Case Conceptualization and Treatment of Comorbid Body Dysmorphic Disorder and Bulimia Nervosa Elizabeth R. Didie, Butler Hospital/Alpert Medical School of Brown University Mark A. Reinecke, Northwestern Medical School/Northwestern University Medical Center Katharine A. Phillips, Butler Hospital/Alpert Medical School of Brown University Body dysmorphic disorder (BDD) and eating disorders often co-occur and share some clinical features. In addition, the co-occurrence of BDD and an eating disorder may be associated with greater impairment in functioning. Furthermore, clinical impressions suggest that this comorbidity may be more treatment resistant than either disorder alone. The current article discusses the treatment of a 48-year-old female diagnosed with BDD and comorbid bulimia. We attempted to address these co-occurring disorders in a strategic, formulation- based manner using a variety of cognitive-behavioral strategies such as cognitive restructuring, rational disputation, exposure with response prevention, and mirror retraining. Despite the complexity of this case, results suggest that comorbid BDD and bulimia nervosa can be effectively managed with cognitive behavioral therapy. B ODY dysmorphic disorder (BDD) is defined as a distressing or impairing preoccupation with an imagined defect in appearance; if a slight anomaly is present, the concern is markedly excessive (American Psychiatric Association, 2000). The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, and it must not be better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). Studies have found that BDD is relatively common, occurring in 0.7% to 2.4% of community samples (Bienvenu et al., 2000; Faravelli et al., 1997; Koran, Abujaoude, Large, & Serpe, 2008; Rief, Buhlmann, Wilhelm, Borkenhagen, & Brahler, 2006), 2% to 13% of student samples (Biby, 1998; Bohne et al., 2002; Mayville, Katz, Gipson, & Cabral, 1999), and 13% of psychiatric inpatients (Grant, Kim, & Crow, 2001). BDD is associated with very poor psychosocial functioning and quality of life (Phillips, 2000; Phillips, Menard, Fay, & Pagano, 2005), and a high rate of suicide ideation and attempts (Phillips, Coles, et al., 2005; Phillips & Menard, 2006; Veale et al., 1996). BDD is often comorbid with other disorders (e.g., Gunstad & Phillips, 2003), but its relationship to them is unclear. For example, it has been suggested that BDD and eating disorders may be related conditions (Grant & Phillips, 2004). Some authors suggest that body image dissatisfaction may be the essential pathology underlying both BDD and eating disorders (Cororve & Gleaves, 2001; Rosen & Rameriz, 1998). BDD is the only diagnosis in the DSM-IV- TR, other than an eating disorder, that is characterized by a disturbance in body image. BDD and eating disorders also share some phenomenological features, such as body image dissatisfaction (Rosen & Ramirez, 1998), obses- sional thinking (Godart, Flament, Perdereau, & Jeammet, 2002; Halmi, 2005), poor interpersonal functioning (Fairburn, 1997), and chronic low self-esteem (Polivy & Herman, 2002). In addition, many patients with eating disorders are preoccupied with non-weight aspects of appearance, such as the size of their stomach or thighs, or even body areas such as the skin or nose (Grant, Kim & Eckert, 2002; Gupta & Gupta, 2001; Gupta & Johnson, 2000), similar to patients with BDD, although the latter concerns would be diagnosed as BDD if diagnostic criteria are met. Conversely, some BDD patients are preoccupied with body weight and shape (Kittler, Menard, & Phillips, 2007; Phillips & Diaz, 1997). BDD individuals with weight concerns have been found to be as impaired or more impaired, across measures of symptom severity, comor- bidity, and quality of life as those who have more classic BDD concerns (e.g., nose, skin, and hair; Kittler et al., 2007). The prevalence of eating disorders in individuals with BDD has varied across studies and appears elevated compared to the prevalence in the general population. In a study of 293 subjects with BDD, 10% had anorexia nervosa (AN) and/or bulimia nervosa (BN) at some point in their life (3% with AN, 8% with BN), and 4% had 1077-7229/10/259–269$1.00/0 © 2010 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved. Available online at www.sciencedirect.com Cognitive and Behavioral Practice 17 (2010) 259–269 www.elsevier.com/locate/cabp