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The links between body dysmorphic disorder and eating disorders
Eur Psychiatry 2000 ; 15 : 302-5 © 2000 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S0924933800003989/FLA
ORIGINAL ARTICLE
The links between body dysmorphic disorder and eating disorders J. Rabe-Jablonska Jolanta*, M. Sobow Tomasz II Department Of Psychiatry, Medical University Of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland (Received 10 August 1998; revised 28 April 2000; accepted 2 May 2000)
Summary – The aim of the study was to search for a body dysmorphic disorder (BDD) period preceding the symptoms meeting the criteria of either anorexia or bulimia nervosa, and an evaluation of the prevalence of BDD symptoms in a control group of girls without any eating disorder. Ninety-three girls (12–21 years old) were included in the study (36 with anorexia nervosa, 17 with bulimia nervosa and 40 healthy controls). The Structured Clinical Interview (SCID), including the BDD module, and a novel questionnaire (for the presence of preceding life events) were used. We found the symptoms of BDD in 25% of anorexia nervosa sufferers for at least six months before observing a clear eating disorder picture. Moreover, other mental disorders were also present among these patients. The results may support the idea that BDD and anorexia nervosa both belong to either OCD or affective disorders spectra. © 2000 Éditions scientifiques et médicales Elsevier SAS anorexia nervosa / body dysmorphic disorder / bulimia nervosa
INTRODUCTION Body dysmorphic disorder (BDD; the term dysmorphophobia is also used) belongs to the somatoform disorder spectrum according to both ICD and DSM-IV classifications [1]. In the latest ICD version, the diagnosis is not specified as a distinct heading as in the DSM-IV, and as a consequence, one cannot find separate diagnostic criteria there. Some authors stress the clinical similarities between body dysmorphic disorder and obsessive-compulsive disorder (OCD) or even more, they treat BDD as belonging to the OCD spectrum [2-4]. Moreover, in one co-morbidity study it has been shown that features of BDD are most common in patients with social phobia and OCD and so they concluded that it may share etiologic elements with both social phobia and obsessive-compulsive disorder [5]. * Correspondence and reprints
Individuals with BDD frequently present obsessions, e.g., repetitive thoughts about specific features of their physical appearance and compulsive checking and inquiring other people about it. Characteristic behavior also includes specific rituals aimed at covering “defects.” Patients with both OCD and BDD respond well to selective serotonin reuptake inhibitors treatment. According to some researchers, this implies dysregulation of the serotoninergic system as a common etiology of both disorders [6, 7, 9]. Other authors believe that BDD belongs to the broadly defined affective disorders spectrum. They refer to epidemiologic data which show that affective disorders (mainly major depression) are more common among patients suffering from BDD than in the general population [7, 8]. In a small number of research cases it has also been found that first-degree relatives of patients
BDD and eating disorders
with BDD suffer more frequently from affective disorders than individuals in the general population [7, 10, 13]. Supposed links between BDD and anorexia nervosa are also taken into consideration and are considered interesting. A group of authors supports the opinion that in some patients diagnosed as anorexic, symptoms of BDD precede eating disorder clinical manifestations. In such cases patients may try to improve their physical appearance by employing low-calorie diets, gymnastics, purgatives and diuretics. Moreover, it may be restricted to some parts of the body, mainly the face and the legs. It seems that the more anxious a patient is of his or her physical appearance, the more complicated the system of corrective activities. As a consequence it leads to psychopathological symptoms fulfilling the criteria of anorexia nervosa and finally to numerous somatic symptoms. It has to be stressed that according to both ICD and DSM-IV the diagnosis of BDD cannot be used if the symptoms