Special Article
Psychotlier Psychosom 1992:58:119-124
Philipsnaith
Body Image Disorders
Keywords
Abstract
Body image Body image disorders Dysmorphophobia Body dysmorphic disorder
The concepts of disorders of body image are reviewed from three aspects: sociocultural, neurological and psychiatric dis orders. Particular attention is paid to the construct of body dysmorphic disorder as defined in the DSM III-R and the sep aration of this from somatic delusional disorder. The recogni tion of associated psychopathology will frequently lead to suc cessful treatment before too much time is spent on fruitless attempts at treatment of the presenting complaint.
Introduction
Attention to disturbances of the person’s perception of his own body, its size and de fects (real or imagined), has gained in promi nence in the last decade. Professional focus upon eating disorders, especially anorexia nervosa with its characteristic gross distortion of self-perception of body size, has led to increasing awareness of milder and atypical presentations of eating disorders. The special relationship of body image disparagement to more general psychic disturbance, especially lowering of self-esteem with limitation of per sonal efficacy, has brought the subject out of the narrower clinical domain into the wider aspect of community survey.
The other major emphasis has been the recognition of psychopathological disorder and presentation of patients suffering from such disorders in the non-psychiatric fields such as plastic surgery and dermatological clinics. The association of certain irrational beliefs or overvalued ideas to true delusions and the presence of later indubitable psychiat ric disorder in some sufferers has led to a ren ewed interest in the specific disorder once termed dysmorphophobia but now, in the DSM III-R. renamed as body dysmorphic dis order. Yet another influence on the development of disturbance of body image has been the bombardment of the public with so-called standards of personal 'good looks’ by the ad-
Philip Snaith Academy Unit of Psychiatry' Leeds University Leeds LS97TF (UK)
©1992 S. Kargcr AG. Basel 0033-3190/92/ 0584-0119$2.75/0
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
Academic Unit of Psychiatry. Leeds University. Leeds. UK
Non-Clinical Aspects
The state of research into body image dis turbance in non-clinical populations at the commencement of this decade is well sum marised by Thompson [1], In the 1980’s alongside research into the phenomena of anorexia nervosa, there was increased interest in the extent of dissatisfaction with personal appearance in the population, the state for which the phrase ‘normative discontent’ was coined. These aspects of body image were considered under the constructs of: (1) a per ceptual component (the person’s own concept of the size of the body or a part of the body); (2) a subjective component, i.e. the person’s dissatisfaction and distress concerning body image; (3) a behavioural component which concerns the degree to which the person takes action, either in attempt to alter bodily ap pearance or avoidance of situations involving self-exposure to observation by others. The prevalence of discontent with body image is certainly high in the Western world: the proliferation of publications addressing
120
Snailh
the topic of ‘dieting’ attests to this. Nielsen (quoted by Thompson) stated that over half of all females in the 25-54 years of age range were on a diet. There is a large cultural factor which makes it impossible to extrapolate findings from one culture to another or one ethnic group to another, even within a single geographical area. It appears to be generally true that people in the Third World, expecially India and Africa hold opposite atti tudes to Westerners and equate fatness with feminine beauty. Furnham and Alibhai [2] showed that Kenyan Asians rated larger fig ures more favourably than did white British women living in Britain, whereas Asian women born in Kenya but living in Britain had an intermediate attitude to their body shape. The study was conducted on small, possibly unrepresentative, samples, but the authors considered that their Findings were in accord with other observations of cultural dif ferences, i.e. that there was no disparagement of obesity in less affluent, developing coun tries. Within a Western society social class has probably an influence, with women of higher social status valuing slimness more than those in lower social strata. The greatest differential factor is gender, with men being on the whole more content with their bodily dimensions than women; these gender-re lated differences may commence at puberty or before. Salmons et al. [3] conducted a study in samples of schoolchildren of differ ent gender and different age groups in Bir mingham, England: subjects were instructed by a self-rated questionnaire, to assess the size of various aspects of their body (chest, stomach, hips, bottom and thighs) as ‘much too big’, ‘a bit big’, ‘about right' or ‘too small'. In all three age groups (11-13. 14-15 and lb 18) boys used the statement ‘much too big' less freuquently than girls with respect to all parts of the body. In girls, apart from the bust, there was a distinct rise in estimation of all
Body Image Disorders
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
vertising industry, greatly enhanced by gigan tic posters in the streets and invasion of living room space on the television screen. Through such influences it is extremely difficult to avoid perpetual reminders of one’s own notso-good appearance with the constant exhor tation to take corrective action, probably by purchasing and application of some medica tion or supposedly wholesome foodstuff. This chapter will present a general over view of the field in the early 1990’s with exclu sion of those aspects related to clinical eating disorders. The specific characteristic concern with bodily appearance which is a hallmark of the gender dysphoria state of transsexualism will also be excluded from consideration here.
