REGULAR ARTICLE

Comorbidity of Body Dysmorphic Disorder and

Eating Disorders: Severity of Psychopathology and
Body Image Disturbance
Jessica S. Ruffolo, PhD1,2
Katharine A. Phillips, MD1,2*
William Menard, BA1
Christina Fay, BA1
Risa B. Weisberg, PhD2,3
ABSTRACT
Objective: The current study examined
comorbidity and clinical correlates of
eating disorders in a large sample of
individuals with body dysmorphic disor-
der (BDD).
Method: Two hundred individuals with
DSM-IV (4th ed. of the Diagnostic and
Statistical Manual of Mental Disorders.
Washington, DC: American Psychiatric
Association; 1994) BDD completed reliable
interviewer-administered and self-report
measures, including diagnostic assess-
ments and measures of body image, symp-
tom severity, delusionality, psychosocial
functioning, quality of life (QOL), and his-
tory of psychiatric treatment.
Results: A total of 32.5% of BDD sub-
jects had a comorbid lifetime eating dis-
order: 9.0% had anorexia nervosa, 6.5%
had bulimia nervosa, and 17.5% had an
eating disorder not otherwise specified.
Comparisons of subjects with a comor-
bid lifetime eating disorder (n ¼ 65) and
subjects without an eating disorder
(n ¼ 135) indicated that the comorbid
group was more likely to be female, less
likely to be African American, had more
comorbidity, and had significantly
greater body image disturbance and dis-
satisfaction. There were no significant
group differences in BDD symptom
severity, degree of delusionality, or sui-
cidal ideation or attempts. Functioning
and QOL were notably poor in both
groups, with no significant between-
group differences. However, a higher
proportion of the comorbid eating dis-
order group had been hospitalized for
psychiatric problems. This group had
also received a greater number of psy-
chotherapy sessions and psychotropic
medications.
Conclusion: Eating disorders appear
relatively common in individuals with
BDD. BDD subjects with a comorbid
eating disorder differed on several
demographic variables, had greater
comorbidity and body image distur-
bance, and had received more mental
health treatment than subjects without
a comorbid eating disorder. These find-
ings have important implications for the
assessment and treatment of these
comorbid body image disorders. ª
2005 by Wiley Periodicals, Inc.
Keywords: body dysmorphic disorder;
comorbid eating disorder; body image
disturbance; psychotherapy; somato-
form disorders; dysmorphophobia
(Int J Eat Disord 2006; 39:11–19)

(DSM-IV),1 consists of a distressing or impairing

Introduction
Body dysmorphic disorder (BDD), classified as a
somatoform disorder in the 4th ed. of the Diagnos-
tic and Statistical Manual of Mental Disorders
Accepted 3 February 2005
Supported by Grants R01 MH60241 and K24 MH63975 from the
National Institute of Mental Health to Dr. Phillips.
*Correspondence to: Katharine A. Phillips, MD, Butler Hospital,
345 Blackstone Boulevard, Providence, RI 02906.
E-mail: Katharine_Phillips@brown.edu.
1
preoccupation with an imagined or slight defect
in appearance. Preoccupations most often focus
on the face or head (e.g., facial scarring or a huge
nose) but can involve any body area.2 BDD is rela-
tively common,3,4 and is associated with high levels
of perceived stress,5 poor psychosocial functioning
and quality of life (QOL),2,6,7 and a high prevalence
of suicide attempts.8,9 To better understand BDD
and its pathogenesis, researchers have examined the
relationship of BDD to other disorders with simi-
lar symptomatology—in particular, obsessive-com-

2
Butler Hospital, Providence, Rhode Island
pulsive disorder (OCD) and mood disorders.10–12
Department of Psychiatry and Human Behavior, Brown
University Medical School, Providence, Rhode Island However, the relationship of BDD to eating disor-
3
Department of Family Medicine, Brown University Medical ders has received very little investigation, even
School, Providence, Rhode Island though BDD is a body image disorder.13,14
Published online 27 October 2005 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20219 Like eating disorders, BDD is characterized by
ª 2005 Wiley Periodicals, Inc. excessive concerns about physical appearance and

