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Cognitive and Behavioral Practice 17 (2010) 259269

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Case Conceptualization and Treatment of Comorbid Body Dysmorphic

Disorder and Bulimia Nervosa
Elizabeth R. Didie, Butler Hospital/Alpert Medical School of Brown University
Mark A. Reinecke, Northwestern Medical School/Northwestern University Medical Center
Katharine A. Phillips, Butler Hospital/Alpert Medical School of Brown University
Body dysmorphic disorder (BDD) and eating disorders often co-occur and share some clinical features. In addition, the co-occurrence of
BDD and an eating disorder may be associated with greater impairment in functioning. Furthermore, clinical impressions suggest that
this comorbidity may be more treatment resistant than either disorder alone. The current article discusses the treatment of a 48-year-old
female diagnosed with BDD and comorbid bulimia. We attempted to address these co-occurring disorders in a strategic, formulationbased manner using a variety of cognitive-behavioral strategies such as cognitive restructuring, rational disputation, exposure with
response prevention, and mirror retraining. Despite the complexity of this case, results suggest that comorbid BDD and bulimia nervosa
can be effectively managed with cognitive behavioral therapy.

dysmorphic disorder (BDD) is defined as a

distressing or impairing preoccupation with an
imagined defect in appearance; if a slight anomaly is
present, the concern is markedly excessive (American
Psychiatric Association, 2000). The preoccupation causes
clinically significant distress or impairment in social,
occupational, or other important areas of functioning,
and it must not be better accounted for by another mental
disorder (e.g., dissatisfaction with body shape and size in
anorexia nervosa). Studies have found that BDD is
relatively common, occurring in 0.7% to 2.4% of
community samples (Bienvenu et al., 2000; Faravelli et
al., 1997; Koran, Abujaoude, Large, & Serpe, 2008; Rief,
Buhlmann, Wilhelm, Borkenhagen, & Brahler, 2006), 2%
to 13% of student samples (Biby, 1998; Bohne et al., 2002;
Mayville, Katz, Gipson, & Cabral, 1999), and 13% of
psychiatric inpatients (Grant, Kim, & Crow, 2001). BDD is
associated with very poor psychosocial functioning and
quality of life (Phillips, 2000; Phillips, Menard, Fay, &
Pagano, 2005), and a high rate of suicide ideation and
attempts (Phillips, Coles, et al., 2005; Phillips & Menard,
2006; Veale et al., 1996). BDD is often comorbid with
other disorders (e.g., Gunstad & Phillips, 2003), but its
relationship to them is unclear. For example, it has been
suggested that BDD and eating disorders may be related
conditions (Grant & Phillips, 2004).
ODY

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Published by Elsevier Ltd. All rights reserved.

Some authors suggest that body image dissatisfaction

may be the essential pathology underlying both BDD and
eating disorders (Cororve & Gleaves, 2001; Rosen &
Rameriz, 1998). BDD is the only diagnosis in the DSM-IVTR, other than an eating disorder, that is characterized by
a disturbance in body image. BDD and eating disorders
also share some phenomenological features, such as body
image dissatisfaction (Rosen & Ramirez, 1998), obsessional thinking (Godart, Flament, Perdereau, & Jeammet,
2002; Halmi, 2005), poor interpersonal functioning
(Fairburn, 1997), and chronic low self-esteem (Polivy &
Herman, 2002). In addition, many patients with eating
disorders are preoccupied with non-weight aspects of
appearance, such as the size of their stomach or thighs, or
even body areas such as the skin or nose (Grant, Kim &
Eckert, 2002; Gupta & Gupta, 2001; Gupta & Johnson,
2000), similar to patients with BDD, although the latter
concerns would be diagnosed as BDD if diagnostic criteria
are met. Conversely, some BDD patients are preoccupied
with body weight and shape (Kittler, Menard, & Phillips,
2007; Phillips & Diaz, 1997). BDD individuals with weight
concerns have been found to be as impaired or more
impaired, across measures of symptom severity, comorbidity, and quality of life as those who have more classic
BDD concerns (e.g., nose, skin, and hair; Kittler et al.,
2007). The prevalence of eating disorders in individuals
with BDD has varied across studies and appears elevated
compared to the prevalence in the general population. In
a study of 293 subjects with BDD, 10% had anorexia
nervosa (AN) and/or bulimia nervosa (BN) at some point
in their life (3% with AN, 8% with BN), and 4% had

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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.

