Body Image 1 (2004) 113–125

Advances in a cognitive behavioural model of

body dysmorphic disorder

David Veale *

Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical
School, University of London, London, UK

Received 19 June 2003 ; received in revised form 14 July 2003 ; accepted 17 July 2003

Abstract

Body dysmorphic disorder (BDD) is the most distressing and handicapping of all the body image disorders. A cognitive
behavioural model of BDD is discussed which incorporates evidence from recent studies and advances in the author’s 1996
conceptual model. The model aims to understand the maintenance of symptoms in BDD, to assist in the process of engagement
of therapy and to guide the strategies to use. At the core of BDD is an excessive self-focussed attention on a distorted body
image, the negative appraisal of such images leading to rumination, changes in mood and the use of safety behaviours. Evidence
for possible risk factors in the development of BDD is also discussed.
© 2003 Elsevier B.V. All rights reserved.

Keywords: Body dysmorphic disorder; Cognitive behaviour therapy; Risk factors; Body image

Introduction der (OCD) ( Neziroglu, McKay, Todaro, & Yaryura

Tobias, 1996; Phillips & Diaz, 1997 ; Veale et al.,
Body dysmorphic disorder (BDD) is characterised 1996a ). There is also heterogeneity in the presenta-
by a preoccupation with an imagined defect in one’s tion of BDD from individuals with borderline per-
appearance or, in the case of a slight physical anomaly, sonality disorder with self-harming behaviours to
the person’s concern is markedly excessive. The others with muscle dysmorphia ( Pope, Gruber, Choi,
person must also be significantly distressed or handi- Olivardia, & Phillips, 1997 ), who are less handicap-
capped in his or her occupational and social function- ped. They share a common feature of a preoccupation
ing ( American Psychiatric Association, 1994 ). There with an imagined defect or minor physical anomaly.
is frequent comorbidity in BDD especially for depres- The most common preoccupations concern the skin,
sion, social phobia and obsessive–compulsive disor- hair, nose, eyes, eyelids, mouth, lips, jaw, and chin,
however any part of the body may be involved and
the preoccupation is frequently focussed on several
* Present address: Department of Psychiatry, The Priory Hos-
body parts simultaneously ( Phillips, McElroy, Keck,
pital North London, The Bourne, Southgate, London N14 6RA,
UK. Tel.: +44-208-882-8191; fax: +44-208-447-8138. Pope, & Hudson, 1993 ). Complaints typically involve
E-mail address: [email protected] (D. Veale). perceived or slight aws on the face, asymmetrical or

1740-1445/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S1740-1445(03)00009-3
114 D. Veale / Body Image 1 (2004) 113–125

