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David J Castle, and Katherine A Phillips. Stroud: Wrightson Biomedical Publishers Ltd, 2002, $79.00 (hardback), pp 176. ISBN 1-871816-47-5
This collection of review chapters has a predominantly American–Australian provenance with further contributions from Great Britain and South Africa. The central emphasis is on disorders of body image as they present to clinical psychiatrists and psychologists and four of the 10 chapters deal with these subjects. Additional chapters on anthropology and normative data in childhood and adolescence provide a wider perspective. The principal body image disorders, body dysmorphic disorder and anorexia/bulimia nervosa, are part of the obsessive compulsive spectrum and have many features in common, including a strong genetic aetiology, obsessive compulsive symptoms, neuroimaging evidence of striatal dysfunction, further evidence of serotonergic dysregulation, and a therapeutic response to selective serotonin reuptake inhibitors.
Certain sections call for special mention. There is an excellent review by the editors of body dysmorphic disorder, a long recognised condition that has only recently gained acceptance in DSM-III. Many of these patients present to surgeons and dermatologists and an accompanying chapter draws attention to the hazards therein. The review of body image disorder in anorexia/bulimia nervosa is the most provocative. Anorexic subjects selectively restrict carbohydrate intake, leading to a fall in serotonergic activity. Normal dieters respond in much the same way, but when anorexics recover and return to a normal body weight cerebrospinal fluid 5HIAA levels are raised, suggesting a permanent state of serotonergic dysregulation. A number of studies have demonstrated an association between raised 5HIAA levels and traits of obsessionality, perfectionism, pessimism, and negative affect (in contrast to an association between low 5HIAA and aggressivity and impulsivity). Kay et al suggest that such individuals restrict their carbohydrate intake to lower brain serotonergic activity so as to modify dystonic personality traits. Accordingly anorexia is an epiphenomenon rather than a primary goal.
Two chapters stand outside the mainstream. A neurologist provides a succinct account of the cortical representation of body image. Neurological disorders of body image—neglect, phantoms—are briefly described. Neuroimaging evidence for the cerebral localisation of emotion, particularly disgust, is the subject of another review. Sites of activation are listed but there is little attempt to interpret or to integrate these findings within a neurological framework.
The various contributions are, almost without exception, clear, concise, and easy to read. This is very much a mainstream offering, dealing as it does with an area of psychiatry in which cultural, psychological, and biological factors rub shoulders and it can be recommended to a wide range of trained psychiatrists and psychologists and to quite a few of their more adventurous trainees.