Research on treatment efficacy suggests that cognitive

behavioral therapy (CBT) may be effective for both BDD
(Veale, Gournay, et al., 1996; Wilhelm, Otto, Lohr, &
Deckersbach, 1999) and bulimia (for review see Fairburn,
2006). Although few controlled treatment outcome
studies for BDD have been completed, preliminary
studies on the efficacy of CBT are very promising
(Neziroglu & Khemlani-Patel, 2002). In a randomized
controlled trial of group CBT for BDD, 54 women were
assigned to a CBT treatment group or to a wait list (Rosen,
Reiter, & Orosan, 1995). Subjects who received CBT had
significantly greater improvement in BDD symptoms, selfesteem, and depression than those on a waiting list. Veale,
Gournay, and colleagues (1996) randomized 19 patients
to 12 weekly sessions of CBT (n = 9) or a 12-week wait list
(n = 10). Two measures of BDD symptoms showed
significant improvement with CBT compared to the
wait-list control. In an open trial of group CBT (n = 13;
Wilhelm et al., 1999) group CBT was associated with
significant improvement in symptoms (improving from
severe to moderate). Other smaller case series offer
support for CBT's efficacy (Neziroglu & Khemlani-Patel,
2002). Numerous reviews and meta-analyses have examined the efficacy of CBT for BN (for review see Fairburn,
2006). CBT has been the most extensively studied
psychosocial treatment for BN and its utility the most
consistently substantiated (American Psychiatric Association, 2000). The leading form of treatment for BN is a
specific form of CBT (Fairburn, Marcus, & Wilson, 1993).
CBT for BN appears very effective at reducing core
features of the disorder, including purging, dietary
restraint, and improving maladaptive attitudes toward
weight and shape (Fairburn et al., 1995; Thackwray,
Smith, Bodfish, & Meyers, 1993). These results suggest
that CBT appears to be an effective intervention for both
disorders of body image. IPT has also been shown to be
efficacious for BN (Agras, Walsh, Fairburn, Wilson, &
Kraemer, 2000; Cooper, & Steere, 1995; Fairburn, 1997;
Fairburn et al., 1991) but has not been studied in BDD.
In sum, BDD and eating disorders often co-occur and
share some clinical features. Comorbidity of BDD and ED
may be associated with greater impairment. Given the
significant rates of co-occurrence of these disorders,
treatments are needed that address comorbidity in
BDD. In this article, we present a case study of a patient
who presented for treatment with BDD and comorbid BN.
Treatment followed the CBT conceptualization and
treatment strategies recommended by Fairburn et al.
(1993) for BN and Rosen (1995a) for BDD. The purpose
of this article is to describe an application of CBT in the
treatment of a 48-year-old female with significant body
dysmorphic and bulimic symptoms. In this clinically
complex case, we attempted to address co-occurring
disorders in a strategic, formulation-based manner.

