Body Dysmorphia and Eating Disorders

Body Dysmorphia And Its Relationship With Eating Disorders

Article Contributed by Sharon McConville, MB, BCh, BAO (Eating Disorder Hope)

Body Dysmorphic Disorder (BDD), or Body Dysmorphia, is a condition that affects a person’s body image.  It is diagnosed when three criteria are met.  First, the sufferer must be either preoccupied with an imagined defect in their appearance or excessively concerned about a slight physical anomaly.  Secondly, the sufferer must be significantly distressed by their preoccupation or excessive concern with their appearance and/or be impaired in terms of what work-related and social activities they can participate in.  Finally, their preoccupation must not be better diagnosed under the heading of a different mental illness, such as anorexia, where body image is also a factor¹.

What are the symptoms?

A person with BDD may be concerned about any part of their body, although skin, hair and facial features being involved most frequently².  While many sufferers are preoccupied with their eyes, eyelids, nose, mouth or chin, it is also fairly common for the breasts or genitalia to be the site of the perceived defect³.  Some people have a very precise complaint about a particular feature; others have a vaguer perception of ugliness².  Either way, people with BDD frequently attach strong personal meanings to their beliefs about their appearance.  For example, one man thought that his nose made him look like an unlovable crook; another thought that tiny flaws in his skin made him dirty².  People with these kinds of beliefs usually expect other people to have the same beliefs about them and to evaluate them negatively because of their appearance, which is very disabling socially².  Other people with BDD may realize –often having been told many times – that others do not perceive them to have a disfigurement; however, the perceived defect remains very real to them personally³.

Because people with BDD are so consumed with thinking about an aspect of their appearance, they often spend a lot of time either examining the perceived defect or trying to disguise it².  For example, a sufferer may gaze at the mirror for excessive periods of time, engage in long personal grooming rituals, or attempt to camouflage the perceived defect with heavy make-up.  People with BDD may also attempt ‘DIY surgeries’ such as flattening the nose with tape or reshaping it by placing tissue paper inside, and many go on to seek cosmetic surgery².  When surgery goes ahead, it is frequently perceived to be unsuccessful, while in cases where satisfaction is achieved, 50% of people with BDD have been shown to develop a preoccupation with a previously unaffected body part².

People with BDD are at a high risk for depression and suicide, and have been shown to have a greater degree of distress than people with depression, diabetes, or bipolar disorder⁴.  They tend to avoid social situations because they do not want others to see and judge them, and because their perceived defect causes them to be afraid of dating or intimacy².  They may employ unhelpful strategies to help them endure such situations, such as drinking alcohol to excess, or they may become housebound.  Because of this, attempts at following a course of study or taking part in paid employment are frequently disrupted.  All of these factors may lead to interpersonal difficulties with family members who cannot understand the extent of the disability which the person with BDD faces².

Who gets Body Dysmorphic Disorder?

The proportion of adults living with BDD in the United States has been found to be 2.4%, with men and women affected equally⁵.  It commonly begins in adolescence at the time when people are most sensitive about their appearance, but many sufferers live with it for years before seeking help for fear that they will be considered vain^2,3.  What is more, BDD is often under-diagnosed, partly because treating physicians are not good at recognising it⁶ and partly because patients tend to talk to healthcare professionals about other related symptoms such as anxiety or depression rather than revealing their underlying concern³.  Children can get BDD too, but they are often unable to articulate their problems; instead, signs that they are ill can include refusing to attend school and making plans for suicide².

What causes Body Dysmorphic Disorder?

BDD is under-researched compared with other disorders of body image such as eating disorders.  There are both biological and psychological explanations for the development of BDD³.  In the biological model, a person has a genetic predisposition to the condition, which emerges after they are exposed to certain life stressors such as bullying or abuse.  Once BDD has developed, an imbalance in neurotransmitters such as serotonin may perpetuate the problem³.  In the psychological model, BDD is related to low self-esteem and a tendency to judge oneself according to appearance.  A person may develop false beliefs linking a perceived defect in their appearance to their worth as a person:  “If I am unattractive my life is not worth living”.  In this model, the BDD is then maintained by extreme self-focused behaviours such as appearance checking and comparing the feature perceived to be defective with that of other people³.  As further research is carried out, it is likely that a more inclusive bio-psycho-social model of illness causation will be developed.

Is Body Dysmorphic Disorder an eating disorder?

There is some overlap between characteristics of BDD and eating disorders including, for example, body image dissatisfaction and disturbance, rituals and behaviours relating to appearance, and a tendency to compare⁷.  However, although dieting can be a feature of BDD that involves a body part perceived to be large, eating and weight are not usually disturbed, and BDD is not diagnosed if an eating disorder is thought to be present.  People with an eating disorder can also be diagnosed with BDD and individuals who have both have been found to have more severe psychopathology⁷.  They may therefore require a more aggressive treatment plan.

How is Body Dysmorphic Disorder best treated?

At present, it is accepted that the treatment with the best evidence-base in BDD is a combination of an SSRI antidepressant with cognitive behavioural therapy (CBT)⁸.  A form of “exposure with response prevention” is usually included in CBT for BDD³.  This means that the patient is exposed to their fear – for example, of looking in the mirror or being seen in public without make-up – without being able to respond in the usual way, such as by covering up, so that he or she becomes used to the experience and begins to find it less distressing.  CBT can be delivered equally successfully to individuals or to a group of patients with BDD⁹.

Conclusion

Clearly, Body Dysmorphic Disorder is a complex and devastating illness that requires specialist treatment.  Problems occur when people are reluctant to ask for help or when health professionals fail to recognize the condition, so education and awareness campaigns are crucial.  While BDD is not an eating disorder, it can present to eating disorder professionals, who should be aware of the appropriate treatment and referral pathways.

References:

1. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4^th edition, text revision. American Psychiatric Association.
2. Veale, D: Body dysmorphic disorder. Postgraduate Medical Journal 2004;80:67-71
3. Mind. Body dysmorphic disorder. Web address: http://www.mind.org.uk/mental_health_a-z/7990_body_dysmorphic_disorder Accessed May 29th, 2013
4. Philips, KA: Quality of life for patients with body dysmorphic disorder. Journal of Nervous and Mental Disorders 2000;188:170-175
5. Koran, LM et al: The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectrums 2008;13:316-322
6. Grant, JE, Kim, SW, Crow, SJ: Prevalence and clinical features of body dysmorphic disorder in adult and adolescent psychiatric inpatients. Journal of Clinical Psychiatry 2001;62:517-522
7. Dingemans, AE et al: Body dysmorphic disorder in patients with an eating disorder: prevalence and characteristics. International Journal of Eating Disorders 2012;45:562-569
8. Ipser, JC et al: Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Systematic Review 2009;21:CD005332
9. Prazeres, AM et al: Cognitive-behavioral therapy for body dysmorphic disorder: a review of its efficacy. Neuropsychiatric Disease and Treatment 2013;9:307-316
10. Daily Mail (UK) http://www.dailymail.co.uk/femail/beauty/article-1195336/Body-dysmorphic-disorder-Four-beautiful-women-distorted-way-THEY-themselves.html Accessed May 30th, 2013