can easily be acquired from textbooks. They have offered a useful overview of cognitive—behavioural strategies that can be applied in BDD—such as response prevention exercises with mirror use and cognitive restructuring—though the scientific basis for such treatments is not made clear. The advice will be valuable to psychologists as well as psychiatrists. With psychopharmacological treatment the focus is on selective serotonin reuptake inhibitors but other treatment options are discussed. Throughout the book, research references are up to date and comprehensive. The evidence base consists mainly of studies with small numbers; few randomized trials have been done. Disorders of Body Image—well written and signposted with clear subheadings—will be a useful work of reference for general psychiatrists who see the occasional patient with BDD; we therefore recommend it to libraries in mental health trusts. Psychologists will find it helpful in cognitive—behavioural therapy, and psychiatrists with a special interest in BDD (most of whom will be in private practice) will wish to have their own copy. Cosmetic surgeons too.