by Jenni Schaefer & Katharine Phillips, MD
Jenni Schaefer is a bestselling author, popular speaker, and a National Recovery Advocate for Eating Recovery Center’s Family Institute. Her books include Life Without Ed; Goodbye Ed, Hello Me; and Almost Anorexic. In partnership with Insight Behavioral Health Centers, Eating Recovery Center provides specialized treatment for eating disorders as well as related disorders, including BDD. To learn more, visit www.jennischaefer.com/seek-help.
Katharine Phillips, MD, is internationally known for her pioneering research and clinical work in body dysmorphic disorder and related conditions. She has published more than 300 scientific papers, and she has authored or edited nine books on BDD and obsessive-compulsive and related disorders, including a 2017 edited volume on BDD (published by Oxford University Press). She provides evaluation and treatment for patients in her clinical practice in New York City at Weill Cornell Medical College, and she is a Professor of Psychiatry and Human Behavior at the Alpert Medical School of Brown University. Dr. Phillips is also a member of the IOCDF’s Scientific and Clinical Advisory Board. To learn more visit www.KatharinePhillipsMD.com.
This article was initially published in the Winter 2017 edition of the OCD Newsletter
I stared in the mirror and obsessed about whether or not a space existed between my thighs. Commonly referred to as ‘thigh gap’, I did my best to stand at specific angles that might create such a space. When I couldn’t achieve this so-called ideal after a considerable amount of effort, I wore baggy clothes to hide the perceived flaw. Instead of hanging out with friends, I stayed in — again.
The description above is just one example of how an eating disorder used to control my life. For many years, my body was a prison.
If your body keeps you from engaging in life, it might be a sign that you have an eating disorder (ED). However, another condition, body dysmorphic disorder (or BDD), can also cause people to feel as if they are imprisoned by their bodies. While these two disorders share many similarities, and sometimes in fact get confused with each other, it is important to understand and recognize how they differ, as the treatment for each can differ.
What is Body Dysmorphic Disorder or BDD?
BDD consists of a preoccupation with perceived defects or flaws in one’s physical appearance, which are actually nonexistent or only slight. People with BDD think that the perceived flaws are clearly noticeable and look abnormal to others. This appearance preoccupation causes significant emotional distress (e.g., sadness, shame, or anxiety) and/or impairment in day-to-day functioning (e.g., avoidance of social situations or impairment in one’s job or school work). In addition, people with BDD perform excessive repetitive behaviors, such as frequent mirror checking, skin picking, or excessive grooming in an attempt to fix, check, hide, or obtain reassurance about the disliked body areas.
What does an Eating Disorder look like?
Eating disorders are sometimes life-threatening illnesses in which people experience severe disturbances in their eating behaviors and related thoughts and emotions. People with EDs typically become preoccupied with food and their body size and shape. The DSM-5, the mental health field’s diagnostic manual, describes several types of eating disorders:
- Anorexia Nervosa is characterized by severe food restriction leading to significantly low body weight and intense fear of weight gain or of becoming fat, or behavior that interferes with weight gain (despite very low weight). There is also a disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on one’s self-evaluation, or persistent lack of recognition of the seriousness of one’s low body weight.
- Binge Eating Disorder is characterized by eating abnormally large quantities of food in a short period of time. Binge eating feels out of control and causes marked distress.
- Bulimia Nervosa is characterized by eating abnormally large quantities of food in a short period of time, followed by compensatory behavior (e.g., self-induced vomiting, excessive exercise, fasting) intended to neutralize the impact of binge eating on shape and weight. In addition, self-evaluation is unduly influenced by body shape and weight.
- Other Specified Feeding or Eating Disorder (OSFED) is characterized by symptoms characteristic of an eating disorder that cause significant distress or impairment in functioning but don’t meet all of the diagnostic criteria for anorexia nervosa, binge eating disorder, bulimia nervosa, or another feeding or eating disorder.
Over a person’s lifetime, an individual may struggle with different types of eating disorders. As an example, I battled Other Specified Feeding or Eating Disorder (OSFED), which eventually transformed into anorexia nervosa. I struggled with the anorexia nervosa subtype that includes binge eating and purging as well as the more commonly known behavior of food restriction. All in all, an eating disorder, regardless of the specific diagnosis and behaviors, is a serious illness that may severely impact one’s quality of life and health.
How do BDD Symptoms and ED Symptoms Overlap?
Much like with ED, if you battle BDD, negative body image might control your life. You might perform checking behaviors, like excessive mirror gazing, or avoidance behaviors, such as not going out with friends. You may feel the need to constantly seek reassurance from friends and family with regard to your appearance. In addition to sharing these similarities, both BDD and ED are also associated with depression and low self-esteem. While these similarities can make BBD and ED difficult to tell apart, there are some key differences.
What’s the difference between an eating disorder and BDD?
What I (J.S.) didn’t share as part of my story above is one of the key differences between the two diagnoses: I didn’t eat that day. In order to be diagnosed with an ED, as indicated in the diagnostic criteria listed above, eating must be significantly impaired. A BDD diagnosis does not require a problem with eating; abnormal eating sometimes occurs as a symptom of BDD but is usually less severe and problematic than in an eating disorder.
In terms of body image difficulties, while BDD tends to be focused more on specific parts of the body like nose or hairline, the preoccupation with the body in an ED is more generalized to shape and weight concerns. However, BDD can also involve larger body areas such as weight and body shape, which can sometimes make it difficult to distinguish them, as discussed below.
In my (J.S.) case, it was important to look at how body image concerns impacted my life. When I struggled with an eating disorder, I really didn’t like my nose and I hated the blemishes on my chin. Because these concerns never caused severe anxiety, shame, or other significant emotional distress, and didn’t impact my day-to-day functioning, I didn’t meet diagnostic criteria for BDD. Instead, what prevented me from truly living my life were concerns about my shape and weight combined with extreme binge eating and fasting— all accompanied by intense shame, anxiety, and depression.