Int J Eat Disord 39:1 11–19 2006 11

SOMERVILLE RUFFOLO ET AL.
body dissatisfaction.13,15 Some authors have
described the essential pathology of both BDD
and eating disorders as a disturbance in body
image.16–18 In addition, both eating disorders and
BDD are characterized by obsessional preoccupa-
tions and repetitive behaviors (e.g., mirror check-
ing, body measuring).13,15 Indeed, modifications
of the Yale-Brown Obsessive Compulsive Scale
(Y-BOCS) are used to assess the severity of both
BDD and eating disorders (anorexia nervosa [AN]
and binge eating disorder [BED]),19–21 and both
disorders have been characterized as obsessive-
compulsive spectrum disorders.22–24 In addition,
clinical observations suggest that BDD and eating
disorders share overvalued and often firmly sus-
tained appearance-related beliefs, as well as a
quest to improve one’s appearance.13,14 There
have also been reports of patients shifting their
primary diagnosis between BDD and an eating dis-
order,24–26 and the clinical symptoms and body
areas of fixation (e.g., size of stomach, hips, thighs)
in these disorders sometimes overlap.13,15
Despite these apparent similarities, few studies
have examined the relationship between BDD and
eating disorders. One study17 compared 45 outpa-
tients with AN or bulimia nervosa (BN) with 51
outpatients with BDD and 50 nonclinical controls.
In that study, both clinical groups had equally
severe body image disturbance (including body
dissatisfaction, body checking, and preoccupation)
and negative self-esteem. However, the eating dis-
order patients endorsed more widespread psy-
chological symptoms (on the Brief Symptom
Inventory), and the BDD patients reported more
negative self-evaluation due to appearance and
greater avoidance of activities due to self-con-
sciousness about appearance. A study by Grant et
al.27 of 41 inpatients ascertained for AN found a
very high lifetime prevalence (39%) of comorbid
BDD (unrelated to weight concerns). The majority
(81.3%) of the comorbid AN/BDD group consid-
ered BDD their biggest or a major problem. Com-
pared with AN patients without comorbid BDD, the
comorbid AN/BDD group was more severely ill.
They had significantly lower scores on the Global
Assessment of Functioning Scale, greater appear-
ance preoccupation and delusionality, double the
number of psychiatric hospitalizations (6.3 ± 2.8 vs.
3.8 ± 3.2, p ¼ .015), and three times as many sub-
jects with comorbid BDD had attempted suicide
(63% vs. 20%, p ¼ .009).
To our knowledge, the only previous studies to
examine the converse—that is, eating disorders in
individuals with BDD—reported only on the prev-
alence of eating disorder comorbidity and age at
12
onset. In a study of 293 subjects with BDD, 10% of
subjects had lifetime AN and/or BN (3% AN, 8%
BN), and 4% had current comorbid AN/BN (1% AN,
3% BN).28 Another study in a small BDD sample
(n ¼ 16) found a higher lifetime prevalence of eat-
ing disorders (19%).29 However, neither study
examined clinical correlates of eating disorder
comorbidity. In addition, both studies consisted of
individuals who were seeking or receiving psychi-
atric treatment, and 40% of subjects in the larger
study participated in pharmacotherapy trials,28
which may have introduced various biases.30
The primary aim of the current study was to
assess lifetime prevalence of comorbidity and clin-
ical correlates of eating disorder comorbidity in a
broader sample ascertained for BDD (one third of
subjects were not currently seeking or receiving
mental health treatment). We compared subjects
with lifetime comorbid AN and/or BN (n ¼ 65)
with subjects without comorbid AN and/or BN
(n ¼ 135) in a variety of domains. We predicted
that the comorbid group would be more severely
ill and impaired than those without a comorbid
eating disorder, with poorer functioning and QOL,
and that a higher proportion of the comorbid group
would have attempted suicide and would have
been hospitalized for psychiatric problems. This
hypothesis was based on the findings of Grant et
al.,27 as well as on the findings that greater Axis I
comorbidity more generally is associated with
poorer functioning31–33 and increased suicide
attempts and lethality of the attempt.34,35 We also
hypothesized that subjects with a comorbid eating
disorder would have greater overall body image
disturbance because they have two body image
disorders and because previous findings suggest
that body image disturbance may be greater when
both weight and non–weight-related body image
concerns are present.36
Methods
Participants
Participants were 200 individuals with BDD enrolled in
a longitudinal study examining the course of BDD. Only
data collected during the intake interview are presented
in the current report. All participants were diagnosed
with lifetime (past or current) DSM-IV BDD or its delu-
sional variant (delusional disorder, somatic type). Eighty-
nine percent met criteria for current DSM-IV BDD, 7.5%
were in partial remission, and 3.5% were in full remission
(all subjects had met full BDD criteria in the past). Addi-
tional study inclusion criteria were (a) age 12 or older, (b)
Int J Eat Disord 39:1 11–19 2006

