A case of early-stage epithelial ovarian cancer in pregnancy

There are few reports in the literature of platinum-based chemotherapy administered in pregnancy. We present a case of serous adenocarcinoma of the ovary complicating pregnancy. Following laparotomy at 16 weeks of gestation, four cycles of cisplatin were administered prior to confinement at 32 weeks. There were no neonatal sequelae. We believe there is increasing evidence for the safe use of cisplatin in pregnancy.

Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study

BACKGROUND

Research on the pharmacotherapy of body dysmorphic disorder (BDD) is limited. No placebo-controlled, continuation, maintenance, or discontinuation studies have been published. Only one augmentation study has been published.

METHOD

In this chart-review study of 90 patients with DSM-IV BDD treated for up to 8 years by the first 2 authors (K.A.P., R.S.A.) in their clinical practice, response to a variety of medications, including augmentation strategies, was assessed. The relapse rate with medication discontinuation was also determined.

RESULTS

All subjects received a serotonin reuptake inhibitor (SRI), with 63.2% (55/87) of adequate SRI trials resulting in improvement in BDD symptoms; similar response rates were obtained for each type of SRI. Discontinuation of an effective SRI resulted in relapse in 83.8% (31/37) of cases. Response rates to selective SRI augmentation were clomipramine, 44.4% (4/9) of trials; buspirone, 33.3% (12/36) of trials; lithium, 20.0% (1/5); methylphenidate, 16.7% (1/6); and antipsychotics, 15.4% (2/13) of trials.

CONCLUSION

These findings from a clinical setting suggest that a majority of BDD patients improve with an SRI and that all SRIs appear effective. Certain SRI augmentation strategies may be beneficial. The high relapse rate with SRI discontinuation suggests that long-term treatment is often necessary. These preliminary findings require confirmation in placebo-controlled efficacy studies and effectiveness studies.

Current perspectives on BRCA1- and BRCA2-associated breast cancers

The identification of two breast cancer predisposition genes, BRCA1 and BRCA2, in the mid-1990s has led to a better understanding of the molecular pathogenesis of hereditary breast cancer and to a new era in breast cancer research. The present article reviews the current state of knowledge regarding the biology of BRCA1 and BRCA2, the cancer risks associated with carrying a pathogenic mutation in either of these genes and the possible genetic and environmental risk modifiers. The phenotypes of BRCA1- and BRCA2-associated hereditary breast cancers are reviewed. Research into BRCA1- and BRCA2-associated breast cancer is in its infancy and much remains to be learned, particularly about modifiers of genetic risk and the clinical implications of carrying a mutation in one of these two genes. Australia has an excellent research infrastructure in place, through the Australian Breast Cancer Family Study and the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer, to contribute substantially to future research in this area.

Deciding where and how to be tested for HIV: what matters most?

This study examined preferences for specific types of HIV tests as well as for test attributes such as cost, counseling, and privacy. A survey was administered to 354 clients of public testing services. Nonparametric tests and logistic regression were used to compare test preferences and attribute ratings, and to assess differences by demographic and risk groups. Nearly two thirds of respondents chose a public clinic test as their first choice, whereas 24% chose a home self-test, 12% chose a test at a doctor's office, and 1% chose a home specimen-collection test. Three attributes (accuracy/timeliness, privacy of test disclosure, and linking of test results) were rated equally-and most-important. In-person counseling was endorsed as the fourth most important attribute. Availability of in-person counseling was the strongest predictor of "loyalty" to public clinic tests-a consistent preference for that type of test even when the other tests were offered as additional no-cost options. There was also substantial interest in home self-tests. The results suggest specific attributes of testing that may be particularly important to individuals from diverse demographic and risk backgrounds.

A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice

BACKGROUND

Dermatologic surgeons frequently see patients with body dysmorphic disorder, a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Recognition of this disorder is essential to avoid unnecessary and generally unsatisfying surgical outcomes, but no screening tools are available for use in a dermatology setting.

OBJECTIVE

To develop and validate a brief self-report questionnaire to screen for body dysmorphic disorder in dermatology settings.

METHODS

A questionnaire was developed and its sensitivity and specificity determined in 46 subjects, using a reliable clinician-administered diagnostic interview for body dysmorphic disorder. The interrater reliability of a defect severity scale was also determined (n = 50).

RESULTS

The self-report questionnaire had a sensitivity of 100% and a specificity of 93%. The interrater reliability (ICC) of the defect rating scale was.88.

CONCLUSIONS

This brief questionnaire was a highly effective screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Use of this questionnaire may help identify patients with this syndrome.

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

CONTEXT

Atrial fibrillation is the most common arrhythmia in elderly persons and a potent risk factor for stroke. However, recent prevalence and projected future numbers of persons with atrial fibrillation are not well described.

OBJECTIVE

To estimate prevalence of atrial fibrillation and US national projections of the numbers of persons with atrial fibrillation through the year 2050.

DESIGN, SETTING, AND PATIENTS

Cross-sectional study of adults aged 20 years or older who were enrolled in a large health maintenance organization in California and who had atrial fibrillation diagnosed between July 1, 1996, and December 31, 1997.

MAIN OUTCOME MEASURES

Prevalence of atrial fibrillation in the study population of 1.89 million; projected number of persons in the United States with atrial fibrillation between 1995-2050.

