Is anorexia nervosa a subtype of body dysmorphic disorder (BDD)? Well, probably not, but don’t click the close button just yet. In this post, I’ll explore the relationship between anorexia nervosa and BDD, and discuss how understanding this relationship might help us develop better treatments for both disorders.Â
Despite the fact that there are obvious similarities between the disorders, studies exploring the relationship between BDD and AN are few and far between. In a recent paper, published in the Clinical Psychology Review, Andrea Hartmann and colleagues summarized the current state of knowledge in the field. The review compared clinical, personality, demographic, and treatment outcome features of AN and BDD. I’ll summarize the key points of the paper in this post.
(I will be focusing on the relationship between AN and BDD, as opposed to EDs and BDD, because that’s the scope of the review article.)
First, what is body dysmorphic disorder?
BDD is defined as distressing or impairing preoccupation with an imagined[/perceived] or slight defect in physical appearance. If a slight physical anomaly is present, the preoccupation is markedly excessive (APA, 2000). Most patients with BDD engage in compulsive behaviors to examine, hide, or improve the perceived defect (Phillips, McElroy, Keck, Pope, & Hudson, 1993; Phillips, Menard, Fay, & Pagano, 2005a) […]. Appearance-related preoccupations and compulsions are time consuming and cause clinically significant distress and/or impairment in social, occupational, or other important areas of functioning (APA, 2000).
Approximately 1/3 of individuals do NOT recognize that the beliefs about their appearance are due to a mental disorder and 2/3 believe that other people are laughing/staring at them because of their defects. The DSM-5 includes (I was going to write “will include” but it is already out now) an insight specifier which is meant to capture the range of insight that patients with BDD may have about their disorder. Unfortunately, an insight specifier is not included in the DSM-5 for eating disorder diagnoses.
(I’m going to assume that I do not need to include a definition of anorexia nervosa  for this audience?)
So, what are the similarities between BDD and AN? I’ve tried to summarize the salient points of the review below, but feel free to ask questions or request clarifications in the comments section if something is unclear.
DIAGNOSTIC OVERLAP BETWEEN AN and BDD
Onset, demographic characteristics, and illness course:
ONSET:Â Similar, usually in the mid-teens
PREVALENCE:
- Similar rates, around 0.5-2%, although BDD seems to be more prevalent than AN
- AN is more prevalent in females whereas the frequency of BDD is only slightly higher among females
- Just as with AN, however, there are differences in how males and females present with their symptoms (i.e., the concerns they have tend to differ)
COURSE OF ILLNESS: Both seem to be long-lasting disorders for a large proportion of the patients, although BDD appears to be chronic for a larger portion of those diagnosed than AN (That said, there are so many biases that come into play when evaluating long-term outcomes that it is really hard to say.)
The authors point to other differences among AN and BDD patients (in socioeconomic status, educational attainment, prevalence among different ethnic groups, likelihood of being in a relationship, etc.) but, to be quite honest, I don’t trust the data because there are so many things affecting who seeks treatment and participants in studies that one or two studies suggesting a difference are hardly sufficient.
Comorbidities:
COMORBIDITY WITH OTHER DISORDERS:
- AN is highly comorbid with depression, anxiety disorders (including OCD), and substance abuse
- BDD is commonly diagnosed with depression, social anxiety disorder, OCD, and substance abuse
- Both are comorbid with “Cluster C” personality disorders: avoidant, dependent, and obsessive-compulsive
COMORBIDITY WITH EACH OTHER:
- It is hard to say. The studies cited in the review are tiny. One found that 25% of females between the ages of 12-21 had showed symptoms of BDD, whereas 0% of females with bulimia nervosa had. Sample size: 36 inpatients with AN and 17 with BN. In another study of 41 AN inpatients, 39% had lifetime BDD diagnoses.
- On the other hand, 9% of BDD patients had lifetime AN diagnoses. In cases with comorbid BDD and AN, BDD seems to precede AN. Unsurprisingly, those with dual diagnoses fared worse than those with just one.
Clinical characteristics:
BODY IMAGE DISTURBANCES & ATTRACTIVENESS BELIEFS:
- Individuals with AN and BDD both have body image disturbances (and these are more pronounced in those suffering from both AN and BDD). Patients with AN focus on weight/shape, whereas patients with BDD can have weight and shape related concerns but tend to focus on other parts of the body such as skin, hair, and nose.
- Individuals with AN and BDD tend to have appearance-related behaviours, such as body checking, and tend to avoid places/activities where they might feel more self-conscious because of their appearance (like the beach, for example).
- Some studies suggest that body image disturbances are more serious in BDD than AN, and that patients with BDD tend to overestimate the importance of their appearance and invest more time in it. (This is not surprising, I feel.)