Treatment of Comorbid BDD and Bulimia

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

change her perception of the appearance of her breasts

and made her even more anxious and preoccupied with
her appearance. At the time of her initial evaluation with
the first author, Jan was seeking a consultation for a fourth
procedure, but was unable to afford the additional
surgery. She reported feeling very helpless and sought
support from on-line surgery chat rooms. She pursued
psychological treatment after being reprimanded at work
for repeated lateness and decreasing job performance.
Jan attributed her tardiness at work to her rigid exercise
routine. Jan reported that she had also been spending
more time in cosmetic surgery chat rooms on-line and
feeling more depressed that she would never look right
again.
Jan has been chronically concerned about her weight
and shape since the age of 20. She perceived that her
lower body (legs, hips, and buttocks) were too large and
fat and thought her thighs were huge and flabby. She
also reported that she often worried that her stomach was
no longer flat. She took great pride in having washboard
abs but came to believe that her stomach turned to
mush. She was also concerned with her weight. Jan is
within the normal weight range for her height and
medium frame (5 5 and 135 lbs.). Jan never met criteria
for anorexia nervosa; her lowest adult weight was 115
pounds. She reported that she was proud of the fact that
people often noticed and remarked on her tight stomach
and slender physique when she was younger.
Jan acknowledged that she was frequently binge
eating, which was also causing her great distress due to
a fear of gaining weight. Jan reported recurrent episodes
of binge eating (rapid consumption of a large quantity
of food in a discrete period of time), with a feeling of a
lack of control over eating during these binges about 4
days per week. Jan reported that her eating behavior
became problematic while in college following the
break-up with her boyfriend. Jan stated that since
college she has been restricting her caloric intake to
approximately 1,000 kcals/day and refused to include fat
in her diet. She engaged in rigorous exercise in order to
prevent weight gain on a daily basis. She gets up at 4:00
A.M. to run at least 6 miles and then lifts weights for an
hour. Jan reported clear dietary rules (e.g., caloric limit
that if broken she would need to work out longer or run
an extra mile for every 100 calories over 1,000 she
consumed). Jan reported that she will run more if she
eats a bad food. She denied self-induced vomiting, use
of laxatives, diuretics, or fasting.
Jan's avoidance of social situations was partly due to
concerns that other people would judge her negatively
(e.g., too fat, eating too much). She reported that her
appearance (including weight and shape) was the most
important factor that influenced how she felt about
herself, and her current dissatisfaction with her weight

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262

contributed to her depressed mood. Jan acknowledged

avoidance of exposure of her body to others because of
her feelings of being fat. She has not missed any
menstrual cycles over the past 3 months. Depressive
symptoms appeared secondary to the onset of her body
image concerns.

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 of Comorbid BDD and Bulimia

related avoidance. This appeared to be the case for Jan.
She reported that she often got mixed messages about her
appearance from her familyon the one hand she was
teased about not being curvy and on the other she would
be praised for being thin. Jan felt that no matter what she
did, her appearance would never be acceptable. She
insisted her appearance always had to be just so. Jan
seemed to manifest a range of dysfunctional attitudes or
core beliefs: I'm unlovable, Unless I'm perfect, I'm a
failure and worthless. These damaging beliefs had
negative implications for Jan's relationships, leaving her
to believe that people would find her unattractive and
worthless.
Patients with eating disorders often judge their selfworth largely in terms of shape and weight (Fairburn et
al., 1986). Jan shared a common misperception that if she
changed her outward appearance she will improve her
self-esteem. She associated physical attractiveness with
desirable traitsbeing successful, popular, and well-liked.
Studies that have examined self-esteem in individuals with
BDD have found significant associations between negative
body image and self-esteem (Biby, 1998; Phillips, Pinto, &
Jain, 2004). In clinical samples, BDD is associated with
poor self-esteem, with more severe BDD symptoms related
to worse self-esteem (Phillips et al., 2004). This relationship also appears mediated by depressive symptoms
(Nierenberg et al., 2002). In addition, severity of BDD is
associated with severity of depression (Phillips, Didie, &
Menard 2007). Thus, Jan's poor self-esteem and associated depression became a target for intervention.

