Eating Disorders And Body Dysmorphia: How These Mental Health Conditions Intersect

Many people assume that eating disorders always involve body dysmorphia, a cognitive distortion involving an unrealistically negative and critical view of their bodily appearance. Research indicates otherwise. While some eating disorders can be driven in part by a distorted body image, others may have different pathologies. Understanding the complex relationship between body image dysfunction and disordered eating may shed light on how these conditions arise and how they can be treated.

Body dysmorphia can be a symptom of another disease or a disorder in its own right. In the latter case, it’s commonly known as body dysmorphic disorder. Symptoms of body dysmorphia can be present in conditions like anorexia, in which case they can contribute to unhealthy behaviors like food restriction and purging. However, they may play a lesser role in binge eating disorder and other eating-related mental illnesses. In many cases, therapy can be helpful for those living with body dysmorphia, eating disorders, or both.

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What are body dysmorphia and body dysmorphic disorder?

As defined by the American Psychological Association, body dysmorphia is when an individual holds an extreme and unjustified negative view of some aspect of their own physical appearance. This can take a variety of forms, including the following:

• Fixating obsessively on perceived flaws or blemishes that other people don’t notice or view as minor
• Imagining a defect that isn’t there, such as perceiving your eyes as being too close together or thinking you’re overweight when you’re not
• Perceiving part of your body as too large or too small
• Judging your overall appearance as highly unattractive when others don’t agree

If you’re experiencing such severe body dysmorphia that it causes you significant distress or makes everyday function difficult, it could indicate the presence of a mental illness known as body dysmorphic disorder, or BDD. 

Symptoms of body dysmorphic disorder

The diagnostic criteria for body dysmorphic disorder include an unrealistic negative fixation on some aspect of bodily appearance. Other symptoms include repetitive behaviors or mental activity related to these self-perceived defects, such as those listed below:

• Checking their appearance in the mirror frequently
• Grooming their hair repeatedly
• Picking at their skin
• Seeking reassurance about their appearance from others
• Comparing themselves mentally or verbally to others
• Repeatedly feeling a particular body part

Due to the presence of this type of ritualized or compulsive thought and behavior, BDD is classified as a disorder related to obsessive-compulsive disorder (OCD). 

What are eating disorders?

Eating disorders are mental illnesses marked by dysfunctional and unhealthy behaviors and attitudes related to eating, calorie intake, and body weight. This can encompass things like the following:

• Deliberately eating fewer calories than the body needs to function properly
• Inducing vomiting or using laxatives inappropriately to avoid digesting food (purging)
• Engaging in excessive exercise to compensate for any calorie intake
• Restricting eating habits to only a small number of foods
• Eating only tiny portions
• Eating large amounts of food in a short time (binge eating)
• Being intensely afraid of gaining weight
• Preoccupation with thinness, body weight, dieting and calories

Eating disorders can lead to severe medical complications resulting from nutritional deficiencies and purging-related physical damage. 

Are most people with eating disorders body dysmorphic?

For some kinds of eating disorders, an exaggerated tendency toward viewing one’s own body in a negative light may be a common or central symptom. This may be particularly likely in the case of anorexia nervosa (also known as AN or simply anorexia). 

As described by the National Institute of Mental Health, people with anorexia commonly view themselves as overweight, even when they’re severely underweight. Excessive negative attention to real or imagined aspects of the body related to weight and body shape is considered a core symptom of anorexia. 

That said, not all disordered eating behavior is motivated by weight concerns. Binge eating disorder (BED), the most common eating disorder in the United States, usually involves compulsive episodes of overeating rather than attempts to lose weight. While some people with this condition may experience significant weight-related shame, they don’t necessarily have a distorted self-perception.

Another example is avoidant/restrictive food intake disorder (ARFID). People with this condition may undereat or avoid many foods due to sensory aversion or fears of choking. Their behavior is usually unrelated to the desire to become thin. 

Body dysmorphic disorder vs. eating disorders

Current diagnostic criteria for body dysmorphic disorder exclude forms of body image distortion that are related to eating disorders. For instance, if a person with bulimia nervosa inaccurately believes they’re obese and unattractive, this can’t be used as an indicator of body dysmorphic disorder. 

Another potential difference is that people with BDD often experience negative body image and obsession with appearance as intrusive and unwelcome, while those with eating disorders often consider their distressing beliefs accurate and inwardly derived.

How large is the overlap between BDD and eating disorders?

Although body dysmorphic disorder and eating disorders are considered distinct mental illnesses, they occur together frequently and can be considered mutual risk factors. A review from 2022 estimated that approximately 39% of people with eating disorders also meet the criteria for BDD.

Is “bigorexia” an eating disorder?

Another form of body dysmorphia can lead a person to believe their body is small, weak, and lacking in muscle tone, even when they are athletic and muscular by objective standards. They may engage in a variety of unhealthy behaviors, such as excessive strength-building exercise, use of anabolic steroids, and excessive consumption of protein or nutrient supplements. 