- Individuals with BDD and AN tend to associate attractiveness and appearance with things like competence, achievement, and performance more than healthy controls, but it is hard to say how the disorders compare to each other.
COGNITIVE CHARACTERISTICS:
Both BDD and AN patients tend to:
- be detail-oriented (as opposed to globally oriented) and “miss the forest for the trees”
- be more likely to interpret neutral or ambiguous social or appearance-related situations as being negative
- have difficulties with emotional processing, particularly emotion recognition and emotion regulation
- have difficulties with executive function (like decision-making and set-shifting), but more studies have been done in AN than BDD
SUICIDALITY: Suicide attempts and suicidal ideation are high in both BDD and AN, and again, having comorbid BDD and AN seems to increase the rate of attempted suicides.
DELUSIONALITY: Around 1/5 – 1/4 of those with AN seem to have very poor insight into their eating disorder. (Though, there’s a question of whether it is a lack of awareness/poor insight or deliberate denial?) As mentioned previously, about 1/3 of patients with BDD seem to have very poor insight about their disorder.
PERSONALITY CHARACTERISTICS: Both BDD and AN patients have higher perfectionism, neuroticism, negative emotionality, and harm avoidance traits, as well as low novelty seeking and self-directedness than healthy controls. However, to my knowledge, no studies have compared BDD to AN directly.
TREATMENT
Clearly, there are many similarities between AN and BDD. But when it comes to effective treatment modalities , the similarities fade:
While there is only evidence for SSRIs in AN for relapse prevention after weight restoration*, for BDD, pharmacotherapy with (S)SRIs (and potentially an augmentation with atypical neuroleptics as a secondary treatment strategy) has proven to be successful. In terms of psychological treatment, only family therapy is successful in adolescents with AN (my post on FBT); there is limited evidence for other treatments so far, with an enhanced form of CBT and UCAN showing initial promising results [I’m not sure why the authors decided to focus on CBT (I blogged about a not-so-good CBT study here) and UCAN (Check out my post about UCAN here)… I am really puzzled by this]. In BDD, CBT has proven to be successful in adults in several small studies, and there is preliminary support of this treatment in adolescence.
*I just want to mention that, although this is anecdotal and I have not looked at the literature myself, but I found that an SSRI (sertraline) was VERY effective for reducing general anxiety for me at a low weight (BMI 15), and anecdotally, I know many others who found SSRIs effective for anxiety at low BMIs, so, I’m not convinced that it is ineffective at a low weight. It was much more effective than I expected it to be (I was VERY, VERY skeptical).
Anyway, getting back to the paper. The final part of the review was a discussion about what can we learn from AN treatment that can be utilized in BDD and vice-versa. I think there were some good points made here.
What can we learn from AN treatment that we can potentially utilize in treating BDD? Well, involving parents (as in family-based treatment) or partners (as in UCAN) might be helpful. After all, “a combination of communication skills, exchange of conceptualizations of the disorder, and planning for more appropriate dealing with the disorder in particular difficult situations might improve the inclusion of spouses and partners [and family] in the treatment of BDD.”
What can we learn from BDD treatment that we can incorporate into AN treatment? Mindfulness training, which is popular in BDD treatment, is something that can be incorporated into treatment. (Although, I’m sure lots of therapists and clinicians do this.) Emotion recognition training is another tool we might be able to add to AN treatment. (Though, again, I’m sure this is something a lot of therapists incorporate into their practice.) It will be important to decipher whether, and to what extent, these are beneficial (and for what subgroups of patients) and, if they are, what the best way to deliver training. Finally, exposure and ritual prevention training, which, according to the authors is a hallmark of CBT treatment for BDD, might be helpful for AN. Indeed, a recent preliminary study suggests that food exposure might be helpful in treating AN (see Steinglass et al., 2012).
SUMMARY
To conclude, this review highlights some of the similarities between AN and BDD. But (there’s always a but) there’s still more work to be done when it comes to understanding the relationship between AN and BDD (and EDs and BDD in general). Namely, we need more studies directly comparing AN-only, BDD-only, AN+BDD, and healthy controls. Moreover, whether these similarities are reflective of the same underlying causal factors remains to be determined. (This is probably the question that interests me the most.) Finally, although successful treatment modalities for AN and BDD differ, there does appear to be a lot of room for incorporating successful treatment approaches for one disorder to the other. Why not try, anyway?
Readers, what are your thoughts? I’m particularly curious to hear from those who have struggled with BDD and/or BDD and an ED, as well as clinicians who treat either one or both. Do you agree or disagree with any points made in this post? How do your experiences compare with what’s been highlighted by the studies?
References
Hartmann, A.S., Greenberg, J.L., & Wilhelm, S. (2013). The relationship between anorexia nervosa and body dysmorphic disorder. Clinical psychology review, 33 (5), 675-685 PMID: 23685673
Really interesting. Thanks, Tetyana.
