The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder

Since the advent of the remote-control channel-changer, I have found that I can watch three simultaneous movies on television. By flicking back and forth, it is possible to follow the plot and action on all three at the same time, thus emphasizing how much padding there is in the average film.

Reading Dr. Phillips' book is a little reminiscent of this. It is a textbook but written to be comprehensible to the layperson. Because of this, there is a degree of repetitiveness and a need to explain basic concepts in some detail, so the professional reader is frequently tempted to skip-read. This is a pity, because some good material could be missed.

Body dysmorphic disorder is a prolonged and unpleasant condition and, as the author points out, probably not an uncommon one. It causes huge distress to patients, has a heavy impact on families, and frequently causes perplexity and misdiagnosis among physicians. As one of the somatoform group of disorders, it shares the dubious distinction (perhaps equaled only by the personality disorders) of being among the worst-researched aspects of psychiatry.

Until recently, body dysmorphic disorder was an illness that caused almost as much despair among therapists as among patients because there seemed to be no effective treatment. Now that clomipramine and the selective serotonin reuptake inhibitor antidepressants have been shown to be valuable, often in combination with cognitive behavior therapy, the picture has improved strongly for many patients. Also, there is a greater incentive for professionals to recognize and treat body dysmorphic disorder.

Dr. Phillips and her colleagues have been instrumental in promoting and highlighting many of the recent advances in this field, and she has made many significant contributions to the literature. Her book is a comprehensive and considered look at the present state of our knowledge, and she does not hesitate to underscore the many profound gaps in our understanding of body dysmorphic disorder.

There are few books with whose content one does not take some exception, particularly as a critical reviewer, but this one almost makes its home run unscathed. Dr. Phillips' commonsense approach and unwillingness to stray into specious speculation result in a mainstream work that is consonant with current informed thinking. Of course, it helps considerably that she herself has contributed much to that thinking.

In fact, there is only one area in which I seriously disagree with Dr. Phillips. On pages 229–230, she discusses the “controversial” topic of the “delusional variant” of body dysmorphic disorder, by which she means the somatic subtype of delusional disorder. Controversial this certainly is, and she and I have debated it publicly and in print. My point of view, shared by many others, is that any form of delusional disorder is an illness sui generis and to view it as a variant of a totally different condition is to fudge some highly important diagnostic principles.

Having vented that little bit of spleen, I can recommend this book as an introduction to the difficult and misunderstood topic of body dysmorphic disorder. At present there is no other equally comprehensive source of information on the subject, and its balanced and atheoretical approach commends it. However, nearly all of the quotations from distinguished clinicians on the book's cover underline its usefulness to the sufferer rather than to the physician. Sadly, there is no reference list that might be of use to the latter.

Inside The Broken Mirror is a leaner, more incisive work waiting to be written, specifically for those of us who have to diagnose and treat body dysmorphic disorder. I for one intend to buy it when it comes out, and I assure Dr. Phillips that I will read it assiduously and without a channel-changer in my hand.