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

she was uncertain if the therapy would really fix her

problem. Psychoeducation about the limited efficacy of
cosmetic surgery for BDD was crucial and proved to be a
useful intervention to engage Jan in treatment. Given that
Jan was sufficiently distressed by her symptoms and she
could not afford surgery, she agreed to try CBT to address
her body image concerns. We agreed to meet for 20
weekly sessions of 60-minute individual CBT.
Our second dilemma was identifying our initial target
for treatment. Jan's bulimic symptoms were long-standing.
She was very resistant to modifying her current diet or
exercise regimen. Jan was also reluctant to engage in
cognitive restructuring to target her body image concerns
and had difficulty conceding that a nonsurgical intervention would help. Establishing mutually agreed upon goals
for treatment was challenging. We discussed at great
length her motivation for seeking treatment, her previous
failed surgical interventions and therapy, and the efficacy
of CBT for body image concerns and bulimia. Jan
acknowledged she was fearful of losing her job and
agreed that her bingeing and excessive exercise to
compensate for her overeating episodes were significantly
distressing. Jan agreed that we would likely gain some
success early on if we focused on the binge eating so that
she could get to work on time and feel more productive.
The outcome of this initial dialogue was very useful in that
it socialized Jan to the collaborative nature of the therapy
and committed her to a targeted number of CBT sessions.
During the initial phase of treatment we reviewed our
conceptualization of Jan's symptoms and the CBT model
for treatment. Like CBT for other disorders, our
treatment paradigm was problem oriented, present
focused, and strategic. Information, advice, and support
were provided. Treatment goals were achieved over three
phases. During the first phase, an emphasis was placed on
gaining control over binge eating through behavioral
interventions (Fairburn et al., 1993). During the second
phase, more cognitively focused strategies, such as
identifying cognitive errors and maladaptive assumptions,
rational disputation, and restructuring cognitive errors,
were introduced to induce change in maladaptive
thoughts, beliefs, and values. It was during the second
phase of treatment that we incorporated Rosen's treatment strategies to target Jan's BDD beliefs and behaviors.
Exposure and response prevention for BDD was also
introduced. During the third and final stage of treatment,
we focused on maintaining her change and preventing
relapse.
Initially, we attempted to eliminate Jan's binges by
establishing a regular pattern of eating. Self-monitoring
was an essential step in helping Jan to regulate her eating
and to eliminate binge episodes and the need to engage
in inappropriate compensatory behaviors (e.g., excessive
exercise). Adherence to self-monitoring is associated with

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Didie et al.
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

and began to introduce a variety of previously feared

foods into her diet. Once she felt more in control of her
eating, and realized that she did not gain weight as a
direct result of her increased caloric consumption, she
was able to reduce the amount of time she devoted to
exercise. Reducing her rigidly held schedule of physical
activity left her feeling more energetic (since she no
longer had to awake at 4:00 A.M. to exercise), and allowed
her to be more prompt to work.
Although changing Jan's binge eating had proven to be
relatively successful, altering Jan's maladaptive beliefs
related to her appearance presented a greater challenge.
Jan's self-monitoring records provided a useful starting
place to begin addressing her dysfunctional attitudes and
feelings about shape, weight, and eating. After several
weeks, we turned our attention to cognitive restructuring
of the rigidly held beliefs and maladaptive coping
strategies related to her perceived appearance flaws.
Given the overlap of Jan's eating disorder and BDD
beliefs, we were able to focus on beliefs that pertain to
both BDD and BN concurrently.
Jan worked with her therapist to identify developmental antecedents of her body image problems, sociocultural
and familial factors, and immediate triggers for her body
image concerns. She identified perceived criticism as the
main trigger for her current appearance obsession and
rituals. Based on Jan's thought monitoring records, it
became clear that many of her beliefs focused on
achieving what she believed to be appearance perfection. Perfectionism is a common feature in both BDD
and EDs (Frost & Steketee, 1997; Halmi, 2005). This
expectation will ultimately lead to feelings of failure. In
Jan's case, she perceived failed attempts to achieve
unrealistic standards as proof that she was worthless.
Feelings of ineffectiveness and worthlessness lowered her
self-esteem and reinforced her depressive thoughts. As
such, we attempted to reduce her lofty and unreasonable
goals (Katzman, Weiss & Wolchik, 1986). Praise and
achievement of set goals seemed to serve as positive
reinforcements. Jan appeared to be more inclined to
complete skills-building homework assignments as she
achieved smaller more attainable goals she set for
homework.
Cognitive restructuring also targeted Jan's deeper-level
maladaptive and irrational beliefs that others would find
her unlovable and worthless unless she was perfect. Jan
readily acknowledged that the rules and assumptions she
set for herself were unrealistic and contributed to her
feelings of depression. Jan agreed that she held a different
set of standards for herself than she held for family and
friends. Through guided, Socratic discussions, Jan was
able to restructure these assumptions and beliefs. She also
developed a list of characteristics and traits on which she
could base her self-worth other than appearance. She