living locally and able to be interviewed in person, and
(c) willing and able to provide written informed consent
(assent in the case of adolescents). The only exclusion
criterion was the presence of an organic mental disorder.
Sixty-seven percent (n ¼ 134) of participants were cur-
rently receiving mental health treatment (62.0% outpa-
tient, 2.5% inpatient, 1.5% partial hospital, and 1.0%
residential). Participants were referred from a variety of
sources: mental health professionals (46.0%), advertise-
ments (38.6%), our program website and brochures
(10.2%), subject friends and relatives (3.4%), and nonpsy-
chiatric physicians (1.7%). The study was approved by
the hospital institutional review board, and signed state-
ments of informed consent were obtained from all sub-
jects (assent plus parental consent for adolescents).
Assessments
Subjects were assessed with the following measures at
study intake (baseline).
The Structured Clinical Interview for DSM-IV Nonpatient
Version (SCIDI/NP). The SCIDI/NP37 is a standard and
reliable diagnostic instrument for common DSM-IV dis-
orders.
The Body Dysmorphic Disorder Examination (BDDE). The
BDDE38 is a reliable and valid 34-item, interviewer-admin-
istered scale that assesses BDD symptoms and body
image disturbance. In addition to determining total
score, we report on three items that assess overall body
image (not just BDD-related body image): dissatisfaction
with general appearance (range: 0 [no dissatisfaction] to 6
[extreme dissatisfaction]), perceived physical attractive-
ness (i.e., physical attractiveness as perceived by others;
range: 0 [attractive] to 6 [extremely unattractive]), and
avoidance of others looking at their body (range: 0 [no
avoidance of others seeing body unclothed] to 6 [avoids
with extreme frequency]). The BDDE was administered to
the first 98 participants. Scores range from 0 to 168, with
higher scores indicating more severe symptoms.
The BDD Form. The BDD Form obtained data on BDD
that was not available from other measures, including
body areas of concern, certain aspects of functional
impairment due to BDD (e.g., dropping out of school,
days missed from work, being housebound), lifetime sui-
cidal ideation and attempts, and past psychiatric treat-
ment received. This measure is available from the second
author upon request.
The YBOCS Modified for BDD (BDD-YBOCS). The BDD-
YBOCS21 is a reliable and valid 12-item, semistructured,
interviewer-administered measure that assesses BDD-
related obsessional preoccupations (five items), compul-
sive behaviors (five items), insight (one item), and avoid-
ance (one item) during the past week. Scores range from
0 to 48, with higher scores indicating greater severity.
Int J Eat Disord 39:1 11–19 2006
COMORBIDITY OF BDD AND ED
The Brown Assessment of Beliefs Scale (BABS). The
BABS39 is a reliable and valid seven-item, semistructured,
interviewer-administered scale that assesses delusional-
ity (insight) within the past week. For the current study,
the delusionality of BDD beliefs was assessed. Scores
range from 0 to 24, with higher scores indicating greater
delusionality.
The following measures assessed functioning and
QOL. (Two measures were added after the study began
and were therefore completed by a subset of subjects:
142 completed the Social Adjustment Scale-Self-Report
(SAS-SR) and 139 completed the Quality of Life Enjoy-
ment and Satisfaction Questionnaire (Q-LES-Q.)
The Social Adjustment Scale-Self-Report (SAS-SR). The
SAS-SR40 is a reliable and valid 54-item, self-report mea-
sure of current social functioning in the following
domains: work, social and leisure, extended family, pri-
mary relationship, parental, and family unit. An Overall
Adjustment Scale is based on the six domains. Higher
scores indicate greater impairment. SAS-SR scores were
compared with published norms40 for a nonclinical com-
munity sample randomly drawn from the general popu-
lation of an urban area (n ¼ 482).
The Quality of Life Enjoyment and Satisfaction Question-
naire (Q-LES-Q). The Q-LES-Q41 is a reliable and valid self-
report measure of QOL that assesses satisfaction and func-
tioning in the domains of social, leisure, household, work,
emotional well-being, physical, and school. We report the
total score on the Q-LES-Q Short Form (the Short Form is
equivalent to the General Domain of the Q-LES-Q Long
Form). Lower scores indicate greater impairment. Q-LES-Q
scores are compared with scores for a community sample
(Endicott J, personal communication).
The Longitudinal Interval Follow-Up Evaluation-Range of
Impaired Functioning Tool (LIFE-RIFT). The LIFE-RIFT42
is a reliable and valid semistructured, interviewer-rated
measure that assesses the lowest level of functioning for
at least 1 week during the previous month. It includes a
total score, as well as individual scores in the domains of
work, school, household duties, relationships with
family, relationships with friends, and global life satisfac-
tion (patient rated). Higher scores indicate greater
impairment. Inability to work because of psychopathol-
ogy is not accounted for in the total score, and we report
this percentage separately.
The Global Assessment of Functioning Scale (GAF). The
GAF1 is an interviewer-rated global measure of overall
symptom severity and functioning during the past
month (range ¼ 1–100). Lower scores indicate greater
symptom severity and functional impairment.