disproportionate body features, thinning hair, acne, degree of importance attached to one’s appearance in
wrinkles, scars, vascular markings, and pallor, or rud- defining one’s self might be at the extreme end of
diness of complexion. Sometimes the complaint is a normal dimension. However, the distorted imagery
extremely vague or amounts to no more than a general experienced by some BDD patients has a more quali-
perception of ugliness. BDD is characterised by time tative difference to normal body image.
consuming behaviours such as mirror gazing, com-
paring particular features to those of others, excessive
camou age, skin-picking, and reassurance seeking. A cognitive behavioural model of BDD
There is usually avoidance of social situations and
of intimacy. Alternatively such situations are endured There are similar features in psychopathology of
with the use of alcohol, illegal substances or safety BDD with OCD and social phobia, with frequent co-
behaviours similar to social phobia. morbidity. It is not therefore surprising that a cogni-
The prevalence rate of BDD in the community is tive behavioural model of BDD described below has
reported as 0.7% in two studies ( Faravelli et al., 1997 ; some overlap with that of social phobia ( Clark &
Otto, Wilhelm, Cohen, & Harlow, 2001 ) with a higher Wells, 1995 ), OCD ( Salkovskis, 1999 ) and health anx-
prevalence of milder cases in adolescents and young iety ( Warwick & Salkovskis, 1990 ) which in uence I
adults ( Bohne et al., 2002 ). The prevalence of BDD would like to acknowledge. A model for BDD needs
is about 5% in a cosmetic surgery setting ( Sarwer, to focus on features, which are unique to BDD. One
Wadden, Pertschuk, & Whitaker, 1998 ) and 12% in such feature is the relationship with re ective surfaces
a dermatology clinic ( Phillips, Dufresne, Wilkel, & such as mirrors or old photos, which acts a trigger for
Vittorio, 2000 ). Surveys of BDD patients attending the symptoms. The model has some overlap with a
a psychiatric clinic tend to show an equal sex inci- cognitive behavioural model of body image developed
dence and sufferers are usually single or separated by Cash and Pruzinsky (2002) which is most com-
( Neziroglu & Yaryura-Tobias, 1993 ; Phillips & Diaz, monly applied to dissatisfaction for body weight and
1997 ; Phillips et al., 1993; Veale et al., 1996a ). Veale shape in a non-psychiatric population.
et al. (1996a) found a greater preponderance of women Cognitive behavioural models are relevant for an-
but this may be because of a referral bias. It is also pos- swering questions about the maintenance of symp-
sible that, in the community, while more women are af- toms. For example, why does an individual with BDD
fected overall, a greater proportion experience milder “see” a grossly distorted body image in a mirror when
symptoms. others view the person as genuinely attractive and con-
Although the age of onset of BDD is during adoles- tradict their views? Furthermore, the model needs to
cence, patients are usually diagnosed 10–15 years later be understood by a patient; to provide an alternative
( Phillips, 1991 ; Phillips & Diaz, 1997 ; Veale et al., explanation for their experience; to assist in the pro-
1996a ). Patients may be secretive because they may cess of engagement and to guide the strategies to use
think they will be viewed as vain or narcissistic. They in therapy. For each section of the model, I will dis-
are therefore more likely to present to mental health cuss the theory, the evidence for the model so far and
practitioners with symptoms of depression or social the clinical implications in therapy. I will discuss pu-
anxiety unless they are specifically questioned about tative risk factors for the development of BDD in the
symptoms of BDD. BDD patients are the most dis- second half of the article.
tressed and handicapped of all the body image disor-
ders with a high rate of depression and suicide or “do
it yourself” (DIY) cosmetic surgery. Phillips (2000) The self as an aesthetic object
used a quality of life measure and found a degree of
distress that is worse than that of depression, diabetes The self as an aesthetic object refers to the experi-
or bipolar disorder. ence of extreme self-consciousness and self-focussed
BDD is probably best conceptualised as having both attention on a distorted image. It is proposed that
quantitative and qualitative differences from normal the cycle begins when an external representation of
body dissatisfaction and body image. For example, the the person’s appearance (e.g. looking in a mirror)
 D. Veale / Body Image 1 (2004) 113–125 115

Trigger (external
representation
of appearance)
Selective attention

Processing of self
Negative appraisal of as an aesthetic object
internal body image

Rumination on
Safety behaviours ugliness & compare
to camouflage and to ideal
alter appearance Mood ( disgust

& depression)

Fig. 1. A cognitive behavioural model of BDD.