RESULTS

A total of 17 974 adults with diagnosed atrial fibrillation were identified during the study period; 45% were aged 75 years or older. The prevalence of atrial fibrillation was 0.95% (95% confidence interval, 0.94%-0.96%). Atrial fibrillation was more common in men than in women (1.1% vs 0.8%; P<.001). Prevalence increased from 0.1% among adults younger than 55 years to 9.0% in persons aged 80 years or older. Among persons aged 50 years or older, prevalence of atrial fibrillation was higher in whites than in blacks (2.2% vs 1.5%; P<.001). We estimate approximately 2.3 million US adults currently have atrial fibrillation. We project that this will increase to more than 5.6 million (lower bound, 5.0; upper bound, 6.3) by the year 2050, with more than 50% of affected individuals aged 80 years or older.

CONCLUSIONS

Our study confirms that atrial fibrillation is common among older adults and provides a contemporary basis for estimates of prevalence in the United States. The number of patients with atrial fibrillation is likely to increase 2.5-fold during the next 50 years, reflecting the growing proportion of elderly individuals. Coordinated efforts are needed to face the increasing challenge of optimal stroke prevention and rhythm management in patients with atrial fibrillation.

An online educational facility for medical oncology trainees: www.vmotg.org

PURPOSE

To design, implement, and evaluate a comprehensive educational Web site for medical oncology trainees.

METHODS

The Web site was designed with three main areas (termed Journal Club, Key Papers, and Oncology Links) and compiled from articles presented at the Victorian Medical Oncology Trainees' Group journal club from the preceding 3 years. The Key Papers section was then reviewed by 30 academic medical oncologists. The site was advertised by mail and at the Annual Meeting of the Medical Oncology Group of Australia. Evaluation was by mail survey.

RESULTS

The Web site, which may be accessed at www.vmotg.org, comprises more than 170 pages and 30,000 words of text. Journal club sessions are summarized with presented articles linked to abstracts from PubMed. Key Papers lists from five to 25 pivotal articles in each of 35 categories. Oncology Links is an extensive list of links in 10 categories including organizations, journals, and practice guidelines. Twenty-six of 45 trainees and 82 of 190 oncologists responded to the survey. Eighty-one percent of these trainees and 28% of oncologists have used the Web site. Ninety-six percent consider the Web site easy to use and "a useful medical oncology resource." All trainees rated the site good to excellent in terms of relevance and 94% considered the site beneficial to their education.

CONCLUSION

The Web site www.vmotg.org is a relevant and useful educational resource for Australian medical oncology trainees and oncologists. As far as the authors are aware, this is the only educational site specifically for medical oncology trainees throughout the world. It may be a valuable oncology education resource for trainees in other countries, particularly those in isolated areas.

Breast conservation in BRCA1 or BRCA2 mutation carriers with early stage breast cancer

The role of breast conservation therapy (limited surgery and irradiation of the breast with/without axilla) in the approximately 5% of breast cancer patients who harbour a germline mutation in BRCA1 or BRCA2, is a largely unexplored area and is seen by some as controversial. The relatively high cumulative risk of second primary cancers in such patients and concern about a possible decreased ability of mutation carriers to repair DNA damage caused by radiation has fuelled this controversy. Published studies of breast conservation therapy in carriers of a mutation in BRCA1 or BRCA2 are reviewed, with particular attention to their methodology. These studies have not demonstrated any increase in radiation sensitivity of normal tissues in mutation carriers, either in terms of increased early or late toxicity or tumourigenesis. Likewise, tumour sensitivity to radiotherapy, which might be expected based on the known functions of the BRCA1 and BRCA2 genes, has not been documented to date in mutation carriers. Further, methodologically rigorous studies of large numbers of breast cancer patients who carry a mutation in BRCA1 or BRCA2 are required to fully elucidate these issues.

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.

Kleptomania, compulsive buying, and binge-eating disorder

Although recognized since at least the early 19th century, kleptomania, compulsive buying, and binge-eating disorder are poorly understood conditions that have received little systematic study. In this article, we review the available studies of these three conditions, which suggest that they are more common than realized, occur more frequently in women than in men, cause significant morbidity, are related to other psychiatric disorders (especially to one another, impulse control disorders, obsessive-compulsive disorder, and mood disorders), and often respond to available psychopharmacologic and psychological treatments. We hypothesize that these three conditions might best be viewed as impulse control disorders that belong to an extended family of compulsive-impulsive spectrum disorders. The compulsive-impulsive spectrum disorders may, in turn, belong to the larger family of affective spectrum disorder.

Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both?

Over the past century, body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, has been hypothesized to be related to obsessive-compulsive disorder (OCD). More recently, BDD has also been hypothesized to be a form of affective spectrum disorder. Affective spectrum disorder refers to a family of disorders postulated to have a common pathophysiologic abnormality. This grouping of disorders has been identified on the basis of their response to pharmacologic treatments and is supported by comorbidity and family studies. Available data suggest that BDD should be considered a candidate form of affective spectrum disorder--a disorder that may eventually be demonstrated to belong to this family of disorders. Available data also strongly support the hypothesis that BDD is an obsessive-compulsive spectrum disorder. Because OCD itself has been hypothesized to be an affective spectrum disorder, BDD may be more narrowly conceptualized as an obsessive-compulsive spectrum disorder and more broadly as a candidate form of affective spectrum disorder.

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.

Health and economic benefits of increased beta-blocker use following myocardial infarction

CONTEXT

beta-blockers are underused in patients who have myocardial infarction (MI), despite the proven efficacy of these agents. New evidence indicates that beta-blockers can have benefit in patients with conditions that have been considered relative contraindications. Understanding the consequences of underuse of beta-blockers is important because of the implications for current policy debates over quality-of-care measures and Medicare prescription drug coverage.

