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PAPERS:
Margot W. M. De Waal, Ingrid A. Arnold, Just A. H. Eekhof, and Albert M. Van Hemert
Somatoform disorders in general practice: Prevalence, functional impairment and comorbidity with anxiety and depressive disorders
The British Journal of Psychiatry 2004; 184: 470-476 [Abstract] [Full text] [PDF]
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[Read eLetter] Underestimation of Body Dysmorphic Disorder in the community
David Mikael Veale   (5 October 2004)

Underestimation of Body Dysmorphic Disorder in the community 5 October 2004
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David Mikael Veale,
Consultant Psychiatrist
Royal Free & University College Medical School, UCL & The Priory Hospital North London

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Re: Underestimation of Body Dysmorphic Disorder in the community

david{at}veale.co.uk David Mikael Veale

De Waal et al (2004) found no cases of Body Dysmorphic Disorder (BDD) in the community. This needs to be interpreted with caution as is at odds with the findings of Faravelli et al (1997) and Otto et al (2001), who both found a prevalence of 0.7% of BDD in the community. The negative finding in de Waal et al (2004) may have been because the study excluded anyone under the age of 25, where the majority of cases of BDD may occur, and neither of the screening tools (The Physical Symptom Checklist or The Hospital Anxiety Depression Scale) enquire about symptoms of BDD.

Assuming a few BDD patients passed the screen because of comorbid depression/anxiety, they were then interviewed with the WHO’s Schedule for Clinical Assessment in Neuropsychiatry (SCAN). The SCAN interview is also inadequate for detecting BDD as there is only one question that asks whether their appearance seems to have seems to have changed recently. Many BDD patients have experienced symptoms since childhood or adolescence and key issue is a preoccupation with an imagined defect or minor physical anomalies.

BDD patients may avoid attending their family doctor because of rears of being physically examined or are too ashamed to volunteer their symptoms - for example in a study of in-patients, Grant et al (2001) interviewed 101 consecutive adult in-patients and 21 consecutive adolescent inpatients presenting for admission. Sixteen of the 122 (13.1%) were diagnosed as having BDD. None of the subjects had been diagnosed as having BDD by their treating psychiatrist but had comorbid diagnoses of a depressive episode or substance abuse. All 16 subjects reported that they would not raise the issue with them unless specifically asked due to feelings of shame or fears of being labeled vain. Clinicians should use an open question for screening, for example, “Some people worry a lot about their appearance. Do you worry a lot about the way you look a lot and wish you could think about it less?” In those who answer positive, then one can ask abut the specific concerns, the amount of time it’s on their mind, the degree of distress or handicap it causes.

References

De Waal, M. W. M., Arnold, I. A., Eekhof, J. A. H., et al (2004) Prevalence, functional impairment and comorbidity with anxiety and depressive disorders. British Journal of Psychiatry, 184, 479-476.

Faravelli, C., Salvatori, S., Galassi, F., et al (1997) Epidemiology of somatoform disorders: a community survey in Florence. Social Psychiatry & Psychiatric Epidemiology, 32, 24-29.

Grant, J. E., Won Kim, S., and Crow, S. J. (2001) Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. Journal of Clinical Psychiatry, 62, 517-522.

Otto, M. W., Wilhelm, S., Cohen, L. S., et al (2001) Prevalence of body dysmorphic disorder in a community sample of women. American Journal of Psychiatry, 158, 2061-2063.