Treatment of Comorbid BDD and Bulimia

noted, for example, that she has talents as a painter, is a
loving sister, and has good teaching skills.
Once Jan had become comfortable using cognitive
restructuring skills, we introduced exposure and response
prevention techniques. Specifically, we focused on social
situations that Jan had previously been avoiding. It was
helpful for Jan to use her newly developed skills in
rational responding to challenge automatic thoughts and
beliefs that plagued her thinking in situations that
exposed her flaws. Jan and her therapist created a
hierarchy of feared situations that she had been avoiding,
for example, going to dinner with friends wearing clothes
that did not camouflage her body areas of concerns. One
of the most anxiety-provoking situations for Jan was to go
shopping with friends on a day that she had not exercised.
Jan reported many rituals related to her appearance
concerns (e.g., body checking, weighing, mirror checking, reassurance seeking, comparing). She acknowledged
that these rituals reduced her anxiety in the short run, but
ultimately made her more concerned with her appearance. Response prevention for BDD involves the suppression of urges and rituals that help reduce anxiety caused
by appearance concerns. It also involves instructing Jan to
refrain from carrying out a ritual until the urge to do so
subsides or is reduced.
She found it useful to conduct exposure and response
prevention exercises as behavioral experiments in which
she would test specific predictions regarding the outcome
of a particular exposure. For example, in one of Jan's
experiments she predicted that if I wear fitted clothes,
then my friends will be disgusted with my appearance.
She was encouraged, in a systematic and structured way,
to gradually meet friends without using the safety net of
her rituals such as wearing clothes that did not
camouflage her appearance. Based on her hierarchy,
Jan began to wear clothing that fit, accept dates, and sit
next to attractive persons without using her comparing
ritual. In order to assist Jan, our first exposure and
response prevention exercise was conducted in session.
For example, Jan remarked that she found it moderately
anxiety provoking speaking with the receptionist in our
office. She thought the receptionist was very attractive and
was concerned that she was being judged negatively.
Therefore, Jan would hide her body by wearing oversized
clothes to our appointments. For one of Jan's first
exposures she decided to make eye-contact and converse
with the receptionist wearing clothes that were an
appropriate size. This was also an opportunity for Jan to
practice her newly developed cognitive skills to challenge
cognitive errors such as mind reading. For example, Jan
was able to take note that her automatic thought when
speaking to the receptionist was, She thinks I'm fat and
therefore won't make eye contact. Jan was able to devise a
specific behavioral experiment testing out this prediction