The Social and Occupational Functioning Scale
(SOFAS). The SOFAS1 is similar to the GAF, but assesses
only functioning.
13
SOMERVILLE RUFFOLO ET AL.
Regarding interrater reliability, kappa coefficients were
1.0 for the diagnoses of BDD, AN, BN, and eating disorder
not otherwise specified (EDNOS). Intraclass correlation
coefficients for the BDD-YBOCS, BABS, LIFE, GAF, and
SOFAS ranged from .98 to 1.0.
Data Analysis
The current and lifetime prevalence of eating disorders
(AN, BN, and EDNOS) were determined. The 65 BDD
participants with lifetime comorbid AN, BN, or EDNOS
were compared with the 135 subjects without an eating
disorder using these measures (all analyses include the
full sample except where indicated in Table 3.) Between-
group differences for gender, age, race/ethnicity, and
number of comorbid disorders were performed using
two-tailed independent t tests for continuous variables
and Pearson chi-square tests for categorical variables.
The group with a comorbid eating disorder had a signifi-
cantly higher proportion of females (89.2% vs. 58.5%, p <
.001) and a higher number of comorbid disorders, exclud-
ing the comorbid eating disorder (4.4 ± 1.8 vs. 3.8 ± 1.6, t ¼
2.38, df ¼ 198, p ¼ .02). Therefore, other analyses were
performed using analysis of covariance (ANCOVA) for con-
tinuous variables or logistic regression for categorical
variables controlling for gender and number of comorbid
disorders, as well as age. Given the exploratory nature of
the analyses, an alpha level of p < .05 was used. However,
because of the number of significance tests conducted,
caution should be used when interpreting significant
results, as some of them, particularly those of only modest
significance, may represent chance associations. Effect size
estimates for ANCOVA were determined with partial eta
squared (.01 is a small effect size, .06 is a medium effect
size, and .14 is a large effect size). Effect size estimates for t
tests (corrected for unequal sample sizes) were determined
with Cohen’s d (d ¼ .2 is a small effect size, .5 is a medium
effect size, and .8 is a large effect size), and effect size
estimates for chi-square tests were determined with the
phi coefficient (Cramer’s V [V ¼ .1 is a small effect size,
.3 is a medium effect size, and .5 is a large effect size]).
Results
Table 1 shows the current and lifetime prevalence of
eating disorders. As can be seen, 32.5% of BDD par-
ticipants had a comorbid lifetime eating disorder,
including BED and other variants of EDNOS. A total
of 9.5% had a current eating disorder. A majority of
participants with an eating disorder (63.1%) devel-
oped BDD before the onset of their eating disorder
(55.5% developed BDD before AN, 84.6% before BN,
and 62.5% before EDNOS). 16.9% developed BDD and
an eating disorder within the same year (27.8% for AN,
14
TABLE 1. Lifetime prevalence of eating disorders in
200 subjects with BDD
Lifetime (n ¼ 65) Current (n ¼ 19)
Comorbid Disorder n (%) n (%)
Anorexia nervosa (AN) 18 (9.0) 2 (1.0)
Bulimia nervosa (BN) 13 (6.5) 6 (3.0)
AN and BN total 30 (15.0)a 8 (4.0)
Eating disorder not
otherwise specified (NOS)b 35 (17.5) 11 (5.5)
Binge eating disorder 11 (5.5) 4 (2.0)
Total 65 (32.5)a 19 (9.5)
Note: BDD ¼ body dysmorphic disorder.
a
One subject had lifetime AN and BN.
b
Eating disorder NOS includes binge eating disorder.
7.7% for BN, and 12.5% for EDNOS). Only 20.0% devel-
oped BDD after the onset of an eating disorder (16.7%
for AN, 7.7% for BN, and 25.0% for EDNOS).
A majority of participants without an eating dis-
order, as well as those with an eating disorder,
endorsed BDD as their most problematic current
diagnosis (81.7% and 69.6%, respectively; w2 ¼ 3.19,
p ¼ .07) and most problematic lifetime diagnosis
(81.0% and 65.8%, respectively; w2 ¼ 3.32, p ¼ .07).
The second most problematic diagnosis for both
groups was major depression, with no significant
differences between the two groups. In the current
study, 7.9% of the BDD subjects with an eating dis-
order reported that their eating disorder was their
most problematic lifetime disorder and 8.9%
reported that it was their most problematic current
disorder.
As shown in Table 2, BDD participants with a
comorbid eating disorder were significantly more
likely to be female (with a medium effect size) and
significantly less likely to be African American
(although the effect size was small). With regard to
clinical features (Table 3), body image disturbance
(BDDE total score) was significantly greater in the
comorbid eating disorder group, including greater dis-
satisfaction with general appearance (p ¼ .03). By
definition, all individuals with an eating disorder are
excessively preoccupied with body shape/weight.
However, when asked to choose a most disliked body
area, participants in both groups responded similarly
(skin was most often disliked in both groups, as shown
in Table 3). As expected, the two groups did not
significantly differ in terms of BDD symptom sev-
erity (BDD-YBOCS scores) or delusionality regarding
BDD-related appearance flaws (BABS scores). How-
ever, the group with a comorbid eating disorder had a
significantly greater number of comorbid disorders
(excluding their eating disorder), with a small to me-
dium effect size.
The proportion of participants who had expe-
rienced lifetime suicidal ideation and suicide
Int J Eat Disord 39:1 11–19 2006
 COMORBIDITY OF BDD AND ED