activates a distorted mental image ( Fig. 1 ). A mental spective compared to a field perspective, similar to a
image is defined as “contents of consciousness that finding in social phobia ( Hackmann, Surawy, & Clark,
possess sensory qualities, as opposed to those that are 1998 ). An observer perspective consists of the individ-
purely verbal or abstract” ( Horowitz, 1970 ). The pro- ual looking at him or her self from another person’s
cess of selective attention has the effect of increasing perspective. A. field perspective consists of an indi-
awareness of the image and of specific features within vidual on the inside looking out of one’s own body.
the image. The image is used to construct how the per- Stopa (2003) has noted that an observer per-
son looks in the mirror and provide information about spective is not abnormal per se but is more likely
how he or she appears to others (also referred to as the to occur with trauma and false memories. How-
process of “mind reading”). The evidence for imagery ever, BDD and social phobic patients may use the
in BDD so far is a descriptive study that compared observer perspective initially in order to distance
18 BDD patients with 18 healthy controls using a themselves and avoid emotion associated with nega-
semi-structured interview and questionnaires ( Osman, tive evaluative experiences. The observer perspective
Cooper, Hackmann, & Veale, 2003 ). BDD and con- may therefore become a maintaining factor through
trols were just as likely to experience spontaneous im- continued avoidance of emotion. An external per-
ages of their appearance (like Fig. 1 ). However BDD spective may increase its “authority” and increase
patients were more likely to rate the images as signifi- the tendency to make internal attributions about an
cantly more negative, recurrent and vivid than normal event.
controls. Images in BDD patients were more distorted It is proposed that activation of imagery is associ-
and the “defective” features took up a greater propor- ated with an increased self-focussed attention. Self-
tion of the whole image. They typically reported visual focussed attention is defined as an awareness
images, which were sometimes associated with other of self-referent, internally generated information
sensory modalities (e.g. organic sensations of hunger ( Ingram, 1990 ). Self-referent information can in-
or fatigue). Of particular significance is that the images clude a wide range of stimuli from an awareness of
were more likely to be viewed from an observer per- sensations, thoughts, images, or emotions from past
116 D. Veale / Body Image 1 (2004) 113–125

memories that in uence the self in the present. It is The role of imagery and self-focussed attention has
therefore a non-specific process that occurs in a wide significant implications for therapy. First, a discussion
range of disorders from social phobia to schizophre- of the role of imagery, the link with early experiences
nia. The degree of self-focussed attention is likely to and the meaning attached to the image will all assist
be related to the severity of the symptoms and de- in the process of engagement. First, the therapist and
gree of preoccupation ( Woodruff-Borden, Brothers, patient can talk about the “image” as the problem
& Lister, 2001 ). It is proposed that in severe cases rather than the person’s appearance. This can lead to
of BDD the attentional capacity is taken over by the a discussion about the way perception is constructed
distorted image and negative appraisal. Furthermore, and is not just a picture on the back of the retina
the system may be so rigid that it is unable to switch that is faithfully reproduced. Second, when assessing
to any external information about one’s appearance. patients, more negative self-beliefs can be accessed
In less severe cases, there appears some attentional via images and from earlier memories than via verbal
capacity to external information so that the image thoughts ( Osman et al., 2003 ). Third there are a num-
may be less stable and associated with doubts about ber of techniques for modifying the meaning of the
how the person appears to others. In this case, the image by historical reviews or rescripting an image es-
individual may feel driven by a need to know exactly pecially for teasing, bullying and sexual trauma ( Arntz
how they look. The person might be rewarded only & Weertman, 1999 ; Hackmann, 1998 ) or the be-
with certainty whilst he is looking in a mirror, which liefs about the imagery ( Layden, Newman, Freeman,
is then reinforced. However the longer a person looks & Morse, 1993; Smucker & Niederee, 1995 ). Lastly,
in front of a mirror, the more self-conscious he be- clinicians may find it helpful to explore the role of
comes, the worse he feels and the more it reinforces the observer perspective. For example, is emotion
his or her view of being ugly and defective. Patients more or less intense with observer or field perspective
become genuinely confused about how their appear- images? ( Stopa, 2003 ).
ance might alter from day to day or hour to hour. The model also suggests that techniques that help
However, this might occur in the context of mood to train individuals to increase the proportion of at-
changes and occasional reinforcement of feeling bet- tention away from self-referent information towards
ter in a particular light or a “good” mirror when tasks or the environment will be of assistance. This
there is less self-focussed attention. Hence patient strategy has been described for social anxiety ( Bogels,
may believe that in every mirror they look, they see a Mulkens, & De Jong, 1997 ) or health anxiety ( Wells,
different image ( Veale & Riley, 2001 ). 1990, 2000 ). The principle of increasing attention on
Increased self-focussed attention on physical ap- a task such as shaving or combing one’s hair can also
pearance increases the specificity for BDD, but in- be applied to mirror retraining ( Veale & Riley, 2001 )
dividuals with a disfigurement or an eating disorder or routine activities such as walking down a street and
will also be more self-conscious about their appear- becoming more aware of the environment from a field
ance. The process of selective attention appears to be perspective.
focussed on specific features of an image leading to
a heightened awareness and relative magnification of
certain aspects, which contributes to the development Negative appraisal of body image
of a distorted body image. One might predict that
selective attention would lead to increased accuracy The next step is the negative appraisal and aesthetic
of certain aspects of one’s body. For example, Jerome judgement of the image, by activation of assumptions
(1992) found that patients on a waiting list for cos- and values about the importance of appearance. In
metic rhinoplasty (but not diagnosed as BDD) were BDD, appearance has become over-identified with the
more accurate than healthy controls in estimating the self and at the centre of a “personal domain” ( Veale,
size of their nose. This work needs to be replicated 2002 ). The term, “personal domain”, was first used
in BDD patients who may be selectively attending by ( Beck, 1976 ) to describe the way a person attaches
to a distorted body image and may therefore be less meaning to events or objects around them. At the cen-
accurate. tre of a personal domain are a person’s characteristics,
 D. Veale / Body Image 1 (2004) 113–125 117