OBJECTIVE

To examine the potential health and economic impact of increased use of beta-blockers in patients who have had MI.

DESIGN AND SETTING

We used the Coronary Heart Disease (CHD) Policy Model, a computer-simulation Markov model of CHD in the US population, to estimate the epidemiological impact and cost-effectiveness of increased beta-blocker use from current to target levels among survivors of MI aged 35 to 84 years. Simulations included 1 cohort of MI survivors in 2000 followed up for 20 years and 20 successive annual cohorts of all first-MI survivors in 2000-2020. Mortality and morbidity from CHD were derived from published meta-analyses and recent studies. This analysis used a societal perspective.

MAIN OUTCOME MEASURES

Prevented MIs, CHD mortality, life-years gained, and cost per quality-adjusted life-year (QALY) gained in 2000-2020.

RESULTS

Initiating beta-blocker use for all MI survivors except those with absolute contraindications in 2000 and continuing treatment for 20 years would result in 4300 fewer CHD deaths, 3500 MIs prevented, and 45,000 life-years gained compared with current use. The incremental cost per QALY gained would be $4500. If this increase in beta-blocker use were implemented in all first-MI survivors annually over 20 years, beta-blockers would save $18 million and result in 72,000 fewer CHD deaths, 62,000 MIs prevented, and 447,000 life-years gained. Sensitivity analyses demonstrated that the cost-effectiveness of beta-blocker therapy would always be less than $11,000 per QALY gained, even under unfavorable assumptions, and may even be cost saving. Restricting beta-blockers only to ideal patients (those without absolute or relative contraindications) would reduce the epidemiological impact of beta-blocker therapy by about 60%.

CONCLUSIONS

Our simulation indicates that increased use of beta-blockers after MI would lead to impressive gains in health and would be potentially cost saving. JAMA. 2000;284:2748-2754.

Implications of the genetics revolution for health services research: pharmacogenomics and improvements in drug therapy

OBJECTIVE

To review the societal and economic implications of the use of genetic information to individualize drug therapies. Although studies have begun to address the ethical issues raised by the use of genetic information , few have examined the implications of pharmacogenomics f rom the perspective of health services research.

PRINCIPAL FINDINGS

We propose a research agenda for health services research in three areas: (1) to evaluate the effectiveness and cost-effectiveness of pharmacogenomics; (2) to evaluate the effect of pharmacogenomics from the perspective of patients, providers, insurers, industry, and government ; and (3) to evaluate the ethical and societal implications of pharmacogenomics. Throughout the article we use the example of HIV genotyping as an illustration of how genetic technology is disseminated and used.

CONCLUSION

More research is needed on the societal and economic implications of pharmacogenomics to inform the clinical and policy decisions about its use that will be increasingly urgent in the future.

Immunophenotypic and pathologic differences between BRCA1 and BRCA2 hereditary breast cancers

Morphologically and clinically, breast cancer is a heterogeneous group of diseases. This heterogeneity may be a manifestation of differences in the molecular genetic events underlying distinct breast cancer pathogenesis pathways. Examination of hereditary breast cancers (HBC), which have in common an underlying germline mutation in BRCA1 or BRCA2, may provide further insight into this concept. Multiple studies have confirmed that BRCA1-associated HBC (BRCA1-HBC) generally exhibit a specific phenotype that is characterized by high tumor grade and estrogen receptor negativity. Conversely, discrepancies exist between the findings of studies that have examined BRCA2-HBC, and a specific phenotype has not been consistently described. The characteristic phenotype of BRCA1-associated tumors may prove a useful additional tool in selecting individuals with breast cancer who should be offered BRCA1 mutation testing, although further studies are required. Lastly, evidence is emerging to suggest that BRCA1 might be involved in the pathogenesis of a subgroup of non-HBC (by gene underexpression rather than mutation) and that these tumors may exhibit the same phenotype as their hereditary counterparts.

HIV-1 drug resistance genotyping. A review of clinical and economic issues

The development of mutations associated with resistance to antiretroviral therapy (ART) has been shown to be a major cause of treatment failure in patients infected with HIV-1. These resistance mutations can be assessed by a genotyping test that probes for specific mutations within the HIV genome or sequences specific genes, at a cost $US500/test (2000 prices). The stated goal of HIV-1 genotyping is to target HIV therapy effectively. This, as shown in the preliminary research, should result in better clinical outcomes and a lower incidence of virological failure and may be associated with lower costs of treatment. Failure of ART may result in an increase in costs of at least $US250 per patient per month, as assessed in 1 study, with costs rising further as patients experience multiple virological failures. Therefore, there is an economic as well as a therapeutic premium on the prevention of ART failure. The actual economic cost of genotyping has been preliminarily explored in the context of the antiretroVIRal ADAPTation (VIRADAPT) trial, which found no significant difference in the 1-year treatment cost of patients with and without genotyping. There is some evidence of cost neutrality or savings with genotypic testing but it needs to be further explored within the context of carefully framed prospective trials.

The cost-effectiveness of expanded HIV counselling and testing in primary care settings: a first look

OBJECTIVE

To estimate the cost-effectiveness of approaches to expanded HIV counselling and testing.

DESIGN

A cost-effectiveness analysis.

SETTING

Primary care practices in the USA.

