Body Dysmorphia

Reviewed by Jason Nagata MD, MSc

Body dysmorphic disorder (BDD) is a type of obsessive-compulsive disorder in which a person becomes preoccupied or obsessed with what they perceive as a flaw in their physical appearance that is not observable to others or is a slight physical difference.1 People with BDD also engage in compulsive behaviors and thoughts such as repeated mirror checking or comparing their appearance to others.1 In order to be diagnosed with BDD the preoccupation with appearance must not be better explained by concerns about body image or weight as in the case of an eating disorder but rather an inability to stop thinking about a specific body part or their general appearance (i.e. their nose, feeling deformed).1 The person must also experience clinically significant distress or impairment in social, occupational, and/or other important areas of life.1 Muscle dysmorphia is a subtype of body dysmorphia in which individuals become preoccupied with a perceived flaw in their build and believe that their musculature is inadequate. They often engage in compulsive behaviors such as dieting, exercise or lifting weights in some cases to the point of causing physical injury and might also use dangerous anabolic steroids and other substances in an effort to increase their musculature.1 Approximately 2.4% of adults in the United States will be diagnosed with BDD at some point in their lives.1 Rates of BDD overall are higher among those who seek plastic surgery and among girls and young women compared to males of the same age; however, muscle dysmorphia occurs primarily in males.1 

Link Between Body Dysmorphic Disorder and Eating Disorders


Whereas body image issues for individuals with eating disorders are typically related to weight and shape concerns, people with body dysmorphic disorder (BDD) have concerns about specific aspects of their appearance (i.e. their facial features, skin, or hair etc).2,3 Despite being two distinct disorders with different diagnostic criteria, eating disorders and BDD have many overlapping symptoms and often co-occur.3 Though there is limited research on the topic, studies have found that 25–39% of individuals with anorexia nervosa will also be diagnosed with BDD and 32% of those with BDD will be diagnosed with an eating disorder at some point in their lifetime.4

The following are some of the similarities between individuals with eating disorders and body dysmorphic disorder: 

  • Experience distorted body image and have poor insight about their obsessive thoughts and compulsive behaviors.1 While people with BDD and eating disorders like anorexia nervosa both have a distorted self perception, individuals with BDD usually have more delusional beliefs about their appearance and poorer awareness that such beliefs are false.4
  • Both disorders typically begin during adolescence.5
  • Share similar emotions such as feelings of shame, disgust, anger and/or anxiety related to their appearance and self-perception.6,7
  • Similar behaviors like body checking in the mirror or obsessively taking selfies, avoiding social situations due to feelings of insecurity about their appearance, seeking reassurance from others about how they look, and/or camouflaging their perceived flaws by wearing baggy clothing.1,6
  • Increased risk for co-occurring disorders such as depression, anxiety, obsessive-compulsive disorder, substance use disorder, and suicide ideation.1
  • Difficulties with visually processing the body and physical features accurately.4 
  • Similar personality traits such as having low self-esteem, perfectionism, and anxiety.6,8
  • Engaging in compensatory behaviors such as dieting or exercise to alter the body.1 Studies have found this overlap is greater between anorexia nervosa and muscle dysmorphia.8

The similarities between BDD and eating disorders have prompted some researchers to speculate that there may be a link between them, though there have been limited studies to explore how they may be related.7,9 The overlapping symptoms between BDD and anorexia nervosa have also prompted some researchers to propose that it would be more accurate to classify one of these disorders as a subtype of the other or that a new diagnosis should be created to encompass both disorders (i.e. ‘body image disorders’).8,10 However, there has been little research into whether classifying these disorders as a subtype of one another or as a new type of disorder is more accurate than the current diagnostic model.11

Health Consequences


Both eating disorders and body dysmorphic disorder are serious mental health conditions which have a much higher rate of mortality than the general population. For example, anorexia nervosa has the second highest mortality rate of any mental illness with studies finding a six-fold increase in mortality compared to the general population.12 Reasons for this increased mortality rate include the effects of starvation, substance abuse, and suicide.12 Individuals with body dysmorphic disorder also have increased risk of death. This increased risk is primarily due to suicide, with approximately 24–28% attempting suicide and .3% dying by suicide per year, which is significantly greater than other types of mental illnesses and the general population.8 Furthermore, individuals who have both disorders exhibit more severe symptoms of each disorder as well as higher rates of psychiatric hospitalizations.3

Learn more about the health consequences of eating disorders here.

