Does Everyone With an ED Have Body Dysmorphia?

Woman sitting down next to a lake

Eating Disorders are most often accompanied by low body dissatisfaction, lowered self-esteem, and distorted body image.

Body Dysmorphia is a severe condition where obsessional, fixated thoughts are around particular body parts or areas of the body that are perceived to be misshapen or grotesque in some way. Often these two can be co-occurring.

Body Dysmorphia Defined

Body Dysmorphic Disorder (BDD) is a disorder where there are self-perceived flaws that can lead to mental distress and lack of daily functioning in an individual [1]. Often the imperfections are seen as a defect, and the person attempts to hide or conceal the area of fixation.

The person may engage in obsessive rituals, such as body checking, constant grooming, or multiple attempts to conceal the area. The behaviors are very similar in nature to obsessive-compulsive behaviors seen in OCD.

Body Dysmorphia is also considered to be within the Anxiety Disorder family and not in the eating disorder categories.

In both disorders, negative body image is a connector, and some researchers feel that both disorders are a part of each other. The Harvard Review of Psychiatry published a study that found that anorexic individuals can develop ‘excessive concerns related to other body aspects than weight [1].’

The researchers on this study suggested that anorexia is a subtype of body dysmorphic disorder even though there is no other research in this area of thought.

Even with many similarities in obsessive body checking, significant time spent on getting dressed or grooming behaviors, and obsessive thinking around body shape and size, there is no evidence showing that all individuals diagnosed with an eating disorder also has body dysmorphic disorder.

It is seen, however, that the two disorders can co-occur together if there is a presence of negative body image. It can be assumed therefore that BDD is a consequence of an eating disorder.

Couple at base of the treeWhen an individual is dieting or engaging in unhealthy eating disorder behaviors, it can change the brain’s way of operating as well as self-perception. Both eating disorders and body dysmorphia can occur together, but create a severe illness and exacerbation of both disorder symptoms.

A UCLA study that looked at the relationship between BDD and body image found that there were impairments in the visual cortex in those with body dysmorphia. It was concluded that the way these individuals see themselves has to do with the fact that they actually see themselves differently [1].

Other studies show that 39-88% of those in eating disorder treatment really meet the criteria for body dysmorphic disorder and 32% of those with BDD meet an eating disorder diagnosis criteria [2].

Obsessional Thinking

Negative body image is a significant part of an eating disorder. Individuals are often consumed with negative thinking around body shape, size, and perception of their self by others.

In some individuals it can become where distorted body image perceptions can lead to attempts to change appearance, increasing thoughts of self-loathing and body dysmorphia.

Most clinicians would put body dysmorphia in the Obsessive Compulsive Disorder (OCD) category or within that spectrum.

Most therapies used to treat this disorder are around cognitive behavioral therapy or other anxiety-based therapies. The focus is around working on reducing compulsive acts of body checking or fixating, as well as obsessional thinking around appearance [2].

Many of the symptoms of eating disorders and BDD are similar. Body checking, body dissatisfaction, preoccupation with body image distress, negative self-evaluation, and avoidance of activities are all shared symptoms.

Treatment

Individuals who engage in treatment will have their assumptions about body shape, size, and perceived flaws challenged. They will be thinking about personal beliefs around their own appearance, cognitive distortions, as well as reframing unhealthy and negative thoughts [3].

Treatment also involves learning to accept and move on from distress thoughts. Using techniques from Cognitive Behavioral Therapy, Acceptance Commitment Therapy, and Dialectical Therapy, individuals are able to notice and recognize the thoughts they have without acting on them.

Another aspect of treatment is trigger identification. Learning what triggers the BDD symptoms and ED symptoms can help a person learn what situations to avoid, or when to use healthy coping skills learned through individual and group therapy.

Woman in fall leaves

Exposure is also used to desensitize individuals to wanting to engage in obsessional thinking and behaviors. It is about being able to slowly work up to anxiety-provoking situations from least anxiety to highest anxiety with the help of a trained clinician.

The DSM-5 places BDD in the Obsessional-Compulsive and Related Disorders criterion [4]. A BDD diagnosis requires a person to have a preoccupation with appearance, whether slight flaw or imagined.

It involves thinking and ruminating about the defect for at least one hour a day. This is followed by repetitive behaviors where the person is performing compulsive, repetitive behaviors and/or thoughts because of their appearance distress.

BDD also has to cause significant disruption to a person’s daily routine and significant distress is social and occupational routines. One key feature to diagnosis is that it is different from an eating disorder.

BDD individuals are not focused on by weight concerns, fear of being fat or gaining weight [4]. Suicidal thoughts and attempts are also common in those with BDD and can increase due to the severity of BDD symptoms and comorbid depressive disorders.

In conclusion, body dysmorphia and eating disorders do commonly occur, it does not mean that having one disorder automatically means that a person will have both.

Typically eating disorders develop prior to BDD, and the longer an eating disorder and body dissatisfaction occur, the higher the rates of BDD occurring.

With treatment including cognitive behavioral therapies and dialectical behavioral therapies, a person can recover from both BDD and ED behaviors.

Workin on exposure work and trigger recognition as well as psychoeducation on the body sensations and emotional regulation an individual can learn to manage their symptoms and have a healthy and productive life.


Image of Libby Lyons and familyAbout the Author: Libby Lyons is a Licensed Clinical Social Worker and Certified Eating Disorder Specialist (CEDS). Libby has been practicing in the field of eating disorders, addictions, depression, anxiety and other comorbid issues in various agencies. Libby has previously worked as a contractor for the United States Air Force Domestic Violence Program, Saint Louis University Student Health and Counseling, Saint Louis Behavioral Medicine Institute Eating Disorders Program, and has been in Private Practice.

Libby currently works as a counselor at Fontbonne University and is a Adjunct Professor at Saint Louis University, and is a contributing author for Addiction Hope and Eating Disorder Hope. Libby lives in the St. Louis area with her husband and two daughters. She enjoys spending time with her family, running, and watching movies.


References:

[1] The Impact of Eating Disorders on Body Image. (n.d.). Retrieved September 25, 2017, from http://www.bulimia.com/topics/body-image/
[2] Mitchison, D., Crino, R., & Hay, P. (2013, June 13). The presence, predictive utility, and clinical significance of body dysmorphic symptoms in women with eating disorders. Retrieved September 25, 2017, from https://jeatdisord.biomedcentral.com/articles/10.1186/2050-2974-1-20
[3] Body Dysmorphic Disorder and Addiction. (n.d.). Retrieved September 25, 2017, from http://www.dualdiagnosis.org/body-dysmorphic-disorder-addiction/
[4] Diagnosis and Clinical Assessment in BDD. (2016, February 03). Retrieved September 25, 2017, from https://bdd.iocdf.org/professionals/diagnosis/


The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on November 3, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on November 3, 2017.
Published on EatingDisorderHope.com