his physical attributes, his goals and values. Clustered a motivational salience—the extent to which they
around are the animate and inanimate objects in which attend to their appearance and engage in appearance
he has an investment such as his family, friends, and management behaviours. Items for the self-evaluative
possessions. An idealised value occurs when one of concerns include: “What I look like is an important
the values develops into such over-riding importance part of who I am” or “My appearance is responsible
that it defines the “self” or identity of the individual for much of what’s happened to me in my life”. The
or becomes the very centre of a personal domain. The instrument has not yet been studied in BDD and does
idealised value in BDD is usually the importance of not cover specific assumptions or rules such as those
appearance of certain features but other values may described above.
include social acceptance, perfectionism, symmetry or In common with other mood disorders, such ap-
youth. Such values will reinforce processing of the praisals will contribute to the bias towards beliefs
self as an aesthetic object (and in social situations as that are confirmatory. For example, compliments are
a social object ( Clark & Wells, 1995 ). Without these easily dismissed in a process of “discounting the
idealised values, it might be possible to adapt to a dis- positive”. Examples include “They are saying it to be
torted body image in the way that some individuals nice to me” or “They have to love me because they
with a disfigurement may accept themselves and be- are my parents”. Alternatively neutral comments may
come less self-conscious ( Partridge, 1990 ). be turned into negative and be self-referential.
The conditional assumptions and rules about one’s Therapy involves (a) identifying and helping indi-
appearance will be driven by the values about the im- viduals to question the meaning of the defectiveness
portance of appearance to one’s identity. Typical as- (not the defect itself); (b) challenging the assumptions
sumptions include: “If I am unattractive, then life is about being defective; (c) modifying values by a prag-
not worth living”, “If I am defective, then I will be matic approach (e.g. questioning their functional cost)
alone all my life” or “I can only do something when I ( Veale, 2002 ); (d) reducing the importance of the ap-
feel comfortable about my appearance” ( Veale et al., pearance in defining the self ( Dryden, 1998; Lazarus,
1996a ). Geremia and Neziroglu (2001) have noted 1977 ); (e) reverse role-play to strengthen an alterna-
other assumptions such as “If I looked better then my tive belief in which patients can practice arguing the
whole life will be better”, “How I feel about myself case for their alternative belief whilst the therapist ar-
as a person is related to how I feel about how I look”. gues the case for the old beliefs or values ( Cromarty
Typical core beliefs that are activated are based on & Marks, 1995 ). This is standard cognitive therapy
(a) being a failure or generally inadequate; (b) being but clinical experience suggests that such strategies
worthless; (c) being ugly, repulsive or abnormal; (d) are better used later in therapy when an individual is
being unlovable or unacceptable; (e) being rejected by engaged in the model, is using less safety behaviours
others and being alone for the rest of their life ( Osman and has become more functional.
et al., 2003 ). Most of these core beliefs are not spe-
cific to BDD but are common themes in depression
and personality disorders. The model predicts that ac- Rumination and comparison with
tivation of the negative appraisals will have a negative ideal
feedback and will increase self-focussed attention on BDD is defined as a “preoccupation” with many
the image. individuals reporting that it is on their mind most
The degree of investment on appearance-related hours of the day. Some of the cognitive processes that
self-schemas has also been explored by Cash and determine a preoccupation can be explained by the
Pruzinsky (2002) and Cash, Melnyk, and Hrabosky fixed attentional capacity on the distorted imagery and
(in press) who have developed and revised the appear- negative appraisal described above. However little is
ance schemas inventory (ASI) to assess the degree of known in BDD about other cognitive processes that
importance attached to one’s body image. The ASI contribute to the nature of the “preoccupation” and the
has two factors—the person’s self-evaluative salience similarities or differences to worry or an obsession. For
which measures the degree to which an individual example, the process might include meta -cognitions;
defines themselves by their physical appearance and comparisons with an ideal internal image or with
118 D. Veale / Body Image 1 (2004) 113–125