and gather evidence to challenge her assumptions. We

then increased the difficulty of the tasks by varying the
situations with respect to familiarity, physical proximity,
and type of social interaction. For example, we then
moved on to practicing the same exposure with some of
Jan's colleagues whom she perceived to be highly
attractive and evoked greater anxiety.
A mirror retraining exercise was introduced to address
Jan's anxiety about her appearance and to normalize her
relationship with mirrors (Katzman et al., 1986). Jan both
excessively checked mirrors for hours a day, hoping to be
reassured about her appearance, but also avoided mirrors
at times because she feared what she would see. As part of
this exercise, Jan was encouraged to examine her body in
front of a full-length mirror and to describe positive
features about each body part. To develop a more
holistic view of her appearance, she was encouraged
to describe her entire body rather than focusing on just
on the disliked areas. Jan was asked to refrain from critical
self-talk while looking in the mirror and to substitute
more positive or objective descriptions of their appearance. Her descriptions were to be based on functional
rather than physical attributes. Exposure therapy and
relaxation training were used to extinguish anxiety at the
sight of troublesome body features. These exercises
served to increase Jan's appreciation of her body's
strengths and led her to view her body more realistically.
Jan often found it difficult to manage the expression of
anger and to disagree with loved ones. Jan believed it was
necessary to be available to other people at all times. She
worried that if she refused requests from others, they
would become angry and would abandon her. We used
interactions with family members as an opportunity to
challenge Jan's belief that I will end up alone if I'm not
perfect. In addition, Jan's binges served to soothe and
distract her from her own negative feelings. Cognitive
restructuring exercises helped resolve irrational fears
about losing control of her anger, and possible criticism
or rejection for its expression (Johnson et al., 1987). Jan
developed a rational response that highlighted that she
could set limits with family members, assert her own
needs, and could still be loved. Katzman et al. (1986) have
found that role-playing can reassure the client that anger
is a normal, healthy emotion that can be expressed in a
productive way. We used visualization techniques in which
she imagined herself expressing her needs and having
people become angry with her. The use of graded
exposures served to challenge these long-held beliefs.
Jan was assigned skills-building exercises to be completed between sessions. At first, Jan was ambivalent about
completing these assignments given her busy work
schedule. We emphasized the importance of working on
skills outside of session in order to maintain gains and
achieve the goals that Jan identified at the onset of

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Didie et al.

266

therapy. Jan gradually made completing her homework a

priority, especially after she began to see some gains and
see tangible successes in treatment.
The final component of treatment centered on
preventing relapse. Lapses are a natural part of the
recovery process, and patients should not be discouraged
when such incidents occur. Thackwray et al. (1993) have
suggested that lapses can be useful for developing more
adaptive problem-solving strategies. Jan recognized that
she would not always have a smooth course after
completing therapy. This was an important acknowledgment, given her previous focus on perfection. Relapse
prevention and maintenance of change is encouraged
through additional self-monitoring and self-reinforcing
behaviors. Turner, Wang, and Westerfield (1995) have
devised a Relapse Prevention Model that offers strategies
rooted in social learning theory. According to this
paradigm, Jan was encouraged to view lapses as a learning
opportunity and as an indication that more practice in the
specific skill may be needed. Additionally, Jan was
encouraged to write down the skills and techniques that
worked best for her during treatment to remind herself of
her progress after termination. After the conclusion of the
acute phase of treatment, we scheduled booster sessions
once a month for 4 months in order to ensure that gains
she made over the course of treatment were maintained
and to provide additional practice and support.
Definite studies that examine the efficacy of CBT for
comorbid BDD and BN have not been completed. Based
on clinical experience, it is likely that at least partial
remission of overall BDD and BN symptoms can be
achieved. For example, it is expected that exercise would
continue but at a more moderate rate and that overall
symptoms will be more manageable. While patients may
continue to report continued dissatisfaction with their
appearance, they may not be so preoccupied with
perceived flaws and will likely report a reduction in
interference and distress. Patients may also report more
flexibility in their food intake with a reduction in dietary
rules and restrictions. Functional improvement may also
be evident. For example, patients may report increased
participation in previously avoided activities, improvement in interference and concentration at work and
improvement in relationships.