This phenomenon occurs mainly in men, although not exclusively, and is often referred to as “bigorexia nervosa.” Some researchers have suggested that it should be classified with other eating disorders like anorexia since it involves a pathological concern with body weight. However, current diagnostic categories describe bigorexia as a subtype of body dysmorphic disorder called “muscle dysmorphia.”

How body dysmorphic disorder can affect eating disorder symptoms

Research suggests that the presence of body dysmorphic disorder in people with eating disorders may lead to more severe symptoms. People with this comorbidity tend to be hospitalized at greater rates and may require more therapy sessions and medications as part of the recovery process. 

This may be linked to the increased levels of self-criticism that can be prompted by BDD. As reported in the Journal of Nervous and Mental Disease, people with this condition commonly exhibit significantly higher-than-average levels of shame.

These negative emotions can also feed into the pathology of conditions like anorexia, bulimia, and binge eating disorder. Disordered eating behaviors may arise partly as an attempt to correct perceived flaws or soothe the distress arising from feelings of shame. 

Shared risk factors for body dysmorphic disorder and eating disorders

Many of the same variables that can place a person at risk for BDD can also make them more vulnerable to eating disorders. Some of these risk factors can include personality characteristics, thought patterns, and emotional reactivity. For example, low self-esteem tends to be a strong predictor of eating disorders, and it can also lead to a higher risk of body dysmorphia. 

A tendency toward perfectionism may play a similar role. 

These internal factors may also be influenced by a person’s environment and life experiences. Childhood trauma is a known risk factor for eating disorders, BDD, and a host of other mental illness symptoms. Some forms of trauma, such as sexual or emotional abuse, may be particularly strong predictors for these conditions.

High levels of exposure to media content related to weight loss, beauty, and appearance — for example, through excessive social media use — may be another mechanism driving body image concerns and disordered eating.

Treating BDD and eating disorders

Current evidence suggests that cognitive behavioral therapy (CBT) or metacognitive therapy may be the most effective psychological treatments for body dysmorphic disorder. Both of these approaches generally focus on helping individuals let go of maladaptive thinking patterns, such as unrealistic self-criticism. This approach may be supplemented with medications on a case-by-case basis.

CBT is also considered an effective form of treatment for most eating disorders, although some people may benefit from other forms of therapy, such as interpersonal therapy, family-based therapy, or interpersonal therapy. 

Clinical guidelines also typically recommend incorporating medical oversight, nutrition counseling, and other supportive interventions. 

BDD and eating disorder treatment barriers

Despite the considerable health risks posed by eating disorders and body dysmorphic disorder, many people are hesitant to seek treatment, which can significantly delay and impair recovery. Some common obstacles to treatment include the following: 

• Not recognizing their symptoms as an illness
• Lack of social support or encouragement in seeking treatment
• Shame and fear of stigma
• Delays within the healthcare system
• Concerns about cost

How to tell when someone has an eating disorder or body dysmorphia

Because many people with BDD or eating disorders have a hard time recognizing what they’re experiencing as a mental disorder, encouragement from friends and loved ones may play a significant role in convincing them to pursue treatment. Here are a few signs that might indicate that someone you care about is experiencing pathological body image concerns:

• They’ve withdrawn from social activities
• They frequently criticize their looks in ways that don’t match your perceptions
• You often notice them checking their reflection or attempting to “fix” aspects of their appearance
• Conversations with them often turn to subjects like dieting, calories, weight, cosmetics, plastic surgery, or physical attractiveness
• They frequently wear clothing that disguises their body shape or physical features
• They rarely eat in front of others or often disappear after meals
• They’ve gained or lost a lot of weight in a short time
• You notice signs of malnutrition (e.g., thinning hair, brittle nails, constant fatigue, dry and yellowing skin, etc.)
• They show symptoms consistent with purging behaviors, such as yellowing teeth or swollen cheeks and neck

Encouraging someone to seek help for BDD or eating disorders

If you think that someone in your life might be living with an eating disorder or body dysmorphic disorder, you may want to be careful about how you raise the subject to avoid a negative reaction that could lead them to further isolate themselves.

Rather than telling them you think they have a mental illness, you may want to simply note some of the problematic behaviors you’ve observed and explain that you’re concerned about their health and well-being. You can let them know you’re willing to listen if there’s anything on their mind. If they’re receptive to the conversation, you might also suggest that therapy could help them manage any stress or difficult emotions they’re experiencing. 

How to find treatment for eating disorders and body dysmorphia

When you’re ready to pursue recovery from an eating disorder or BDD, talking with your primary care doctor can be a good first step. They can assist with any medical complications from disordered eating behavior and refer you to specialists, such as psychiatrists or dietitians, as needed. 

Another option is to pursue therapy over the internet, which can often be more convenient than getting help in person. Online therapy tends to offer adaptable and flexible scheduling, making it easier to build time for treatment into your schedule.

Research findings indicate that internet-based interventions can be a useful mode of treatment for conditions linked to body image concerns. A 2020 study of individuals who received online CBT for eating disorders reported that they showed sustained improvements in both eating disorder symptoms and body dissatisfaction, as well as greater self-esteem and overall quality of life.