Eating Disorders are Not the Same as Body Dysmorphic Disorder (And Why It Matters)

By Eva Fisher, PhD, Fugen Neziroglu, PhD, ABBP, ABPP, and Jamie Feusner, MD

Many people (including therapists and clinicians) have questions about the similarities and differences between eating disorders and body dysmorphic disorder. Eating disorders and body dysmorphic disorder are both severe body image disorders that have high morbidity and mortality rates1. Differentiating between them is crucial for effective diagnosis and treatment.

Body dysmorphic disorder includes obsessive thoughts and repetitive behaviors related to perceived appearance flaws2. Eating disorders are characterized by a pathological disturbance of attitudes and behaviors related to food. Anorexia nervosa, bulimia nervosa, and binge eating disorder are three classifications of eating disorders2.

“Body dysmorphia” is used to describe experiences in both conditions, but the term is more confusing than helpful. Body dysmorphia, according to the American Psychology Association (APA), refers to an extreme disparagement of some aspect of one’s appearance3. This could occur in body dysmorphic disorder, eating disorders, or in people without a psychiatric disorder. 

Eva Fisher, PhD, recovered from body dysmorphic disorder after being obsessed with the shape and size of her nose for almost 15 years. Her recovery story is available on the International OCD Foundation website4. She is currently a communication faculty member at Colorado State University Global and has written a book about coping with body dysmorphic disorder — The BDD Family: Coping with Body Dysmorphic Disorder in a Peer Support Group.  

The article’s co-authors, Fugen Neziroglu, PhD, ABBP, ABPP, and Jamie Feusner, MD, specialize in research and treatment for body dysmorphic disorder, obsessive compulsive disorder, and eating disorders. Fugen and Jamie have published numerous articles on potential environmental and neurobiological causes for the disorders, along with treatment manuals.

Similarities between body dysmorphic disorder and eating disorders 

Individuals with body dysmorphic disorder and those with eating disorders share similar negative emotions (shame, disgust, anger) and obsess about their perceived appearance flaws. They engage in similar behaviors, such as mirror checking, taking excessive selfies, asking others about their appearance (reassurance seeking), and using clothing to conceal perceived defects (camouflaging).

In both disorders, avoidance of places and activities are prevalent due to self-consciousness about one’s appearance. In addition, they share a delusional variant where individuals lack insight into whether their body image beliefs are distorted5.

Abnormalities in brain functioning and cognitive distortions occur in anorexia nervosa and body dysmorphic disorder. Both conditions share an information processing bias toward more detailed visual information rather than viewing images globally (seeing the trees rather than the forest)6

Functional magnetic resonance imaging (fMRI) experiments that directly compared and contrasted body dysmorphic disorder and anorexia suggest they may have similar, although not identical, abnormal visual system processing6,7,8. Other studies indicate there are distinguishing neurobiological features between the two disorders, such as reduced dopamine receptors in body dysmorphic disorder, and lower activation of hunger and pain receptors in eating disorders9,10.

Personality characteristics of people with eating and body dysmorphic disorders overlap as well11. Both have low self-esteem and high levels of introversion, rejection sensitivity, neuroticism, perfectionism, obsessive compulsiveness, and social anxiety. However, people with eating disorders have higher levels of agreeableness and conscientiousness than those with body dysmorphic disorder.

Differentiating between body dysmorphic disorder and eating disorders

Individuals with body dysmorphic disorder experience more functional impairment in their daily lives than those with eating disorders12. They have a higher rate of suicidality, including suicide ideation and suicide attempts, and more severe levels of depression13,14

Obsessive thoughts in body dysmorphic disorder are most often focused on perceived defects in specific parts of one’s body2. The most common areas of concern are the face, head, skin, nose, hair, jaw, and/or teeth, although any body part could be of concern, as well as body shape in general and weight15,16. Individuals with eating disorders (with body image disturbance) primarily focus on their weight and body size in general, as well as specific body parts perceived to be too large or fat such as thighs, abdomen, and hips (areas of concern that also occur in those with BDD)1,17.

People with body dysmorphic disorder engage in repetitive behaviors meant to fix, change, or improve the disliked body part(s), such as seeking cosmetic procedures. Research indicates 76% of people with body dysmorphic disorder have contemplated cosmetic procedures to fix their perceived flaws and 66% have received aesthetic treatments18

However, even when the procedure is successful and individuals feel better about one part of their body, the image obsession often moves to one or more different body parts. That is because cosmetic surgery cannot effectively treat body dysmorphic disorder.

Eating disorder behaviors and symptoms include restricting calories, binge eating, purging after meals, frequent bathroom breaks after eating, or unexplained weight changes. Core symptoms of anorexia include drastic weight loss, low body weight, fear of becoming fat, and disturbed experience of one’s body or weight19

Body dysmorphic disorder and eating disorders can occur together

Two or more disorders are considered comorbid when they occur in one person at the same time. Body dysmorphic disorder is often comorbid in individuals with eating disorders, and vice versa. In a study of patients with eating disorders, 60% also had body dysmorphic disorder20.  Another study found that 32.5% of people with body dysmorphic disorder had a comorbid lifetime eating disorder: 9% had anorexia, 6.5% had bulimia, and 17.5% had an eating disorder not otherwise specified (EDNOS)21

Other conditions that are often comorbid with eating disorders and body dysmorphic disorder are obsessive compulsive disorder (OCD), depression, substance abuse, and anxiety disorders. These comorbid mental health conditions result in greater functional impairment and increase the likelihood of suicidal ideation and suicide attempts in people with body dysmorphic disorder and eating disorders22.