other individuals, and anticipatory worry about future that one has been unable to achieve one’s respon-
events. sibilities and is therefore liable for punishment (the
Theories of social comparison ( Festinger, 1954 )or anticipated presence of negative outcomes seen in
social ranking ( Allan & Gilbert, 1995; Gilbert, Price, social phobia). Veale et al. (2003) explored the role
& Allan, 1995 ) have been applied to body dissatis- of self-discrepancy theory in 72 BDD patients and
faction ( Heinberg & Thompson, 1992 ). The theory 42 controls who completed a modified version of
assumes that individuals compare themselves with the selves questionnaire ( Higgins, Bond, Klein, &
others and engage in upward comparisons or choose Strauman, 1986 ) requiring them to list and rate phys-
inappropriate comparison targets with unrealistic ide- ical characteristics according to the following stand-
als. In BDD, the appearance comparison appears to points: (a) self-actual; (b) self-ideal; (c) self-should;
be on specific feature(s) that are regarded as defec- (d) other-actual; and (e) other-ideal. Compared to
tive. Those who view their feature as very unattractive controls, BDD patients displayed significant greater
may desire to just blend in with an average. A minor- discrepancies between their self-actual and both their
ity who view their feature as average might desire an self-ideal and self-should. There were no significant
unrealistic standard or perfectionism. When in front discrepancies in BDD patients compared to controls
of a mirror the comparison may be another image. however, between their self-actual and other-actual
Alternatively the comparisons may be with an old or other-ideal domains. The results suggest that BDD
photo of him or her self or a picture in the media. In patients have their own ideal as to how they should
social situations, the comparison is usually of peers look and are more concerned with a failure to achieve
the same age and sex. The constant comparison has their own aesthetic standard than with being pun-
a negative feedback on increasing negative appraisal ished for failing to achieve the ideals of others. A
and self-focussed attention on the image. similar instrument (the Body Image Ideals Question-
The evidence for repeated comparisons in BDD is naire) has been developed by Cash and Szymanski
limited but we have some data from a study based (1995) to assess evaluative body image and discrep-
on self-discrepancy theory ( Veale, Kinderman, Riley, ancy between self-perceived physical attributes and
& Lambrou, 2003 ). Self-discrepancy theory proposes internalised standards or ideals from one’s own and a
three basic domains of self-beliefs: (a) the actual significant other’s standpoint. In addition, the degree
sel —the individual’s representation of the attributes of importance attached to each of these discrepancies
fthat someone (self or significant other) believes the is assessed so that body image satisfaction depends
individual actually possesses; (b) the ideal self —the on (a) the extent to which body image is matched
individual’s representation of the attributes that some- with ideals; (b) the importance attached to having or
one (self or significant other) would ideally hope attaining those ideals. The BIQ is based upon 10 phys-
the individual to possess; (c) the should or ought ical characteristics including height, weight, chest
sel —the individual’s representation of the attributes size, physical strength or co-ordination which are not
fthat someone (self or significant other) believes the usually relevant for most individuals with BDD who
individual ought as a sense of duty or moral obli- are more likely to focus on aspects of their face. The
gation to possess. The ideal and should selves are strength of the BIQ is that it assesses both discrepancy
referred to as self-guides. It is assumed that a dis- and degree of importance attached to the discrepancy.
crepancy between the actual self and the self-guides Further data on cognitive processes and appearance
determine the individual’s vulnerability to negative comparison in BDD were provided by a study explor-
emotional states ( Higgins, 1987 ). For example, in a ing attention to emotional faces. Anson, Veale, and
self-actual: self-ideal discrepancy, the individual is De Silva (2003) compared 25 BDD patients with 17
vulnerable to dejection-related emotions (e.g. depres- normal controls with a modified dot probe paradigm
sion, internal shame), resulting from the appraisal originally used by Mansell, Clark, Ehlers, and Chen
that his or her hopes and aspirations are unfulfilled (1999) and Mansell, Clark, and Ehlers (2003) .Inthe
with the absence of positive reinforcement. In a study by Mansell et al. (1999) , high and low socially
self-actual: other-should discrepancy, the individual anxious individuals (without BDD) were brie y pre-
is vulnerable to anxiety resulting from the appraisal sented with pictures containing a face paired with a
 D. Veale / Body Image 1 (2004) 113–125 119