Neurological Aspects
Gross neurological disorder leading to dis tortion of the body schema [5] involve lesions of the parietal lobes and somatosensory relay stations, and of the temporal lobes. The uni lateral misperception of one’s own body socalled hemiasomatognosia form of anosognosia for hemiplegia occurs in right cerebral hemisphere lesions leading to left-sided stroke. The side of the body may be neglected or even disowned. Lesions in either parietal lobe lead to hemi-inattention and hemispatial neglect. Another disturbance of body schema based on parietal lobe lesion is the Gerstmann syndrome with the triad of finger agnosia, acalculia and right-left disorientation: the in ability to name parts of the body may extend from the fingers alone to include other re gions. Other aspects of distortion of the body image based upon neurological disturbances are discussed by Trimble [6] who considers temporal lobe lesions in some detail. Deper sonalisation is the most pervasive of the body image disturbances and it may be limited to the experience of desomatisation. There may be a rich array of other symptoms including perception of the distortion of the size of the body and perceptual disturbances which re late to the self, including hallucination of the self (autoscopy) or another (Doppelgänger). A peculiar and characteristic aspect of temporal lobe disturbance is the sensation of swelling passing through the body in a cephalic direc tion, a sensation which gave rise to the an cient notion of the uterus taking leave of its moorings in the pelvis and the concept of the globus hystericus.
121
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aspects of their body as too large. The authors commented that ‘girls become more deeply immersed in the slimness culture as they be come young adults and meet peer pressure and media incitement to conform. They are likely to have dieted also, in response to these pressures and in striving for a sense of selfmastery’. The phenomena of discontent with body image seems to be correlated with such fea tures as low self-esteem and depression al though no strong conclusions can be drawn owing to the paucity of studies in non-eating disordered populations, poor definition of the concepts of self-esteem and ‘depression’, and the overlap of constructs when assessing body image attitudes and ‘depression’. With more rigorously defined constructs the field is ripe for further investigation, especially of the re lation of attitudes to body image to emotional factors. The onset of menstruation in girls appears to play an important part in body image [1]; the role of this developmental stage seems obviously related to the gain in weight and also to the girl’s perception of herself as a sex ual competitor. Thompson [1] reviews the theories that have been advanced to explain body image dissatisfaction. The ‘self-ideal discrepancy’ theory relates to the personal standards of perfection. Other theories, the ‘adaptive fail ure' and the ‘perceptual artefact' theory, relate particularly to the genesis of eating disorders and will not be reviewed here. In general, it may be stated that socio-cultural factors play a large role in determining personal attitudes to, and dissatisfaction with, their own bodies. There not only are the ethnic and gender influences noted above but there is good evi dence from survey of bodily configuration in fashion magazines and sexually titillating lit erature that, in the Western world, the ‘ideal’ has changed over the last 100 years [4].
