Letters

Violence may be serious in men with body dysmorphic disorder

EDITORPhillip and Castle in their editorial on body dysmorphic disorder in men said that patients disappointed with ineffective surgical or dermatological treatment may become violent towards the treating physician.¹ There are grounds for considering that violence may be a more serious problem in this disorder than hitherto recognised, especially in view of the associated use of anabolic steroids.

I have reported the case of a patient with body dysmorphic disorder whose violence against others led to his compulsory detention in a secure unit under the Mental Health Act.² My review of the literature on body dysmorphic disorder suggested violence to be more common in the condition than previously recognised.

Perugi et al found that 29% of 34 men and 46% of 24 women with body dysmorphic disorder responded affirmatively to at least one of the following questions: "Are you ever so enraged and in despair that you lose control and become insulting, aggressive or violent towards your relatives and friends?" and "At these times do you break any object or punch and kick walls and doors?"³ Similarly, 38% of the young patients in Albertini and Phillips' study acknowledged a history of violence owing to body dysmorphic disorder.⁴

These two studies differ from others in that the subjects were asked directly about aggressive and violent behaviour. Their answers revealed an unexpectedly high incidence. Phillips and Castle indicate that men and boys do not volunteer their core symptoms of body dysmorphic disorder.¹ Unless sought by direct questioning, this is also likely to apply to associated violence and aggression, which may profoundly affect the life of the person with body dysmorphic disorder and his family.²

Philip Lucas, consultant forensic psychiatrist. 
North London Forensic Service, Hadley Lodge, Chase Farm Hospital, Enfield EN2 8JL philip.lucas{at}enfieldcc-tr.nthames.nhs.uk