household object. The faces were negative, neutral or cial evaluative concerns and believe they would have
happy. Each face–object pair was followed by one of no symptoms of BDD in the hypothetical situation of
two letters in a location corresponding to the centre being left alone on a desert island. This re ects the
of one of the pictures, and participants had to indi- heterogeneity and complexity of BDD and the impor-
cate as quickly as possible which letter they saw. The tance of an individual formulation in treatment plan-
assumption is of a faster reaction time to letters that ning. The importance of this part of the model is that
follow the location of the picture (i.e. face or object) appearance comparisons are another factor that main-
to which subject was attending. Mansell et al. (1999) tains distorted negative appraisals and imagery in a
found that high socially anxious individuals showed negative feedback loop. Furthermore, the attention is
an attentional bias away from emotional (negative and often selective and unrepresentative and likely to in-
positive) faces, but only when tested under conditions terfere with processing of other external information.
of anticipatory social threat. One goal of therapy therefore involves resisting the
In the study by Anson et al. (2003) , the anticipa- frequent comparison and rating of one’s appearance
tory threat induction was modified to include a BDD against others.
threat and no threat condition. The threat condition in-
volved an appearance-related social evaluative threat,
in which subjects were told that they would be video Emotion
recorded, and would then observe volunteers watch-
ing the video (although this did not actually happen). Emotions in BDD are complex and will depend
The authors found that attention to faces as a whole upon the exact appraisal of the situation and event. The
was significantly greater in BDD patients compared to emotions include (a) internal shame (or self-disgust)
controls in the absence of threat, with the effect being when the individual compares and ranks his or her
particularly prominent for neutral and positive faces. appearance as lower than others; (b) external shame
Under anticipatory threat, attention to neutral and pos- and anticipatory social anxiety based on judgements
itive faces was suppressed, while attention to negative about how others are likely to scrutinise, humiliate
faces remained unchanged. This effect was in contrast or reject them; (c) depression and hopelessness at
to the results obtained by Mansell et al. in high socially the person’s failure to reach his or her aesthetic stan-
anxious patients. Anson et al. (2003) hypothesised that dard, perhaps living in social isolation, inter-personal
in the absence of threat, BDD patients may have been con icts and deficits in relationships; (d) anger and
comparing themselves to faces, especially neutral and frustration at oneself for damaging his or her appear-
positive images, which they may have rated as more ance (e.g. do it yourself surgery, skin-picking); others
attractive, or relevant in terms of comparison target. not understanding or agreeing with their concerns;
However, appearance comparison is likely to be a po- not having enough money to pay for cosmetic surgery
tentially anxiety-provoking process, which may have or not obtaining satisfaction in cosmetic surgery; (e)
been activated under conditions of threat, leading to guilt at damaging one’s appearance either by oneself
reduction in attention to neutral and positive faces. A or seeking cosmetic surgery. With the prominence of
further possible explanation is that social evaluative hopelessness and shame, it is not therefore surpris-
threat may result in reduced attention to faces belong- ing that there is a high degree of comorbidity with
ing to particular groups of people whom BDD patients depression and risk of suicide ( Phillips et al., 1993 ;
are most concerned about in terms of negative appear- Veale et al., 1996a,b ). As in other areas, there is
ance evaluation. a negative feedback loop as increases in emotional
Clinically a few patients appear to have little or arousal will tend to increase the frequency or severity
no social evaluative concerns and would still be dis- of negative appraisal of one’s body image and in-
tressed and looking in mirror if they were left alone on crease self-focussed attention. Symptoms of arousal
a desert island. Most regard social evaluative concerns are not normally targeted in CBT, but any strategy
as an additional burden and would be less distressed in that improves mood or increased tolerance to negative
a hypothetical situation of being left alone on a desert states would theoretically decrease preoccupation and
island. Some individuals have almost exclusively so- negative appraisal. In this regard, there is evidence
120 D. Veale / Body Image 1 (2004) 113–125

for the modest benefit of selective serotonergic re- (c) camou age a feature;
uptake inhibitor anti-depressants in two randomised (d) distract attention from a feature; or
controlled trials ( Phillips, 2002 ; Phillips, Albertini, & (e) reduce uncertainty or distress about an image.
Rasmussen, 2002 ) although the mechanism of their
action is unknown. Of note is that patients with or Examples of various safety behaviours are provided
without a delusional disorder did equally well with below.
an SSRI and there is no evidence for the benefit of (a) A man who tore up all photos of himself to prevent
anti-psychotic medication alone in BDD. him from thinking about the “wrong” impression
that he was giving.
(b) A man who had had three rhinoplasties but was
Safety behaviours now preoccupied with scarring from the first op-
eration.
BDD is frequently conceptualised as on the spec- (c) A woman who spent time using various beauty
trum of OCD partly because of the similarities in treatments to camou age her face, which she be-
psychopathology (e.g. “compulsive behaviours” such lieved to have numerous lines and scars.
as mirror checking). This is incorporated in the most (d) A woman who shaved of all the hair on her head
widely used outcome measure (Yale Brown Obses- and had a large tattoo to distract attention in public
sive Compulsive Scale modified for BDD ( Phillips away from a “ aw” on her nose. This had the effect
et al., 1997 ). I believe however, it is better to concep- of increasing her self-consciousness and attracting
tualise all the behavioural strategies to reduce the risk negative evaluation of her appearance by others.
of danger in feared situations including escape and (e) A man preoccupied with his nose who stood in
non-repetitive behaviours used by BDD individuals front of a mirror and performed mental cosmetic
as “safety behaviours” ( Salkovskis, 1991, 1996 )or surgery on his nose until he felt “comfortable”.
from an evolutionary psychology perspective as “sub- This is similar to a compulsive washing or check-
missive behaviours” ( Allan & Gilbert, 1997 ; Gilbert, ing in OCD as the person is using problematic
2000b; Harper, 1985 ). It is assumed that such learnt criteria for the termination of a compulsion,
behaviours may have been adaptive in the past in namely, feeling “comfortable” or “absolutely
certain contexts. sure” ( Richards & Salkovskis, 1995 ) or the “right
Traditionally safety behaviours for all anxiety dis- feeling” ( Yaryura-Tobias & Neziroglu, 1997 ).
orders are actions within situations designed to pre-
vent feared catastrophes. The essence of a submissive The importance for the model is that there is
behaviour in a social situation is damage-limiting another negative feedback loop. Safety behaviours
self-presentations ( Gilbert, 2000b ) rather than acquis- may brie y decrease distress or uncertainty but are
itive ones. Safety or submissive behaviours include counter-productive and increase self-consciousness,
(a) avoidance or active escape behaviours when the preoccupation and negative appraisal. Furthermore,
emotion is overwhelming; (b) subtle behaviours such safety behaviours (a) involve enormous mental effort
as camou aging to reduce scrutiny by others; (c) com- and attention which means less capacity for external
pulsive behaviours that are repeated until the person information; (b) often lead to further monitoring (e.g.
feels “comfortable” or “just right”. Safety behaviours mirror checking to determine if the camou age is
are often idiosyncratic and have personal meaning to “working”); (c) may objectively make one’s appear-
the individual. Thus one woman may be using ex- ance worse (for example, skin-picking); (d) increase
cessive make-up to camou age facial skin. Another attention by others to one’s appearance (for example,
woman may be avoiding make-up believing that it a person holding their hand up against their face).
would attract attention towards her. Safety behaviours In clinical practice, an idiosyncratic version of the
in BDD are generally adapted by the individual to: model is drawn up with the patient which focuses on
a specific episode of increased worry about one’s ap-
(a) avoid thinking about a feature; pearance (e.g. a person looking in a mirror in the hope
(b) alter a feature; that he does not look as bad as he thinks he does in his
 D. Veale / Body Image 1 (2004) 113–125 121

