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        Somatoform disorders: a topic for education
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We read with interest Bass et al's (2001) review on somatoform disorders. Although the authors usefully pointed out that these disorders are common and cause severe disability, we were dismayed to find that, ironically, they neglected to mention one of the more common somatoform disorders: body dysmorphic disorder (BDD; also known as dysmorphophobia). A distressing or impairing preoccupation with an imagined or slight defect in appearance, BDD has reported rates in the community of 0.7-2.3% (Phillips, 2001). People with this disorder commonly present to psychiatrists, dermatologists, cosmetic surgeons and other physicians (Phillips & Castle, 2001).

Body dysmorphic disorder causes severe distress and marked impairment in functioning (Veale et al, 1996; Phillips, 2001). A high proportion of patients require hospitalisation, become housebound and/or attempt suicide. Completed suicide has been reported in both psychiatric and dermatology settings. Mental-health-related quality of life is poorer than that reported for patients with depression, obsessive—compulsive disorder and a variety of physical illnesses, including recent myocardial infarction and type II diabetes.

Like the other somatoform disorders, BDD is often neglected by psychiatrists. The diagnosis is usually missed in mental health settings (Phillips & Castle, 2001). This is unfortunate, because a majority of these patients request and receive non-psychiatric treatments, such as dermatological treatment and surgery, which are usually ineffective. Many patients consult numerous physicians, request extensive work-ups, and pressure dermatologists and surgeons to provide unsuitable and ineffective remedies. Some patients, in desperation, even perform their own surgery. As one dermatologist stated, “The author knows of no more difficult patients to treat than those with body dysmorphic disorder” (Cotterill, 1996).

The good news is that emerging data indicate that a majority of these patients can be successfully treated with selective serotonin reuptake inhibitors or cognitive—behavioural therapy (Phillips, 2001). It is important that psychiatrists and other physicians screen patients for this disorder so that effective treatment can be provided. Body dysmorphic disorder is a severe psychiatric illness that we cannot afford to neglect.

EDITED BY MATTHEW HOTOPF

Bass, C., Peveler, R. & House, A. (2001) Somatoform disorders: severe psychiatric illnesses neglected by psychiatrists. British Journal of Psychiatry 179, 1114.
Cotterill, J. A. (1996) Body dysmorphic disorder. Dermatology Clinics, 14, 457463.
Phillips, K. A. (2001) Body dysmorphic disorder. In Somatoform and Factitious Disorders (ed. Phillips, K. A.), pp. 6794. Washington, DC: American Psychiatric Press.
Phillips, K. A. & Castle, D. J. (2001) Body dysmorphic disorder. In Disorders of Body Image (eds Castle, D. J. & Phillips, K. A.). Petersfield: Wrightson Biomedical, in press.
Veale, D., Boocock, A., Gournay, K., et al (1996) Body dysmorphic disorder. A survey of fifty cases. British Journal of Psychiatry, 169, 196201.