Undue concern with some aspect of per sonal appearance was called dysmorphophobia by Morselli in 1886 [7, 8], The term per sists although objection has been raised on the grounds that a phobic state is not an aspect of the disorder. The ICD-10 has no separate cat egory but the DSM III-R considers disorders under two categorical headings: (1) delusional disorder, somatic type; (2) body dysmorphic disorder. The distinction between these cate gories rests upon whether the bodily concern has the characteristics of a true delusion, but a clear distinction cannot always be made; moreover, the non-delusional state may pro gress to the delusional state in the course of time. It may be noted that the classificatory system recongizes the disturbances as being discrete categories but the view has been put forward that such disturbance is always symp tomatic of some other psychiatric disorder [9], The actual definitions in the DSM glos sary [10] are as follows: Delusional Disorder, Somatic Type
Somatic delusions occur in several forms. Most common are convictions that the person emits a foul odor from his/her skin, mouth, rectum or vagina: that he or she has an infestation of insects of or in the skin: that he or she has an internal parasite; that certain parts of his or her body (e.g. the large intestine) are not functioning; that certain parts of the body are, contrary to all evidence, misshapen or ugly. People with so matic delusions usually consult non-psychiatric physi cians for treatment of their perceived somatic condi tion. The age of onset is generally in middle or late adult life but can be younger. Body Dysmorhic Disorder
The essential feature is a pre-occupation with some imagined defect in appearance in a normally appearing person. The most common complaints involve facial flaws such as wrinkles, spots on the skin, excessive facial hair, shape of the nose, mouth, jaw or eyebrows and swellings of the face. More rarely the complaint involves the appearance of the feet, hands, breasts, back or some other part of the body. In some cases a
122
Snailh
slight physical anomaly is present but the person's con cern is excessive. In the past this condition was called dysmorphophobia. but since the disturbance does not involve phobic avoidance that term was a misnomer. The term dysmorphophobia has been used to include cases in which the belief in a defect in appearance is of delusional intensity. It is unclear, however, whether the two different disorders can be distinguished by whether or not the belief is a delusion or whether there are merely two variants of the same disorder. In this manual a belief in the defect of delusional intensity is classified as delusional disorder, somatic type. The age of onset is most commonly between the ages of adoles cence and the third decade. The disorder persists over several years.
It may be observed that this definition is not entirely satisfactory: it commences with the statement that the defect is ‘imagined’ and later considers that a defect may be present but that the concern is excessive and this of course entails a subjective judgement on the part of the examiner. It may also be noted that the definition of body dysmorphic disorder makes no refer ence to the size of the genitals. Hay [11] recorded the concern with the size of the penis in 3 of 12 male patients considered to be suf fering from dysmorphophobia. It is of course the focus of concern in the culture-bound con dition of koro. Aspect of bodily appearance may be sin gled out for disproportionate attention. The feature may ‘remind’ the person of some dis liked relative. Personal insecurity, low self esteem or emotional disorder may be man aged by the intrapsychic defence of focus on a part of the body. In those patients who are not actually psychotic, personality traits of the sensitive and perfectionistic type may be prominent [11]. In other cases the concern may be a prelude to psychosis, and in such cases the concern may be expressed in a curious manner e.g. ‘the skin under my eyes meets the nose in a strange way’ [7], It is possi ble to construct elaborate psychodynamic in-
Body Image Disorders
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
Psychiatric Disorders
ative. Even in non-delusional cases a trial of such medication is helpful, may sometimes lead to resolution of the complaint with spar ing of years of misery and aggravation for both the patient and the medical advisers. Anhedonic depressive patients should be treated with an adequate dose of antidepres sant medication. Patients whose complaint is a symptom of more pervasive anxiety state or neurotic disorder may respond to anxiety management techniques, congitive restructur ing or brief psychodynamic therapy. The largest study of patients referred for plastic surgery was undertaken by Reich [ 15], He concluded: ‘From the surgical point of view, the main indication for surgical altera tion in appearance is the existence of correcta ble deformity. From the point of view of men tal health, the existence of a psychiatric disor der is not a contraindication to operation as such, but should be viewed in relation to two criteria: (a) the realism of the patient’s expec tations, and (b) the likely ability of the patient to withstand an imperfect result. Psychiatric support is indicated if these criteria are not satisfied and if emotional problems exist which reinforce the patient’s preoccupation with this deformity.’