Grant et al. found that the onset of body dysmorphic disorder preceded the onset of eating disorder pathology in most individuals with comorbid body dysmorphic disorder23. This finding suggests that body dysmorphic concerns may serve as a risk factor for the development of some eating disorders.

Taken together, eating disorders (including anorexia, bulimia, and binge eating disorders) are more prevalent than body dysmorphic disorder. As a class, eating disorders affect up to 5% of the population in the United States. Bulimia is seen in roughly 1.5% of women and 0.5% of men, and anorexia in 0.35% of women and 0.1% of men24

Binge eating disorder is found in 0.2% and 3.5% of females and about 0.9% and 2.0% of males24. Studies have found that body dysmorphic disorder impacts from 1.7% to 2.9% of adults in the United States, with the disorder affecting about 2.5% of women and 2.2% of men25.

Treatment for body dysmorphic disorder and eating disorders

Cognitive behavioral therapy (CBT) can be effective for treating body dysmorphic disorder, along with selective serotonin reuptake inhibitors (SSRIs)26. Psychotherapy involves modification of intrusive thoughts and beliefs about physical appearance (cognitions) and elimination of problematic body image behaviors. Medications can reduce or eliminate cognitive distortions, depression, anxiety, negative beliefs, and compulsive behaviors. They can also increase levels of insight and improve daily functioning27.

Cognitive restructuring, exposure and response prevention, and behavioral experiments have been empirically supported as effective strategies in improving body dissatisfaction, distress, and avoidant behaviors in some individuals with body dysmorphic disorder and in some with eating disorders28.29.

For underweight individuals with anorexia nervosa, weight restoration is often a critical first goal. There are no medications that have been proven effective for acute anorexia, but SSRIs can be effective for some with bulimia nervosa and binge eating disorder30. In addition, other classes of medications (lisdexamfetamine, topiramate) can be helpful for binge eating disorder31

Psychotherapy approaches like family-based treatment may be helpful for some adolescents with anorexia, whereas interpersonal psychotherapy and CBT have been effective for treating bulimia and binge eating disorder29.32.33. We believe that effective treatment must target core self-schemas related to achieving an internalized ideal of attractiveness in both body dysmorphic disorder and eating disorders34.  

In conclusion, eating disorders and body dysmorphic disorder are both severe body image disorders. They share similarities, but also some important differences in emotions, obsessive thoughts, compulsive behaviors, cognitions, neurobiology, and personality traits (see BDD/ED chart). Individuals must be properly diagnosed with body dysmorphic disorder and/or an eating disorder so they receive effective treatment for their symptoms. 

BDD/ED Chart

Similarities Dissimilarities
Emotions Self-conscious emotions: shame, disgust; anger; anxiety BDD: Higher suicidality; more severe depression
Obsessions Defects in one’s appearance BDD: preoccupation with perceived defects in specific parts of one’s appearance (may or may not involve the body)

Eating disorders: focus on size and weight of body and specific body parts

Compulsions Mirror checking, reassurance seeking, picture taking, camouflaging of body to hide perceived defects; avoidance of places and activities Eating disorders: Restricting calories, binge eating, purging after meals
Cognitions Low insight; high overvalued ideation BDD: Cognitions based more on appearance

Eating disorders: Cognitions based on appearance (shape, body parts), weight, eating, and food

Neurobiology Bias toward more detailed visual information than global; abnormal visual system processing BDD: Reduced dopamine receptor availability in the striatum35

Eating disorders: Normal or increased dopamine receptor availability in the striatum in anorexia nervosa, depending on acute or recovered status (mixed findings)36,37,38

Personality Introversion, social anxiety, low self-esteem, rejection sensitivity, perfectionism, obsessive compulsiveness, neuroticism, and anxiety BDD: Lower levels of agreeableness and conscientiousness

Eating disorders: Higher levels of agreeableness and conscientiousness

Treatment Cognitive-behavioral therapy; SSRIs BDD: May need exposure-response therapy (ERP)

Eating disorders: May require nutritional medical provider, Family-Based Therapy for anorexia nervosa

About the Authors:

Eva Fisher, PhD, is a member of the BDD Special Interest Group at the IOCDF and facilitates peer support groups for people with body dysmorphic disorder and therapists with BDD and OCD.

Fugen Neziroglu, PhD, ABBP, ABPP, is a member of the IOCDF Scientific and Clinical Advisory Board, a member of the Anxiety and Mood Disorder Association Scientific Counsel, Board Certified in Cognitive Behavior Therapy and Executive Director of Bio Behavioral Institute, in Great Neck, NY.

Jamie Feusner, MD, is a member of the IOCDF Scientific and Clinical Advisory Board, professor of psychiatry at the University of Toronto, and Senior Scientist at the Centre for Addiction and Mental Health.



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