Step forward, Two steps back

Brody at the NY Times is right that Research Is Starting to Shed Light on Body Dysmorphic Disorder. I'm really pleased about this because BDD causes so much suffering and is almost universally misunderstood.

I'm not so pleased that BDD is gaining better understanding at the price of eating disorders: "unlike eating disorders, which mainly affect women seeking supermodel thinness."

One, the proportion of male ED patients is roughly 1/5, not some meaningless minority. It should go without saying that the sex ratio is a matter of incidence but not of the severity for the individual patient. Male eating disorder patients don't suffer less, there are simply fewer sufferers. This is true for MS and other illnesses as well, but we would not think to bring that up except as statistical information. We do it with eating disorders because we mistakenly think it "means" something at a societal level. It is time to stop repeating that endlessly and making male patients and their families feel marginalized.

Two, eating disorder patients are not "seeking supermodel thinness." That is absurd and offensive. Eating disorders occur at and persist into all weight ranges and the patient's perception of body size bears little relation to actual size and the distress is not lessened at "supermodel thinnness." Patients are not "seeking" anything; they are compulsively driven to avoid food and weight gain and report a range of "reasons" for doing so. It is a mental illness not a vanity play.

The saddest thing about the article throwing in that line is that the whole article could usefully have been written ABOUT eating disorders. The mistaken ideas about the illness, the treatment, and the anguish could be written of eating disorders. I happen to think of eating disorders as BDD with compensatory behaviors that maintain the illness, myself, in most cases.

Unhelpfully, the expert in BDDs cited in the article muddies the water in her blog post by describing anorexia as different from BDDs based on the tautology that it isn't because it isn't. If we looked at EDs as a form of BDD, or at BDD as a co-morbid or maintaining factor of an eating disorder, we'd be making progress. By defining an eating disorder as not BDD by describing the additional symptoms of an ED I think we serve neither population well.

One last mini-rant. The body dysmorphia of an eating disorder is often allievated or cured by weight and nutrition restoration. This is such an important fact that it amazes me that it is so rarely discussed. Eating treats the dysmorphia in most eating disorder patients. Patients often feel more normal in body size as they gain weight toward normalization. All the therapy we throw at the body image distress of an eating disorder, but we rarely talk about the functional role of malnourishment in those symptoms.**

**Well, some people do. See Guisinger.


  1. "unlike eating disorders, which mainly affect women seeking supermodel thinness." ..... jaw drop. wow.

  2. Laura, I am so upset about Jane Brody's incorrect assertions about EDs that I am literally shaking. I sent a letter to the NYT directed to Jane Brody, taking her to task for her lack of correct info about ED's. I am going to keep after her to do her research and then feature the latest knowledge about EDs and treating them. I subscribe to the NYT and will continue to make my displeasure about this known to them.

  3. I am still boiling about this. I posted your blog on my Facebook and told my "friends" how mad I am. Jane Brody's columns are read by millions of people, and she has got to get it right.

  4. "unlike eating disorders, which mainly affect women seeking supermodel thinness."

    Whoa! NOT OK. And what utter BS! I have yet to hear of someone with AN being happy at even the lowest, lowest weight. Ergo, it's NOT ABOUT THE WEIGHT.

    And what about those of us with Binge Eating Disorder? We're not thin at all, and binge eating cannot in any way be construed as trying to be "supermodel thin". And I've got BDD like WHOA, and have all my life. So ARRRGH!

    I am SO mad.

  5. Like you Laura, and those who have already commented, I also object STRONGLY to the inference that eating disorders are about seeking supermodel thinness.

    As you know, I have a very long history of anorexia nervosa (AN). I do not view my AN as being caused by body dissatisfaction or BDD. It had a lot more to do with controlling anxiety, and it was driven by compulsive behaviours. My weight and shape were merely visual markers of my ability to adhere to my eating and exercise routines.

    Some people with EDs do have BDD; others do not. People without EDs can have BDD. I personally don't see the two conditions as being directly related.

    Like you I do believe that BDD can be a symptom of AN, and that this BDD is often alleviated by re-feeding and the attainment of a healthy did weight.

