• Background
• BDD was first categorised as a diagnosis in 1987.
• It is underlined by anxiety and is closely associated with obsessive compulsive disorder (OCD).
• It usually starts in adolescence and is often hidden and can be long-lasting.
• BDD may be underdiagnosed due to a variety of factors, including shame and a lack of recognition of the issue.
• A review of 33 studies estimated that 15.04% of plastic surgery patients had BDD, the average age was 34 and 74% were women. For dermatology patients, 12.65% had BDD, the average age was 28 and 76% were women.

Behaviours

BDD involves a focus on one or more perceived defects or flaws in physical appearance that are not observable or appear minimal to others. It consists of a preoccupation that causes significant distress that disrupts social and occupational functioning.

Individuals affected by BDD may:

• Engage in compulsive, time consuming and repetitive behaviours – reassurance seeking, mirror checking, excessive grooming and skin picking which can lead to lesions
• Compare themselves to others in response to appearance concerns
• The appearance related preoccupation is not primarily explained by concerns about weight as can occur in an eating disorder

Skin concerns can emerge for both men and women. For some women it may be their legs, whilst for men it may be their body build and muscle. Men from a sexual minority may be affected by body dysmorphia due to rejection sensitivity and concealing their sexual orientation.

Insight difficulties

A person’s level of insight can change during their experience of BDD. For example, whether they do/not believe what BDD tells them (good/fair insight), whether they they think it’s probably true (poor insight), or whether they are completely convinced the BDD beliefs are true (absent insight/delusional beliefs).

Consequences

It’s essential to understand that for the person, the beliefs about their flaw(s) feel real. In some instances, they may approach a dentist, dermatologist or surgeon to undergo a procedure to rectify the issue or for example, improve social or romantic relationships. Behaviours associated with BDD are often secretive, underlined by shame and those such as mirror checking do not bring short-term relief, but increase self-consciousness, heighten perceptions of defects and in turn, increase distress. Seeking and having surgery or medical procedures may not bring relief for the person.

Self-image amongst those with BDD may relate to early stressful experiences in childhood. BDD is often hidden as people tend not to seek professional help, and those that do, may be reluctant to discuss their difficulties. Some may report misdiagnosis before finding appropriate treatment. BDD often co-exists with other disorders, with depression being the most common. Others include social phobia, obsessive compulsive disorder (OCD) and generalised anxiety disorder.

People with BDD may report significant distress, productivity problems at work or school and in some instances, withdrawal from school or job losses. The person may believe that others are disgusted at a particular aspect of their appearance. Individuals who experience BDD may express a desire to ‘become invisible’. They may prefer colder weather in order to wrap up i.e. camouflage their perceived flaw and also prefer to leave the house after dark. They may hear positive feedback from others and feel it is intended as pity or sarcasm. They may miss out on social cues and information that may moderate their negative self-image. BDD can lead to social avoidance and self-imposed isolation from family, friends and partners due to worry about being viewed negatively by others. This isolation can contribute to additional distress.

A sense of worthlessness can be part of someone’s experience. BDD increases risk of suicide.

Treatment

Treatment barriers can include: shame, low perceived need and a preference for cosmetic and medical treatments.

Treatment can vary from medication to psychological such as cognitive behavioural psychotherapy (CBT), or a combination of medication and therapy.

Impact of Covid-19:

Research has highlighted:

• Higher psychosocial stress levels than pre-Covid-19
• Not being able to work, people experiencing anxiety about an unpredictable future
• Self-isolation can heighten other issues, including eating disorders, OCD, depression and suicide risk – feeling of hopelessness and worthlessness during pandemic
• The pandemic might lead to thoughts of not being needed or feeling not important since socialising has been restricted and substance use can also increase suicide risk
• Individuals who were living alone, younger, may report higher dysmorphic concerns, engage in more frequent appearance-focused behaviours and greater distress over the closure of beauty services

It often goes undetected as, to the on-looker, the individuals affected seem to be merely very focused on health and fitness. Weight may not necessarily be very low because when you exercise compulsively your body compensates by slowing down metabolically.

One of the signs that exercise is becoming compulsive is that the person affected will have begun to schedule their lives more and more around exercise, missing social engagements and even missing work and appointments in order to work out.