Treatment Considerations


Given the serious physical and psychological consequences that can result from eating disorders and body dysmorphic disorder, it is important to seek professional help as soon as possible. Eating disorders and body dysmorphic disorder may be treated at the same time and in some cases can be treated in the same manner, such as with cognitive behavioral therapy which has been found to be effective in the treatment of both disorders.13,14 However, due to the overlapping symptoms of these disorders it can be more difficult for clinicians to distinguish between them and provide an accurate diagnosis.9 This is particularly the case with anorexia nervosa, which shares more symptoms with BDD than other types of eating disorders.14 Since recovery from one disorder does not ensure recovery from another, it is essential for professionals to assess patients with body image concerns for both these conditions so they can both be accurately diagnosed and appropriately treated. 

Learn more about treatment here.

Learn more about finding a treatment provider here.

Sources


[1]  American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

[2] Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of eating disorders, 10(1), 132. https://doi.org/10.1186/s40337-022-00654-2

[3]  Grant, J. E., Leppink, E. W., & Redden, S.A. (2017). The Relationship Between Body Dysmorphic Disorder and Eating Disorders. In K.A. Phillips (Ed.), Body dysmorphic disorder: Advances in research and clinical practice (pp. 503-513). New York: Oxford University Press. https://academic.oup.com/book/24591/chapter-abstract/187880255?redirectedFrom=fulltext&login=false 

[4] Moody, T. D., Morfini, F., Cheng, G., Sheen, C. L., Kerr, W. T., Strober, M., & Feusner, J. D. (2021). Brain activation and connectivity in anorexia nervosa and body dysmorphic disorder when viewing bodies: relationships to clinical symptoms and perception of appearance. Brain imaging and behavior, 15(3), 1235–1252. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921207/ 

[5] Zhang, A., Leow, A., Zhan, L., GadElkarim, J., Moody, T., Khalsa, S., Strober, M., & Feusner, J. D. (2016). Brain connectome modularity in weight-restored anorexia nervosa and body dysmorphic disorder. Psychological medicine, 46(13), 2785–2797. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5305274/ 

[6] Fisher, E., Neziroglu, F., & Feusner, J. (2023). Eating disorders are not the same as body dysmorphic disorder (and why it matters). OCD Newsletter, 37(2). https://iocdf.org/download/summer-2023-vol-37-num-2/    

[7]  Matos, M., Coimbra, M., & Ferreira, C. (2023). When body dysmorphia symptomatology meets disordered eating: The role of shame and self-criticism. Appetite, 186, 106552. https://doi.org/10.1016/j.appet.2023.106552

[8] Cerea, S., Bottesi, G., Grisham, J. R., & Ghisi, M. (2018). Non-weight-related body image concerns and Body Dysmorphic Disorder prevalence in patients with Anorexia Nervosa. Psychiatry research, 267, 120–125. https://doi.org/10.1016/j.psychres.2018.05.068

[9] Vaughn, D. A., Kerr, W. T., Moody, T. D., Cheng, G. K., Morfini, F., Zhang, A., Leow, A. D., Strober, M. A., Cohen, M. S., & Feusner, J. D. (2019). Differentiating weight-restored anorexia nervosa and body dysmorphic disorder using neuroimaging and psychometric markers. PloS one, 14(5), e0213974. https://doi.org/10.1371/journal.pone.0213974

[10] Phillipou, A., Castle, D. J., Rossell, S. L. (2019). Direct comparisons of anorexia nervosa and body dysmorphic disorder: A systematic review. Psychiatry Research, 274, 129–137. https://doi.org/10.1016/j.psychres.2019.01.106

[11]  Schneider, S. C., Baillie, A. J., Mond, J., Turner, C. M., & Hudson, J. L. (2018). The classification of body dysmorphic disorder symptoms in male and female adolescents. Journal of affective disorders, 225, 429–437. https://doi.org/10.1016/j.jad.2017.08.062 

[12] Papadopoulos, F. C., Ekbom, A., Brandt, L., & Ekselius, L. (2009). Excess mortality, causes of death and prognostic factors in anorexia nervosa. The British journal of psychiatry: the journal of mental science, 194(1), 10–17. https://doi.org/10.1192/bjp.bp.108.054742

[13] Harrison, A., Fernández de la Cruz, L., Enander, J., Radua, J., & Mataix-Cols, D. (2016). Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clinical psychology review, 48, 43–51. https://doi.org/10.1016/j.cpr.2016.05.007

[14] Linardon J. (2018). Meta-analysis of the effects of cognitive-behavioral therapy on the core eating disorder maintaining mechanisms: implications for mechanisms of therapeutic change. Cognitive behaviour therapy, 47(2), 107–125. https://doi.org/10.1080/16506073.2018.1427785