Brief Report

Possible Association of Body Dysmorphic Disorder

With an Occupation or Education in Art and Design
David Veale, M.D. the same information for 100 patients with a major depressive
Michelle Ennis, B.A. episode, 100 with obsessive-compulsive disorder (OCD), and
100 with posttraumatic stress disorder (PTSD).
Christina Lambrou, B.Sc.
Results: Twenty percent of the patients with body dysmorphic
Objective: The authors hypothesized that because patients disorder had an occupation or education in art or design, com-
with body dysmorphic disorder are preoccupied with their ap- pared with 4% of the patients with major depressive episode,
pearance and aesthetics, they are more likely to have an occu- 3% of those with OCD, and 0% of those with PTSD.
pation or education in art and design than patients with other
Conclusions: Onset of body dysmorphic disorder is usually
psychiatric disorders.
gradual during adolescence, and an education in art and design
Method: Information on occupation and higher education or may be a contributory factor to its development in some pa-
training was extracted from the case notes of 100 consecutive tients. An equally plausible explanation is that patients with
patients with body dysmorphic disorder and compared with body dysmorphic disorder tend to have an interest in aesthetics.

(Am J Psychiatry 2002; 159:1788–1790)

O ne of two community surveys of body dysmorphic

disorder (1, 2) was in a city renowned for its art (Florence,
(3%). The diagnoses were made according to DSM-IV but without
a structured diagnostic interview schedule.
The comparison groups represent the most common diag-
Italy) (1). A cognitive behavior model of body dysmorphic
noses seen for routine psychiatric assessment. The case notes
disorder has proposed that these patients have idealized were examined retrospectively, and there was no test of diagnos-
values about the importance of appearance and that some tic reliability. Information on the individual’s occupation, higher
may also value perfectionism (3). The aim of the current education, and training was extracted from a questionnaire that
preliminary study was to investigate whether the interest was completed by all patients. Patients were asked details regard-
ing their occupational history as well as any higher education or
of patients with body dysmorphic disorder in aesthetics
training received.
would be manifested in their occupation, training, or An individual was defined as an artist if he or she had, at any
higher education. We hypothesized that patients with time, either education or training in art, fine art, art history, or de-
body dysmorphic disorder are more likely to have an oc- sign or an occupation as an artist, an art teacher, an architect, or a
cupation or education in art and design than patients with graphics, fashion, or textile designer. Both current and past occu-
pation, training, or higher education in art and design were used
other psychiatric disorders.
to classify a patient. For example, a patient who had a degree in
fine art but was working as a waiter was classified as an artist.
Method
The occupation and education of 100 consecutive patients at
Results
first presentation with the diagnosis of body dysmorphic disorder Data on the age, sex, and employment status of patients
were compared with the occupation and education of 100 con- in the four groups are given in Table 1. The groups were
secutive patients with a major depressive episode, 100 consecu-
tive patients with a diagnosis of posttraumatic stress disorder
matched according to sex but not according to age. The
(PTSD), and 100 consecutive patients with obsessive-compulsive patients with body dysmorphic disorder were significantly
disorder (OCD). All participants were outpatients in a private psy- younger than the patients in all three comparison groups,
chiatric hospital from 1996 onward. and the patients with OCD were significantly younger
Most of the patients were funded privately; a minority were than those with PTSD and those with major depressive
funded by the National Health Service or had research assess- episode.
ments. The primary diagnosis was used to select the patient
Twenty percent of the patients with body dysmorphic
groups and the main focus of treatment. The most common co-
morbid diagnoses among patients with body dysmorphic disor- disorder had an occupation or education in art or design
der were delusional disorder (52%), major depressive episode (four graphic design, two architecture, two fine art degree,
(26%), and social phobia (20%). All of these patients were being five art history degree, six art and design degree, one art-
treated primarily for body dysmorphic disorder. Comorbid diag- ist). In contrast, 4% of the depressed patients (one fine art
noses among the patients with major depressive episode were
degree, one art history degree, one artist, one art teacher),
dysthymia (7%) and generalized anxiety disorder (6%). The one
comorbid diagnosis among the patients with OCD was major de- 0% of the PTSD patients, and 3% of the OCD patients (one
pressive episode (16%). Comorbid diagnoses among the patients graphic design, one architecture, one fine art degree) had
with PTSD were major depressive episode (15%) and dysthymia such occupations or training (χ2=38.6, df=3, p<0.001).