appeared at the same time as the symptoms of the eating disorders. The presented views seem to be of a theoretical value only, due to the lack of systematic studies in this area. Moreover, anorexia nervosa is treated by most of the authors as consisting of several subgroups of a different pathogenesis which include OCD, affective disorders, somatoform disorders, primary phobias, etc. The same is being proposed for bulimia nervosa, which may belong to the OCD spectrum, affective disorders or impulse control disorder. The aim of the retrospective study presented was to search for a BDD period preceding the symptoms meeting the criteria of eating disorders, either anorexia or bulimia nervosa, and to evaluate the prevalence of BDD symptoms in a control group of girls without any eating disorder. Occurrence of other mental disorders in the studied group was also examined, as well as life events which are characteristic for the group. SUBJECTS AND METHOD Ninety-three girls aged between 12 and 21 years of age were included in the study. In that sample, 36 girls met DSM-IIIR and DSM-IV criteria of anorexia nervosa, 17 for bulimia nervosa and 40 were considered healthy age- and education-matched controls. The mean symptomatic period in the anorexia nervosa subgroup was 2 years and 10 months (range: 1–4 years), in the bulimia nervosa subgroup 1 year and 2 months (range: 6 Eur Psychiatry 2000 ; 15 : 302–5
303
months–2 years). All examined girls were patients of the Adolescent Inpatient Unit or the Outpatient Unit of the IInd Department of Psychiatry, Medical University of Lodz, Poland, and all had signed a written consent. In both eating disorders groups as well as in the control group the symptoms of BDD preceding eating disorders for a period of at least six months were diagnosed according to DSM-III-R using the Structured Clinical Interview for DSM-III-R (SCID) with the BDD module [1, 11-14]. Furthermore, in a group of patients with BDD and anorexia nervosa, the presence of other mental disorders in the past was screened using the same tool (SCID). Psychiatric co-morbidity was also examined in the anorexia nervosa subgroup. Using a questionnaire originally developed for this purpose, all the girls were examined for the presence in their histories of any events preceding a symptomatic period, such as rejection by girls of the same age, lack of interest in boys, loss of a partner, negative remarks on patient’s physical appearance, or special emphasis by the parents on physical appearance (subjective evaluation of their opinions, reactions and behavior). The results were statistically analyzed (Fisher exact test, two-tailed). RESULTS BDD symptoms were present in 25% of anorexia nervosa suffering girls for at least 6 months (range: 6 months–3 years, mean: 14 months) before observing a clear eating disorder picture. The difference between patients suffering from bulimia nervosa and healthy controls was statistically non-significant (table I), though patients with anorexia nervosa recognized more often than subjects with bulimia and controls the shape of faces (“too wide”, “too round-shaped”, “too chubbycheeked”) or the shape of limbs (“too fat”, “too fat and too short”) as a defect of their physical appearance. No members in the group of bulimics presented BDD symptoms, though 7.5% of subjects in the control group had slightly pronounced symptoms. In a latter group, girls considered as defects the shapes of their noses, teeth, faces and legs and other parts of the body. The “defects” were minor but real beauty flaws. In a subgroup of anorexia nervosa sufferers with a distinct preceding period of BDD symptoms, additional diagnoses of OCD (six girls), obsessivecompulsive personality disorder (one girl) or affective disorders, either major depression or dysthymic disor-
304
J. Rabe-Jablonska Jolanta, M. Sobow Tomasz
Table I. The frequency of BDD symptoms among patients with diagnosis of anorexia nervosa (AN) and bulimia nervosa (BN) and in a control group*. AN N = 36
Statistical significance
BN N = 17
Statistical significance
Control N = 40
Statistical significance
AN + BDD
AN + BDD versus control P = 0.57
BN + BDD
AN + BDD versus BN + BDD P = 0.44
BDD
BN + BDD versus control NS
N=9
N=0
N=3
* Fisher exact test, two-tailed.
