Written by Lillian Reuman
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Be it a debilitating fear of gaining weight or a conviction that they look hideous or deformed, individuals with eating disorders and body dysmorphic disorder (BDD) struggle to accept their body image. Each disorder has its distinct aspects and is categorized separately according to the diagnostic manual, but recent research has revealed that these disorders may have more in common than previously suggested.
Researchers have proposed that disturbed body image may be the essential pathology of both BDD and anorexia nervosa. However, this specific preoccupation with body image may differ across disorders: skin, hair, nose, and other facial concerns are more common among patients with BDD, whereas general shape and weight concerns may be most important for an eating disordered patient.
Obsessional worries, intrusive thoughts, and repetitive behaviors characterize both eating disorders and BDD. Individuals from both groups strive to improve their appearance by way of potentially detrimental, time-consuming behaviors such as inspecting body parts, grooming excessively, and obtaining cosmetic surgery.
Just as elaborate makeup routines may calm a patient with BDD so that s/he can go out in public, extreme dietary restriction may be a ritualistic behavior designed to reduce stress associated with feelings of being fat for an anorexic patient. These individuals may harbor a misperception that a change in one’s outward appearance will improve self-esteem and social standing. In order to achieve this change, patients may embrace a range of dysfunctional attitudes in their quest for perfectionism, a common feature in both BDD and eating disorders. Individuals with BDD, bulimia nervosa, and anorexia nervosa may utilize mirror-checking, purging, and over exercising, respectively, to carry out this transformation.
Not surprisingly, a high proportion (32.5%) of individuals with BDD also had a lifetime comorbid eating disorder. Individuals within this group were more likely to be female and exhibit greater body image disturbance. Researchers also found that symptoms of BDD emerged in 25% of anorexia nervosa sufferers for at least six months prior to the clinical manifestation/onset of their eating disorder.
Perhaps the most profound difference between anorexia nervosa and BDD exists within the individual’s actual appearance. A formal diagnosis for anorexia entails a noticeable appearance deficiency: body weight at 85% or less of what is expected. Conversely, a diagnosis for BDD states that the individual is overly concerned or convinced that s/he is misshapen or deformed even though the physician finds either no abnormality at all or, if one is present, a trivial abnormality that would typically go unnoticed. Essentially, BDD patients may be preoccupied with something unrealistic that others cannot perceive.
A difference in the location of the perceived defects also exists. BDD patients report greater dissatisfaction with their face and hair than healthy controls, whereas anorexic patients place an emphasis on concerns with weight and body shape.
The distribution of patients with BDD and eating disorders is also mildly different: about 90% of patients with anorexia are female whereas 50-60% of patients with BDD are female.
Lastly, although patients with anorexia and BDD exhibit body image disturbance and negative self-esteem, subjects with BDD report more negative self-evaluation and more avoidance of activities due to appearance-related reasons.
At times it may be difficult to distinguish between eating disorders and BDD since the borderline between BDD and symptoms of an eating disorder is not always clear. Whether the differences are small or large, it is important that patients are properly diagnosed so that they can pursue appropriate treatment. To date, cognitive behavioral therapy (CBT) appears to be an effective intervention for both disorders of body image. Practicing cognitive restructuring and receiving positive reinforcement for goal achievement may serve as two of many effective strategies for developing skills to incite rational thinking and develop a more holistic view of one’s appearance. However, a single treatment may not be effective for all sufferers. Treatment plans may become more complicated as anxiety due to physical appearance increases. Patients who have BDD in addition to anorexia nervosa exhibit greater functional impairment and a significantly higher rate of suicide attempts. In these cases, pharmacological treatment may also be necessary. However, pharmacotherapy of BDD and eating disorders differs, and research to date has not examined whether medication, CBT, or a combination of both may be more efficacious in the treatment of both disorders.
Although many questions with regard to differential diagnostics remain, it is undeniable that individuals suffering from BDD and/or eating disorders report poor quality of life on their quest to attain body perfection and should seek professional help.
If you suspect that you or someone you know may be suffering from BDD and/or an eating disorder, we strongly encourage you to call our clinic at (617) 726-6766 or e-mail bdd@partners.org
References:
- Didie, E. R., Reinecke, M. A., & Phillips, K. A. (2010). Case conceptualization and treatment of comorbid body dysmorphic disorder and bulimia nervosa. Cognitive and Behavioral Practice, 17(3), 259-269.
- Grant, J. E. & Phillips, K. A. (2004). Is anorexia nervosa a subtype of body dysmorphic disorder? Probably not, but read on…Harvard Review of Psychiatry, 12(2), 123-126.
- Hrabosky, J. I., Cash, T. F., Veale, D., Neziroglu, F., Soll, E. A., Garner, D. M., et al. (2009). Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: A multisite study.Body Image, 6(3), 155-163.
- Phillips, K. A., Wilhelm, S., Koran, L. M., Didie, E. R., Fallon, B. A., Feusner, J., & Stein, D. J. (2010). Body dysmorphic disorder: Some key issues for DSM-V. Depression and Anxiety, 27, 573-591.
- Rabe-Jablonska Jolanta, J., & Sobow Tomasz, M. (2000). The links between body dysmorphic disorder and eating disorders. European Psychiatry, 15(5), 302-305.
- Rosen, J. C., & Ramirez, E. (1998). A comparison of eating disorders and body dysmorphic disorder on body image and psychological adjustment. Journal of Psychosomatic Research, 44(3-4), 441-449.
- Ruffolo, J. S., Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. B. (2006). Comorbidity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance. International Journal of Eating Disorders, 39(1), 11-19.
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