PARTICIPANTS

New patient visits.

INTERVENTIONS

Two approaches were examined: (i) requesting all patients to complete an HIV-risk screening instrument, with counselling as well as testing offered only to patients disclosing risk factors ('risk histories' option); and (ii) routine offering of voluntary testing to all patients, with consent obtained but no pre-test counselling ('routine testing').

MAIN OUTCOME MEASURES

The primary outcome was the cost per infection identified. We also examined: (i) the costs and numbers of infections averted if individuals change their risk behaviours; and (ii) the additional years of life and quality-adjusted life years (QALY) gained as a result of earlier HIV testing and treatment for infected individuals.

RESULTS

Routine testing is the most cost-effective approach to identifying infected individuals at an incremental cost of US$4200 per infection identified. Although using risk histories is more costly and less effective than routine testing, it becomes similarly cost-effective using plausible ranges for sensitivity analyses. If at least 10% of HIV-positive individuals change their behavior, both routine testing and using risk histories would save money. If testing identifies infected individuals one year earlier than they otherwise would have been diagnosed, routine testing would cost US$22000 per QALY gained.

CONCLUSION

Routine testing is the most cost-effective approach to identifying new HIV infections. However, using risk histories may be similarly cost-effective under various assumptions. Both routine testing and using risk histories are more cost-effective than current practices.

Assessing the cost-effectiveness of pharmacogenomics

The use of pharmacogenomics to individualize drug therapy offers the potential to improve drug effectiveness, reduce adverse side effects, and provide cost-effective pharmaceutical care. However, the combinations of disease, drug, and genetic test characteristics that will provide clinically useful and economically feasible therapeutic interventions have not been clearly elucidated. The purpose of this paper was to develop a framework for evaluating the potential cost-effectiveness of pharmacogenomic strategies that will help scientists better understand the strategic implications of their research, assist in the design of clinical trials, and provide a guide for health care providers making reimbursement decisions. We reviewed concepts of cost-effectiveness analysis and pharmacogenomics and identified 5 primary characteristics that will enhance the cost-effectiveness of pharmacogenomics: 1) there are severe clinical or economic consequence that are avoided through the use of pharmacogenomics, 2) monitoring drug response using current methods is difficult, 3) a well-established association between genotype and clinical phenotype exists, 4) there is a rapid and relatively inexpensive genetic test, and 5) the variant gene is relatively common. We used this framework to evaluate several examples of pharmacogenomics. We found that pharmacogenomics offers great potential to improve patients' health in a cost-effective manner. However, pharmacogenomics will not be applied to all currently marketed drugs, and careful evaluations are needed on a case-by-case basis before investing resources in research and development of pharmacogenomic-based therapeutics and making reimbursement decisions.

Personality disorders, history of trauma, and posttraumatic stress disorder in subjects with anxiety disorders

The purpose of the study was to examine the association of personality disorders, history of trauma, and posttraumatic stress disorder (PTSD) in a large sample of subjects with anxiety disorders. Categorical and continuous indices of personality disorders were compared in three groups from the Harvard/Brown Anxiety Disorders Research Project (HARP): subjects with no history of trauma (n = 403), subjects with a history of trauma but no history of PTSD (n = 151), and subjects with a current or past diagnosis of PTSD (n = 68). Subjects with PTSD were more likely to meet criteria for borderline or self-defeating personality disorder than subjects in the other two groups. PTSD subjects also had higher scores on the continuous measures (total number of criteria met) for borderline and self-defeating personality disorder than the other two groups. The findings suggest that a diagnosis of PTSD rather than a history of trauma is associated with borderline and self-defeating personality disorder features. Alternative conceptualizations of axis II features in individuals with PTSD are discussed.

Characteristics of memory dysfunction in body dysmorphic disorder

Although body dysmorphic disorder (BDD) is receiving increasing empirical attention, very little is known about neuropsychological deficits in this disorder. The current study investigated the nature of memory dysfunction in BDD, including the relationship between encoding strategies and verbal and nonverbal memory performance. We evaluated 17 patients with BDD and 17 healthy controls using the Rey-Osterrieth Complex Figure Test (RCFT) and the California Verbal Learning Test (CVLT). BDD patients differed significantly from healthy controls on verbal and nonverbal learning and memory indices. Multiple regression analyses revealed that group differences in free recall were statistically mediated by deficits in organizational strategies in the BDD cohort. These findings are similar to patterns previously observed in obsessive-compulsive disorder (OCD), suggesting a potential relationship between OCD and BDD. Studies in both groups have shown that verbal and nonverbal memory deficits are affected by impaired strategic processing.

Tool use in wild capuchin monkeys (Cebus albifrons trinitatis)

White-fronted capuchins were observed to use leaves as cups to retrieve water from tree cavities. On multiple occasions several individuals performed this behavior. Thus, these capuchins engage in habitual tool use, as defined by McGrew's classificatory scheme of tool using behavior.

Applying GPS to the study of primate ecology: a useful tool?