der (two girls), were made (table II). It has been also shown retrospectively that OCD symptoms existed in all cases for at least a few years before the onset of eating disorders while affective disturbances appeared much later, after all the symptoms of eating disorders were already present. However, the data can be seriously biased as in most of the cases they are based on patients’ reports, and only three of them were confirmed by the relatives (the presence of obsessions or compulsions not related to eating). Two subgroups of anorexia nervosa sufferers and bulimic patients were also compared for the presence in Table II. Coexisting mental disorders in a subgroup of anorexia nervosa sufferers with preceding BDD symptoms period. Additional psychiatric diagnosis according to DSM-IV criteria
Number of patients
Fraction
%
1) obsessive-compulsive disorder 2) affective disorders – major depression – dysthymic disorder 3) obsessive personality disorder
6 2 1 1 1
0.167 0.056 0.028 0.028 0.028
16.7 5.6 2.8 2.8 2.8
Total
9
0.25
25.1
their histories of such events preceding a symptomatic period as rejection of same-age girls, lack of interest in boys, loss of a partner, negative remarks on patient’s physical appearance, or special emphasis by the parents on their physical appearance. The total number (at least 1, and 2, 3, and over 3) of such events in anorexic patients with a BDD period was significantly higher (P = 0.001) than in a group without such a preceding period (table III), while the bulimic patients did not differ from either anorexics without BDD or healthy controls (not shown). It may be hypothesized that accumulation of these events might influence the development of negative self-esteem and anxiety about not being “ugly” or “funny.” DISCUSSION In the study it has been shown that 25% of anorexia nervosa sufferers experienced a distinct preceding period of BDD symptoms. In that period, the exclusive diagnosis of BDD could be made, but the prevalence of such a period was not significantly higher in the anorexia group than in bulimia nervosa group (0%) or in healthy controls (7.5%). In each analyzed case the
Table III. Specific events preceding BDD and anorexia nervosa symptoms. Type of event N Same age group rejection Lack of interest in boys Remarks on a physical appearance Emphasis on physical appearance by relatives Loss of a partner Number of events 1 2 3 >3 at least one event (1, 2, 3, and > 3)
AN, N = 27 %
AN + BDD, N = 9 N %
Statistical significance (Fisher exact test, two-tailed)
7 7 4 3 2
25.9 25.9 14.8 11.1 7.4
4 5 5 4 2
44.4 55.6 55.6 44.4 22.2
NS NS NS NS NS
6 2 1 0 9
22.2 7.4 3.7 0 33.3
1 2 5 1 9
11.1 22.2 55.6 11.1 100.0
NS NS NS NS *significant P = 0.001 Eur Psychiatry 2000 ; 15 : 302–5
BDD and eating disorders
borderline between BDD and clear anorexia nervosa symptoms periods was not distinct and there was no asymptomatic period present. Some of the patients had additionally either obsessive-compulsive personality disorder features or symptoms of OCD. In some cases the influence of the environment should also be taken into consideration. The presence of existing but slight beauty defects was often emphasized by members of the family (especially by the mother). Some girls also experienced awkward situations of being critically compared to others. The latter implied disadvantage in the same age group, though sometimes only as an emotional rather than a real experience. The features listed above were present only in some cases. In the period of clear anorexia nervosa symptoms in some girls coexisting OCD or affective disorder could be diagnosed, which both negatively influence the clinical course of eating disorders [3]. Perhaps this is why the subgroup with coexisting BDD constitutes at the same time the subgroup with a longer clinical course of the disorder. After summarizing the data, it is possible to find the specific subgroup of anorexia nervosa sufferers with a preceding period of BDD and coexisting mental disorder such as OCD or affective disorders (major depression or dysthymic disorder). This may support the idea that BDD and anorexia nervosa both belong to either OCD or affective disorder spectra. In many cases it is difficult to draw clear time boundaries between the periods. Moreover, the symptoms of different disorders may coexist. A variety of symptoms present in many adolescent patients accounts for complex, multidirected therapeutic approaches. In the studied group, the patients with bulimia nervosa did not present any symptoms of preceding BDD. It is highly difficult to discuss the phenomenon having such a small sample. It is possible that the results are artifacts due to the reduced sample size, so further studies on larger popu-