1788 Am J Psychiatry 159:10, October 2002

 BRIEF REPORTS

TABLE 1. Age, Sex, and Employment Status of Patients With Body Dysmorphic Disorder, Major Depressive Episode, Post-
traumatic Stress Disorder (PTSD), or Obsessive-Compulsive Disorder (OCD)
Body Dysmorphic Depression
Characteristic Disorder (N=100) (N=100) PTSD (N=100) OCD (N=100) Analysis
Mean SD Mean SD Mean SD Mean SD F df p

Age (years) 29.8 9.23 42.9 13.4 40.0 14.4 34.2 12.0 14.0 3, 399 <0.001

N N N N χ2 df p

Male sex 40 45 39 39 1.02 3 <0.80

Employment status 18.77 15 <0.22
Unemployed 38 22 26 19
Employed full-time 39 45 44 44
Employed part-time 9 12 10 16
Student 7 4 4 7
Homemaker 5 10 10 11
Retired 2 7 6 3

The patients with body dysmorphic disorder were signif- own appearance. An equally plausible explanation is that
icantly more likely to have an occupation or education in patients with body dysmorphic disorder tend to have an
art and design than patients with major depressive episode interest in aesthetics.
(χ2=12.12, df=1, p<0.001), patients with PTSD (χ2=22.22, The association raises an interesting question about the
df=1, p<0.001), and patients with OCD (χ2=14.20, df=1, definition of body dysmorphic disorder as a preoccupa-
p<0.001). There were no significant differences among the tion with an imagined defect. Patients with body dysmor-
three comparison groups except that patients with major phic disorder might have higher aesthetic standards than
depressive episode were significantly more likely to have the mental health professionals who diagnose them, who
an occupation or education in art and design than those may not appreciate beauty to the same degree. Harris (5)
with PTSD (4% versus 0%). (χ2=4.08, df=1, p<0.04). has proposed that individuals seeking cosmetic surgery
are more aesthetically sensitive (an attribute like being
Discussion musical, which varies in different individuals). Another ex-
To our knowledge, no occupational or educational asso- planation is that patients with body dysmorphic disorder
ciation has been identified previously in patients with have idealized values about the importance of appearance
body dysmorphic disorder. Our findings reveal a possible and aesthetics, which have become overidentified with
association between body dysmorphic disorder and an in- the “self” (3).
terest in art or design. The differences between the body A significant limitation of the present study was the rel-
dysmorphic disorder group and the three comparison atively small number of subjects in the study groups,
groups were relatively large, and the rates in the three which may have led to a selection bias. A larger prospec-
comparison groups were similar, suggesting that the asso- tive study is required in a community sample matched ac-
ciation is worth investigating further. cording to age, sex, and parental social class to confirm
Individuals in certain occupations are at a greater risk of our findings and to determine whether the interest in art
developing a psychiatric disorder; for example, firefighters occurred before the onset of body dysmorphic disorder. It
are more likely to develop PTSD and ballet dancers are would also be interesting to know if art or design is associ-
more likely to have eating disorders. However, we know of ated with specific areas of “imagined” defects. However, it
no psychiatric disorder that has an association with a par- will also be necessary to disconfirm our findings with
ticular occupation except one study (4), which found that other broad groupings of occupation (e.g., health care
patients with schizophrenia were more likely to select oc- professionals).
cupations with a low potential for arousal (e.g., janitors). If the association between body dysmorphic disorder
We do not have any evidence for a causal relationship and an interest in art and design is truly positive, then it
between body dysmorphic disorder and interest in art and raises an intriguing question—if we encouraged our pa-
design. Nor are we able with these data to determine tients with body dysmorphic disorder who do not have an
whether the interest was acquired before or after the onset education in art and design to take up such an interest,
of body dysmorphic disorder. The onset of this disorder is would it help focus their attention away from their ap-
usually gradual during adolescence, and an interest in art pearance or would it make their preoccupation worse?
may be a contributory factor to its development in some Alternatively, should we be discouraging patients with
patients. Patients might develop a more critical eye and body dysmorphic disorder with an interest in art from
appreciation of aesthetics, which are then applied to their such pursuits?