    BDD or body dissatisfaction didn't trigger my AN, but when my BMI was <14 I didn't see myself as thin as other people saw me. When told I was 45 pounds underweight I said that if I gained 45 pounds I would be fat. And so people assumed that I restricted food and over-exercised because I was scared of getting fat, or because I wanted to be skeletally thin. The truth of the matter was that my thinness was a 'side-effect' of compulsive rituals which I had learnt to depend upon to control my anxiety.

  6. Cathy,

    Your thoughts on this are really helpful. You are absolutely right that not all ED patients .body dysmorphia and not all BDD patients have eating disorders.

    Yet I wonder if we are using our terms in the same way. When you say "when my BMI was <14 I didn't see myself as thin as other people saw me." I understand that you suffered from body dysmorphia at that stage of your illness.

    It seems to me that one way that the body dysmorphia works, during malnourishment, is blinding the patient to any urgency in weight restoration. That, and the anxiolytic qualities of low nutrition for those with a certain genetic predisposition and/or the high ambient anxiety of certain people all serve to form a perfect storm to maintain malnourishment and, as a result, the illness.

    Cathy, I'd love to hear your thoughts on Shan Guisinger's work.

  7. Kristine: awesome advocacy out there!!!!!

  8. Hi Laura

    I'll have a look at Shan Guisinger's web-page - and get back to you...

    Meanwhile, I have just addressed a comment on Carrie Arnold's blog in response to a query about the fear of weight gain in AN. I wrote:

    "My AN was never about looking a certain way, or weighing a certain amount, and on many occasions my weight fell to as low as 80 pounds (my height is 5ft 6in). At that very low weight I was scared of gaining weight.

    I never planned to reach such a low weight - and in fact I never planned to lose a lot of weight at any point in my life. My weight dropped or remained low because I had created exercise and diet 'rules/rituals' for myself that I felt compelled to abide to.

    I felt I 'had' to do 'X' minutes of exercise at certain times of the day and eat (restrict) in a certain way. If I didn't adhere to my 'rules/rituals' I felt out of control (of my anxiety), and also quite impulsive (I had the urge to harm myself by cutting etc.).

    I was scared of gaining weight because in order to gain weight I had to break my rules - and therefore face the accompanying anxiety.

    Another issue for many people is that AN causes body image disturbance (not vice versa). Although I could see that I was thin when I was emaciated, I seemed to be able to justify, within my mind, that I was not too thin. I didn't see a 'fat' person in the mirror though.

    So, in summary, the fear of weight gain [for me] related to the fear of the emotions I would feel if I changed my behaviours (and hence broke my 'rules/rituals')."

    I agree with you, Laura, that the BDD that occurs at low weight can blind the individual to the urgency of weight restoration. However, there is also the fact that the low weight anorexic individual is so rigid and so fearful of change that they seem, somehow, to be able to justify to themselves that they are OK. They subconsciously seek evidence to support the idea that remaining sick is beneficial to them.

    I have a friend of my age (44) who is very sick with AN. Her BMI is <12. She can (sort of) see her thinness, but her anorexic thoughts won't permit her to change. She says she feels guilty when she eats: "disgusting" and "greedy". I too am familiar with those powerful thoughts, that almost feel to be a separate part of me. Having tracked the appearance of these thoughts at times through my life I would suggest that they relate to depression, which makes me feel 'worthless' and 'undeserving' of food.

    But, the problem is that depression is worsened by starvation, even though starvation is anxiolytic. And, depression in AN also accompanies an inability to adhere to self-created 'rules' around exercise and eating. Thus, all the time the anorexic individual is fighting anxiety and/or depression - and eating behaviours (with their metabolic and neurophysiological effects) modulate this anxiety and depression. I am therefore inclined to hypothesise that the mood disturbances of AN are more powerful than any effects on body image.

    Do you have a direct e-mail address? I'd like to send you a paper...

  9. "I am therefore inclined to hypothesise that the mood disturbances of AN are more powerful than any effects on body image."

    WOW - brilliant post Cathy. I so agree. I have a loved one with AN (currently in remission) and one with depression but no anorexic behaviours (at rather a high weight but without any binge-eating or other eating disordered behaviours ever) and, admittedly from the outside perspective of someone who loves them, not from their own words, you have hit the nail right on the head- depression seems to trigger obsession, the body image part is less important and, at least around here, came in on the coat-tails of AN, not before


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