Other warning signs might include:

• Working out for hours at a time each day or not taking any rest or recovery days.
• Working out even if you are injured or feeling unwell or exhausted.
• Becoming depressed, irritable, behaving irrationally if you can’t get a work out in.
• Experiencing strong feelings of guilt and anxiety when unable to exercise.
• Never feeling satisfied with your level of fitness or achievement.
• Valuing yourself in terms of physical fitness and appearance, of achievement and performance rather than in terms of inner qualities.
• Giving priority to your exercise schedule before attending to relationships.

Some physical consequences of compulsive exercise:

• Increased risk of injury (such as stress fractures, tendonitis, joint and ligament injuries).
• Fatigue.
• Dehydration.
• Osteoporosis.
• Arthritis.
• Heart problems.
• Hormonal disturbances (loss of libido, irregular or no menstruation) and reproductive problems.
• Poorer physical and mental performance overall.

Psychological consequences:

• Low self-esteem.
• Perfectionist, black and white thinking.
  Depression, anxiety.
• Irritability.
• Rigidity.
• Withdrawal from relationships.
  Social isolation.
• Inability to derive joy from eating or from exercise

To overcome exercise bulimia, help can be obtained from a number of sources:

GP
To assess and monitor the physical impact of excessive exercise (and of any other harmful behaviours).

Therapist
To look at the emotional issues that underlie the compulsion to exercise; to explore the motivation behind your behaviours; to explore attitudes and beliefs around exercise, your body and your health and how these influence your feelings and your behaviour; to help you to reduce your emotional and physiological dependence on exercise.

Nutritionist
To advise on how the cycle of eating/ purging through exercise is affecting the metabolism and to advise on how to rehabilitate and rebalance the metabolism; to help you to redress the balance between nutrition and exercise in your life.

The use of a diary to record both food intake and exercising behaviours can be a very helpful recovery tool.

If you are a regular attender at a gym/fitness club, it would be helpful for you to talk to your trainer/ instructor and seek their support in overcoming your problem.

Muscle dysmorphia is whereby a person feels that they are too small and not muscular enough and they can become obsessively focussed on trying to change this.

Muscle dysmorphia can affect both men and women, although it is more common in men and in most cases, the person affected is not small or lacking in musculature.

Background

Also known as ‘reverse anorexia’ or ‘bigorexia’
The term ‘reverse anorexia’ was first used in a 1993 study with male bodybuilders.
Is linked to body dysmorphic disorder

Involves obsessive compulsive features similar to those seen in eating disorders.

Behaviours

Behaviours of concern, often involving men, may include an attempt to pursue a body figure that is ultimately unobtainable. They may focus unduly on an ideal body that is more muscular than their own. It is important, however, to distinguish between individuals for whom body building is a lifestyle from those for whom it is part of a distorted view of and fixation with their own body shape.

People with muscle dysmorphia resort to a variety of measures to try to focus on muscle mass:

• Excessive exercise, rigorous fitness regimes
• Weightlifting and other body building exercises
• Engaging in abnormal eating patterns, excessive attention to diet, misuse of high protein diet
• Misuse of steroids and other muscle-building drugs
• Spending a significant amount of time at a gym, training through injury

A person with muscle dysmorphia will continue to work out and / or diet despite knowing that it is dangerous to their health and general well-being. Due to the distortion in self-perception it can be very difficult for the person to recognise that they need help.

Feelings and avoidance

People with muscle dysmorphia may feel shame, anxiety, guilt and embarrassment in association with their experiences. Intensive and pre-occupying thoughts and feel they have to punish themselves. The obsession with becoming more muscular takes over the person’s life to the extent that they may avoid places, people and activities because of their perceived body defect. This includes social, work related or recreational activities, connections with friends, families and partners. They may experience long bouts of social isolation. It is preferable, in their mind, to train even when injured, than to miss a workout.

The preoccupation causes major distress and can have a severe impact on relationships as the person’s life becomes restricted to the pursuit of an unattainable ideal body.

Owing to fears they that look too small, some people may:

• Decline social invitations
• Refuse to be seen at the beach
• Wear heavy clothes in the heat of summer

Health consequences and treatment

Muscle failure, osteoporosis, heart and kidney failure are among some of the risks associated with muscle dysmorphia. Depression is often co-existent with the condition.