123
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terprctations in any particular case; these may satisfy the psychiatrist but not relieve the patient. Psychiatric examination will detect the presence of associated psychotic illness, ob sessional disorder, excessive anxiety and de pression. It is important to distinguish be tween the concept of depression which is a state of demoralization consequent upon a chronic handicap or illness, a depression which is an aspect of low self-esteem, and the concept of depressive disorder which may be expected to respond to treatment by antide pressant drugs; the presence of pronounced anhedonia is probably the best clinical marker for the biogenic depressive state [12], A much quoted study [ 13] from a dermato logical clinic found that a group of patients selected by the physician as having no ade quate basis for their complaint had a high depression score on the Beck Depression In ventory. The problem with such instruments is that they cover a wide spectrum of disorder, including somatic concern and symptoms and will therefore predictably show high scores in such samples. The use of the simple selfassessment device, the Hospital Anxiety and Depression Scale [14] may provide useful in formation in these patients since the depres sion subscale focusses on anhedonia. The management of the importunate pa tient who persistently requests treatment for a bodily ‘abnormality’ when such abnormality is either absent or minimal, is difficult. There are of course no absolute standards o f‘normality’ of appearance. In doubtful cases good medical practice does require psychiatric opinion; emotionally disturbed or prepsychotic patients may become more dissatisfied by collusion with their demands. The malignant nature of body dysmorphic disorder has often been un derlined (see above reviews for evidence). In delusional disorder the treatment is ob vious and antipsychotic medication is imper
R eferen ces
7 Birtchnell SA: Dysmorphophobia. a centenary discussion. Br J Psychia try 1988; I S3(suppl 2):41 -43. 8 Phillips KA: Body dysmorphic dis order: The distress of imagined ugli ness. Am J Psychiatry 1991:148: 1138-1149. 9 Bychowski G: Disorders of the body image in the clinical picture of psy choses. J Nerv Ment Dis 1943:97: 310-334. 10 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3. rev. Wash ington. American Psychiatric Asso ciation. 1987.
124
Snaith
6 Trimble MR: Body image distur bance and the temporal lobes. Br J Psychiatry 1988; 153(suppl 2): 12— 14.
11 Hay GG: Dysmorphophobia. Br J Psychiatry' 1970:116:399-406. 12 Snaith RP: Anhedonia. Br Med J 1992:305:134. 13 Hardy GE, Cotterill JA: A study of depression and obscssionality in dysmorphophobic and psoriatic pa tients. BrJ Psychiatry' 1982; 140:19— 22. 14 Zigmond A. Snaith RP: The hospi tal anxiety and depression scale. Acta Psychiatr Scand 1983:67:361 — 370. 15 Reich J: The surgery of appearance: Psychological and related aspects. M edJ Austr 1969:2:5-13.
Body Image Disorders
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
1 Thompson JK: Body Image Distur bance: Assessment and Treatment. New York. Pergamon Press. 1990. 2 Furnham A. Alibhai N: Cross-cul tural differences in the perception of female body shapes. Psychol Med 1983:13:829-837. 3 Salmons PH, l.ewis VJ. Rogers P. Gatherer AJH. Booth DA: Body shape dissatisfaction in schoolchil dren. Br J Psychiatry 1988; 153(suppl 2):27—3 1. 4 Silvcrstein B. Peterson B. Perdue L: Some correlates of the thin standard of bodily attractiveness for women. Int J Eating Disord 1986:5:895— 906. 5 Cumming WJK: The neurobiology of the body schema. Br J Psychiatry 1988; 153(suppl 2):7-11.
Psychotlier Psychosom 1992:58:119-124
Philipsnaith
Body Image Disorders
Keywords
Abstract
Body image Body image disorders Dysmorphophobia Body dysmorphic disorder
The concepts of disorders of body image are reviewed from three aspects: sociocultural, neurological and psychiatric dis orders. Particular attention is paid to the construct of body dysmorphic disorder as defined in the DSM III-R and the sep aration of this from somatic delusional disorder. The recogni tion of associated psychopathology will frequently lead to suc cessful treatment before too much time is spent on fruitless attempts at treatment of the presenting complaint.
Introduction
Attention to disturbances of the person’s perception of his own body, its size and de fects (real or imagined), has gained in promi nence in the last decade. Professional focus upon eating disorders, especially anorexia nervosa with its characteristic gross distortion of self-perception of body size, has led to increasing awareness of milder and atypical presentations of eating disorders. The special relationship of body image disparagement to more general psychic disturbance, especially lowering of self-esteem with limitation of per sonal efficacy, has brought the subject out of the narrower clinical domain into the wider aspect of community survey.
