BDD and Anorexia Nervosa: What’s the big difference? Is there a difference?

BDD and Anorexia Nervosa: What’s the big difference? Is there a difference?

Written by Lillian Reuman

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 selfesteem, 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
[email protected]

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.