Dysmorphia and the DSM-V

Muscle dysmorphia and the DSM-V conundrum brings up interesting issues.

I have been arguing for a while that the name and way we diagnose "eating" disorders is barking up the wrong tree. The name implies that it is about eating and the diagnosis implies that its severity can be measured by the effects of eating behaviors.

I've also argued that dysmorphia can be seen as a common symptom of an eating disorder but isn't the same thing as an eating disorder: it can exist without ED compulsions or behaviors and the symptoms of dysmorphia can sometimes be a symptom of malnourishment alone - resolving with normalized nutrition. Not all eating disorder patients experience dysmorphia, either.

Hey, I know how to parse all this very efficiently!

What if we saw both eating disorders and dysmorphia as part of the OCD spectrum? Get rid of the category of eating disorders and make it a subset of the OCD diagnosis. What if we were diagnosing these MENTAL illnesses by the thoughts and behaviors instead of by the effects OF the thoughts and behaviors. What if we saw the obsessive thoughts and compulsive behaviors of an eating disorder as OCD, and the same for muscle dysmorphia and body dysmorphia?

I know, we'd still need to parse out what symptoms were being set in place by malnourishment.

We'd have to throw out most of the eating disorder research literature because both diagnosis and definition of recovery have been based on the medical state - and a minimum one at that.

But really, is the way we're doing it working now? Could we be treating eating disorders and dysmorphia better if we considered them an obsessive compulsive disorder?


  1. I like this post very much Laura :) I agree that EDs are defined by a pattern of obsessive-compulsive behaviours that a person gets stuck in. For some people the trigger may be fat phobia and/or body dissatisfaction, but for others (myself included) the behaviours were never driven by body dissatisfaction.

    The starvation of AN does tend to distort one's physical self perception, but unfortunately too many clinicians/researchers have considered 'body image' distortion as the CAUSE of ED behaviours, when actually it's the EFFECT of these behaviours. And so EDs have been categorised as disorders of 'body image', which I feel is incorrect. This, in turn, has led to what I feel is a waste of research money and time on the study of 'body image' in EDs.

    (BTW, I think the construct of 'body image' per se is really crass, and there's even an entire journal, developed by Thomas Cash, that is devoted to the study of 'body image'...).

    As for 'muscle dysmorphia': it's been called 'reverse anorexia' by some researchers, because those 'suffering' from it describe themselves as insufficiently muscular or big enough. I think you're correct that it is just another form of OCD. However, to call it 'reverse anorexia' is just silly. If it were not 10 pm in the UK and time for bed I'd elaborate as to why I think the concept of 'reverse anorexia' is so silly!

  2. Sounds like a great idea to me. People with EDs are trapped and ruled by their obsessive thoughts and compulsive behaviors in the same way as those with OCD and dysmorphia. In my opinion, recovery is only complete when there is relief from that thinking and the need to do the behaviors.

  3. Laura

    I love this. As you know I have been banging on about the commonalities of ALL mental illnesses and the twist of fate which makes them present in different ways.

    I still subscribe to the "common cold" theory - some people get a sore throat, others an ear infection or headaches or sinusitus or a bad cough. If we could make the "experts" work on the theory that Mental Illness is the problem and the way it presents itself (ie sore throat/schizophrenia, sinusitis/eating disorder, chesty cough/aspergers) is down to the individual's brain. Sometimes you get a cough AND a sore throat but the root cause is the same virus.

    I am more than happy to throw the dysmorphia out of the window - d had it for a very short time and many do not suffer from it at all. I think that society's obsession with being "thin" has permeated into the human sub-concious at a very early age and that eating disorder sufferers are unable to express that they are ill except through our limited language.

    Perhaps we could hire a hotel and lock a load of experts from across the whole mental illness spectrum into it until they realise it too..........


  4. I am very much liking this mini debate :) I love both Kristine's and Charlotte's posts above. Not only is the 'body image' construct in itself rather naff (actually vague), but every human being on this planet is sensitive to their physical appearance. It is part of being human - but it has been over-medicalised.

    As some of you know, I have a (bad) habit of reading the 'femail' section of the Daily Mail online. My objective is usually to find the most vacuous and meaningless article I can (which is not very difficult). However, I am struck by the public's obsession with 'body image'. The Daily Mail, like other popular media, tends to criticise slimness and 'celebrate curves', and 100s of comments are left on these articles. It seems that A LOT of women who don't have clinical EDs have concerns about their physical appearance.

    As a former sufferer of AN I can tell you that what drives it is obsessions and compulsions. For example, in terms of exercise: if my desire had simply been to expend as much energy as I could do to lose weight or keep my weight low I would have been happy to do ANY form of exercise, ANYWHERE. But no; I HAD to go to the gym at 7 am every morning and I HAD to exercise on the SAME treadmill in exactly the SAME routine. If someone was on 'my' treadmill my mood slumped to despair - and sometimes I threw a tantrum in public :( The important thing was to do the behaviour in exactly the 'right' way. Now, post-AN, I still have obsessions and compulsions; it's just that they're not so dangerous to my health.

    I am not saying that people with EDs don't have concerns about their physical appearance (I refuse to use the term 'body image'...). However, I don't believe that body dissatisfaction is what triggers, or even drives EDs, and starvation can distort the way that the brain processes information, including information about physical appearance. I think that pre-existing anxiety and neurological factors are the drivers of these conditions - and that starvation magnifies these pre-existing characteristics many fold.

    I was reading the suggestions for DSM V this morning and was quite astounded by how many apparently separate/distinctive disorders are proposed to exist. Some of them sound so familiar that it would be very difficult for a general adult psychiatrist to differentiate between them. And, actually, some of these 'illnesses' are not illnesses at all. They're just expressions of different personalities in stressful situations. I am beginning to think that Thomas Szasz has a point...

  5. I'm not convinced that all ED's are variants of OCD. Perhaps AN but I think BN often has more in common with substance abuse than OCD.

  6. it's definitely an idea to consider. i've struggled with OCD for years, followed by body dysmorphia and eventually anorexia.

  7. Crimson - good point.

    I wonder if BN is an addictive self-medication for AN? Possible?

  8. Yes! I believe that, in my case at the very least, ED is not a discrete illness but a symptom of other illnesses. For me, it started out as a way to deal with depression, but also became a way to deal with anxiety. I never understood why EDs were defined as a discrete illness, but obsessive handwashing, self-injury, and the like were not so defined, even though I've never seen any reasoning for why this should be so.


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