Case Study: Body Dysmorphic Disorder and Anorexia Nervosa
Volume 6, Issue 3
Eileen Adams, MS, LMSW
Marian C. Eberly, RN, MSW, LCSW, DAPA
Remuda Ranch Programs for Eating Disorders
Nicole is a 20 year old, single women living with her parents in California. She recently dropped out of a prestigious university. She requested treatment due to an eating disorder (ED), depression, and increased isolation.
Her admitting diagnosis of anorexia nervosa, restricting type is evidenced by her low weight, fear/restriction of food choices, and body image issues. She felt depressed; Beck Depression Inventory-II confirmed this impression. Additionally, Nicole expressed a loss of interest in usual pleasurable activities, fleeting thoughts of suicide, and insomnia. Her complaints of fatigue seemed to stem from depression, malnutrition, and a lack of adequate sleep.
While she presented as highly motivated for treatment, she was initially hesitant to talk about her family and body image issues. She described her family as achievers and herself as an “unsuccessful overachiever.” She identified her father as a workaholic and her mother’s job as “taking care of me and my siblings”. She felt that as she matured, her mother’s attention transferred more and more to her 14 year old brother. Beyond these descriptions, she did not want to focus on her family. She seemed invested in maintaining the appearance of her family. However, later in treatment, preparations for an intensive Family Week and identification of the function and maintenance of her ED clarified her understanding of family love and loyalty. She was then able to make an honest appraisal of her family dynamics.
Completion of a life timeline assignment increased her awareness of her ED dynamics and underlying emotions. She identified age 14 as the onset of her ED, with depressed mood and body image issues starting as early as age 12. Nicole recognized that internalization of family expectations and performance orientation fueled her ED. She experienced heightened anxiety at school and other public settings. Self-conscious as a teenager, she remembers hiding feelings of depression behind a mask and using her athletic abilities to increase her self-esteem. As her body changed and matured, she became fearful of becoming “fat” and used exercise and food restriction to manage her weight. She felt some level of success and accomplishment in losing weight.
Early in treatment, Nicole gained insight and participated actively. However, meal behaviors were fraught with anxiety, distraction, and minimal compliance. Core body image issues began to surface.
Nicole answered negatively to BDD screening questions during her admission intake interview. In her psychological and psychiatric assessments she vaguely answered direct questions about specific body parts and focused only on body image in general. However, Nicole identified spending up to one-half of each day focused on her body, anxious about her body, and/or engaged in behaviors to fix her body. Consequently, she acknowledged enough symptoms to warrant further assessment of body dysmorphic disorder (BDD).
Initial psychological testing suggested interpersonal anxiety, insecurity, attachment/adjustment concerns, fear of failure, and symptoms of social phobia. The Body Dysmorphic Disorder Questionnaire (BDDQ; Phillips, 2005) was given to begin the interview process for BDD. Nicole’s psychiatrist then performed a Structured Clinical Interview (SCID) for BDD (Phillips, 2005). The Body Dysmorphic Examination (BDDE; Rosen & Reiter, 1996) was also utilized to gather more information from the patient. After these initial assessments proved informative, Nicole was given the BDD-YBOCS (Ruffolo, Phillips, Menard, Fay, and Weisberg, 2006) to determine severity of her obsessions. The results of these examinations and interviews supported a diagnosis of BDD in addition to anorexia.
In a written body image assessment, Nicole identified legs and hips as her main areas of distress. She recognized that changes in her maturing body caused her to focus on her hips, but stated she “always” focused on her legs. As her trust grew with her treatment team she said more about the attention she was giving to her legs.
She could identify with other patients’ feelings of body dissatisfaction but described her level of dissatisfaction as “off the charts”. She commented about other patients’ desires to look “perfect” but she just wanted to look “normal.” She admitted quitting the volleyball team because she could no longer tolerate other people seeing her legs. Her obsessional thoughts had become life-interfering. Even as her legs became slightly thinner because of anorexia, they did not look right to Nicole. She believed there was something defective about them; that they were ugly and deformed. She was angry at God for making her this way, and was full of shame and disgust at her legs. She was keenly distressed that others viewed her legs as normal. Her belief about the appearance of her legs was a primary reason for her ED behaviors. However, other ED themes served to reinforce and maintain her ED as a separate diagnosis.
Nicole described a daily ritual of self-examination of her legs every morning. This determined her emotional state for the day. Her perception would also fuel restricting behaviors and over exercising. On most days her ED behaviors were due to feeling “fat,” but on all days her ED behaviors were also intended to change the shape of her legs. She finally told her therapist that focus on her legs was interfering with her eating at Remuda and was the greater source of her anxiety at meals.