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

distinguished from an eating disorder. For example, a

man (or woman) who is preoccupied with perceived acne
or a receding hairline, has no concerns about being
overweight or too fat, has no abnormal eating behaviors,
and meets other diagnostic criteria for BDD would be
diagnosed with BDD, not an eating disorder. Jan was
diagnosed with BDD because she was preoccupied with
her breasts (thinking they were too small and then
asymmetrical). She also performed classic BDD-related
compulsive behaviors (such as mirror checking, frequent
clothes changing, comparing, and repeated plastic
surgery), and avoided social situations because of her
perceived appearance flaws. It is important to differentiate BDD from an eating disorder, especially because
treatment approaches for these disorders differ. For
example, symptoms characteristic of BDDsuch as
prominent ideas or delusions of reference, persistent
seeking of surgical or dermatologic treatment, and skin
pickingneed to be targeted by psychotherapy. In
addition, the pharmacotherapy of BDD and eating
disorders differs (see below). Thus, it is important for
clinicians to screen for and recognize BDD in their eating
disorder patients, and vice versa.
In other cases, however, distinguishing BDD from an
eating disorder is not as straightforward as in Jan's case.
The more complex diagnostic conundrum pertains to the
diagnosis of eating disorder NOS versus BDD. The
diagnostic boundaries of eating disorder NOS (for
variations other than binge eating disorder, in particular)
are not well defined (Grant & Phillips, 2004). Additional
research is needed on both eating disorder NOS and on
BDD, including their overlap and differentiation. Needed
research includes studies that directly compare BDD and
eating disorders across a variety of domains (e.g.,
phenomenology, comorbidity, information processing,
neuroimaging) to better understand their relationship to
each other.
Another issue raised by this case is that eating disorders
appear to be relatively common in individuals with BDD.
The co-occurrence of BDD and an eating disorder
appears associated with increased morbidity. Grant et al.
(2002) found that inpatients with anorexia who had
comorbid BDD had significantly lower overall social and
occupational functioning, greater suicidality, more psychiatric hospitalizations and greater delusionality than
those without anorexia. A study of BDD subjects found
that those with a comorbid eating disorder had greater
body image disturbance, a greater number of comorbid
disorders, and had received significantly more mental
health treatment (Ruffolo et al., 2006). Thus, it is
important for clinicians to be aware of this comorbidity
when present.
The relatively high comorbidity between BDD and
eating disorders, as well as their shared clinical features

Treatment of Comorbid BDD and Bulimia

(e.g., body image dissatisfaction and disturbance), raises
the question of whether they may be related. If BDD and
eating disorders are related disorders, does the body
image disturbance associated with BDD metamorphose
into weight and shape dissatisfaction accompanied by
disordered eating in some patients? While longitudinal
studies of this important question have not been done,
cross-sectional studies have found that onset of BDD often
precedes onset of an eating disorder. The case of Jan with
the eating symptoms predating the BDD is atypical. In one
BDD study, BDD began before a comorbid eating
disorder in 63% of subjects (Ruffolo et al., 2006). In
another BDD study, BDD preceded the onset of BN in
most cases (88%), although AN was equally likely to begin
before or after onset of BDD (Gunstad & Phillips, 2003).
In a study of inpatients with anorexia nervosa (Grant et
al., 2002), 94% developed BDD before their eating
disorder. Longitudinal studies of body image and
preoccupation (although not BDD specifically) have
found that thin body preoccupation precedes the onset
of eating disorders (Killen et al., 1994; The McKnight
Investigators, 2003). Additional research is needed to
examine the temporal onset and longitudinal associations
between the course of BDD and eating disorders.
Research is also needed on risk factors and shared
neurobiological, psychosocial, and cognitive vulnerabilities of these commonly co-occurring disorders.
This case also raises several treatment issues. As we saw
with Jan, deciding which disorder to focus on first can be a
challenge. As with all collaborative treatments, establishing mutually agreed upon goals was essential. Ultimately,
it would have to be Jan's decision and hard work that
would allow her to achieve her goals. Assisting Jan with
identifying her most important goal, weighing out the
cost/benefits of achieving this goal, and assessing the
likelihood of making gains in a specified area all
contributed to our decision to work on reducing binge
eating.
Engaging patients in CBT can be quite challenging,
particularly for those with BDD. In addition, the
difficulties of engaging some eating disorder patients in
therapy are well-documented (Vitousek, Watson, &
Wilson, 1998). Patients who have very poor insight into
the inaccuracy of their appearance beliefs (as in BDD or
anorexia) or are severely depressed present unique
challenges for even the most talented CBT therapists. As
with all CBT approaches, the general therapist stance is
collaborative, inquisitive, and hopeful. Most patients with
BDD do not recognize the inaccuracy of their beliefs and
maintain they have a true physical problem. However,
patients often are willing to agree that they are suffering,
significantly distressed by their appearance concerns, and
that they are not living the kind of life they would prefer.
As described in Jan's case, she was initially reluctant to