Eur Psychiatry 2000 ; 15 : 302–5
305
lations are necessary to address this question in a more adequate way. REFERENCES 1 Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1995. 2 Holden NL. Is anorexia nervosa an obsessive-compulsive disorder? Br J Psychiatry 1990 ; 157 : 1-5. 3 Rabe-Jablonska J. Obsessive-compulsive disorder among girls with eating disorders. Psychiatr Pol 1996 ; 2 : 187-200. 4 McKay D, Neziroglu F, Yaryura-Tobias JA. Comparison of clinical characteristics in obsessive-compulsive disorder and body dysmorphic disorder. J Anxiety Disord 1997 ; 11 : 447-54. 5 Brawman-Mintzer O, Lydiard RB, Phillips KA, Morton A, Czepowicz V, Emmpanuel N, et al. Body dysmorphic disorder in patients with anxiety disorders and major depression: a comorbidity study. Am J Psychiatry 1995 ; 152 : 1665-7. 6 Braddock LE. Dysmorphophobia in adolescence: a case report. Br J Psychiatry 1987 ; 140 : 199-201. 7 Connolly FH, Gibson M. Dysmorphophobia: a long-term study. Br J Psychiatry 1978 ; 132 : 568-70. 8 Halmi KA, Eckert E, Marchi P, Sampugnaro V, Apple R, Cohen J. Comorbidity of psychiatric diagnoses in anorexia nervosa. Arch Gen Psychiatry 1991 ; 10 : 675-81. 9 Heimann SW. SSRI for body dysmorphic disorder. J Am Acad Child Adolesc Psychiatry 1997 ; 36 : 868. 10 Hudson JL, Pope HG Jr. Affective spectrum disorder: does antidepressant response identify a family of disorders with common pathophysiology? Am J Psychiatry 1990 ; 147 : 552-64. 11 Diagnostic and statistical manual of mental disorders. 3rd ed. Revised. Washington: American Psychiatric Association press; 1987. 12 Phillips KA, Atala KD, Pope HG. Diagnostic instruments for body dysmorphic disorder 1995. Miami: New Research Program and Abstracts, APA; 1995. 13 Philips KA, McElroy SL, Hudson JL, Pope HG Jr. Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum, or both? J Clin Psychaitry 1995 ; 56 Suppl 4 : 41-51. 14 Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: history, rationale, and description. Arch Gen Psychiatry 1992 ; 49 : 624-9.
ORIGINAL ARTICLE
The links between body dysmorphic disorder and eating disorders J. Rabe-Jablonska Jolanta*, M. Sobow Tomasz II Department Of Psychiatry, Medical University Of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland (Received 10 August 1998; revised 28 April 2000; accepted 2 May 2000)
Summary – The aim of the study was to search for a body dysmorphic disorder (BDD) period preceding the symptoms meeting the criteria of either anorexia or bulimia nervosa, and an evaluation of the prevalence of BDD symptoms in a control group of girls without any eating disorder. Ninety-three girls (12–21 years old) were included in the study (36 with anorexia nervosa, 17 with bulimia nervosa and 40 healthy controls). The Structured Clinical Interview (SCID), including the BDD module, and a novel questionnaire (for the presence of preceding life events) were used. We found the symptoms of BDD in 25% of anorexia nervosa sufferers for at least six months before observing a clear eating disorder picture. Moreover, other mental disorders were also present among these patients. The results may support the idea that BDD and anorexia nervosa both belong to either OCD or affective disorders spectra. © 2000 Éditions scientifiques et médicales Elsevier SAS anorexia nervosa / body dysmorphic disorder / bulimia nervosa
INTRODUCTION Body dysmorphic disorder (BDD; the term dysmorphophobia is also used) belongs to the somatoform disorder spectrum according to both ICD and DSM-IV classifications [1]. In the latest ICD version, the diagnosis is not specified as a distinct heading as in the DSM-IV, and as a consequence, one cannot find separate diagnostic criteria there. Some authors stress the clinical similarities between body dysmorphic disorder and obsessive-compulsive disorder (OCD) or even more, they treat BDD as belonging to the OCD spectrum [2-4]. Moreover, in one co-morbidity study it has been shown that features of BDD are most common in patients with social phobia and OCD and so they concluded that it may share etiologic elements with both social phobia and obsessive-compulsive disorder [5]. * Correspondence and reprints