Data on the spatiotemporal distribution of resources can be collected and plotted using GPS (global positioning system) and GIS (geographical information system) technologies. By combining such data with information on foraging and ranging behavior of nonhuman primates, one can analyze the influence of resource distribution on social organization and group cohesion. We investigated the abilities of a three-channel GPS receiver to collect location data under varying canopy densities in both temperate and tropical forests. Eighty randomly selected points were sampled in a beech-maple forest in northeast Ohio, USA; 65 points also were sampled at several tropical forests in Costa Rica and Trinidad. At each point we attempted to obtain a GPS position fix; we also determined the speed of satellite acquisition and measured canopy density using a spherical densiometer. The ability to obtain a reading differed greatly between the two forest types (chi(2) = 53.79, P < 0.001). Ninety-seven percent of all attempts were successful in the temperate forest, whereas only a 34% acquisition rate was obtained in the tropical forests. Logistic regression showed that the probability of obtaining a reading in Neotropical forests was 75% but only when canopy cover was less than 20%. Thus, these minimal-channel GPS units may be of limited utility for behavioral ecologists working in closed-canopy Neotropical forests.

Implications of stroke risk criteria on the anticoagulation decision in nonvalvular atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF) but increases the likelihood of bleeding. Accurately identifying patients who need anticoagulation is critical. We assessed the potential impact of prominent stroke risk classification schemes on this decision in a large sample of patients with NVAF.

METHODS AND RESULTS

We used clinical and electrocardiographic databases to identify 13 559 ambulatory patients with NVAF from July 1996 through December 1997. We compared the proportion of patients classified as having a low enough stroke risk to receive aspirin using published criteria from the Atrial Fibrillation Investigators (AFI), American College of Chest Physicians (ACCP), and the Stroke Prevention in Atrial Fibrillation Investigators (SPAF). In this cohort, AFI criteria classified 11% as having a low stroke risk, compared with 23% for ACCP and 29% for SPAF (kappa range, 0.44 to 0.85). This 2- to-3-fold increase in low stroke risk patients by ACCP and SPAF criteria primarily resulted from the inclusion of many older subjects (65 to 75 years+/-men >75 years) with no additional clinical stroke risk factors.

CONCLUSIONS

The age threshold for assigning an increased stroke risk has a dramatic impact on whether to recommend warfarin in populations of patients with NVAF. Large, prospective studies with many stroke events are needed to precisely determine the relationship of age to stroke risk in AF and to identify which AF subgroups are at a sufficiently low stroke risk to forego anticoagulation.

Barriers to care among racial/ethnic groups under managed care

We describe barriers to care reported by racial/ethnic groups and explore the extent to which barriers vary between persons enrolled in managed care and those in non-managed care plans, using data from the 1996 Medical Expenditure Panel Survey (MEPS). Most respondents expressed satisfaction with their care; however, a substantial percentage reported experiencing barriers. Minorities, particularly Hispanics and Asian Americans, were more likely than non-Hispanic whites were to report barriers. Managed care enrollees across racial/ethnic groups faced different types of barriers than non-managed care enrollees did. Although managed care enrollees were more likely to report having a usual source of care and greater continuity of care, they also reported more difficulties obtaining care and less satisfaction with their care.

Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons

Patients with body dysmorphic disorder (BDD) often present to dermatologists and cosmetic surgeons. BDD is a relatively common yet underrecognized disorder that consists of a distressing or impairing preoccupation with an imagined or slight defect in appearance. Although any body area can be the focus of concern, preoccupation with the appearance of the skin, hair, and nose are most common. Typical associated behaviors include skin picking, mirror checking, and camouflaging (e.g., with a hat or makeup). Reassurance seeking is another common behavior that may be enacted with surgeons and dermatologists. BDD is associated with marked impairment in functioning, notably poor quality of life, and a high suicide attempt rate. The disorder appears relatively common in dermatologic and cosmetic surgery settings; in fact, dermatologists may be the type of practitioner most often consulted by patients with BDD. Psychoeducation is an important element in the treatment of BDD. For patients who compulsively pick at their skin, it is generally ineffective to simply advise them to stop picking. Educating them that the picking is a symptom of BDD, and is treatable, can be helpful. For skin pickers, a combination of psychiatric and dermatologic treatment may be best. It is probably best to avoid cosmetic procedures. Although definitive data on the treatment outcome of surgery and dermatologic treatment for BDD are lacking, and although no one can predict how a given patient will respond to such treatment, available data suggest that these treatments are unlikely to be successful and may even make the patient's condition worse. Rather than referring the patient to another dermatologist or cosmetic surgeon, we recommend attempting to refer the patient to a psychiatrist for cognitive-behavioral therapy or pharmacotherapy. Available data indicate that serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are often effective for BDD. In recent years, BDD has gone from being a neglected psychiatric disorder to one that is becoming better recognized and understood. Nonetheless, research on this disorder is still in its early stages, and much more investigation of BDD is needed, especially in surgical and dermatologic settings. Treatment recommendations will be modified in the future as more research is done. In the meantime, it is important that dermatologists and surgeons screen patients for BDD and accurately diagnose this condition, as available psychiatric treatments are very promising for patients with this distressing and sometimes disabling disorder.

Cognitive function in breast cancer patients receiving adjuvant chemotherapy

PURPOSE

Breast cancer patients receiving chemotherapy have complained of difficulties in their ability to remember, think, and concentrate. This study assessed whether there are differences in cognitive function between breast cancer patients treated with standard-dose adjuvant chemotherapy compared with healthy controls.

PATIENTS AND METHODS

The High Sensitivity Cognitive Screen and the Profile of Mood States (POMS) were used to assess cognitive function and mood in a group of 107 women. The women consisted of 31 breast cancer patients receiving adjuvant chemotherapy (group A), 40 breast cancer patients who had completed adjuvant chemotherapy a median of 2 years earlier (group B), and 36 healthy controls (group C).