The other major emphasis has been the recognition of psychopathological disorder and presentation of patients suffering from such disorders in the non-psychiatric fields such as plastic surgery and dermatological clinics. The association of certain irrational beliefs or overvalued ideas to true delusions and the presence of later indubitable psychiat ric disorder in some sufferers has led to a ren ewed interest in the specific disorder once termed dysmorphophobia but now, in the DSM III-R. renamed as body dysmorphic dis order. Yet another influence on the development of disturbance of body image has been the bombardment of the public with so-called standards of personal 'good looks’ by the ad-
Philip Snaith Academy Unit of Psychiatry' Leeds University Leeds LS97TF (UK)
©1992 S. Kargcr AG. Basel 0033-3190/92/ 0584-0119$2.75/0
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
Academic Unit of Psychiatry. Leeds University. Leeds. UK
Non-Clinical Aspects
The state of research into body image dis turbance in non-clinical populations at the commencement of this decade is well sum marised by Thompson [1], In the 1980’s alongside research into the phenomena of anorexia nervosa, there was increased interest in the extent of dissatisfaction with personal appearance in the population, the state for which the phrase ‘normative discontent’ was coined. These aspects of body image were considered under the constructs of: (1) a per ceptual component (the person’s own concept of the size of the body or a part of the body); (2) a subjective component, i.e. the person’s dissatisfaction and distress concerning body image; (3) a behavioural component which concerns the degree to which the person takes action, either in attempt to alter bodily ap pearance or avoidance of situations involving self-exposure to observation by others. The prevalence of discontent with body image is certainly high in the Western world: the proliferation of publications addressing
120
Snailh
the topic of ‘dieting’ attests to this. Nielsen (quoted by Thompson) stated that over half of all females in the 25-54 years of age range were on a diet. There is a large cultural factor which makes it impossible to extrapolate findings from one culture to another or one ethnic group to another, even within a single geographical area. It appears to be generally true that people in the Third World, expecially India and Africa hold opposite atti tudes to Westerners and equate fatness with feminine beauty. Furnham and Alibhai [2] showed that Kenyan Asians rated larger fig ures more favourably than did white British women living in Britain, whereas Asian women born in Kenya but living in Britain had an intermediate attitude to their body shape. The study was conducted on small, possibly unrepresentative, samples, but the authors considered that their Findings were in accord with other observations of cultural dif ferences, i.e. that there was no disparagement of obesity in less affluent, developing coun tries. Within a Western society social class has probably an influence, with women of higher social status valuing slimness more than those in lower social strata. The greatest differential factor is gender, with men being on the whole more content with their bodily dimensions than women; these gender-re lated differences may commence at puberty or before. Salmons et al. [3] conducted a study in samples of schoolchildren of differ ent gender and different age groups in Bir mingham, England: subjects were instructed by a self-rated questionnaire, to assess the size of various aspects of their body (chest, stomach, hips, bottom and thighs) as ‘much too big’, ‘a bit big’, ‘about right' or ‘too small'. In all three age groups (11-13. 14-15 and lb 18) boys used the statement ‘much too big' less freuquently than girls with respect to all parts of the body. In girls, apart from the bust, there was a distinct rise in estimation of all
Body Image Disorders
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
vertising industry, greatly enhanced by gigan tic posters in the streets and invasion of living room space on the television screen. Through such influences it is extremely difficult to avoid perpetual reminders of one’s own notso-good appearance with the constant exhor tation to take corrective action, probably by purchasing and application of some medica tion or supposedly wholesome foodstuff. This chapter will present a general over view of the field in the early 1990’s with exclu sion of those aspects related to clinical eating disorders. The specific characteristic concern with bodily appearance which is a hallmark of the gender dysphoria state of transsexualism will also be excluded from consideration here.
Neurological Aspects
Gross neurological disorder leading to dis tortion of the body schema [5] involve lesions of the parietal lobes and somatosensory relay stations, and of the temporal lobes. The uni lateral misperception of one’s own body socalled hemiasomatognosia form of anosognosia for hemiplegia occurs in right cerebral hemisphere lesions leading to left-sided stroke. The side of the body may be neglected or even disowned. Lesions in either parietal lobe lead to hemi-inattention and hemispatial neglect. Another disturbance of body schema based on parietal lobe lesion is the Gerstmann syndrome with the triad of finger agnosia, acalculia and right-left disorientation: the in ability to name parts of the body may extend from the fingers alone to include other re gions. Other aspects of distortion of the body image based upon neurological disturbances are discussed by Trimble [6] who considers temporal lobe lesions in some detail. Deper sonalisation is the most pervasive of the body image disturbances and it may be limited to the experience of desomatisation. There may be a rich array of other symptoms including perception of the distortion of the size of the body and perceptual disturbances which re late to the self, including hallucination of the self (autoscopy) or another (Doppelgänger). A peculiar and characteristic aspect of temporal lobe disturbance is the sensation of swelling passing through the body in a cephalic direc tion, a sensation which gave rise to the an cient notion of the uterus taking leave of its moorings in the pelvis and the concept of the globus hystericus.