Individuals with BDD frequently present obsessions, e.g., repetitive thoughts about specific features of their physical appearance and compulsive checking and inquiring other people about it. Characteristic behavior also includes specific rituals aimed at covering “defects.” Patients with both OCD and BDD respond well to selective serotonin reuptake inhibitors treatment. According to some researchers, this implies dysregulation of the serotoninergic system as a common etiology of both disorders [6, 7, 9]. Other authors believe that BDD belongs to the broadly defined affective disorders spectrum. They refer to epidemiologic data which show that affective disorders (mainly major depression) are more common among patients suffering from BDD than in the general population [7, 8]. In a small number of research cases it has also been found that first-degree relatives of patients
BDD and eating disorders
with BDD suffer more frequently from affective disorders than individuals in the general population [7, 10, 13]. Supposed links between BDD and anorexia nervosa are also taken into consideration and are considered interesting. A group of authors supports the opinion that in some patients diagnosed as anorexic, symptoms of BDD precede eating disorder clinical manifestations. In such cases patients may try to improve their physical appearance by employing low-calorie diets, gymnastics, purgatives and diuretics. Moreover, it may be restricted to some parts of the body, mainly the face and the legs. It seems that the more anxious a patient is of his or her physical appearance, the more complicated the system of corrective activities. As a consequence it leads to psychopathological symptoms fulfilling the criteria of anorexia nervosa and finally to numerous somatic symptoms. It has to be stressed that according to both ICD and DSM-IV the diagnosis of BDD cannot be used if the symptoms appeared at the same time as the symptoms of the eating disorders. The presented views seem to be of a theoretical value only, due to the lack of systematic studies in this area. Moreover, anorexia nervosa is treated by most of the authors as consisting of several subgroups of a different pathogenesis which include OCD, affective disorders, somatoform disorders, primary phobias, etc. The same is being proposed for bulimia nervosa, which may belong to the OCD spectrum, affective disorders or impulse control disorder. The aim of the retrospective study presented was to search for a BDD period preceding the symptoms meeting the criteria of eating disorders, either anorexia or bulimia nervosa, and to evaluate the prevalence of BDD symptoms in a control group of girls without any eating disorder. Occurrence of other mental disorders in the studied group was also examined, as well as life events which are characteristic for the group. SUBJECTS AND METHOD Ninety-three girls aged between 12 and 21 years of age were included in the study. In that sample, 36 girls met DSM-IIIR and DSM-IV criteria of anorexia nervosa, 17 for bulimia nervosa and 40 were considered healthy age- and education-matched controls. The mean symptomatic period in the anorexia nervosa subgroup was 2 years and 10 months (range: 1–4 years), in the bulimia nervosa subgroup 1 year and 2 months (range: 6 Eur Psychiatry 2000 ; 15 : 302–5
303
months–2 years). All examined girls were patients of the Adolescent Inpatient Unit or the Outpatient Unit of the IInd Department of Psychiatry, Medical University of Lodz, Poland, and all had signed a written consent. In both eating disorders groups as well as in the control group the symptoms of BDD preceding eating disorders for a period of at least six months were diagnosed according to DSM-III-R using the Structured Clinical Interview for DSM-III-R (SCID) with the BDD module [1, 11-14]. Furthermore, in a group of patients with BDD and anorexia nervosa, the presence of other mental disorders in the past was screened using the same tool (SCID). Psychiatric co-morbidity was also examined in the anorexia nervosa subgroup. Using a questionnaire originally developed for this purpose, all the girls were examined for the presence in their histories of any events preceding a