Peggy Claude-Pierre described the state of despair in anorexia as a civil war in the mind and coined the term ‘confirmed negativity condition’ or CNC. She wrote that eating disorders is to CNC as measles is to a rash, or mumps is to swollen glands. The eating disorder is the symptom of the state of mind. She said that it can include depression, agoraphobia, panic attacks, obsessive-compulsive disorders or somatic disorders (ways that pain can be internalised). She went on to describe how this hypercritical state will cause individuals with anorexia to perceive every comment as a negative reflection of herself, and assume blame in every situation, even when it is completely unrelated to her situation. I agree with Claude-Pierre, when she stated that this emotional state goes far deeper than low self-esteem, because individuals with eating disorders have no sense of self, they just feel bad, wicked and evil and this negativity is founded on ‘evidence’ that is not there. For instance, I have seen many individuals with anorexia who also suffer from some form of body dysmorphic disorder.

Body Dysmorphic Disorder or BDD is a condition where there is a perceived body flaw that is obsessed about. It could be any part of the body, and often these perceptions and obsessions are discounted by others. But these obsessions are extreme, and feel very real, and people with BDD become preoccupied with the ‘flaw’ to the point that it governs behaviour and decisions. Philips, K. (1986) an MD in the states, wrote the first book on the subject. She noticed that when BDD is severe, friendships, intimate relationships, and work disintegrate and could even eventually lead to suicidal feelings. She pointed out that what is so intriguing about BDD, is that people who have it focus on defects that others don’t see or consider minimal. But to the individual, the problem looks hideous and repulsive, magnified by the mind’s eye. So, it makes no sense to others, in the same way that anorexia makes no sense, and in fact the parallels and overlaps are obvious.

People with BDD can go to great lengths to correct the ‘flaws’, carrying mirrors, applying tonics and concealers, surgery and even amputation. Families are at a loss to know how to help, and don’t know how to reassure them. They see the individual get depressed and withdrawn and refuse to socialise.

Like anorexia, people can suffer in silence. Many of my clients have revealed some aspect of BDD during the course of treatment, but only when they feel absolutely safe. They feel embarrassed and ashamed. Sometimes it is difficult to determine whether the anorexia is symptom of the BDD, or the other way around. Philips questioned whether these two disorders could be variants of, or in fact the same disorder. She wrote that anorexia, BDD and bulimia nervosa all share the same core, a preoccupation with the appearance of the body and a distorted body image.

“In anorexia, the distortion consists of thinking one is too fat, which leads to excessive weight loss. People with bulimia binge on food in an out-of-control way, and attempt to counteract the binges with vomiting, laxatives, diuretics or excessive dieting. BDD and eating disorders are also similar, in that they both often involve mirror checking and body measuring. BDD sometimes involves unusual eating or excessive dieting-for example to make one’s face less wide. BDD can also fixate on body areas that are typically focussed on in eating disorders, such as the size of the stomach, hips, or thighs”.

I would support Philips in most of her findings, and I do agree that they share a common core. However, my understanding is that the core lies beneath the preoccupation. In fact, the preoccupation is a symptom of the ‘CNC’. I would also say that the intensity with which do eating disorders or BDD is very similar. I also suspect that what starts as BDD, could develop into anorexia, if dieting is involved and the anorexia takes a grip.

Phillips pointed out a number of differences between BDD and eating disorders:

1.People with anorexia think they look better as they loose weight even when they look skeletal. (I would argue with this. In my experience, people think they will look better, but often dissatisfaction increases as the weight drops).

2.People with BDD focus on specific body parts, whilst people with eating disorders typically focus primarily on overall body weight. Again, I would argue that most of the clients who I have seen have had one part of their body that they really hate. Most often it is the stomach area, but it could be any body part. However, it is true that there is an overall focus on body weight and size.

3.BDD and eating disorders differ in the significant difference in the male-to-female ratio, with women constituting the vast majority of people with eating disorders. The statistics that Philips offers will be out of date now, and there are many conflicting studies. However, it is safe to say that the men-to-women ratio for BDD is much higher than for eating disorders in more recent studies.

Social phobia or avoidance typically runs through both disorders and manifests in similar ways. That is, exceptionally poor self-esteem and image are projected to a part of, or all of, the body. Endless obsessions and attempts to correct the perceived flaws do not work, because the strategies are not directed at the problem. The failed attempts to correct the flaws and therefore feel better create further distress and feelings of futility. It is only when the whole process is embraced that healing can happen.

Phillip’s book, The Broken Mirror, is an excellent resource for anyone who needs more information or who is trying to make sense of BDD. It explores the process of social phobia and discusses how debilitating it can be.