First, I’m glad you are enjoying working 🙂
Well, you know my ‘story’ so I won’t repeat it here. Even though I know that my AN was not driven or underpinned by BDD, I am nevertheless interested in co-morbid BDD and AN.
I have never liked my face and especially my nose. I see my nose as huge and misshapen. I have even consulted a plastic surgeon about my nose and he advised that my concerns about my nose are psychological and that he wouldn’t operate. (I actually applaud him for not just taking the money which I had saved up!). So apparently I have BDD, as far as my nose/face are concerned. I just don’t look at my face in the mirror more often than I need to nowadays.
But I am assuming that what you are most interested to hear is comments from people who relate their AN to BDD and don’t see AN and BDD as being separate and unrelated?
Glad you liked it Cathy!
I’m really sorry I have yet to reply to your comment on the other post. I’ve been really busy with all these “little” to-do things (like catch-up on comments, etc) which are less crucial than, you know, get groceries and reply to “business” emails so yeah. I will do so sometime today. I don’t want to make you feel like I’m ignoring you.
I didn’t know about your experiences with body dysmorphia. I’m really happy that the surgeon didn’t want to operate! That’s good to hear. Did you get any help for that? Do you feel like it was a big issue for you in terms of being social?
I just wonder if the link for some people is more to do with anxiety and/or OCD, and for others with more visual processing or somatosensory processing deficits (or just differences)? I don’t know much about BDD.
I’ve never experienced it myself. I was self-conscious about my body hair, but in a normal 13/14-year-old kind of way. Nothing too serious. I tried to bleach it and thought about removing it, but, that passed with a year or two. It was definitely not BDD and probably had a lot more to do with social norms and the obsession our society has with hairlessness. I never had issues with my face or other features of my body.
I’m very thankful for that. When I did have issues with feeling like my body was GIGANTIC even though it wasn’t, and that I was “too fat” to do things, like go to school or study (“What’s the point, I’m so fat”), it was terrible. Hating my body was immensely time-consuming and had a huge negative impact on the quality of my life, so I can imagine what it would be like for someone with BDD where it is not (or even is) connected to EDs. For me, it was definitely ED related.
In retrospect, I do think a huge part of it was just dumping all of my anxieties about my self-worth and competence onto my body because it was something I felt I could deal with actively, ie, lose weight. My body image was really just a reflection of my feelings about myself, more than anything to do with my actual body.
I just wonder about all of these things and how true they are for BDD-only sufferers. Again, because I don’t really know much about BDD.
Wow this has been rambly.
Not rambly at all. What you write makes a lot of sense. I am sorry you have struggled with body dissatisfaction. I think many people do – whether they have an ED or not. But it would also seem that some people’s body dissatisfaction or BDD develops as a direct consequence of weight loss and doesn’t pre-date weight loss.
You asked how my facial BDD influenced my capacity to be social:
I was already socially anxious before I developed a fixation on the size of my nose, so I guess my concerns about my nose merely added to the problem. Of course, my nose looked MUCH bigger when I lost a lot of weight, because my face became even narrower and very gaunt. However, I was probably more self conscious about my thinness – because I have always been aware that I am thin. (I didn’t perceive myself to be larger when very underweight). Being a university lecturer, I felt desperately self-conscious standing up in front of a class of students because I knew they were all gasping with horror at my thinness. I felt very embarrassed. And my nose genuinely did look very big at the time, so it was all quite confusing.
“But it would also seem that some people’s body dissatisfaction or BDD develops as a direct consequence of weight loss and doesn’t pre-date weight loss.”
Yes, for me it did, definitely. I talked a lot about this to “A:)” recently, as it did predate the ED for her. I wonder if there are differences, long-term in terms of outcomes or personality variables, between those who’ve had clear BDD or body dissatisfaction prior to ED onset and those who developed it as a result of the weight loss (like fear of gaining weight even though had no dissatisfaction at a higher weight before ED onset). Of course, difficult question to answer clinically, and runs into the problem of when the ED onset is at a young age, how cognitive aware are the individuals about their body image (dissatisfaction) and can they verbalize it effectively?
Regarding your experiences, I’ve experienced similar situations about my thinness but only in the last few years, and only if I’m around my sister or my boyfriend, because I feel like I’m really disappointing them. (And probably because my sister and I have nearly identically figures, and I’m considerably older, so being a lot thinner just doesn’t feel right. I felt embarrassed and ashamed.) That said, I do usually overestimate my size, even now. But there were times in high-school when that overestimation was very severe. I thought the scales were rigged. Now it is not that bad at all, I just don’t realize I’m smaller than I think I am, but that might also be due to the fact that I’m pretty short.
Thanks Tetyana 🙂
In terms of your comment: “….when the ED onset is at a young age, how cognitive aware are the individuals about their body image (dissatisfaction) and can they verbalize it effectively?”
