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2010 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
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Didie et al.
current comorbid AN/BN (1% with AN, 3% with BN;
Gunstad & Phillips, 2003; this study did not assess the
prevalence of an eating disorder NOS). Another small
study of 16 individuals with BDD found that 19% of
subjects reported a lifetime prevalence of an eating
disorder (Zimmerman & Mattia, 1998). Both studies,
however, consisted of individuals who were seeking or
receiving psychiatric treatment, and 40% of the subjects
in the former study were participating in a pharmacotherapy trial (Gunstad & Phillips, 2003), which may have
introduced a selection bias. In a recent naturalistic study
of 200 individuals with lifetime BDD who were not seeking
or receiving treatment as part of the study, 33% reported
having a lifetime eating disorder (9% with AN, 6.5% with
BN, and 17.5% with an eating disorder NOS; Ruffolo,
Phillips, Menard, Fay, & Weisberg, 2006). Those with
(n = 65) and without (n = 135) a comorbid eating disorder
were compared across a number of clinical variables,
including severity of body image disturbance, functioning, and suicidality. BDD subjects with and without an
eating disorder did not significantly differ on most
variables. However, those with comorbid BDD and an
eating disorder were more likely to be female, less likely to
be African American, and had more comorbidity.
Controlling for gender, comorbidity, and age, those
with comorbid BDD and ED had greater body image
disturbance and dissatisfaction, were more likely to have
been hospitalized, and had received more psychotherapy
and medication (Ruffolo et al., 2006). In a study of 41
inpatients diagnosed with AN (Grant et al., 2002), 39%
were found to have a lifetime diagnosis of BDD with
concerns unrelated to weight. Those with comorbid AN
and BDD had lower overall levels of functioning and
higher levels of delusionality than those without BDD.
The comorbid AN and BDD group also had double the
number of psychiatric hospitalizations, and three times as
many subjects with comorbid AN and BDD had attempted
suicide (63% versus 20%).
Despite the co-occurance of these disorders and clinical
similarities, only one study (Rosen & Ramirez, 1998) has
compared the clinical features of BDD and eating disorder
patients directly. In this study, 45 female outpatients with
AN or BN were compared with 51 female outpatients with
BDD and 50 nonclinical controls. Both clinical groups had
equally severe body image overall and poor self-esteem.
However, BDD patients reported slightly more avoidance
and negative self-evaluation due to appearance concerns,
whereas the eating disorder patients reported more
widespread psychopathology. Limitations of this study are
that the BDD group included only females and the groups
were compared on only a small set of variables and
important questions regarding many central features about
the commonalities and differences between these disorders have remained unanswered.
Client Description
Jan (based on a composite of patients), a 48-year-old
single, Caucasian female, was self-referred to her local
community mental health center. She currently lives
alone, is not involved in a romantic relationship, and has
no children. She is currently employed part-time as a
substitute teacher. Jan is a self-described artist who used to
enjoying painting but of late has found little enjoyment in
this work. She reported having an eye for aesthetics but
has never sold her artwork or pursued this line of work.
Presenting Complaint
Jan reported being preoccupied with the appearance
of her breasts since the age of 30. Jan reported that she
would think about her appearance for at least 5 to 8 hours
a day. Her preoccupation with her appearance resulted in
significant social interference and more recently was
beginning to affect her performance at work. Although
she received many social invitations, she rarely accepted.
Jan was currently avoiding all social contact with friends.
She would still see family members from time to time, but
as Jan described her sisters were very annoyed with her
constant requests for reassurance about her appearance.
Jan also engaged in several additional time-consuming,
repetitive behaviors related to her appearance, including
mirror checking, searching the Internet for surgery
information, changing her clothes to try to look better,
comparing her appearance with that of other people,
restrictive dieting, and excessive exercise. Jan reported
that she would engage in these behaviors from the time
she got home from work until the time she went to sleep.
Because of her excessive worries about her appearance
and compulsive behaviors, Jan reported that her productivity was beginning to suffer at work, which resulted in
conflicts with her supervisors. Jan also acknowledged that
she was in a constant state of fatigue and worry, and she
had limited time or energy for little else.
During the past 3 years, she had undergone three
separate cosmetic surgeriesone augmentation surgery
and two corrective procedures. While Jan reported that
she had always been concerned about her appearance
(mostly her shape and weight), she was pushed over the
edge after a remark from a family friend that she would
be perfect if she only had larger breasts. Jan reported
being consumed with the idea of having what she
perceived to be a more proportional figure and because
of this remark decided to get silicone breast implants.