To sum it up, here are the two main questions to ask when distinguishing between BDD and eating disorders:
- Is eating impaired?To be diagnosed with an eating disorder, someone must have substantial difficulty with eating, like restricting food intake, binging, and/or purging that fulfills the definition of an eating disorder in the DSM-5. To receive a diagnosis of BDD, eating does not have to be impaired; if it is, it is not impaired enough to meet the definition of an eating disorder.
- Where is the body image disturbance?BDD usually focuses on perceived abnormalities of the skin, face, or head (e.g., “scarred and blotchy” skin, a “huge” nose, or perceived balding). Body image disturbance in an ED is more focused on general shape and weight concerns.However, to complicate matters, BDD can also involve concerns with body weight, shape, and overall body size. Examples include a preoccupation with one’s weight or the belief that one’s thighs, arms, or stomach are too fat when this is not actually the case. People with such concerns should be evaluated for an eating disorder. If these concerns fulfill the DSM-5’s definition of an eating disorder, that diagnosis takes precedence over a diagnosis of BDD. In other words, an eating disorder, rather than BDD, should be diagnosed.
Again, differentiating between BDD and an eating disorder isn’t always clear-cut. If a person’s appearance concerns do not qualify for a diagnosis of an eating disorder, yet they are preoccupied with being fat when they actually aren’t, and eating behavior is not entirely normal, it can be challenging to determine whether an eating disorder or BDD is the more fitting diagnosis. In such cases, a clinician with expertise in these conditions can determine whether an eating disorder or BDD is the more accurate diagnosis.
Can someone be diagnosed with both an ED and BDD?
Some people do struggle with both BDD and an eating disorder. Here’s an example:
A man is preoccupied with both a perceived defect of his nose, believing that it’s “huge and crooked,” as well as “feeling fat,” and he fasts and exercises compulsively to try to lose weight. Both of these body image concerns cause severe distress and make it difficult to socialize with friends or attend class.
While most people with ED strongly dislike, or even hate their bodies, this alone would not qualify them for a BDD diagnosis. As with the example above, for someone with an eating disorder to also be diagnosed with BDD, they must also intensely struggle with one or more perceived appearance defects that do not qualify for an eating disorder diagnosis. The man in the example had an eating disorder and BDD surrounding his beliefs about his nose.
Is there a Relationship Between BDD and ED?
More research is needed to identify the exact relationship between BDD and ED. Based on the research that’s been done so far, they appear to be separate conditions that also have some overlapping features. One overlapping feature is that people with BDD and anorexia nervosa appear to actually see themselves differently than other people do: people with anorexia nervosa and those with BDD tend to over focus on tiny details when looking at faces, bodies, or other objects and to have difficulty seeing “the big picture.”
It is worth mentioning that almost one third of individuals with BDD also struggle with an eating disorder at some point during their lifetime. Conversely, research suggests that the symptoms of BDD may appear in 25 percent of anorexia nervosa sufferers for at least six months prior to the eating disorder entering the picture. When BDD is present in addition to anorexia nervosa, the odds of needing psychiatric hospitalization and attempting suicide are markedly elevated compared to having anorexia nervosa without co-occurring BDD, so it is important to diagnose both conditions when they are present.
Why does this matter?
Both BDD and eating disorders are complicated, real, and terrifying to those affected. A specific diagnosis cannot measure pain and suffering. Yet, a correct diagnosis points toward the most effective treatment options. Someone suffering with an eating disorder without BDD would follow a different treatment path than a person with an eating disorder plus BDD or someone with BDD and no eating problems. An individual with an ED needs treatment that helps him or her overcome the disordered eating behavior and incorporates learning how to nourish one’s body in a balanced way. Medication and other types of therapy are also often helpful for an eating disorder, although specific approaches differ somewhat for different types of eating disorders. BDD is treated with serotonin-reuptake inhibitor (SRI) medications specifically (other medications are sometimes used in addition to an SRI) as well as cognitive-behavioral therapy that is specific to BDD’s unique symptoms.
Above all, know that healing from both BDD and eating disorders is possible. With treatment, effort, and persistence, people do get better. I did. And, in my work as an advocate, I have connected with countless people who have healed from both BDD and eating disorders. Some had struggled with both. Surprisingly, thanks to the gift of recovery, many of us are now in a place where our attitude about our body is actually healthier than that of the average person! Like many things in life, our struggles made us stronger. If you (or your loved one’s) relationship with their body is a problem, know that treatment is available.
A body doesn’t have to be a prison. Instead, our bodies can be precious vehicles for life. Don’t quit until you find it.
Grant, J. E., Lepink, E. W., & Redden, S. A. (2017). The relationship between body dysmorphic disorder and eating disorders. In Phillips, K.A., (Ed), Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press.
Hartmann, A. S., Thomas, J. J., Greenberg, J. L., Matheny, M. L., & Wilhelm, S. (2014). A comparison of self-esteem and perfectionism in anorexia nervosa and body dysmorphic disorder. The Journal of Nervous and Mental Disease, 202(12), 883-888.
Li, W., Lai, T. M., Bohon, C., Loo, S. K., McCurdy, D., Strober, M., Bookheimer, S., & Feusner, J. (2015). Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information. Psychological Medicine, 45(10), 2111-2122.
Phillips, K. A. (2009). Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY: Oxford University Press.
Rabe-Jablonska Jolanta, J., & Sobow Tomasz, M. (2000). The links between body dysmorphic disorder and eating disorders. European Psychiatry, 15(5), 302-305.
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),