Am J Psychiatry 159:10, October 2002 1789

 vey in Florence. Soc Psychiatry Psychiatr Epidemiol 1997;
Received April 2, 2001; revisions received Oct. 15, 2001, and March 32:24–29
3 and May 3, 2002; accepted May 16, 2002. From the Department of 2. Otto MW, Wilhelm S, Cohen LS, Harlow BL: Prevalence of body
Psychiatry and Behavioural Sciences, Royal Free Campus, Royal Free
dysmorphic disorder in a community sample of women. Am J
and University College School of Medicine, University College, Univer-
sity of London; the Department of Psychology, Rollins College, Winter Psychiatry 2001; 158:2061–2063
Park, Fla.; and the Department of Psychology, Institute of Psychiatry, 3. Veale D: Cognitive behaviour therapy for body dysmorphic dis-
London. Address reprint requests to Dr. Veale, The Priory Hospital order. Advances in Psychiatr Treatment 2001; 7:125–132
North London, Grovelands House, The Bourne, Southgate, London
4. Muntaner C, Pulver AE, McGrath J, Eaton WW: Work environ-
N14 6RA, U.K.; David@veale.co.uk (e-mail).
ment and schizophrenia: an extension of the arousal hypothe-
sis to occupational self-selection. Soc Psychiatry Psychiatr Epi-
References demiol 1993; 28:231–238
1. Faravelli C, Salvatori S, Galassi F, Aiazzi L, Drei C, Cabras P: 5. Harris DL: Cosmetic surgery—where does it begin? Br J Plast
Epidemiology of somatoform disorders: a community sur- Surg 1982; 35:281–286

Brief Report

Elevated Homocysteine Levels in Young Male Patients

With Schizophrenia

Joseph Levine, M.D. Method: A one-way analysis of covariance with age and sex as
covariates was performed on the total plasma homocysteine
Ziva Stahl, M.Sc.
levels of 193 patients with schizophrenia compared with 762
Ben Ami Sela, Ph.D. subjects without the diagnosis of schizophrenia who were eval-
Slava Gavendo, M.Sc. uated in a screening program for employee health.
Vladimir Ruderman, M.D. Results: The effect of schizophrenia was marked: the mean ho-
Robert H. Belmaker, M.D. mocysteine level was 16.3 µM (SD=11.8) in patients with schizo-
phrenia compared with 10.6 µM (SD=3.6) in healthy compari-
son subjects. The difference between groups was almost
Objective: Elevated plasma homocysteine has been found to
entirely attributable to the homocysteine levels of young male
be a risk factor for Alzheimer’s disease as well as cerebral vascu-
patients with schizophrenia.
lar disease, suggesting that some risk factors can accelerate or
increase the severity of several CNS disease processes. The au- Conclusions: Elevated levels of homocysteine in young male
thors measured plasma homocysteine levels in patients with patients with schizophrenia could be related to the pathophys-
chronic schizophrenia in their catchment area. iology of aspects of this illness.

(Am J Psychiatry 2002; 159:1790–1792)

E levated homocysteine levels in plasma are consid-

ered a risk factor for cardiovascular and cerebrovascular
level of homocysteine. She improved repeatedly after co-
balamin (B12) injections and deteriorated during periods
disease (1). Recently, elevated plasma homocysteine has without treatment. Methylenetetrahydrofolate reductase
also been found to be a risk factor for Alzheimer’s disease activity in cultured skin fibroblasts of this patient was re-
(2), suggesting that some risk factors can accelerate or in- duced to a magnitude that is found among people with
crease the severity of several CNS disease processes. Simi- heterozygous deficiency. A defect in the reductase activity
larly, apolipoprotein E-4, originally found to be a risk fac- causes a deficiency in methylenetetrahydrofolate, with a
tor for Alzheimer’s disease, is apparently also a risk factor
consequent reduction of the remethylation of homocys-
for vascular dementia and exacerbates the severity of
teine to methionine.
other CNS degenerative disorders.
Kruman et al. (3) reported that homocysteine elicits a The gene for methylenetetrahydrofolate reductase is
DNA damage response in neurons that promotes apop- polymorphic in the human population. In its homozygous
tosis and hypersensitivity to excitotoxicity. An oral me- form, a C677T mutation occurs in more than 5% of the
thionine load has classically been reported to exacerbate population and produces a thermolabile variant that re-
schizophrenia and is of course converted to homocysteine duces the overall enzyme activity to less than 30% of nor-
(4). Regland et al. (5) reported a case of a young patient mal (6). Several small studies and case reports suggested
with schizophrenia with a significantly elevated serum that homozygosity for the T677 allele of the methylenetet-

1790 Am J Psychiatry 159:10, October 2002