TABLE 2. Demographic features of 200 BDD subjects with and without a comorbid eating disorder
BDD with a BDD without a
Comorbid Eating Comorbid Eating
Variablea Disorder (n ¼ 65) Disorder (n ¼ 135) Statisticb p Effect Size

Gender (% female) 58 (89.2) 79 (58.5) w2 ¼ 19.18 <.001 v ¼ .31

Age 30.6 ± 11.5 33.6 ± 12.3 t ¼ 1.62 .11 d ¼ .24
Race/ethnicityc
Caucasian 58 (92.1) 113 (83.7) w2 ¼ 2.55 .11 v ¼ .11
African American 1 (1.6) 13 (9.6) — .04 v ¼ .15
Hispanic 3 (4.8) 11 (8.7) — .39 v ¼ .07
Other 4 (6.3) 9 (6.7) — 1.00 v ¼ .01
Marital status w2 ¼ 0.48 .49 0.76 (95% CI, 0.34–1.67)
Single 48 (73.8) 103 (76.3)
Married 17 (26.2) 32 (23.7)
High school or less 20 (30.8) 38 (28.1) w2 ¼ 0.06 .81 0.92 (95% CI, 0.45–1.88)
Employed 35 (53.8) 87 (64.4) w2 ¼ 1.61 .21 0.65 (95% CI, 0.34–1.26)

Note: BDD ¼ body dysmorphic disorder; 95% CI ¼ 95% confidence interval.

a
Results are presented as n (%) or M ± SD.
b
df ¼ 1 for all analyses except age (df ¼ 198).
c
Numbers exceed 100% because some subjects endorsed more than one category.

attempts was very high in both groups but did not
significantly differ between groups (Table 3). Both
groups had very poor functioning and QOL (Table
3). Compared with normative data for the SAS-SR (N
¼ 482), the comorbid eating disorder group scored 2.5
SDs poorer than the normative mean, and scores of
the noncomorbid group were 2.2 SDs poorer. On the
Q-LES-Q Short Form, scores in both groups were 1.8–
2.0 SDs lower than the normative mean. (The mean
converted score was 50.8% for the comorbid eating
disorder group and 53.7% for those without an eating
disorder, compared with 78.1% ± 13.7% for a com-
munity sample.) Scores did not significantly differ
between the two groups on any functioning/QOL
measures. As shown in Table 3, the comorbid eating
disorder group had received a greater number of psy-
chotropic medications and psychotherapy sessions.
In addition, a significantly higher proportion of this
group had been hospitalized for psychiatric problems.
The two groups did not significantly differ in the
proportion of subjects with a history of hospitalization
primarily for BDD, depression, or a substance use
disorder. Regarding hospitalization primarily for an
eating disorder, 9.2% (n ¼ 6) of participants with an
eating disorder reported a history of hospitalization
primarily for their eating disorder. When subjects who
had been hospitalized only for an eating disorder were
excluded from analyses, the between-group differ-
ence was still significant (w2 ¼ 15.13, p < .001, odds
ratio ¼ 4.33 (95% confidence interval [CI] ¼ 2.07–9.07).
Conclusion
The current study found that a high proportion
(32.5%) of individuals ascertained for BDD had a
lifetime comorbid eating disorder, with 15% having
comorbid AN and/or BN. Onset of BDD usually
preceded the onset of an eating disorder. As
expected, BDD symptoms were similar in the two
groups. However, compared with subjects without a
comorbid eating disorder, those with a comorbid
eating disorder were significantly more likely to be
female and less likely to be African American, con-
sistent with findings in the eating disorder litera-
ture.1,43 The comorbid eating disorder group also
had a greater number of comorbid disorders and
greater body image disturbance, and they had
received significantly more mental health treatment.
The lifetime prevalence of AN and/or BN found
in the current study (15.0%) is slightly lower than
that reported by Zimmerman and Mattia29 in 16
subjects with BDD (19%) and somewhat higher
than in the Gunstad and Phillips28 sample of 293
subjects (10%). Conversely, the prevalence of BDD
in 41 patients ascertained for AN27 was notably
higher (39%) than the AN prevalence in our sample
(9%). This difference may reflect the fact that BDD
comorbidity is actually higher in AN patients than
AN comorbidity is in BDD patients. An alternative
explanation is that the higher comorbidity in the
AN study may be attributable, at least in part, to the
fact that all subjects in that study were inpatients,
whereas only 2.5% of our BDD sample were inpa-
tients and one third of subjects were not currently
receiving mental health treatment. Studies done in
clinical settings tend to find higher comorbidity
than those in nonclinical settings.30 The lifetime
prevalence of AN (9%) and BN (6.5%) in our study
is substantially higher than in the general popula-
tion (0.5% for AN; 1%–3% for BN1). The elevated
prevalence of eating disorders in our study might
be attributable, in part, to selection bias,30 but may

