A Dangerous Duo: Body Dysmorphic Disorder with Anorexia Nervosa

Reprinted from Eating Disorders Review
November/December 2003 Volume 13, Number 6
©2002 Gürze Books

According to a team at the University of Minnesota, body dysmorphic disorder (BDD) is relatively common among patients with anorexia nervosa (Int J Eat Disord 2002;32:291). When the two disorders are combined, more serious illness results. Because of this, the authors suggest that all patients with anorexia nervosa be screened for BDD.

BDD is an often-secret preoccupation with an imagined or slight defect in appearance. Patients agonize over noses that seem too long or skin that isn’t perfect. They may spend hours checking and rechecking themselves in mirrors, or measuring their bodies again and again. In severe cases, patients won’t leave their homes because of their imagined defects. This distressing and often disabling condition is often under-diagnosed because patients with BDD are extremely secretive about their feelings and actions. As the authors learned, patients with both disorders are much more ill than those with anorexia nervosa alone.

A high percentage of morbidity

When Dr. Jon E. Grant and colleagues at the University of Minnesota screened 41 consecutive patients with anorexia nervosa (41 females with a mean age of 26.7 years), 16, or 39%, were diagnosed with comorbid BDD. Fourteen of the 32 patients with anorexia nervosa, restricting subtype (43.8% of the total group) and 2 of the 9 patients with anorexia nervosa, binge eating subtype (22.2%), were found to have BDD. None of the women had been diagnosed with BDD while hospitalized for treatment.

The problems with BDD appeared before anorexic symptoms in 15 (93.8%) of anorexia nervosa patients with BDD. Those with comorbid AN and BDD also reported an earlier age of onset of anorexia nervosa compared to patients without BDD. The 16 women with AN and BDD had a variety of other current Axis I disorders: 14 met DSM-IV criteria for an Axis I disorder in additional to AN and BDD. More than half had a major depressive disorder a fourth had social phobia, and 19% had obsessive-compulsive disorder. Patients with anorexia nervosa without comorbid BDD met DSM-IV criteria for a current Axis I disorder other than anorexia nervosa—major depressive disorder (12, or 48%); obsessive-compulsive disorder (4, or 16%), and alcohol abuse (2, or 8%).

More severe symptoms

Those with AN and BDD were more ill than were those without comorbid BDD. The rate of attempted suicide was significantly greater and they were hospitalized significantly more often than the anorexic patients without BDD. More than half of those with comorbid disease had consulted a non-psychiatric physician for an appearance concern not related to anorexia nervosa. Seven had sought plastic surgery although none had undergone surgery. (In 4 cases the physician refused to do the surgery and 3 other patients couldn’t afford it). Four others who sought dermatological help were all treated with dermabrasion and antibiotics.

AN and BDD share a number of features, including compulsive symptoms such as mirror-checking and body measuring. Both have high rates of obsessive-compulsive symptoms, and there is evidence that both disorders respond to serotonin reuptake inhibitors.

Failure to detect BDD may have important implications for treatment, according to the authors. In their study, 69% of patients with AN and BDD first sought non-psychiatric treatment to correct their perceived “defects” in appearance. Nonpsychiatric treatment usually does not improve BDD symptoms, and such treatment should be avoided or approached with caution in this population. A potential increase of suicides also underscores the importance of screening for BDD.

DSM-IV Criteria for BDD

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

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