On having this interpretation of anorexia offered to me, my first reaction was of course not! Although in the 1980s a famous eating disorder clinician named John Stonehill proposed that all the eating disorders be renamed “Body Image Disorders”. The concept never caught on.,
A key feature of body dysmorphic disorder is that people have fixated beliefs of bizarre content regarding their body or aspects of their body, such as their nose or facial appearance. This is usually accompanied by compulsive behaviour to deal with their beliefs (such as avoiding mirrors or hiding). Insight into the deluded thinking is lost and there is no resistance to compulsive urges to engage in compensatory actions. The rituals that accompany BDD can be disabling, and what interested psychiatrists was that no sufferers had other forms of thought disorder and so they could not be viewed as psychotic.
A person fixated about the size of their nose would thus perceive other aspects of their life fairly normally. Because of the rituals associated with fixated thinking, for a long while BDD was regarded as a form of obsessive-compulsive disorder.
Anorexia sufferers may believe with absolute certainty that they are fat even when they are emaciated. They also have extreme shifts in body perceptions after eating food that they deem forbidden or fattening. Hence these foods are avoided in extremis. Eating disorder clinicians call this “thought-action-fusion”, a disorder of thinking, not of the body itself. Anorexic beliefs, despite their fixated nature, are thus considered to be overvalued ideas that are not “alien” beyond common understanding, unlike other forms of BDD. Their content (food is dangerous, I’m fat) is experienced by many women and men. Its just that this disturbance is at the extreme end of a spectrum and matters a great deal. Many people share beliefs about being “too fat” but the impact of these ideas on their wellbeing is minimal since their self-worth is vested in other things, like having a good relationship with their friends. In other words, their beliefs matter less.
It is true that people with BDD and with anorexia share a range of odd ideas about their appearance that range from the obsessional to the psychotically delusional. This has led clinicians to regard anorexia as a compartmentalised psychosis, necessitating enforced treatment such as nasogastric feeding in cases where a persons’ life is at risk.
My biggest concern about labelling anorexia as BDD is that it restricts our ability to look outside our mental box. A clinician with fixated opinions about the nature of any mental health condition is blind about the other possibilities of what is going on. Anorexia and other eating disorders share features with MANY other mental health conditions such as addiction, anxiety disorder, OCD, psychosis, to name but a few. Anorexia has also been conceptualised as a monomania, a developmental disorder, a cultural phenomenon or a rebellion against women’s place in a patriarchal society. If you consider anorexia is BDD; and if BDD is a form of OCD; and if OCD is an anxiety disorder; and an anxiety disorder is a response to trauma, then it follows that anorexia is a trauma condition. Really?
Reductio ad absurdam.
What distinguishes anorexia from other forms of BDD is the Anorexic Voice. We all talk to ourselves but the Anorexic Voice is more persistent, intrusive and often concrete (i.e., real). Is the anorexia hence BDD with schizophrenia? How one labels a complex condition like anorexia is of more than academic interest. A diagnosis of delusional disorder like this may lead to a lifetime of antipsychotic medication, which never cures anorexia.
And even when the scales fall from someone’s eyes, and they both know and feel that they are skin and bone, it still is not enough to get the anorexic person to start eating again. They are not suddenly recovered so what do we think is going on now?
It is unhelpful therefore to fit everyone with delusional beliefs about the body into the same diagnostic box, no matter how much we have vested our truth in it. We could, for example, call gender dysphoria a form of BDD, implying delusional beliefs about being in the wrong body, with extreme, compulsive and aggressive actions taking place (hormone therapy, genital or breast amputation etc) to help a person feel better. I am not sure it will go down well to place people questioning their gender to be forced into therapy for BDD. (“You aren’t really a woman in a man’s body, you just have BDD”)
My final plea is to allow anorexia to sit in a place on its own, where it has aspects of BDD and OCD and psychosis and pretty much everything else. This is why it is so pervasive and difficult to treat. There is no single therapy or therapist up to the job of rescuing a person from their toxic relationship with food and with themselves. Unlike with other forms of BDD, recovery is concomitant with a rise in self-worth. I am going to fight the anorexia, because “I’m worth it”.
Deanne Jade 2024