Int J Eat Disord 39:1 11–19 2006 15

SOMERVILLE RUFFOLO ET AL.

TABLE 3. Clinical features of 200 BDD subjects with and without a comorbid eating disorder
BDD with a BDD without a
Comorbid Eating Comorbid Eating
Variablea Disorder (n ¼ 65) Disorder (n ¼ 135) Wald or ANCOVAb p Effect Sizeb

Body image
BDDE total score (n ¼ 98) 99.7 ± 26.5 78.9 ± 30.0 F ¼ 4.90 .03 0.050
General appearance dissatisfaction 4.7 ± 0.9 3.8 ± 1.4 F ¼ 5.20 .03 0.053
Perceived physical attractiveness 2.6 ± 2.1 1.9 ± 1.8 F ¼ 1.00 .32 0.011
Avoidance of others looking at body 3.7 ± 2.5 2.8 ± 2.7 F ¼ 0.77 .38 0.008
Most disliked body areasc
Skin 16 (24.6) 41 (30.4) w2 ¼ 0.37 .54 0.80 (95% CI, 0.38–1.66)
Hair 6 (9.2) 19 (14.1) w2 ¼ 0.02 .90 1.07 (95% CI, 0.37–3.14)
Face 8 (12.3) 7 (5.2) w2 ¼ 3.00 .08 2.93 (95% CI, 0.87–9.91)
Stomach 6 (9.2) 7 (5.2) w2 ¼ 0.01 .92 0.94 (95% CI, 0.27–3.33)
Thighs 7 (10.8) 4 (3.0) w2 ¼ 2.14 .14 2.66 (95% CI, 0.72–9.88)
Weight 2 (3.1) 5 (3.7) w2 ¼ 0.33 .57 0.60 (95% CI, 0.11–3.44)
BDD severity (BDD-YBOCS)
Total score 29.7 ± 9.3 26.5 ± 10.4 F ¼ 0.39 .53 0.002
Preoccupations 12.0 ± 3.9 11.0 ± 4.3 F ¼ 0.27 .61 0.001
Compulsions 12.7 ± 4.5 10.8 ± 5.1 F ¼ 0.52 .47 0.003
Delusionality/insight (BABS) (n ¼ 191)d 15.2 ± 6.5 15.4 ± 6.8 F ¼ 1.08 .30 0.006
Number of comorbid disorderse 4.4 ± 1.8 3.8 ± 1.6 F ¼ 9.34 .003 .045
Suicidal ideationf 55 (84.6) 101 (74.8) w2 ¼ 1.12 .29 1.59 (95% CI, 0.67–3.78)
Suicide attemptsf 24 (36.9) 31 (23.0) w2 ¼ 0.56 .46 1.33 (95% CI, 0.63–2.79)
Functioning and quality of life
SAS-SR total score (n ¼ 142) 2.4 ± 0.6 2.3 ± 0.5 F ¼ 0.88 .35 0.006
Q-LES-Q (Short Form) (n ¼ 139)g 42.4 ± 10.2 44.1 ± 10.1 F ¼ 0.06 .81 <0.0001
LIFE-RIFT (n ¼ 199)h 14.0 ± 3.8 12.9 ± 3.7 F ¼ 1.16 .28 0.006
GAF 44.8 ± 13.3 49.6 ± 13.3 F ¼ 3.29 .07 0.017
SOFAS (n ¼ 116) 48.8 ± 16.9 51.3 ± 15.5 F ¼ 0.06 .81 0.001
Not working due to psychopathology 24 (36.9) 42 (31.1) w2 ¼ 0.92 .34 1.42 (95% CI, 0.69–2.91)
Housebound due to BDD (n ¼ 199)f 16 (25.0) 38 (28.1) w2 ¼ 0.66 .42 0.74 (95% CI, 0.35–1.54)
Days missed from work (n ¼ 195)f 34.2 ± 75.2 45.2 ± 125.6 F ¼ .002 .97 <0.0001
Dropped out of schoolf
Temporarily 6 (9.2) 13 (9.6) w2 ¼ 0.67 .41 1.65 (95% CI, 0.50–5.43)
Permanently 7 (10.8) 15 (11.1) w2 ¼ 0.23 .63 0.77 (95% CI, 0.26–2.25)
Treatment historyf
Psychotropic medications 5.4 ± 5.2 3.6 ± 4.0 F ¼ 7.10 .008 0.035
Psychotherapy 195.1 ± 311.3 93.7 ± 167.8 F ¼ 5.37 .02 0.027
Psychiatric hospitalizations 40 (61.5) 39 (28.9) w2 ¼ 18.77 <.001 5.01 (95% CI, 2.42–10.37)

