The links between body dysmorphic disorder and eating
J. Rabe-Jablonska Jolanta*, M. Sobow Tomasz
II Department Of Psychiatry, Medical University Of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland
(Received 10 August 1998; revised 28 April 2000; accepted 2 May 2000)
Summary – Theaimofthestudywastosearchforabodydysmorphicdisorder(BDD)periodprecedingthesymptoms
meeting the criteria of either anorexia or bulimia nervosa, and an evaluation of the prevalence of BDD symptoms in a
control group of girls without any eating disorder. Ninety-three girls (12–21 years old) were included in the study (36
with anorexia nervosa, 17 with bulimia nervosa and 40 healthy controls). The Structured Clinical Interview (SCID),
including the BDD module, and a novel questionnaire (for the presence of preceding life events) were used. We found
the symptoms of BDD in 25% of anorexia nervosa sufferers for at least six months before observing a clear eating
idea that BDD and anorexia nervosa both belong to either OCD or affective disorders spectra. © 2000 Éditions
scientifiques et médicales Elsevier SAS
anorexia nervosa / body dysmorphic disorder / bulimia nervosa
Body dysmorphic disorder (BDD; the term dysmor-
phophobia is also used) belongs to the somatoform
classifications . In the latest ICD version, the diag-
nosis is not specified as a distinct heading as in the
DSM-IV, and as a consequence, one cannot find sepa-
rate diagnostic criteria there.
Some authors stress the clinical similarities between
body dysmorphic disorder and obsessive-compulsive
disorder (OCD) or even more, they treat BDD as
belonging to the OCD spectrum [2-4]. Moreover, in
one co-morbidity study it has been shown that features
of BDD are most common in patients with social
phobia and OCD and so they concluded that it may
share etiologic elements with both social phobia and
obsessive-compulsive disorder .
Individuals with BDD frequently present obsessions,
e.g., repetitive thoughts about specific features of their
physical appearance and compulsive checking and
Patients with both OCD and BDD respond well to
selective serotonin reuptake inhibitors treatment.
According to some researchers, this implies dysregula-
tion of the serotoninergic system as a common etiology
of both disorders [6, 7, 9].
Other authors believe that BDD belongs to the
to epidemiologic data which show that affective disor-
ders (mainly major depression) are more common
* Correspondence and reprints
Eur Psychiatry 2000 ; 15 : 302-5
© 2000 Éditions scientifiques et médicales Elsevier SAS. All rights reserved
with BDD suffer more frequently from affective disor-
ders than individuals in the general population [7, 10,
Supposed links between BDD and anorexia nervosa
are also taken into consideration and are considered
interesting. A group of authors supports the opinion
that in some patients diagnosed as anorexic, symptoms
In such cases patients may try to improve their physical
to some parts of the body, mainly the face and the legs.
It seems that the more anxious a patient is of his or her
physical appearance, the more complicated the system
of corrective activities. As a consequence it leads to
psychopathological symptoms fulfilling the criteria of
It has to be stressed that according to both ICD and
DSM-IV the diagnosis of BDD cannot be used if the
symptoms appeared at the same time as the symptoms
of the eating disorders.
The presented views seem to be of a theoretical value
only, due to the lack of systematic studies in this area.
Moreover, anorexia nervosa is treated by most of the
authors as consisting of several subgroups of a different
pathogenesis which include OCD, affective disorders,
somatoform disorders, primary phobias, etc. The same
is being proposed for bulimia nervosa, which may
belong to the OCD spectrum, affective disorders or
impulse control disorder.
The aim of the retrospective study presented was to
search for a BDD period preceding the symptoms
meeting the criteria of eating disorders, either anorexia
or bulimia nervosa, and to evaluate the prevalence of
eating disorder. Occurrence of other mental disorders
in the studied group was also examined, as well as life
events which are characteristic for the group.