121
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aspects of their body as too large. The authors commented that ‘girls become more deeply immersed in the slimness culture as they be come young adults and meet peer pressure and media incitement to conform. They are likely to have dieted also, in response to these pressures and in striving for a sense of selfmastery’. The phenomena of discontent with body image seems to be correlated with such fea tures as low self-esteem and depression al though no strong conclusions can be drawn owing to the paucity of studies in non-eating disordered populations, poor definition of the concepts of self-esteem and ‘depression’, and the overlap of constructs when assessing body image attitudes and ‘depression’. With more rigorously defined constructs the field is ripe for further investigation, especially of the re lation of attitudes to body image to emotional factors. The onset of menstruation in girls appears to play an important part in body image [1]; the role of this developmental stage seems obviously related to the gain in weight and also to the girl’s perception of herself as a sex ual competitor. Thompson [1] reviews the theories that have been advanced to explain body image dissatisfaction. The ‘self-ideal discrepancy’ theory relates to the personal standards of perfection. Other theories, the ‘adaptive fail ure' and the ‘perceptual artefact' theory, relate particularly to the genesis of eating disorders and will not be reviewed here. In general, it may be stated that socio-cultural factors play a large role in determining personal attitudes to, and dissatisfaction with, their own bodies. There not only are the ethnic and gender influences noted above but there is good evi dence from survey of bodily configuration in fashion magazines and sexually titillating lit erature that, in the Western world, the ‘ideal’ has changed over the last 100 years [4].
Undue concern with some aspect of per sonal appearance was called dysmorphophobia by Morselli in 1886 [7, 8], The term per sists although objection has been raised on the grounds that a phobic state is not an aspect of the disorder. The ICD-10 has no separate cat egory but the DSM III-R considers disorders under two categorical headings: (1) delusional disorder, somatic type; (2) body dysmorphic disorder. The distinction between these cate gories rests upon whether the bodily concern has the characteristics of a true delusion, but a clear distinction cannot always be made; moreover, the non-delusional state may pro gress to the delusional state in the course of time. It may be noted that the classificatory system recongizes the disturbances as being discrete categories but the view has been put forward that such disturbance is always symp tomatic of some other psychiatric disorder [9], The actual definitions in the DSM glos sary [10] are as follows: Delusional Disorder, Somatic Type
Somatic delusions occur in several forms. Most common are convictions that the person emits a foul odor from his/her skin, mouth, rectum or vagina: that he or she has an infestation of insects of or in the skin: that he or she has an internal parasite; that certain parts of his or her body (e.g. the large intestine) are not functioning; that certain parts of the body are, contrary to all evidence, misshapen or ugly. People with so matic delusions usually consult non-psychiatric physi cians for treatment of their perceived somatic condi tion. The age of onset is generally in middle or late adult life but can be younger. Body Dysmorhic Disorder
The essential feature is a pre-occupation with some imagined defect in appearance in a normally appearing person. The most common complaints involve facial flaws such as wrinkles, spots on the skin, excessive facial hair, shape of the nose, mouth, jaw or eyebrows and swellings of the face. More rarely the complaint involves the appearance of the feet, hands, breasts, back or some other part of the body. In some cases a
122
Snailh
slight physical anomaly is present but the person's con cern is excessive. In the past this condition was called dysmorphophobia. but since the disturbance does not involve phobic avoidance that term was a misnomer. The term dysmorphophobia has been used to include cases in which the belief in a defect in appearance is of delusional intensity. It is unclear, however, whether the two different disorders can be distinguished by whether or not the belief is a delusion or whether there are merely two variants of the same disorder. In this manual a belief in the defect of delusional intensity is classified as delusional disorder, somatic type. The age of onset is most commonly between the ages of adoles cence and the third decade. The disorder persists over several years.