Note: BDD ¼ body dysmorphic disorder; ANCOVA ¼ analysis of covariance.

a
Results are presented as n (%) or M ± SD for each group. N ¼ 200 for all analyses unless noted in the table. Higher scores represent greater severity for
BDDE (Body Dysmorphic Disorder Examination), BDD-YBOCS (Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive Compulsive Scale),
BABS (Brown Assessment of Beliefs Scale), SAS-SR (Social Adjustment Scale-Self Report), and LIFE-RIFT (Longitudinal Interval Follow-Up Evaluation-Range of
Impaired Functioning Tool). Lower scores represent greater impairment for Q-LES-Q (Quality of Life Enjoyment and Satisfaction Questionnaire), GAF (Global
Assessment of Functioning), and SOFAS (Social and Occupational Functioning Assessment Scale).
b
df ¼ 1 for all chi-square analyses; for F scores, dfs are BDDE (1,93), BDD-YBOCS (1,195), BABS (1,186), number of comorbid disorders (1,196), SAS-SR
(1,137), Q-LES-Q (1,134), LIFE-RIFT (1,194), GAF (1,195), SOFAS (1,111), days missed from work (1,190), psychotropic medications (1,195), and psychotherapy
(1,195).
c
These body areas were the most disliked areas for the entire sample.
d
Average scores are in the poor insight range.
e
Excluding a comorbid eating disorder.
f
These are lifetime measures.
g
The mean Q-LES-Q converted score was 50.8% for the comorbid eating disorder group and 53.7% for those without an eating disorder.
h
Does not include patients not working or not in school due to psychopathology.

also reflect a shared pathogenesis between BDD
and eating disorders. Indeed, BDD and eating
disorders have some similarities. Both involve
excessive concerns with physical appearance,
body image dissatisfaction, and body image distur-
bance.13,15 Some authors have suggested that a dis-
turbance in body image may be the essential
pathology of both BDD and eating disorders.16–18
Although in many cases the focus of the appear-
ance concerns is different (most often the skin,
hair, or nose in BDD vs. body weight and shape in
eating disorders), in some cases there is overlap
(e.g., large thighs and stomach in both BDD and
eating disorders).13,15 It is noteworthy that BDD
onset proceeded eating disorder onset in the
majority of cases both in our study (63%) and in
the Grant et al.27 study of patients ascertained for
AN, in which 94% developed BDD before AN.
Although this finding requires replication, it raises
interesting questions about the relationship