SUBJECTS AND METHOD
Ninety-three girls aged between 12 and 21 years of age
were included in the study. In that sample, 36 girls met
DSM-IIIR and DSM-IV criteria of anorexia nervosa,
17 for bulimia nervosa and 40 were considered healthy
tomatic period in the anorexia nervosa subgroup was 2
years and 10 months (range: 1–4 years), in the bulimia
nervosa subgroup 1 year and 2 months (range: 6
months–2 years). All examined girls were patients of
the Adolescent Inpatient Unit or the Outpatient Unit
sity of Lodz, Poland, and all had signed a written
In both eating disorders groups as well as in the
control group the symptoms of BDD preceding eating
disorders for a period of at least six months were diag-
nosed according to DSM-III-R using the Structured
Clinical Interview for DSM-III-R (SCID) with the
BDD module [1, 11-14]. Furthermore, in a group of
patients with BDD and anorexia nervosa, the presence
the same tool (SCID). Psychiatric co-morbidity was
also examined in the anorexia nervosa subgroup.
Using a questionnaire originally developed for this
purpose, all the girls were examined for the presence in
their histories of any events preceding a symptomatic
interest in boys, loss of a partner, negative remarks on
patient’s physical appearance, or special emphasis by
the parents on physical appearance (subjective evalua-
tion of their opinions, reactions and behavior).
The results were statistically analyzed (Fisher exact
BDD symptoms were present in 25% of anorexia ner-
vosa suffering girls for at least 6 months (range: 6
months–3 years, mean: 14 months) before observing a
clear eating disorder picture. The difference between
patients suffering from bulimia nervosa and healthy
controls was statistically non-significant (table I),
cheeked”) or the shape of limbs (“too fat”, “too fat and
too short”) as a defect of their physical appearance.
No members in the group of bulimics presented
BDD symptoms, though 7.5% of subjects in the con-
trol group had slightly pronounced symptoms. In a
latter group, girls considered as defects the shapes of
their noses, teeth, faces and legs and other parts of the
body. The “defects” were minor but real beauty flaws.
In a subgroup of anorexia nervosa sufferers with a
distinct preceding period of BDD symptoms, addi-
tional diagnoses of OCD (six girls), obsessive-
compulsive personality disorder (one girl) or affective
disorders, either major depression or dysthymic disor-
BDD and eating disorders
Eur Psychiatry 2000 ; 15 : 302–5
der (two girls), were made (table II). It has been also
shown retrospectively that OCD symptoms existed in
disorders while affective disturbances appeared much
later, after all the symptoms of eating disorders were
already present. However, the data can be seriously
reports, and only three of them were confirmed by the
related to eating).
Two subgroups of anorexia nervosa sufferers and
their histories of such events preceding a symptomatic
period as rejection of same-age girls, lack of interest in
boys, loss of a partner, negative remarks on patient’s
physical appearance, or special emphasis by the parents
1, and 2, 3, and over 3) of such events in anorexic
patients with a BDD period was significantly higher
(P = 0.001) than in a group without such a preceding
period (table III), while the bulimic patients did not
differ from either anorexics without BDD or healthy
controls (not shown). It may be hypothesized that
opment of negative self-esteem and anxiety about not
being “ugly” or “funny.”
In the study it has been shown that 25% of anorexia
of BDD symptoms. In that period, the exclusive diag-
nosis of BDD could be made, but the prevalence of
such a period was not significantly higher in the anor-
exia group than in bulimia nervosa group (0%) or in
healthy controls (7.5%). In each analyzed case the
Table I. The frequency of BDD symptoms among patients with diagnosis of anorexia nervosa (AN) and bulimia nervosa (BN) and in a control
AN Statistical significanceBN Statistical significanceControl
N = 40
N = 36
AN + BDD
N = 17
BN + BDD AN + BDD versus
P = 0.57
AN + BDD versus
BN + BDD
P = 0.44
BN + BDD versus
NSN = 9N = 0N = 3
* Fisher exact test, two-tailed.
Table II. Coexisting mental disorders in a subgroup of anorexia
nervosa sufferers with preceding BDD symptoms period.
Additional psychiatric diagnosis
according to DSM-IV criteria
1) obsessive-compulsive disorder
2) affective disorders
– major depression
– dysthymic disorder
3) obsessive personality disorder
Table III. Specific events preceding BDD and anorexia nervosa symptoms.
