Authors: Deborah Mitchison (corresponding author) ; Rocco Crino ; Phillipa Hay [3,4]
The presence, predictive utility, and clinical significance of body dysmorphic symptoms in women with eating disorders
The eating disorders (EDs) and body dysmorphic disorder (BDD) are disorders of body image . While the main concern is with overall body shape and/or weight in the EDs, in BDD the primary concerns vary widely, and commonly include concerns with facial features, skin, and hair . It has been suggested that BDD and the EDs might be better clustered under an encompassing ?body image disorder? . However, the current hierarchical organization of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR)  stipulates that a diagnosis of BDD cannot be provided if symptoms are ?better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa? (p510 ). Discussions about the validity of this hierarchy have also raised questions such as whether the EDs are in fact a variant of BDD .
Studies have reported that between 39 to 88% of patients in an ED treatment setting concurrently meet diagnostic criteria for BDD [6, 7, 8]. Conversely, it has also been found that 32.5% of a clinical BDD sample had a lifetime diagnosis of an ED . The higher proportion of cases of BDD in ED than vice versa is expected due to the wider array of appearance concerns in BDD . This high comorbidity would suggest that there may be underlying similarities in the predisposition to both EDs and BDD. It is possible however that comorbid cases would be more likely to seek treatment , and this may be due to implied greater severity. Further, the majority of people with EDs and BDD may not present for treatment of their body image problems [11, 12, 13], and because of this, research using non-clinical samples may provide a more representative account of comorbidity.
Based on its phenomenological similarity to obsessive compulsive disorder (OCD), BDD has been considered an OCD ?spectrum? disorder, and its classification (see DSM-5 draft criteria) , assessment (e.g. the Yale-Brown Obsessive Compulsive Scale) , and recommended treatment (i.e. exposure and response prevention)  have been aligned to that of OCD. As such, the cognitive behavioral therapy (CBT) model of BDD has focused on compulsive acts (e.g. checking, fixing, and camouflaging the imagined defect in appearance; making mental comparisons to others? bodies) in response to obsessive preoccupation with appearance [17, 18]. As far as is known, previous research has not explored the relevance of this model to an ED sample, however elements of the model may be applicable. For instance, ?fixing behaviors? is also a commonly recognized feature in models of EDs . While ?fixing? presents in BDD primarily through behaviors such as excessive cosmetic surgery and grooming, patients with EDs may attempt to ?fix? perceived fatness through extreme dieting and compulsive exercising and purging. Another behavioral BDD feature is excessive body-checking, which has been suggested to be present in up to 92% of ED patients [20, 21], for example in the form of mirror examining, weighing, measuring, and skin-pinching. Finally, although it has received little attention in the field of EDs, preoccupation with appearance may be more predictive of EDs in comparison to other cognitive constructs such as body image perception and body dissatisfaction . Camouflaging, reassurance-seeking, comparison-making, and social avoidance are also likely to present in and maintain pathology in ED patients, although research is yet to firmly establish this.
Clinically severe BDD symptomatology may be present in people with EDs, regardless of comorbidity. For instance, studies have found that participants with EDs scored similarly to participants with BDD on measures of body dissatisfaction, checking, appearance evaluation, appearance fixing, body image distress and preoccupation, but lower on measures of negative self-evaluation, avoidance of activities, overvaluation of appearance, body image disturbance, and quality of life impairment [23, 24]. …