RESULTS

Univariate analysis showed statistically significant differences (P =.009) in overall cognitive function scores between groups A and C, with poorer function in patients receiving adjuvant chemotherapy. These differences remained significant (P =.046) when controlling for age, education level, and menopausal status. More patients had moderate or severe cognitive impairment in groups A and B than in controls (P </=.002). There were no significant differences in POMS scores between the groups, suggesting that the differences seen in cognitive scores were unlikely to be because of mood disturbance.

CONCLUSION

Cognitive differences were observed in breast cancer patients receiving adjuvant chemotherapy compared with healthy controls. These differences did not seem to be caused by significant differences in mood disturbance between the two groups. If confirmed, these results have substantial implications for informed consent, counseling, and psychosocial support of patients receiving adjuvant chemotherapy for breast cancer.

Personality disorders and traits in patients with body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) have been postulated to have schizoid, narcissistic, and obsessional personality traits and to be sensitive, introverted, perfectionistic, and insecure. However, data on personality traits and disorders in BDD are limited. This study assessed 148 subjects with BDD, 26 of whom participated in a fluvoxamine treatment study; 74 subjects were assessed for personality disorders with the Structured Clinical Interview for DSMIII-R Personality Disorders (SCID-II), 100 subjects completed the NEO-Five Factor Inventory (NEO-FFI), and 51 subjects completed the Rathus Assertiveness Scale. Forty-two subjects (57%) had one or more personality disorders, with avoidant personality disorder (43%) being most common, followed by dependent (15%), obsessive-compulsive (14%), and paranoid (14%) personality disorders. On the NEO-FFI, the mean scores were in the very high range for neuroticism, the low range for extraversion and conscientiousness, the low-average range for agreeableness, and the average range for openness to experience. On the Rathus Assertiveness Scale, the mean score was -17.1 +/- 32.0 for women and -17.0 +/- 32.3 for men. Among fluvoxamine responders, the number of personality disorders significantly decreased between the study baseline and endpoint. These findings suggest that the rate of personality disorders in BDD is relatively high, with avoidant personality disorder being most common. The high neuroticism scores and low extraversion scores are consistent with this finding.

Perceptions of Ashkenazi Jewish breast cancer patients on genetic testing for mutations in BRCA1 and BRCA2

The perceived benefits and risks of genetic testing may vary between groups of individuals with different cultural, demographic, and family history features. This multicentre study examined the factors that influenced the decision to undergo genetic testing for BRCA1 and BRCA2 in Canadian Jewish women with breast cancer. A self-administered questionnaire was developed and distributed to 134 individuals enrolled in a research-based testing program for Ashkenazi women. The questionnaire assessed demographic, social, and family history parameters, and the influence of medical, family, social, psychological, and cultural/religious factors on decision making about genetic testing. Seventy-six percent of women completed the questionnaire. Forty-one percent of study participants had no family history of breast or ovarian cancer. The most important factors influencing the decision to undergo testing were a desire to contribute to research, potential benefit to other family members, curiosity, and the potential for relief if not found to be a carrier (endorsed by 87, 78, 70, and 60% of participants, respectively). The main perceived risks of undergoing genetic testing related to insurance discrimination, confidentiality, accuracy and interpretability of results, potential impact on marriage prospects for family members, and focus on the Jewish community (endorsed by 28, 24, 30, 17, and 14% of participants, respectively). This study provides novel information on the motivating factors for BRCA1 and BRCA2 mutation testing in Canadian women of Ashkenazi Jewish descent. The focus on altruistic factors and those related to perceived psychological benefits of testing is notable.

Body dysmorphic disorder: diagnostic controversies and treatment challenges

Body dysmorphic disorder (BDD) is a distressing, impairing, and relatively common yet underrecognized disorder. This clinically focused article discusses the following diagnostic controversies and challenges associated with BDD: the underdiagnosis and misdiagnosis of BDD, the relationship between BDD and obsessive-compulsive disorder, the relationship between BDD and depression, the delusionality controversy, and whether BDD can be diagnosed in children and adolescents. This article also discusses treatment controversies and challenges associated with serotonin reuptake inhibitors, antipsychotics, cognitive-behavioral therapy, approaches to treatment-resistant BDD, and getting reluctant patients to accept psychiatric treatment.

Rate of body dysmorphic disorder in dermatology patients

BACKGROUND

Dermatologists appear to be the physicians most often seen by patients with the psychiatric condition body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. The frequency of BDD among patients seeking dermatologic treatment is unknown, however.

OBJECTIVE

This study determined the percentage of patients seeking dermatologic treatment who screened positive for BDD.

METHODS

A validated self-report questionnaire and a reliable defect severity scale were used to determine the rate of BDD in 268 patients seeking dermatologic treatment.

RESULTS

A total of 11.9% (95% confidence interval [CI], 8.0%-15.8%) of patients screened positive for BDD. Rates were similar in a community general dermatology setting (14.4% [95% CI, 8.5%-20.3%]) and a university cosmetic surgery setting (10. 0% [95% CI, 6.1%-13.9%]).

CONCLUSION

BDD appears relatively common among patients seeking dermatologic treatment. Further research is needed to confirm these findings and to assist dermatologists in identifying these potentially high-risk patients.