As Nicole shared more of her body image problems, she was given education on BDD. An assignment used to expose the effects of cognitive distortions further validated the pervasiveness of her BDD. She began to gain insight into the strength of her obsessional thoughts.
Nicole received education about treatment options. She was reluctant initially to share the extent of her BDD with peers. However, as she gained information about BDD, she was able to communicate differences between EDs and BDD to peers and gain their support.
Nicole agreed to psychotropic medication therapy once she fully understood the risks, benefits, and alternatives. An SSRI, Celexa, was selected for depression. Once it was evident that her thoughts were delusional in nature, an antipsychotic medication, Abilify, was added. Later in treatment, Buspar was added as an anti-anxiety medication because the SSRI was not altogether successful in relieving her underlying anxiety.
A BDD-specific treatment plan of cognitive therapy, behavioral assignments, and exposure with response prevention was discussed with her. Nicole worked with her treatment team to apply the new cognitive and behavioral skill sets she was learning to BDD in addition to her ED. For example, as she practiced distress tolerance techniques she found she was able to be with people for longer periods of time without continually being distracted by interfering thoughts about her legs.
In Skills Group, a Biblically-based cognitive-behavioral therapy group, Nicole applied distress tolerance and emotion regulation skills specifically to her BDD distress at meals. In Body Image Group, she applied the text assignment, “Body Image Cognitive Distortions” (Cash, 1997), both to general body image issues and the specific area related to BDD, her legs. Throughout treatment, she journaled and processed her feelings of anger at God for giving her misshapen legs. She was able to see how her obsessions had profoundly affected her spiritual life. Eventually, through prayer and Christian readings, Nicole was able to gain greater peace in her relationship with God, revitalizing her belief from childhood that God loves her and created her, just as she is, for a purpose. She concluded that, to live out her faith with consistency, she would work on accepting her body and her legs as gifts from her Creator.
Armed with new knowledge of selective attention and cognitive distortions, she and her therapist designed behavioral assignments, also referred to as experiments, to test the validity of her distortions. For example, she wore shorts during a therapy session and walked the grounds. Nicole identified a belief that others were examining her legs as they passed by and a belief that they found her disgusting. Both beliefs fell to lack of evidence. Only one patient mentioned her attire, stating, “I’ve never seen you in shorts before. You look nice!” Subsequent experiments proved similarly fruitful; she and her therapist then designed more experiments for Nicole to continue at home after discharge.
Nicole agreed to participate in mirror retraining. Usually this skill is taught early in BDD treatment. However, Nicole was too fearful to confront the mirror in the early stages. In the past, she avoided looking at her legs whenever possible. Yet she also described periods of intense preoccupation, examining and frequently checking her legs in the mirror. After a couple of weeks of mirror retraining, she reported success using the mirror to check her outfit without over-attending to her legs.
These experiments also served as exposure with response prevention exercises. She identified typical anxiety inducing behaviors and repeated some of the experiments with a focus on refraining from her rituals. She made a list of anxiety provoking situations related to the object of dysmorphia, her legs, in ascending order. She addressed the first three items of this hierarchy while an inpatient, the remainder as an outpatient.
During Family Week, Nicole’s family was further educated about BDD and EDs. It was explained that although BDD manifested today as a preoccupation with her legs, it could change to a different body part in the future. Emphasis was given to report any alteration in focus/attention to her treatment team immediately. Nicole described the BDD/ED connection to her family: the continued awareness of her body image issues and the difference between them. Her family was particularly moved by her spiritual renewal. She had overcome many obstacles during treatment and was proud of her success.
Nicole’s discharge plan included continuing with the medication regimen of an SSRI, anxiolytic, and antipsychotic, with regular psychiatric follow up appointments. BDD-targeted interventions would include continuing cognitive-behavioral therapy and working her way through her exposure list with her outpatient therapist. Long term goals included returning to college next semester, expanding her wardrobe to clothes that expose her legs, reconnecting with friends, and continued spiritual growth through renewed church attendance, regular prayer, and Bible readings.
References
Cash, T.F. (1997). The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA: New Harbinger Publications.
Phillips, K.A. (2005). The broken mirror: Understanding and treating body dysmorphic disorder (Rev. and expanded ed.). NY: Oxford University Press.
Rosen, J. & Reiter, J. (1996). Development of the body dysmorphic disorder examination. Behavior, Research and Therapy, 34, 755-766.
Ruffolo, J.S., Phillips, K.A., Menard, W., Fay, C., & Weisberg, R.B. (2006). Comorbidity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance. International Journal of Eating Disorders, 31, 11-19.
