It is important from the start here, to differentiate Body Dysmorphic Disorder (BDD) from the Body Dysmorphia associated with eating disorders. In fact, when it comes to eating disorders, the three terms that are more appropriate to discuss with regards to body dysmorphia are body image distortion, body image internalization and body image distress.
1) BODY IMAGE DISTORTION relates to the degree of perceptual distortion one has when viewing themselves in a mirror or photo and how they visually see themselves, or more accurately perceive themselves. Not all patients with an eating disorder have altered perceptions of their body image while some patients have minor distortions and others suffer with severe distortions, seeing themselves as “huge,” or “obese,” even though their weight may be normal or severely underweight. Such distortions may be caused by changes to the brain that take place during the course of an eating disorder and can, with time, return back to a baseline state.
2) BODY IMAGE INTERNALIZATION relates to the internal personal experience one feel about their body. While it is often correlated to the level of body image distortion, it can vary in severity independently. The degree of distortion with body image internalization tends to vary more frequently, even on a day-to-day basis, compared to body image distortion. Patrons who suffer with distorted internalization describe “feeling” like they are “fat,” “huge,” and “ugly,” with a distorted evaluation of the self. Their perceptions again may be related to a malfunctioning of the brain secondary to the eating disorder. Like body image distortion, this distorted internalization tends to recover as the eating disorder recovers.
3) BODY IMAGE DISTRESS is the severity of the mental stress one experiences with relation to body image distortion and body image internalization. High levels of distortion with one’s perception of themselves can cause extreme anxiety, agitation, and depression leading to significant mood instability, isolation, increased drive-for-thinness and barriers towards recovery. Body image distress is also a major cause of relapse in patients who enter the recovery phase.
When assessing treatment with an eating disorder patient, it is necessary to monitor these aspects about body dysmorphia.
BODY IMAGE DISTORTION + BODY IMAGE INTERNALIZATION
= BODY IMAGE DISTRESS
BODY DYSMORPHIC DISORDER – Most patients who have an eating disorder with body dysmorphia do NOT have Body Dysmorphic Disorder (BDD). BDD is a distinct condition classified in the DSM-5 in the chapter of “Obsessive-Compulsive and Related Disorders. In fact, when diagnosing BDD there is a specific exclusionary criteria for the differentiation from an eating disorder: If the appearance preoccupations focus on being too fat or weighing too much, the clinician must determine that these concerns are not better explained by an eating disorder. If the patient’s only appearance concern focuses on excessive fat or weight, and the patient’s symptoms meet diagnostic criteria for an eating disorder, then he or she should be diagnosed with an eating disorder, not BDD. However, if criteria for an eating disorder are not met, then BDD can be diagnosed, as concerns with fat or weight in a person of normal weight can be a symptom of BDD. Additionally a patient can have both an eating disorder and BDD provided they meet the criteria for BDD separate from the feeling “fat” and weight issues.
To better understand, the additional diagnostic criteria for BDD include:(1)
1) A preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. The most common preoccupations focus on the skin (eg, scarring, acne, color), hair (eg, going bald, excessive facial or body hair), or nose (eg, size or shape), although any body part can be the focus of concern. Furthermore, a preoccupation is often defined as thinking about the perceived appearance defect(s) for at least 1 hour a day (similar to obsessive-compulsive disorder (OCD).
2) To meet criteria as a true disorder, the preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
It is important to note that many patients with Body Dysmorphia and BDD do not spontaneously reveal their BDD symptoms to others including family, friends and clinicians because they fear being further judged. Full disclosure about any body dysmorphia and BDD is important as it needs to be addressed in a treatment plan for recovery.
BDD appears to be relatively common and has been seen in children as young as 5-years-old and in adults in the 80’s. Epidemiologic studies have reported a BDD prevalence of 0.7% to 2.4% in the general population while investigations in nonclinical adult student samples have yielded higher prevalence rates of 2% to 13 %. (2)
Muscle dysmorphia is a specific type of BDD that is found in both males and females, but more common men. The muscle dysmorphia form of BDD is diagnosed if the individual is preoccupied with concerns that that his or her body build is too small or insufficiently muscular. Individuals will often engage in excessive weight training exercises and abuse of steroids and other muscle building supplements which can pose great risk to the individual in the short and long term. Individuals with the muscle dysmorphia are know to have higher rates of depression, mood instability, substance abuse issues and suicide than other types of BDD.
BDD is often misdiagnosed as another disorder. It is important that anyone suspected of having BDD be examined and interviewed by a psychiatrist or other qualified mental health professional to avoid any misdiagnosis that could lead to inappropriate care. Differential diagnosis includes: