Body dysmorphic disorder and eating disorders in elite professional female ballet dancers
Programa de Pós-Graduação em, Psiquiatria e Saúde Mental, Instituto de Psiquiatria da Universidade, Federal do Rio de Janeiro, Rio de Janeiro, Brazil
Programa de Pós-Graduação em, Psiquiatria e Saúde Mental, Instituto de Psiquiatria da Universidade, Federal do Rio de Janeiro, Rio de Janeiro, BrazilLeonardo F. Fontenelle, MD, PhD
Programa de Pós-Graduação em, Psiquiatria e Saúde Mental, Instituto de Psiquiatria da Universidade, Federal do Rio de Janeiro, Rio de Janeiro, Brazil, Departamento de Psiquiatria e, Medicina Legal, Universidade Federal do Rio de Janeiro, Instituto D’Or de Ensino e Pesquisa, Departamento de Psiquiatria, Universidade Federal Fluminense, Niterói, Brazil
BACKGROUND: Our objective is to report the prevalence and the clinical features associated with body dysmorphic disorder (BDD) and eating disorders (ED) in a group of elite Brazilian professional female ballet dancers.
METHODS: Thirty-five elite Brazilian professional female ballet dancers were invited to participate in the study and 19 agreed to be assessed. Individuals were evaluated with a series of instruments, including the Mini International Neuropsychiatric Interview supplemented by the somatoform and eating disorders modules of the Structured Clinical Interview for DSM-IV disorders, the Bulimic Investigatory Test, and the Beck Depression Inventory.
RESULTS: Three dancers (15.78%) had a lifetime diagnosis of anorexia nervosa (restrictive subtype) and 2 others (10.52%) presented a current diagnosis of BDD. No individuals had current or lifetime bulimia nervosa. Results could not be ascribed to comorbid major depression or increased severity of depression.
CONCLUSION: The lifetime prevalence of BDD and ED among elite professional female ballet dancers was higher than the general population. High standards of beauty, public body exposure, and repeated exposure to mirrors in the rehearsal rooms may contribute to the development of body image disorders in this sample.
KEYWORDS: body dysmorphic disorder, eating disorders, anorexia nervosa, etiology
ANNALS OF CLINICAL PSYCHIATRY 2012;24(3):191-194
Body dysmorphic disorder (BDD) and eating disorders (ED) share several sociodemographic and clinical features, including sex ratio, symptomatology, and patterns of comorbidity. For example, although ED and BDD exhibit several relatively specific sex-related features (eg, the parts of the body that cause the most distress), both conditions are more prevalent in women than in men.1,2 Further, although the initial descriptions of anorexia nervosa (AN) did not emphasize the importance of body image dissatisfaction,3,4 which is the central complaint in BDD, subsequent reports and the first accounts of bulimia nervosa (BN) have highlighted this phenomenon as a key feature of eating disorders.5-7
Patients with ED and BDD also present with compulsive behaviors. These include calories counting in ED, excessive use of cosmetics in BDD, mirror checking, and need for reassurance in both conditions. Further, recent studies found a higher incidence of BDD in groups of patients with ED8,9—including individuals with binge eating disorder10—and higher incidence of ED in patients with BDD.11-13 In consideration of the similarity between ED and BDD, it has been suggested that these conditions should be in the same category.14
Pressure to maintain low weight or an athletic body has been considered a risk factor for developing body image dissatisfaction.15 Ballet dancers are exposed to a visual image of their body several hours every day when training in mirrored rooms.16 Several studies have evaluated the prevalence of ED in vulnerable populations, including athletes, models, and ballet dancers.17,18 However, these studies have 1) neglected the occurrence of other body image disorders (ie, BDD) among these individuals; and 2) been conducted exclusively on European, North American, or Asian populations. In our study, we aimed to evaluate the prevalence and the clinical features of ED, BDD, and broadly defined body image disturbances in a group of elite Brazilian professional female ballet dancers.
All women (N = 35) who were dancing in the ballet company of a state theatre in Rio de Janeiro city were invited to take part in this study. This company was chosen because of its rigorous admittance criteria and performance demands. The ballet dancers who agreed to participate were interviewed with regard to sociodemographic (ie, age and marital status), occupational (ie, age at which they started dancing ballet and whether they had attended the ballet company’s dance school), and anthropometric (ie, weight and height) data. The institutional review board from the Institute of Psychiatry, at the Federal University of Rio de Janeiro approved the research project (CAAE-0031.0.249.000-08). Written informed consent was obtained from the volunteers after the procedures involved in the protocol were fully explained.
In terms of psychopathology, dancers were interviewed with a series of questionnaires, including the Brazilian version of the Mini International Neuropsychiatric Interview19 supplemented with the somatoform and ED modules of the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient version.20 Unfortunately, the Eating Disorder Evaluation, usually considered the “gold standard” interview for eating disorders evaluation, has not been translated and validated in Brazilian Portuguese, therefore we were unable to use it. Severity of abnormal eating behaviors was assessed with the Bulimic Investigatory Test, Edinburgh (BITE; Brazilian version).21 The Beck Depression Inventory (BDI; Brazilian version)22 was employed to evaluate the presence and severity of depressive symptoms, which might be a confounding factor in the evaluation of ED symptoms and body image dissatisfaction.
Only 19 of the 35 female dancers in the ballet company agreed to participate in the study. The remaining dancers refused to join after being informed about the purposes of the protocol. Four of these individuals cited the need to be weighed as the reason for their refusal and the other 12 did not offer any explanation. The participants mean age was 34.46 (± 8.85). One-half had completed secondary school and the rest were university graduates. Among the participating dancers, 58.33% were single, 33.33% were married, and 8.33% were widowed or divorced.
The dancer’s mean weight was 50.30 (± 5.07) kg and their median height was 1.61 (± 0.05) meters. Subjects mean body mass index (BMI) was 19.25 (± 0.91) kg/m2. Their mean lifetime lowest weight was 44.46 (± 4.71) kg and the mean lifetime lowest BMI was 17.02 (± 1.21) kg/m2. The ballet dancers who took part in the study started dancing at age 9.38 (± 3.38). At the time of the interview, they had been dancing ballet for 25.07 (± 8.92) years and were part of this ballet company for 14.53 (± 8.03) years.
On the BITE, 2 dancers who had been previously diagnosed with AN presented elevated scores: 1 dancer scored 16, which indicates an altered eating behavior and the other scored 24, which indicates a high risk for bulimia nervosa. According to the BDI, all subjects were free from clinically significant depressive symptoms. Two dancers (10.5% of our sample) presented with BDD and no dancer fulfilled the diagnostic criteria for an ED. Three dancers (15.78%) had a lifetime diagnosis of AN (restrictive subtype). One of these dancers had been hospitalized for AN. No dancer presented with BDD comorbid with any ED. Three dancers (15.78%) had been previously diagnosed with recurrent depressive disorder, 5.26% presented dysthymic disorder, 10.52% had panic disorder, 10.52% presented with generalized anxiety disorder, and 5.26% were diagnosed with substance abuse.
In this study, 3 out of 19 (15.78%) individuals displayed a lifetime history of AN, a rate that is more than 17-times higher than that reported in the general female population.23 Similar prevalence rates of AN (12%) were reported in Norwegian elite athletes of aesthetic sports (including diving, figure skating, gymnastics, rhythmical gymnastics, and sports dance).18 No case of lifetime BN was identified in our sample. Accordingly, previous literature has suggested underreporting of abnormal eating behaviors was more common in elite athletes than controls.17 We speculate that binging and purging, core features of BN, may be more readily recognized by the elite dancers as pathological. As a result, subjects may have underreported BN symptoms in order to avoid shame, stigma, and having their athletic career jeopardized.
To the best of our knowledge, this is the first study to report increased rates of BDD among female ballet dancers (10.5%), a prevalence that is almost 6-times higher than those described in general female population (1.8%).24 This finding supports the notion that, along with ED,18 elite “aesthetic” athletes may be at an increased risk of developing BDD. It is possible that the mechanisms through which ballet dancers develop and/or maintain ED, including high standards of beauty, public bodily exposure, repeated exposure to mirrors in the rehearsal rooms,16 also may play a role in BDD. This finding also strengthens the connection between ED and BDD and suggests that they may share common risk factors.
This preliminary study has a number of limitations. First, the sample was small and age-heterogeneous without an appropriate control group. This was largely because a substantial proportion of individuals enrolled in the ballet company did not participate in the study (n = 16; 45.7%). A number (n = 4) refused to participate because they would not consent to being weighed. Because individuals who fear being weighed are likely to exhibit abnormal eating patterns, it is likely that our rates of ED (and perhaps BDD) represent an underestimation of real figures. However, even if individuals who refused to participate did not exhibit BDD or ED, the rates of both disorders among elite professional female ballet dancers would remain considerably higher than the female general population (ie, 5.7% and 8.5%, respectively).
Our findings suggest that ED and BDD are common among elite ballet dancers and highlight the possibility that these conditions may share common risk factors. Elite dancers should be closely monitored for the development of body image disorders.
DISCLOSURE: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
ACKNOWLEDGEMENTS: The authors would like to thank Dr. Renee Testa for proofreading this manuscript.
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CORRESPONDENCE: Leonardo F. Fontenelle, MD, PhD, Rua Visconde de Piraj, 547, Sala 719, Ipanema, Rio de Janeiro, 22410-003, Brazil E-MAIL: firstname.lastname@example.org
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