engage in treatment. However, she was readily willing to

acknowledge the distress her symptoms were causing her.
Focusing on mutually agreed upon areas, as well as
mutually agreed-upon treatment goals, rather than on the
patient's appearance per se, may help some to engage in
CBT and maintain motivation. Motivational interviewing
strategies (Miller & Rollnick, 1991) modified for BDD
(Wilhelm et al., 2009) may also help engage the resistant
patient in treatment.
Like Jan, a majority of persons with BDD seek and
receive non-mental-health treatment (e.g., surgical, dermatologic) for their perceived appearance flaws, although
such treatment appears to rarely improve overall BDD
symptoms (Crerand, Phillips, Menard, & Fay, 2005;
Phillips, Grant, Siniscalchi, & Albertini, 2001). In a study
of 200 individuals with BDD, subjects retrospectively
reported that only 3.6% of all treatments led to overall
improvement in BDD (Crerand, et al., 2005). In another
study (n = 250), only 7% of treatments led to overall
improvement in BDD (Phillips, Grant, et al., 2001). Veale,
Gournay, et al. (1996) found that 81% of 50 BDD patients
reported being dissatisfied with past medical consultation
or surgery. It is therefore important for patients to be
aware that surgical and other medical interventions are
unlikely to successfully treat their body image concerns.
Psychosocial treatments for BDD and comorbid
disorders such as eating disorders need to be developed
and tested. Treatment research is needed to determine to
what extent these disorders do or do not improve with the
same treatment, and whether treatment modifications are
necessary when these disorders co-occur. It is unlikely that
we could have treated Jan's bulimia and BDD with the
exact same treatment. For example, it seems unreasonable to speculate that a BDD treatment with no specific
focus on regular patterns of eating would have reduced
Jan's bingeing and purging. Alternatively, there are
features of both disorders that potentially can be treated
with one approach such as changing core beliefs,
reducing perfectionism, and improving body image.
This case also raises the role of pharmacotherapy in
the treatment of BDD. At termination, Jan was still
experiencing moderate BDD symptoms and may have
potentially benefited from medication treatment that
targeted her BDD symptoms. Pharmacologic treatment
for BDD is described in more detail elsewhere (National
Collaborating Centre for Mental Health, 2006; Phillips,
2009; Phillips & Hollander, 2008). Recommended treatment for eating disorders is also reviewed elsewhere
(American Psychiatric Association, 2006; National Institute for Clinical Excellence, 2004). In brief, studies that
have examined the efficacy of serotonin-reuptake inhibitors (SRIs, SSRIs) for BDD indicate that these medications
are often efficacious (Hollander et al., 1999; Perugi et al.,
1996; Phillips, 2006; Phillips, Albertini, & Rasmussen,

267

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268

2002; Phillips, Dwight, & McElroy, 1998; Phillips & Najjar,

2003) and that SRIs appear more efficacious for BDD
than non-SRI antidepressants or other types of psychotropic medication (Phillips & Hollander, 2008). It should
be noted that Jan's dose of the SRI fluoxetine was low for
treating BDD, and she took it for only 3 weeks; thus, her
treatment trial was not adequate for BDD.
At this time it is unknown whether medication or CBT
is more efficacious for BDD, as no randomized controlled
studies have directly compared them. Both treatments
appear efficacious, and perhaps the more clinically
relevant question is which treatment is better suited to
which patients. No studies have investigated whether a
combination of CBT and an SRI is more efficacious than
either treatment alone, although we generally recommend both treatments for more severely ill patients.
Future studies are needed to address these important
questions.

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Address correspondence to Elizabeth R. Didie, Ph.D., Butler
Hospital/Brown Medical School, 345 Blackstone Blvd., Body Image
Program, Providence, RI 02906; e-mail: Elizabeth_Didie@brown.edu.
Received: February 2, 2010
Accepted: February 2, 2010
Available online 4 March 2010

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