Quality of life for patients with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common, distressing, and impairing disorder. Quality of life in BDD, however, has not been investigated. In this study, 62 consecutive outpatients with BDD were evaluated with the self-report Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and other scales. SF-36 scores were descriptively compared to published norms for several populations. Physical health-related quality of life scores were generally worse than general U.S. population norms and better than norms for outpatients with a medical illness or depression. However, in all mental health domains, BDD subjects' scores were notably worse than norms for the general U.S. population and for patients with depression, diabetes, or a recent myocardial infarction. More severe BDD symptoms and greater delusionality were associated with poorer mental health-related quality of life. These results indicate that patients with BDD have notably poor mental health status and mental health-related quality of life.

Use of preventive services by managed care enrollees: an updated perspective

We examined whether enrollees in managed care plans received more preventive services than enrollees in non-managed care plans did, by conducting an updated literature synthesis of studies published between 1990 and 1998. We found that 37 percent of comparisons indicated that managed care enrollees were significantly more likely to obtain preventive services; 3 percent indicated that they were significantly less likely to do so; and 60 percent found no difference. Enrollees in group/staff-model health maintenance organizations (HMOs) were more likely to receive preventive services, but there was little evidence, outside of Medicaid managed care, that managed care plans are worse at providing preventive services. However, most of the evidence is equivocal: Provision of preventive services was neither better nor worse in managed versus non-managed care plans. Because of the blurred distinctions among types of health plans, more research is needed to identify which plan characteristics are most likely to encourage appropriate utilization.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.

OBJECTIVE

To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.

DESIGN

Cross-sectional study.

SETTING

Large health maintenance organization.

PATIENTS

13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.

MEASUREMENTS

Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.

RESULTS

Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).

CONCLUSIONS

In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.

OBJECTIVE

To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.

DESIGN

Cross-sectional study.

SETTING

Large health maintenance organization.

PATIENTS

13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.

MEASUREMENTS

Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.

RESULTS

Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).

CONCLUSIONS

In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.

Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness

CONTEXT

Mammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening.

OBJECTIVE

To compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies.

DESIGN

Decision analysis and cost-effectiveness analysis using a Markov model.

PATIENTS

General population of women aged 65 years or older.

INTERVENTIONS

The analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years.

MAIN OUTCOME MEASURES

Deaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios.

RESULTS

Compared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66773 per year of life saved. Continuing mammography to age 79 years in all 10000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles.

CONCLUSIONS

This analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.

Breast carcinomas arising in carriers of mutations in BRCA1 or BRCA2: are they prognostically different?

PURPOSE

To review the preclinical and clinical studies relevant to the prognosis and prognostic associations of BRCA1- and BRCA2-associated breast carcinomas, with an emphasis on research methodology.

METHODS

Reports of relevant studies obtained from a MEDLINE search, and references from these articles, were critically reviewed.

RESULTS

Consistent associations with both favorable (medullary or atypical medullary carcinoma) and unfavorable (high tumor grade, hormone receptor negativity, somatic p53 mutation) prognostic characteristics have been found for BRCA1-associated breast carcinomas. Inconsistent results have been demonstrated for prognostic associations of BRCA2-associated breast tumors. Clinical studies that have directly assessed the prognosis of these tumors have not shown a clear effect of BRCA1 or BRCA2 mutation, but no study has used optimal methodology. In vitro and animal model data suggest a possible influence of these mutations on response to agents that cause double-strand DNA breaks, but clinical data are limited.

CONCLUSION

The elucidation of an identifiable subgroup of breast carcinomas that result from germline mutations in BRCA1 or BRCA2 may be an important step toward genotype-based understanding of prognosis and choice of therapy in this disease. However, currently there are inadequate data to support use of BRCA1 or BRCA2 status to counsel individuals regarding their prognosis or to select treatment. Well-designed studies of population-based inception cohorts of breast cancer patients, which have adequate sample size and complete follow-up, and which use objective outcome criteria and blinding of outcome assessment, are required to optimally address this question.

Thirty-three cases of body dysmorphic disorder in children and adolescents

OBJECTIVE

Body dysmorphic disorder (BDD), a preoccupation with a nonexistent or slight defect in appearance, usually begins during adolescence. Because there have been no studies of the clinical features of BDD in children and adolescents, the authors assessed these features in the largest series to date.

METHOD

Thirty-three children and adolescents with DSM-IV BDD were assessed for demographic characteristics, phenomenology, associated psychopathology, and treatment history and response.

RESULTS

Bodily preoccupations most often focused on the skin (61%) and hair (55%). All subjects had associated compulsive behaviors, most often camouflaging (e.g., with clothing) in 94%, comparing with others (87%), and mirror checking (85%). Ninety-four percent reported impairment in social functioning and 85% in academic or job functioning due to BDD. Thirty-nine percent had had psychiatric hospitalizations, and 21% had made a suicide attempt. Ten (53%) of 19 subjects treated with a serotonin reuptake inhibitor had much or very much improvement in BDD symptoms; in contrast, 0 of 8 trials with other psychotropic medications, 0 of 1 trial of cognitive-behavioral therapy, and 1 of 20 psychotherapy trials resulted in improvement. Twelve (36%) subjects received surgical, dermatological, or dental treatment, with a poor outcome in all cases.

CONCLUSIONS

BDD can cause significant morbidity in children and adolescents. These preliminary data suggest that serotonin reuptake inhibitors may be an effective treatment in this age group.