It may be observed that this definition is not entirely satisfactory: it commences with the statement that the defect is ‘imagined’ and later considers that a defect may be present but that the concern is excessive and this of course entails a subjective judgement on the part of the examiner. It may also be noted that the definition of body dysmorphic disorder makes no refer ence to the size of the genitals. Hay [11] recorded the concern with the size of the penis in 3 of 12 male patients considered to be suf fering from dysmorphophobia. It is of course the focus of concern in the culture-bound con dition of koro. Aspect of bodily appearance may be sin gled out for disproportionate attention. The feature may ‘remind’ the person of some dis liked relative. Personal insecurity, low self esteem or emotional disorder may be man aged by the intrapsychic defence of focus on a part of the body. In those patients who are not actually psychotic, personality traits of the sensitive and perfectionistic type may be prominent [11]. In other cases the concern may be a prelude to psychosis, and in such cases the concern may be expressed in a curious manner e.g. ‘the skin under my eyes meets the nose in a strange way’ [7], It is possi ble to construct elaborate psychodynamic in-
Body Image Disorders
Downloaded by: Monash University 130.194.20.173 - 11/7/2017 8:27:14 PM
Psychiatric Disorders
ative. Even in non-delusional cases a trial of such medication is helpful, may sometimes lead to resolution of the complaint with spar ing of years of misery and aggravation for both the patient and the medical advisers. Anhedonic depressive patients should be treated with an adequate dose of antidepres sant medication. Patients whose complaint is a symptom of more pervasive anxiety state or neurotic disorder may respond to anxiety management techniques, congitive restructur ing or brief psychodynamic therapy. The largest study of patients referred for plastic surgery was undertaken by Reich [ 15], He concluded: ‘From the surgical point of view, the main indication for surgical altera tion in appearance is the existence of correcta ble deformity. From the point of view of men tal health, the existence of a psychiatric disor der is not a contraindication to operation as such, but should be viewed in relation to two criteria: (a) the realism of the patient’s expec tations, and (b) the likely ability of the patient to withstand an imperfect result. Psychiatric support is indicated if these criteria are not satisfied and if emotional problems exist which reinforce the patient’s preoccupation with this deformity.’
123
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terprctations in any particular case; these may satisfy the psychiatrist but not relieve the patient. Psychiatric examination will detect the presence of associated psychotic illness, ob sessional disorder, excessive anxiety and de pression. It is important to distinguish be tween the concept of depression which is a state of demoralization consequent upon a chronic handicap or illness, a depression which is an aspect of low self-esteem, and the concept of depressive disorder which may be expected to respond to treatment by antide pressant drugs; the presence of pronounced anhedonia is probably the best clinical marker for the biogenic depressive state [12], A much quoted study [ 13] from a dermato logical clinic found that a group of patients selected by the physician as having no ade quate basis for their complaint had a high depression score on the Beck Depression In ventory. The problem with such instruments is that they cover a wide spectrum of disorder, including somatic concern and symptoms and will therefore predictably show high scores in such samples. The use of the simple selfassessment device, the Hospital Anxiety and Depression Scale [14] may provide useful in formation in these patients since the depres sion subscale focusses on anhedonia. The management of the importunate pa tient who persistently requests treatment for a bodily ‘abnormality’ when such abnormality is either absent or minimal, is difficult. There are of course no absolute standards o f‘normality’ of appearance. In doubtful cases good medical practice does require psychiatric opinion; emotionally disturbed or prepsychotic patients may become more dissatisfied by collusion with their demands. The malignant nature of body dysmorphic disorder has often been un derlined (see above reviews for evidence). In delusional disorder the treatment is ob vious and antipsychotic medication is imper
R eferen ces
7 Birtchnell SA: Dysmorphophobia. a centenary discussion. Br J Psychia try 1988; I S3(suppl 2):41 -43. 8 Phillips KA: Body dysmorphic dis order: The distress of imagined ugli ness. Am J Psychiatry 1991:148: 1138-1149. 9 Bychowski G: Disorders of the body image in the clinical picture of psy choses. J Nerv Ment Dis 1943:97: 310-334. 10 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3. rev. Wash ington. American Psychiatric Asso ciation. 1987.
124
Snaith
6 Trimble MR: Body image distur bance and the temporal lobes. Br J Psychiatry 1988; 153(suppl 2): 12— 14.
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