symptomatic period, such as rejection by girls of the same age, lack of interest in boys, loss of a partner, negative remarks on patient’s physical appearance, or special emphasis by the parents on physical appearance (subjective evaluation of their opinions, reactions and behavior). The results were statistically analyzed (Fisher exact test, two-tailed). RESULTS BDD symptoms were present in 25% of anorexia nervosa suffering girls for at least 6 months (range: 6 months–3 years, mean: 14 months) before observing a clear eating disorder picture. The difference between patients suffering from bulimia nervosa and healthy controls was statistically non-significant (table I), though patients with anorexia nervosa recognized more often than subjects with bulimia and controls the shape of faces (“too wide”, “too round-shaped”, “too chubbycheeked”) or the shape of limbs (“too fat”, “too fat and too short”) as a defect of their physical appearance. No members in the group of bulimics presented BDD symptoms, though 7.5% of subjects in the control group had slightly pronounced symptoms. In a latter group, girls considered as defects the shapes of their noses, teeth, faces and legs and other parts of the body. The “defects” were minor but real beauty flaws. In a subgroup of anorexia nervosa sufferers with a distinct preceding period of BDD symptoms, additional diagnoses of OCD (six girls), obsessivecompulsive personality disorder (one girl) or affective disorders, either major depression or dysthymic disor-
304
J. Rabe-Jablonska Jolanta, M. Sobow Tomasz
Table I. The frequency of BDD symptoms among patients with diagnosis of anorexia nervosa (AN) and bulimia nervosa (BN) and in a control group*. AN N = 36
Statistical significance
BN N = 17
Statistical significance
Control N = 40
Statistical significance
AN + BDD
AN + BDD versus control P = 0.57
BN + BDD
AN + BDD versus BN + BDD P = 0.44
BDD
BN + BDD versus control NS
N=9
N=0
N=3
* Fisher exact test, two-tailed.
der (two girls), were made (table II). It has been also shown retrospectively that OCD symptoms existed in all cases for at least a few years before the onset of eating disorders while affective disturbances appeared much later, after all the symptoms of eating disorders were already present. However, the data can be seriously biased as in most of the cases they are based on patients’ reports, and only three of them were confirmed by the relatives (the presence of obsessions or compulsions not related to eating). Two subgroups of anorexia nervosa sufferers and bulimic patients were also compared for the presence in Table II. Coexisting mental disorders in a subgroup of anorexia nervosa sufferers with preceding BDD symptoms period. Additional psychiatric diagnosis according to DSM-IV criteria
Number of patients
Fraction
%
1) obsessive-compulsive disorder 2) affective disorders – major depression – dysthymic disorder 3) obsessive personality disorder
6 2 1 1 1
0.167 0.056 0.028 0.028 0.028
16.7 5.6 2.8 2.8 2.8
Total
9
0.25
25.1
their histories of such events preceding a symptomatic period as rejection of same-age girls, lack of interest in boys, loss of a partner, negative remarks on patient’s physical appearance, or special emphasis by the parents on their physical appearance. The total number (at least 1, and 2, 3, and over 3) of such events in anorexic patients with a BDD period was significantly higher (P = 0.001) than in a group without such a preceding period (table III), while the bulimic patients did not differ from either anorexics without BDD or healthy controls (not shown). It may be hypothesized that accumulation of these events might influence the development of negative self-esteem and anxiety about not being “ugly” or “funny.” DISCUSSION In the study it has been shown that 25% of anorexia nervosa sufferers experienced a distinct preceding period of BDD symptoms. In that period, the exclusive diagnosis of BDD could be made, but the prevalence of such a period was not significantly higher in the anorexia group than in bulimia nervosa group (0%) or in healthy controls (7.5%). In each analyzed case the
Table III. Specific events preceding BDD and anorexia nervosa symptoms. Type of event N Same age group rejection Lack of interest in boys Remarks on a physical appearance Emphasis on physical appearance by relatives Loss of a partner Number of events 1 2 3 >3 at least one event (1, 2, 3, and > 3)