I do believe that age of onset of an ED can play a role in both the way that an ED manifests and how the individual makes sense of it. My understanding from online discussions with people who have had pre-pubertal onset of an ED (usually before age 12 years) and their parents is that it is quite common for small children to present with non-fat-phobic EDs. But whether or not the child genuinely does have body dissatisfaction and/or fat phobia is unclear.
Clearly some children (and teens) with EDs have genuine and powerful body dissatisfaction before the onset of their ED and they see their ED behaviours as being directly linked to this body dissatisfaction. But I do wonder whether fat phobia is sometimes induced iatrogenically by well-meaning therapists who are endeavouring to put a common ‘meaning’ to the ED behaviours.
On a personal level, I was a skinny kid who was very active and athletic pre-AN. The behaviours of AN (for me, restriction and over-exercising) were anxiolytic at a time when I felt overwhelmed with anxiety. My anxiety was and is a trait, but around the time of puberty, it escalated to a point of feeling unbearable. I was also depressed. The behaviours of AN seemed to quell all the awful feelings I had been experiencing. I just didn’t link any of this to fear of fatness. And because this was the mid 1970s, when our culture was quite different to nowadays, no clinician seemed keen to attribute my anorexic behaviours to body dissatisfaction or BDD. They just told me and my mother that I was ill and needed to gain weight!
As far as SSRIs go:
I had always been told that they don’t work if BMI is too low. Recently, I tried Fluoxetine for the first time in my life. My BMI was 17 at the time. I have found it surprisingly helpful. It seems to have reduced my general anxiety and depression – and in so doing enhanced my appetite and ability to eat without fear. End result: weight gain 🙂
Yeah, I’m really happy to hear that! I had similar experiences. It made me less anxious, which, in turn, enabled me to eat better and binge/purge WAY LESS. I felt like it slowed down my thoughts a bit, so I could process and be more mindful of what I was feeling. Prior to that, I would just immediately have ED-related urges without even really recognizing what was going on, it was so automatic. I was *SO* skeptical of them, but I thought, well, why not try, I’ve never been on any prescription drugs and as much as I was trying to regulate my eating and decreasing bingeing/purging frequency, my mood was too erratic and my anxiety up and down, so it was really difficult to implement my plans. SSRIs worked *SO* much better than I had expected. I’m really happy it has been the same for you!
I really need to look into the studies suggesting that they don’t work if the BMI is too low. I just don’t buy it. I’ve seen it work for so many people at low BMIs.
I think that a lot of the overlap has to do with the detail oriented focus of mindset and the overlap with perfectionist qualities. My spectrum is basically AN-BP, BDD (mostly with nose and thighs), a lot of general anxiety, and OCD history.
The BDD related anxieties have definitely decreased with resolution of the eating disorder, but I think that they’re both similarly treated. My therapy focus has been on mindfulness and a lot of CBT. Things that worked well for dealing with food/body anxiety with the eating disorder have also let me not focus so much on dysmorphic concerns. It’s hard to differentiate between the two a lot of the time though? I can’t really tell if I think that I am misshapen due to being overweight or just am generally concerned with appearing defective. I’m not sure if that makes sense. It took a while to be diagnosed with BDD because it was assumed by the clinician to be a normal spectrum of the eating disorder.
Thanks for your comment Lauren!
I definitely think this has a lot of truth to it, though it is really hard for me to say if it applies to everyone:
“I think that a lot of the overlap has to do with the detail oriented focus of mindset and the overlap with perfectionist qualities.”
It is definitely hard to differentiate BDD and AN, especially if the dysmorphia is body shape/weight centric.
I’m really happy to hear that mindfulness and CBT have helped you reduce your food/body anxiety. Are there any specific things that have helped that stick out? I’d be interested to hear!
I have BDD but no symptoms of an eating disorder. The similarities are very interesting though. I learned a bit about myself from reading this.
I have struggled with mental health issues for the past ten years (MDD, BPD, PTSD, GAD, PD, excoriation, self-injury I have dealt with or been diagnosed with at one time or another)
Recently I was diagnosed with Anorexia Nervosa, and although I fit the diagnosis I find I’m more preoccupied with hating my body and myself than hating my weight specifically.
After reading up on BDD I’m really starting to think it might be comorbid with the anorexia, and I may have suffered from this for a long time. I feel like it could be the cause of a few of my previous diagnoses.
I can’t remember a time when I liked looking at myself in the mirror. I abhor my skin and if I find the slightest imperfection (bump, dead skin, ingrown hairs, scabs, pimples, Etc) I will obsess over it until it’s gone or I’ve made a mess of my skin. I can spend hours picking at the perceived ‘flaws’ in my skin.
I really think there is more of a co-morbidity between these two disorders than most people realize. More research is definitely needed!!