NYT: Ask the Expert: Is it Anorexia, or Body Dysmorphic Disorder?

Dr. Katharine A. Phillips, a professor of psychiatry at Brown Medical School, is perhaps the best known authority on Body Dysmorphic Disorder (B.D.D.) and the author, most recently, of “Understanding Body Dysmorphic Disorder: An Essential Guide” (Oxford University Press, 2009).  Dr. Phillips answers reader questions at the New York Times in this week's Ask the Expert column. 

Q:  Hello Dr. Phillips, thanks for answering questions. Could you clarify the distinction between body dysmorphic disorder and the severe distortion of weight and shape experienced in eating disorders?



I had severe anorexia for years but worked very hard toward recovery. I have seen a psychologist weekly for the past six years, and in that time, I’ve gone from a 15.7 B.M.I. to about a 22.3.


The thing is, although my eating behaviors and weight have changed and I’m now able to live an energetic life that I truly am able to value at this point, I still wake up every day horrified by the hugeness of my “normal”-sized body. I avoid mirrors, malls, shopping, magazines, tight clothes and even touching or looking down at my body (as much as possible) to avoid triggering feelings of complete revulsion and self-hatred that often lead to self-harming.

It’s actually more of a relief to try to believe that I am crazy (as my friends kindly remind me) than to face the “fact” of the body I see and feel. Needless to say, my body shame (over my bone structure, shape, everything) is a huge hindrance to intimacy and a social life. It seems as if B.D.D. is, like eating disorders, genetically and physiologically embedded. So what is the distinction between eating disorders and B.D.D.?

I also wanted to ask this question because the following comment in the New York Times article accompanying the blog post really bothered me. Jane Brody writes:
                "One presumed factor — societal emphasis on looks — is far less important than you
                  might think. Dr. Phillips said the incidence of B.D.D. was nearly the same all over the
                 world, regardless of cultural influences. Also, unlike eating disorders, which mainly
                 affect women seeking supermodel thinness, nearly as many men as women have body
                 dysmorphic disorder."


Point taken — the demographics for B.D.D. are indeed more evenly distributed across gender lines than those for eating disorders (although eating disorders are found in both males and females of all ages and all cultural and environmental backgrounds, it’s still true that women vastly outnumber men with these diseases). But the statement that eating disorders affect women “seeking supermodel thinness” is just plain ignorant, and suggests that people get eating disorders through a kind of vain willfulness. I’m sure this sentiment is found in your work as well. So how do you convince people who don’t know anything about B.D.D. that it’s not just a condition prompted by vanity and narcissism?

A: Dr. Katharine Phillips responds:
Thank you for your question about the distinction between body dysmorphic disorder and eating disorders -– this is a common question.

These disorders do have some overlapping features. Both involve dissatisfaction with one’s appearance and distorted body image. In fact, studies have found that people with B.D.D. and those with eating disorders have equally severe body image preoccupation, dissatisfaction and distress. And some people with B.D.D. are distressed by their weight or the belief that some parts of their body, such as their stomach or hips, are too fat, and they may diet or exercise excessively.

But there are some important differences between B.D.D. and eating disorders. Most people with B.D.D. aren’t preoccupied with their weight -– rather, they most commonly focus on their skin (such things as perceived acne, scarring or skin color), hair (for example, a belief that they’re losing their hair or have too much body hair), or nose. In fact, they can dislike any part of their body, thinking it looks ugly or abnormal, even though it looks normal to others. And B.D.D. doesn’t involve behaviors like binging on food or inducing vomiting to lose weight.

Another difference, as you noted, is that B.D.D. appears to affect nearly as many men as women, whereas most people with an eating disorder are female. There are also some differences in effective treatment approaches. Research studies that have directly compared people with B.D.D. to people with an eating disorder have found, among other things, that those with eating disorders have more psychological symptoms on a scale called the Brief Symptom Inventory, whereas those with B.D.D. have more negative self-evaluations and lower feelings of self-worth because of appearance concerns, more avoidance of activities because of self-consciousness about appearance, and worse functioning and quality of life because of appearance concerns.

Indeed, B.D.D. usually has very negative effects on people’s daily functioning and quality of life. Some people are unable to work, go to school, socialize or have relationships because of their B.D.D.

This brings me to your last question -– B.D.D. is definitely not a condition prompted by vanity and narcissism. It is a serious, and usually treatable, disorder. Typically, people with B.D.D. suffer tremendously, and those with more severe B.D.D. find that their lives are devastated by their symptoms. Some even commit suicide. This brings home what a serious disorder B.D.D. is. The good news is that most people get better with the right treatmennt.