Frequency of p53 mutations in breast carcinomas from Ashkenazi Jewish carriers of BRCA1 mutations

BACKGROUND

Breast carcinomas occurring in carriers of BRCA1 gene mutations may have a distinctly different pathway of molecular pathogenesis from those occurring in noncarriers. Data from murine models implicate loss of p53 (also known as TP53) gene function as a critical early event in the malignant transformation of cells with a BRCA1 mutation. Therefore, breast tumors from BRCA1 mutation carriers might be expected to exhibit a high frequency of p53 mutations. This study examined the frequency of p53 mutations in the breast tumors of Ashkenazi Jewish carriers and noncarriers of BRCA1 mutations.

METHODS

Tumor DNA from carriers and noncarriers of BRCA1 mutations was screened for mutations in exons 4 through 10 of the p53 gene by use of the polymerase chain reaction and single-strand conformation polymorphism (SSCP) analysis of the amplified DNA. Direct sequencing was performed on gene fragments that showed altered mobility in SSCP analysis.

RESULTS

Mutations in the p53 gene were detected in 10 of 13 tumors from BRCA1 mutation carriers versus 10 of 33 tumors from non-carriers (two-sided P = .007). The p53 mutations were distributed throughout exons 4 through 10 and included both protein-truncating and missense mutations in both groups.

CONCLUSIONS

A statistically significantly higher frequency of p53 mutations was found in breast tumors from carriers of BRCA1 mutations than from noncarriers, which adds to the accumulating evidence that loss of p53 function is an important step in the molecular pathogenesis of BRCA1 mutation-associated breast tumors. This finding may have implications for understanding phenotypic differences and potential prognostic differences between BRCA1 mutation-associated hereditary breast cancers and sporadic cancers.

Body dysmorphic disorder and depression: theoretical considerations and treatment strategies

Body dysmorphic disorder (BDD), also known as dysmorphophobia, consists of a distressing and impairing preoccupation with an imagined or slight defect in appearance. BDD is an underrecognized and relatively common disorder that is associated with high rates of occupational and social impairment, hospitalization, and suicide attempts. BDD is unlikely to simply be a symptom of depression, although it often coexists with depression and may be related to depression. It is important to recognize BDD in depressed patients, because missing the diagnosis can result in refractory BDD and depressive symptoms. Available data indicate that BDD may not respond to all treatments for depression and may instead respond preferentially to serotonin-reuptake inhibitors. In addition, lengthier treatment trials than those required for depression may be needed to successfully treat BDD and comorbid depression. It can be difficult and challenging to diagnose BDD in depressed patients because the symptoms are often concealed due to embarrassment and shame. This paper discusses the relationship between BDD and depression and discusses practical strategies for recognizing and treating BDD and depressive symptoms in patients with depression.

Body dysmorphic disorder: clinical aspects and treatment strategies

Body dysmorphic disorder (BDD), a distressing and impairing preoccupation with an imagined or slight defect in appearance, is an "OCD-spectrum disorder" that appears to be relatively common. BDD often goes unrecognized and undiagnosed, however, due to patients' reluctance to divulge their symptoms because of secrecy and shame. Any body part can be the focus of concern (most often, the skin, hair, and nose), and most patients engage in compulsive behaviors, such as mirror checking, camouflaging, excessive grooming, and skin picking. Approximately half are delusional, and a majority experience ideas or delusions of reference. Nearly all patients suffer some impairment in functioning as a result of their symptoms, some to a debilitating degree. Psychiatric hospitalization, suicidal ideation, and suicide attempts are relatively common. While treatment data are preliminary at this time, selective serotonin reuptake inhibitors (SSRIs) appear to often be effective for BDD, even if symptoms are delusional. Cognitive-behavioral therapy is another promising approach. While much remains to be learned about BDD, it is important that clinicians screen patients for this disorder and accurately diagnose it, as available treatments are very promising for those who suffer from this distressing and sometimes disabling disorder.

A comparison study of body dysmorphic disorder and obsessive-compulsive disorder

BACKGROUND

Body dysmorphic disorder, a preoccupation with an imagined or slight defect in appearance, is classified as a somatoform disorder, but has been hypothesized to be related to obsessive-compulsive disorder. A reflection of this hypothesis, body dysmorphic disorder is included in the Yale-Brown Obsessive Compulsive Scale symptom checklist, and its transfer to the anxiety disorders' section was considered for DSM-IV. However, the similarities and differences between body dysmorphic disorder and obsessive-compulsive disorder have received little investigation.

METHOD

We compared patients with DSM-IV body dysmorphic disorder (N = 53), obsessive-compulsive disorder (N = 53), or both disorders (N = 33) in terms of demographic features, clinical features, comorbidity, and family history. We also assessed the rate of body dysmorphic disorder among 62 of these subjects initially diagnosed with obsessive-compulsive disorder.

RESULTS

14.5% (9 of 62) of subjects initially diagnosed with obsessive-compulsive disorder had comorbid body dysmorphic disorder. The 2 disorders did not differ significantly in terms of sex ratio; most other demographic, course, and impairment variables; illness severity; or lifetime frequency of most associated disorders in probands or first-degree relatives. However, subjects with body dysmorphic disorder were less likely to be married and more likely to have had suicidal ideation or made a suicide attempt because of their disorder. They also had an earlier onset of major depression and higher lifetime rates of major depression, social phobia, and psychotic disorder diagnoses, as well as higher rates of substance use disorders in first-degree relatives.

CONCLUSION

Body dysmorphic disorder appears to be relatively common among patients with obsessive-compulsive disorder. While the 2 disorders have many similarities, they also have some differences and should be differentiated in clinical and research settings.