Treatment should involve medical evaluation and monitoring as well as psychological therapy. A cognitive behavioural approach is often used.

Muscle Dysmorphia Interview
Audio interview featuring a personal account of the condition know as Muscle Dysmorphia, sometimes referred to as reverse anorexia.
Click here to download the audio interview to your computer for playback. (MP3 file)

Orthorexia or orthorexia nervosa (ON) is the name given to a condition which involves a compulsive preoccupation or obsession with dietary purity. There may be preoccupation with the composition and origin of food. Priority may be given to biologically pure foods, which may contribute to significant diet limitations.

Background

• First identified by Dr. Steven Bratman, in 1997
• Currently, orthorexia is not a formal or recognised diagnosis
• Few studies have been conducted internationally to determine prevalence of the issue.
• Research instruments used to assess orthorexia have not been thoroughly validated or examined.

In 2016, Dr Dunn & Dr. Bratman wrote “While the literature is limited in this area, there are convincing case studies and broad anecdotal evidence to conclude that sufficient evidence exists to pursue whether ON is a distinct condition.”

It is clear that some individuals identify with orthorexia. However, further research is required to ground the issue scientifically, and to ensure that best practice is followed to facilitate the identification of possible instances of orthorexia and to inform potential treatments.

What happens?

Attention to a “pure” diet becomes problematic when it is an obsession that has a significant negative impact on a person’s life. Whereas anorexia nervosa and bulimia nervosa are marked by a chronic concern for the quantity of food being consumed, orthorexia is characterised by an over-concern with the quality of the food consumed.

Thinking about food and about how it is prepared becomes a means of coping with the stresses of life and avoiding the experience of negative emotions.

Priority may be given to biologically pure foods, which may contribute to significant diet limitations.

For the person with orthorexia, wavering from their “perfect” diet can lead to periods of even stricter rules around food and eating or to periods of fasting. Going against the “rules” may contribute to feelings of guilt, anxiety and shame, and lead to more stringent diet behaviours. The rules may become more complex and detailed over time. Efforts spent trying to satisfy the rules may increase and a person may avoid social situations where they are unable to follow their food related rules.

Orthorexia type behaviours may lead to a loss of moderation and balance, that is, obsession towards food and withdrawal from life.

Causes may be hidden and masked by the desire for total control over health and life, and the belief that one’s own perspectives on eating are the “best”. An individual may be consumed by the planning, purchase and preparation of food that they consider healthy.

Though often preliminary, past studies have identified to some possible traits of those who may develop orthorexia. These include:

• Individuals affected by obsessive compulsive symptoms and some athletes.
• Those who engage in specialised diets, a strict eating schedule, increased exercise frequency and who never drink alcohol

Treatment

Research on treatment is notably limited. One study suggested that an individual needs to learn that health is not solely based on the quality of food and that it is possible to eat without it becoming an obsession. Other suggested treatments include a multidisciplinary approach and promoting nutrition education. Cognitive behavioural therapy, combined with medication, may be effective in some cases.

Psychological therapy can help a person to gain an understanding of the thoughts, beliefs and value that underlie the emotions that are driving their obsession with the “right” diet and help them to restore balance to their relationship with food and to their lives in general.

According to the American Psychiatric Association (APA), Pica involves the compulsive eating of non-nutritive, non-food substances inappropriate to the developmental level of the individual. The eating behaviour is not part of a culturally or socially supported practice. Cultural beliefs and practices may play a role some societies, though cultural Pica is distinct from childhood Pica.

• Research on Pica, including possible causes, is limited
• The prevalence may be under-reported due to feelings of embarrassment
• Iron deficiencies may be an underlying factor in some cases
• Can occur during and after pregnancy
• Can affect some autistic people or those with an intellectual disability (ID)

Examples of non-food substances

A person may consume soil, clay, paint, paper, coal, wood, string, pebbles, hair, ice or freezer frost.

Consequences

• Medical complications such as lead poisoning, bowel and intestinal problems and mineral deficiencies
• Constipation, ulcerations, perforations
• Dental problems – abrasion and damage to tooth substance, tooth surface loss
• Pica can be life-threatening, resulting in surgery

Treatment options

• Medication, psychological evaluation and/or behavioural interventions
• Applied behaviour analysis (ABA)
• A multi-disciplinary approach

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