Type of event AN, N = 27 AN + BDD, N = 9
Statistical significance (Fisher
exact test, two-tailed)
Same age group rejection
Lack of interest in boys
Remarks on a physical appearance
Emphasis on physical appearance by relatives
Loss of a partner
Number of events
at least one event (1, 2, 3, and > 3)
P = 0.001
J. Rabe-Jablonska Jolanta, M. Sobow Tomasz
Eur Psychiatry 2000 ; 15 : 302–5
borderline between BDD and clear anorexia nervosa Download full-text
symptoms periods was not distinct and there was no
order features or symptoms of OCD.
also be taken into consideration. The presence of exist-
ing but slight beauty defects was often emphasized by
cally compared to others. The latter implied disadvan-
tage in the same age group, though sometimes only as
listed above were present only in some cases.
In the period of clear anorexia nervosa symptoms in
some girls coexisting OCD or affective disorder could
cal course of eating disorders . Perhaps this is why
the subgroup with coexisting BDD constitutes at the
same time the subgroup with a longer clinical course of
the disorder. After summarizing the data, it is possible
ers with a preceding period of BDD and coexisting
mental disorder such as OCD or affective disorders
(major depression or dysthymic disorder). This may
support the idea that BDD and anorexia nervosa both
belong to either OCD or affective disorder spectra. In
many cases it is difficult to draw clear time boundaries
between the periods. Moreover, the symptoms of dif-
ferent disorders may coexist. A variety of symptoms
present in many adolescent patients accounts for com-
plex, multidirected therapeutic approaches.
In the studied group, the patients with bulimia ner-
vosa did not present any symptoms of preceding BDD.
It is highly difficult to discuss the phenomenon having
such a small sample.
It is possible that the results are artifacts due to the
reduced sample size, so further studies on larger popu-
lations are necessary to address this question in a more
1 Diagnostic and statistical manual of mental disorders. 4th ed.
Washington, DC: American Psychiatric Association Press;
2 Holden NL. Is anorexia nervosa an obsessive-compulsive disor-
der? Br J Psychiatry 1990 ; 157 : 1-5.
3 Rabe-Jablonska J. Obsessive-compulsive disorder among girls
with eating disorders. Psychiatr Pol 1996 ; 2 : 187-200.
4 McKay D, Neziroglu F, Yaryura-Tobias JA. Comparison of
dysmorphic disorder. J Anxiety Disord 1997 ; 11 : 447-54.
5 Brawman-Mintzer O, Lydiard RB, Phillips KA, Morton A,
Czepowicz V, Emmpanuel N, et al. Body dysmorphic disorder
in patients with anxiety disorders and major depression: a
comorbidity study. Am J Psychiatry 1995 ; 152 : 1665-7.
6 Braddock LE. Dysmorphophobia in adolescence: a case report.
Br J Psychiatry 1987 ; 140 : 199-201.
7 Connolly FH, Gibson M. Dysmorphophobia: a long-term
study. Br J Psychiatry 1978 ; 132 : 568-70.
8 Halmi KA, Eckert E, Marchi P, Sampugnaro V, Apple R,
Cohen J. Comorbidity of psychiatric diagnoses in anorexia
nervosa. Arch Gen Psychiatry 1991 ; 10 : 675-81.
9 Heimann SW. SSRI for body dysmorphic disorder. J Am Acad
Child Adolesc Psychiatry 1997 ; 36 : 868.
10 Hudson JL, Pope HG Jr. Affective spectrum disorder: does
mon pathophysiology? Am J Psychiatry 1990 ; 147 : 552-64.
11 Diagnostic and statistical manual of mental disorders. 3rd ed.
Revised. Washington: American Psychiatric Association press;
12 Phillips KA, Atala KD, Pope HG. Diagnostic instruments for
body dysmorphic disorder 1995. Miami: New Research Pro-
gram and Abstracts, APA; 1995.
13 Philips KA, McElroy SL, Hudson JL, Pope HG Jr. Body
dysmorphic disorder: an obsessive-compulsive spectrum disor-
der, a form of affective spectrum, or both? J Clin Psychaitry
1995 ; 56 Suppl 4 : 41-51.
14 Spitzer RL, Williams JB, Gibbon M, First MB. The Structured
Clinical Interview for DSM-III-R (SCID). I: history, rationale,
and description. Arch Gen Psychiatry 1992 ; 49 : 624-9.
BDD and eating disorders
Eur Psychiatry 2000 ; 15 : 302–5