16 Int J Eat Disord 39:1 11–19 2006


between these disorders. For example, if BDD and
AN are related, might the body image disturbance
of BDD predispose to and metamorphose into dis-
satisfaction with weight and body shape accompa-
nied by abnormal eating behavior, in at least some
cases? Several longitudinal studies have found that
body image disturbance (thin body preoccupation)
predicts onset of eating disorders.44–45
Although both the noncomorbid group and the
comorbid eating disorder group had high levels of
body image disturbance (total score on the BDDE),
the comorbid eating disorder group had greater
disturbance, perhaps due to the fact that their
body image concerns were fueled by two disorders
rather than one. This explanation is consistent with
the Gupta and Johnson36 finding that the presence
of both weight and nonweight body image con-
cerns in eating-disordered patients was associated
with greater overall body dissatisfaction. It is note-
worthy that the most disliked body areas in our
study were classic BDD concerns and were similar
in the two groups, although this might be expected
in a sample ascertained for BDD.
Our finding that the comorbid eating disorder
group had received significantly more mental
health treatment than the noncomorbid group is
consistent with the Grant et al.27 findings in
patients ascertained for AN, in which AN patients
with comorbid BDD had been hospitalized 6.3 ± 2.8
times, compared with 3.8 ± 3.2 times for the AN
subjects without comorbid BDD. However, con-
trary to findings from that study, our comorbid
group did not have greater delusionality of BDD-
related beliefs as assessed by the BABS. Also con-
trary to the Grant et al. results and our hypotheses,
our comorbid group was not more likely to have
attempted suicide or have significantly poorer
functioning (although there was a trend for the
comorbid group to have poorer GAF scores). One
possible explanation for this finding is that the
majority of participants in our study considered
BDD their most problematic diagnosis, so the addi-
tional diagnosis of an eating disorder did not
significantly worsen ratings. Another possible
explanation is Type II error due to the relatively
small sample size of the comorbid eating disorder
group (although most effect sizes were small). It is
also possible that a comorbid eating disorder may
actually contribute to significantly poorer function-
ing and QOL (to a greater extent than found in the
current study), but that these effects may be atten-
uated by the greater amount of mental health
treatment received by this group. If such treatment
were efficacious (which our study could not deter-
mine), the comorbid eating disorder group might
Int J Eat Disord 39:1 11–19 2006
COMORBIDITY OF BDD AND ED
have been more impaired before treatment. To our
knowledge, the only study that has directly com-
pared patients with BDD with those with an eating
disorder17 did not examine functioning and QOL.
This important issue needs further investigation.
Our findings have several clinical implications. It
is worth highlighting subjects’ markedly poor func-
tioning and QOL, which is consistent with previous
BDD studies.6–8 QOL scores on the SAS-SR and
Q-LES-Q were strikingly poorer than community
norms, and mean converted Q-LES-Q scores were
lower (50.8% in the comorbid eating disorder group
and 53.7% in the noncomorbid group) than have
been reported for social phobia (70.5%), panic dis-
order (68.3%), OCD (65.6%), premenstrual dyspho-
ric disorder (63.9%), dysthymia (61.6%), major
depression (57.5%), or post-traumatic stress disor-
der (PTSD; 56.1%).46 A very high proportion of par-
ticipants in both the comorbid eating disorder
group and the noncomorbid group had experi-
enced suicidal ideation and suicide attempts, con-
sistent with previous BDD studies.8,9 Although our
two groups did not significantly differ in terms of
suicide attempts, it is notable that Grant et al.27
found that AN patients with comorbid BDD had
triple the suicide attempt rate of those with AN
alone (63% vs. 20%). In addition, in the Grant et
al. study, 69% of subjects had considered suicide
specifically because of their BDD symptoms. Thus,
patients with BDD should be monitored carefully
for suicidality. Given these findings, as well as the
high comorbidity between these disorders, it is
important that individuals diagnosed with either
of these body image disorders be further screened
for the presence of the other disorder, especially
because patients may conceal their symptoms
because of embarrassment and shame.15,27
The current study has several limitations.
Although our BDD sample is, to our knowledge,
larger than most and more diverse than previous
samples, it was a sample of convenience. There-
fore, it is unclear how representative it is of indivi-
duals with BDD in the community or of patients
with BDD in clinical settings. In addition, the rela-
tively few subjects in the comorbid eating disorder
group (n ¼ 65) may have introduced Type II error.
Furthermore, because the sample of subjects with a
current eating disorder was relatively small, group
comparisons were performed only for subjects with
lifetime comorbidity, whereas some measures
assessed current severity and functioning. Addi-
tional limitations are that we administered the
BDDE to only a subset of the sample, which may
have limited the power of analyses of this measure,
and we did not use standard measures of eating
17
SOMERVILLE RUFFOLO ET AL.
disorder pathology (e.g., illness severity). Also, we
used the SCIDI/NP rather than the Schedule for
Affective Disorders and Schizophrenia for School-
age Children (K-SADS), although the SCIDI/NP
may be used in adolescents.47,48 However, the cur-
rent study also has several strengths. It is the first
investigation of eating disorder comorbidity and its
clinical correlates in a BDD sample. The sample is
larger than in most previous BDD studies and more
diverse, and a variety of reliable and valid self-
report and interviewer-administered measures
were used.
Nonetheless, additional studies are needed to
address the limitations of the current study. Studies
are needed of larger samples and in different settings
(e.g., community and clinical settings) to further
assess comorbidity and clinical correlates of comor-
bidity. Studies are also needed that compare indivi-
duals with an eating disorder (without comorbid
BDD) with those with BDD and with those with
both BDD and an eating disorder, which could
address a broader range of questions than those
addressed in our study. 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. Finally, studies are
needed (e.g., longitudinal studies, neurobiologic stu-
dies) that shed light on the interesting and likely
complex etiologic relation between these relatively
common and severe body image disorders.
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