AN, N = 27 %
AN + BDD, N = 9 N %
Statistical significance (Fisher exact test, two-tailed)
7 7 4 3 2
25.9 25.9 14.8 11.1 7.4
4 5 5 4 2
44.4 55.6 55.6 44.4 22.2
NS NS NS NS NS
6 2 1 0 9
22.2 7.4 3.7 0 33.3
1 2 5 1 9
11.1 22.2 55.6 11.1 100.0
NS NS NS NS *significant P = 0.001 Eur Psychiatry 2000 ; 15 : 302–5
BDD and eating disorders
borderline between BDD and clear anorexia nervosa symptoms periods was not distinct and there was no asymptomatic period present. Some of the patients had additionally either obsessive-compulsive personality disorder features or symptoms of OCD. In some cases the influence of the environment should also be taken into consideration. The presence of existing but slight beauty defects was often emphasized by members of the family (especially by the mother). Some girls also experienced awkward situations of being critically compared to others. The latter implied disadvantage in the same age group, though sometimes only as an emotional rather than a real experience. The features listed above were present only in some cases. In the period of clear anorexia nervosa symptoms in some girls coexisting OCD or affective disorder could be diagnosed, which both negatively influence the clinical course of eating disorders [3]. Perhaps this is why the subgroup with coexisting BDD constitutes at the same time the subgroup with a longer clinical course of the disorder. After summarizing the data, it is possible to find the specific subgroup of anorexia nervosa sufferers with a preceding period of BDD and coexisting mental disorder such as OCD or affective disorders (major depression or dysthymic disorder). This may support the idea that BDD and anorexia nervosa both belong to either OCD or affective disorder spectra. In many cases it is difficult to draw clear time boundaries between the periods. Moreover, the symptoms of different disorders may coexist. A variety of symptoms present in many adolescent patients accounts for complex, multidirected therapeutic approaches. In the studied group, the patients with bulimia nervosa did not present any symptoms of preceding BDD. It is highly difficult to discuss the phenomenon having such a small sample. It is possible that the results are artifacts due to the reduced sample size, so further studies on larger popu-
Eur Psychiatry 2000 ; 15 : 302–5
305
lations are necessary to address this question in a more adequate way. REFERENCES 1 Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1995. 2 Holden NL. Is anorexia nervosa an obsessive-compulsive disorder? Br J Psychiatry 1990 ; 157 : 1-5. 3 Rabe-Jablonska J. Obsessive-compulsive disorder among girls with eating disorders. Psychiatr Pol 1996 ; 2 : 187-200. 4 McKay D, Neziroglu F, Yaryura-Tobias JA. Comparison of clinical characteristics in obsessive-compulsive disorder and body dysmorphic disorder. J Anxiety Disord 1997 ; 11 : 447-54. 5 Brawman-Mintzer O, Lydiard RB, Phillips KA, Morton A, Czepowicz V, Emmpanuel N, et al. Body dysmorphic disorder in patients with anxiety disorders and major depression: a comorbidity study. Am J Psychiatry 1995 ; 152 : 1665-7. 6 Braddock LE. Dysmorphophobia in adolescence: a case report. Br J Psychiatry 1987 ; 140 : 199-201. 7 Connolly FH, Gibson M. Dysmorphophobia: a long-term study. Br J Psychiatry 1978 ; 132 : 568-70. 8 Halmi KA, Eckert E, Marchi P, Sampugnaro V, Apple R, Cohen J. Comorbidity of psychiatric diagnoses in anorexia nervosa. Arch Gen Psychiatry 1991 ; 10 : 675-81. 9 Heimann SW. SSRI for body dysmorphic disorder. J Am Acad Child Adolesc Psychiatry 1997 ; 36 : 868. 10 Hudson JL, Pope HG Jr. Affective spectrum disorder: does antidepressant response identify a family of disorders with common pathophysiology? Am J Psychiatry 1990 ; 147 : 552-64. 11 Diagnostic and statistical manual of mental disorders. 3rd ed. Revised. Washington: American Psychiatric Association press; 1987. 12 Phillips KA, Atala KD, Pope HG. Diagnostic instruments for body dysmorphic disorder 1995. Miami: New Research Program and Abstracts, APA; 1995. 13 Philips KA, McElroy SL, Hudson JL, Pope HG Jr. Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum, or both? J Clin Psychaitry 1995 ; 56 Suppl 4 : 41-51. 14 Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: history, rationale, and description. Arch Gen Psychiatry 1992 ; 49 : 624-9.