Psychiatric treatments are usually effective

Body image isn't just a women's problem. Many studies reveal that a surprisingly high proportion of men are dissatisfied with, preoccupied with, and even impaired by concerns about their appearance.¹ One American study, for example, found that the percentage of men dissatisfied with their overall appearance (43%) has nearly tripled in the past 25 years and that nearly as many men as women are unhappy with how they look.¹

A more severe form of body image disturbance body dysmorphic disorder or dysmorphophobia is an underrecognised yet relatively common and severe psychiatric disorder.² Body dysmorphic disorder affects as many men as women ^{3 4} and consists of a preoccupation with an imagined or slight defect in appearance that causes clinically significant distress or impairment in functioning. Patients with body dysmorphic disorder often present to non-psychiatric physicians, with reported rates of 12% in dermatology settings and 7-15% in cosmetic surgery settings.⁵ Although the symptoms of body dysmorphic disorder might sound trivial, high proportions of patients require admission to hospital, become housebound, and attempt suicide.³ In a study of dermatology patients who committed suicide most had acne or body dysmorphic disorder.⁶

Men with body dysmorphic disorder are most commonly preoccupied with their skin (for example, with acne or scarring), hair (thinning), nose (size or shape), or genitals. ^{3 4} The preoccupations are difficult to resist or control and can consume many hours each day.³ Nearly all men with body dysmorphic disorder perform repetitive and time-consuming behaviours in an attempt to examine, fix, or hide the "defect." The most common are mirror checking, comparing themselves with others, camouflaging (for example, with a hat), reassurance seeking, and excessive grooming.³

A recently recognised form of body dysmorphic disorder that occurs almost exclusively in men is muscle dysmorphia, a preoccupation that one's body is too small, "puny," and inadequately muscular.¹ In reality, many of these men are unusually muscular and large. Compulsive working out at the gym is common, as is painstaking attention to diet and dietary supplements. Of particular concern, muscle dysmorphia may lead to potentially dangerous abuse of anabolic steroids, and studies indicate that 6-7% of high school boys have used these drugs.¹ While the cause of body dysmorphic disorder is unknown and probably multifactorial, involving genetic-neurobiological, evolutionary, and psychological factors, recent social pressures for boys and men to be large and muscular almost certainly contribute to the development of muscle dysmorphia.

Body dysmorphic disorder interferes with functioning ^{2 4-7} and may lead to social isolation, difficulty with job performance, and unemployment. In a study that used the SF-36 to measure health related quality of life, outpatients with body dysmorphic disorder scored notably worse in all mental health domains than the general US population and patients with depression, diabetes, or a recent myocardial infarction.⁷

Patients with body dysmorphic disorder can be challenging to treat.⁸ However, recent research findings are encouraging, with clinical series, open label studies, and controlled trials indicating that serotonin reuptake inhibitors are effective for most patients.⁹ Higher doses and longer trials than those usually used for depression are often needed.⁹ Clinical series and studies using untreated controls waiting for treatment suggest that cognitive behavioural therapy is also effective.¹⁰ This treatment helps patients develop more realistic views of their appearance, resist repetitive behaviours, and face avoided social situations. Other types of psychotherapy or counselling, in contrast, do not appear effective.²

Most men with body dysmorphic disorder, however, receive dermatological, surgical, or other non-psychiatric treatment.¹¹ Although rigorous studies are lacking, the data suggest that these treatments are usually ineffective.¹¹ Some patients are so disappointed with the outcome that they become severely depressed, suicidal, litigious, or even violent towards the treating physician. A recommended approach⁵ is to educate patients about the disorder and effective psychiatric treatment. It is probably best to avoid cosmetic procedures. Simply trying to talk patients out of their concern is usually futile.

Although body dysmorphic disorder has been described for over a century and reported around the world, it remains underrecognised and underdiagnosed.² Men and boys are often reluctant to reveal their symptoms because of embarrassment and shame, and they typically do not recognise that their beliefs about their appearance are inaccurate and due to a psychiatric disorder. Physicians can diagnose body dysmorphic disorder in men with a few straightforward questions. ^{5 12} These determine whether the man is concerned about and preoccupied with minimal or non-existent flaws in his appearance and whether this concern causes significant distress (depression, anxiety) or interferes with social, occupational, or other aspects of functioning. The challenge is to enhance both physicians' and the public's awareness of body dysmorphic disorder so that effective treatments can be offered and unnecessary suffering and morbidity avoided.

Katharine A Phillips, director, Body Dysmorphic Program. 

Butler Hospital and the Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island 02906, USA (Katharine_Phillips{at}Brown.edu)

David J Castle, professorial fellow. 

Mental Health Research Institute and University of Melbourne, Parkville, Victoria 3052, Australia

1.	Pope HG, Phillips KA, Olivardia R. The Adonis complex: the secret crisis of male body obsession. New York: Free Press, 2000.
2.	Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. New York: Oxford University Press, 1996.
3.	Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 1997; 185: 570-577[CrossRef][Medline].
4.	Perugi G, Akiskal HS, Giannotti D, Frare F, DiVaio S, Cassano GB. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis 1997; 185: 578-582[CrossRef][Medline].
5.	Phillips KA, Dufresne Jr RG. Body dysmorphic disorder: a guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000; 1: 235-243[Medline].
6.	Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997; 137: 246-250[Medline].
7.	Phillips KA, Castle DJ. Body dysmorphic disorder. In: Castle DJ, Phillips KA, eds. Disorders of body image. London: Wrightson (in press).
8.	Cotterill JA. Body dysmorphic disorder. Dermatol Clin 1996; 14: 457-463[Medline].
9.	Phillips KA. Pharmacologic treatment of body dysmorphic disorder: a review of empirical data and a proposed treatment algorithm. Psychiatr Clin North Am 2000; 7: 59-82.
10.	Veale D. Cognitive behavior therapy for body dysmorphic disorder. In: Castle DJ, Phillips KA, eds. Disorders of body image. London: Wrightson (in press).
11.	Phillips KA, Grant JD, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics (in press).
12.	Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27: 457-462[CrossRef][Medline].

http://bmj.bmjjournals.com/cgi/content/full/323/7320/1015

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