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Related Topics
The Broken MirrorReview - The Broken Mirror
Understanding and Treating Body Dysmorphic Disorder
by Katharine A. Phillips
Oxford University Press, 2005
Review by Roy Sugarman, Ph.D.
Jan 2nd 2007 (Volume 11, Issue 1)

From the start, one has to say that the endlessly repetitive case studies are not engaging or interesting, and for the most part Phillips presents the condition as an endless series of one-dimensional entities. Someone becomes obsessed with a particular aspect of their presentation, they spend so much time and effort on that aspect that their psychosocial functioning declines, and they are often not diagnosed. Unlike anorexia and bulimia, they are objectively, physically, not unusual in appearance, and so do not have some delusion that their abnormal appearance is normal or appealing, but the reverse: their normal physical appearance is believed to be marred by their hair, or skin, or some other minute detail that is not apparent to the viewer, but to the patient. Unlike hypochondrias, the focus is not illness, but invisible physical scarring or shape anomalies. Unlike schizophrenia, the presentation is not dominated by bizarre and complex delusions, but minor ones about some aspect of appearance. Requiring longer and higher doses of treatment than major depression, BDD does not have the MRI markers that depression has, and may not clear up when depression does, and seems to have a life of its own. The repetitive compulsions of BDD make it distinct from social phobia, and although similar to OCD, the demographics of lifestyle make it different, and obsessions and compulsions are not of being harmed or poisoned, or checking or counting, but are focused on the self, the corporeal body, not items or environment. Shame and poor self-esteem are thus major features of BDD, not OCD necessarily, which is based on harm avoidance.

The first 50 pages of the book allow the patient's presentations to the doctor to dominate, and I am not sure that the endless repetition is that enlightening or necessary. The condition is defined over 16 pages, and then another 14 are devoted to information as to whether the reader may have BDD. Once we have narrowed it down, from page 50 the many and varying presentations are illustrated, beginning with body parts and behaviors around such. Top of the list is not shape, but skin surface texture or blemish (like the Rorschach scoring), and after the skin (73%), next most frequent in presentation is the hair (56%), followed by the nose, weight, stomach, breast-line, eyes, thighs, teeth and finally legs, after which whole body structure, or general ugliness dominates. Ankles, toes, knees, shoulders etc are seldom presented.

The thing that strikes me with OCD or BDD is the focus of the chosen bits. My OCD patients nearly always expanded on things their parents would have cautioned them endlessly on: did you wash your hands, don't touch that it's filthy, switch off the lights, and so on, and in BDD it's the things that advertising agencies would most focus on, namely skin, hair, weight and so on for the cosmetics and weight-loss industries. There thus must be some innate basis for what we choose when we develop these conditions.

Phillips goes on to catalog how painful the obsessions can be, and also then another huge catalogue of mirror checking, grooming etc that she has already covered, but now expands to include other BDD behaviors, including hand-washing, praying and doorknob touching.

The psychosocial impact is now investigated, ranging from loneliness to suicide. A developmental chapter begins at page 141 with the lifespan and gender dominating, and then the putative origins of BDD are examined in detail, concluding that it is a polymorphic condition with some vague serotonergic and other neurotransmission pathways, and other neurobiological and genetic factors (there are more than 100 references to SSRIs in the book, that's one quarter of the pages). Predictably, there is the need for further research elucidated, and a keen focus on the age at which it may first present, and the developmental factors that may be active at that stage. The statement at the end, namely that "Ultimately, understanding what causes BDD will help us develop more effective treatments and may even enable us to prevent this devastating illness from ever occurring" (page 185) is just silly: the billions of dollars spent on the more prevalent illnesses such as major depression, bipolar affective disorder, schizophrenia and so on have revealed only that these are polymorphic conditions that only about half of medicated people respond to, and that the causative links are, well, polymorphic and thus way out of range of unidimensional scientific views on causality. This is not Huntington's or Alzheimer's, and the money is unlikely to be directed to BDD or if it is, as with the other conditions, unlikely to find the holy grail of prevention and cure. Such statements as Phillips makes are repeated for every DSM-IV condition and most troubling medical conditions, and are unfortunately not worth making at the end of the day. As Phillips notes, the very nature of the condition makes most researchers unlikely to take it seriously enough to avoid 'Chris' having 365 bad hair days a year. In her call for a comprehensive series of bits of research, Phillips fails to state the obvious, is that like any other condition, an integrative approach to neuroscience, a personalized medicine approach, is likely to have some chance of success. One researcher looking at genetics in BDD is unlikely to make a difference, but one in an integrated laboratory could possibly spend less and get more.

Phillips then moves on to discuss, as I did briefly above, that BDD flows from all of our usual concerns, our skin, our tummies, our noses and hair, especially as we age, and the facts are that these organs and body parts do decline with our fading DNA and telomeres. However, as she has made clear in other chapters, BDD affects young people and their concerns appear to be delusional and compulsive, as the blemish is usually quite imagined from the view of the objective clinician. After this brief chapter, Phillips embarks on the treatment modalities, and this dominates the rest of the book, including a chapter for carers and family, and appendixes on other psychiatric conditions. She looks at treatments that don't or won't or can't work, as well as those that can, and do. She also distinguishes other conditions from BDD which helps a lot more than her earlier and detailed patient complaints section, and make it very clear why BDD is a separate entity, although sharing some breadth if not depth with other conditions. Predictably, a major and extensive focus is on CBT, virtually a primer and how to do manual in itself. There are a lot of references at the end, divided by subject, and peppered with Phillip's own research, as well as many others, and a comprehensive index.

Parts of the book are definitely prescribed reading for students and experts alike, but I found a lot of the stories underwhelming, if you prefer the more 'exciting' conditions and the neuroscience behind them. If one plods through the book or dips in where it seems likely there are gems, there certainly are, but as a revised book, I am not sure it needed expanding, rather contracting it would I think have made the message tighter and more concise. Phillips justifies why she re-wrote the book, and clearly it sells, but I am not sure why, apart from the fact there are few books like it anywhere, on this subject. It is a veritable anthology on the subject, but the editor could have switched many of the latter chapters to the beginning, and reduced the vignettes to sharp and tight exemplars, as one finds in the study guide material for the DSM-IV-TR manual (reviewed in Metapsychology 7:50)

I am not sure if Dr Phillips intends a third revision, but I think it is time for her to research causality from an integrated perspective, to isolate why the brain overheats in this way, and why this obsessive pattern emerges, as the case stories she give do not help us understand why and how that person produced that symptom at that stage of their lives.


2007 Roy Sugarman


Roy Sugarman PhD, Conjoint Senior Lecturer in Psychiatry UNSW, Australia


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