However, she was very displeased with the results of the
surgery and tearfully described how the surgeon ruined
her body. Jan described her breasts as asymmetrical and
out of proportion with the rest of her body. As she
remarked, As an artist, I have an eye for these sorts of
things. Since the original procedure, Jan had undergone
two additional corrective procedures, which did little to
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Mental Status
Jan arrived 30 minutes late to her first appointment.
She had also cancelled two previously scheduled appointments. She appeared younger than her stated age,
dressing in clothes that were popular among high-school
students. She reported that her mood was down and blue,
and she was tearful during our initial meeting. Her speech
was a normal rate and rhythm. Her thought content was
focused on her appearance concerns, with the primary
concerns being her breast size/symmetry and weight. Her
thought process was linear and goal directed, although
Jan reported information in an overly detailed manner,
particularly as it related to her appearance, and ruminated about her decision to obtain her first cosmetic
procedure. Jan asked her therapist for feedback on her
appearance during the initial assessment. No obvious
motor abnormalities were detected. Jan reported passive
suicidal ideation (e.g., wishing I won't wake up); she
denied a plan or intent and had no history of suicide
attempts and/or gestures. She had a history of self-injury
in college around the time of a break-up (superficial cut
on her arms which did not require medical attention).
She reported no psychotic symptoms. Insight was poor as
it related to her appearance, and judgment was intact. She
was very concerned that the therapist had experience with
body image problems and asked very detailed questions
about her therapist's training and experience.
Previous Treatment
Jan had a long history of mental health treatment,
primarily psychodynamic and supportive psychotherapy.
She acknowledged that her previous therapies had been
helpful in terms of managing life stressors and getting her
life back on track after several romantic break-ups.
However, she felt that her previous treatment had been
largely ineffective at addressing her long-standing body
image concerns, which remained persistent and chronic.
She has never been hospitalized or in a partial hospital
program. She reported a very brief trial with medication.
She was prescribed 20 mg/day of fluoxetine which she
took for 3 weeks during the year prior to coming to our
clinic. Jan reported that the medication made her feel less
creative and that she was concerned that medication
would numb her out. For these reasons, she was
opposed to incorporating medication into her current
treatment plan. Jan was also concerned that if she took
medication, she would simply let herself go if she were
not so diligent with her diet and exercise. She was also
uncertain if medications would be effective.
Assessment/Conceptualization
During the pretreatment assessment, the Body Dysmorphic Disorder Examination (Rosen & Reiter, 1996) was
administered to obtain the information above. In addition
to the BDDE, the rater-administered Eating Disorder
Examination (EDE; Fairburn & Cooper, 1993) was
performed. The EDE is a widely used instrument for the
assessment of specific psychopathology of eating disorders
and is commonly used in treatment outcomes studies
(Anderson, Lundgren, Shapiro, & Paulosky, 2004).
The initial conceptualization of Jan's presenting
problems was based upon the cognitive-behavioral
model for BDD (Rosen, 1995a) and BN (Fairburn,
Cooper & Cooper, 1986; Fairburn et al., 1993). Rosen's
model of CBT for BDD suggests that several mechanisms
maintain one's preoccupation with appearance. For
example, Jan rehearses negative and distorted thoughts
about her physical appearance repeatedly. Negative
beliefs about her appearance result in depressed mood
and excessive worries. These distressing feelings lead to
attempts to neutralize this distress with ritualistic behaviors (e.g., clothes changing, reassurance seeking, and
mirror checking to see if her looks have improved) and
avoidance of social situations. Avoidance behaviors
prevent Jan from habituating, especially in social situations. Jan's rituals may initially provide relief from her
anxiety but ultimately keep Jan focused on her appearance (Rosen 1995b). Ritualistic and avoidance behaviors
have been theorized to maintain dysfunctional BDDrelated beliefs (Veale, Gournay, et al., 1996; Wilhelm,
Phillips, & Steketee, 2009).
Jan's dieting was conceptualized as another ritual
aimed to reduce distressing feelings associated with the
belief that she was fat. According to Fairburn et al. (1993),
extreme concern with shape and weight, in combination
with low self-esteem, compel some people to adopt strict
and rigid dietary rules and to restrict their eating in
unhealthy ways. Because of the rigidity of these rules, any
minor transgression can lead to an all-or-nothing reaction. When this occurs Jan abandons her dietary rules and
experiences a loss of control over her eating. In order to
cope with binges, Jan excessively exercises and restricts
her eating to regain her perceived loss of control. These
behaviors also reinforce the binge eating; the effects of
Jan's binges can be counteracted by exercise and
restricting her calories; binge eating is continued because
it is no longer inhibited by worries about weight gain. This
results in a vicious cycle of binge eating and excessive
exercise and food restriction.
Both the CBT models for BDD and BN suggest that
poor self-esteem is closely tied to appearance rituals and
Treatment
As noted above, Jan cancelled her first two assessment
appointments and arrived late to her first treatment
session. Given Jan's apparent ambivalence about starting
treatment, our initial goal was to address her ambivalence
and increase her commitment to therapy. Jan confessed
that she had reservations about coming to see someone
for therapy when she felt she had a real physical
problem. In fact, Jan brought information she obtained
on-line about cosmetic surgery and asked for suggestions
for surgical referrals. As such, the initial phase of
treatment was focused on providing education about
BDD. Jan was surprised to learn that BDD even existed
and initially had a difficult time accepting this diagnosis.
She could acknowledge, however, that she was significantly distressed by her appearance and wanted that to
change. We discussed the pros and cons of starting
treatment. For example, some of the benefits of CBT
would be that she would not have to undergo another
operation (something the patient was scared of doing),
and she would be saving money. The patient identified
some of the cons as she would be putting off surgery for 6
months, she would have to put in time for homework, and
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successful outcome in the treatment of BN (Wilson &
Vitousek, 1999). Jan was initially reluctant to write down
what she was eating, particularly on nonvirtuous days.
Acknowledging the difficulty of the task and Jan's fears
reduced some of her initial anxiety about monitoring her
eating.
Jan was diligent about completing self-monitoring
forms. Her food diaries provided an opportunity to
learn together about her struggles. Diaries helped Jan to
explore and identify both internal and external cues that
may trigger episodes and to facilitate the development of
alternative coping strategies. Jan was asked to track exactly
what she ate, the context in which food was consumed,
thoughts and feelings she was having while consuming
food, as well as whether she considered her eating a
binge. Inappropriate compensatory behaviors were also
recorded. Meal times and menus were planned in great
detail, and Jan was provided with sensible nutritional
advice. We scheduled the timing of her meals until she
was able to interpret interoceptive cues of hunger and
satiety on her own (Johnson, Connors, & Tobin, 1987).
Gradually, we introduced previously avoided food into
her dietary repertoire (Kirkley, Schneider, Agras, &
Bachman, 1985). Prior to actually introducing new
foods into her diet, we created a hierarchy of feared
foods. It was only after Jan had already established a
relatively stable schedule of eating that we began
introducing these previously forbidden foods. Psychoeducation was important to counter erroneous beliefs and
superstitions regarding food and feared weight gain
(Johnson et al., 1987).
Behavioral techniques were next introduced to encourage normal eating patterns and to help curtail selfdefeating thoughts during mealtime. Andersen (1987)
suggested that rewarding clients for healthy eating habits
and maintaining dietary plans provides a source of
positive reinforcement. For Jan, we integrated time for
her to paint (an activity she had been denying herself)
when she adhered to her treatment goals for the week. A
secondary goal of her painting was to develop a sense of
self-worth that was independent of weight and appearance. Visualization techniques and models of food were
used to demonstrate appropriate portion sizes, as well as
to reduce anxiety when exposed to meals. Given Jan's
concerns about gaining weight and mistaking feelings of
fullness with being fat, we discussed anticipating feelings
of hunger and fullness. Jan felt more prepared to deal
with the unexpected sensation of a full stomach. We also
incorporated stimulus control techniques to avoid binge
eating, including planning meals and snacks, eating
sitting at the kitchen table, and concentrating on the
taste of the food by slowing down her rate of eating.
Jan was able to adhere to her prescribed eating plan.
She gradually habituated to the amount she was eating
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Discussion
This case study describes the treatment of a woman
with comorbid BDD and BN, two disorders that frequently
co-occur. Her symptoms responded favorably to a
treatment that combined strategies from CBT for BDD
and BN. The current case highlights several issues, one of
which pertains to diagnosis. While both BDD and eating
disorders are characterized by body image preoccupation
and distortion, in most cases BDD can be fairly easily
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