image). A behavioural experiment may be constructed fine the various phenotypes such as perfectionism or
to determine the effect of the safety behaviour on the skin-picking, each of which may have an additive ef-
degree of preoccupation, self-consciousness and neg- fect. Such an approach has been especially helpful in
ative appraisal. Suffice to say all safety behaviours are eating disorders research ( Bulik et al., 2003a,b ).
a major maintenance factor in the preoccupation and
distress of BDD and much creativity may be required Temperament
to help patients stop using their safety behaviours.
Similarly, patients will require exposure to situations There is no published evidence on the role of tem-
avoided without their safety behaviours and with max- peramental factors in BDD. Clinical observations sug-
imum attention on tasks (rather than the self). gest that temperament may be an indirect factor for the
development of BDD, namely, shyness, perfectionism
or an anxious temperament, all of which may be partly
Risk factors genetically determined. If temperamental factors are
relevant then they are likely to be non-specific to BDD.
The cognitive behavioural model described is only
relevant for factors that maintain a distorted body im- Childhood adversity
age. As yet, only limited data are available on risk fac-
tors for the development of BDD and the final pathway Childhood adversity such as teasing or bullying
described above. One of the most important challenges (either about appearance or competence), poor peer
for any epidemiological investigation in this area is relationships; social isolation; lack of support in the
distinguishing between risk factors that are specific to family or sexual abuse may all be non-specific factors
BDD and those that predispose to other disorders. Be- in the development of BDD.
cause of the similarity in phenomenology and reported Body shame has been linked to early sexual and
comorbidity ( Phillips, 1996; Veale et al., 1996a ), BDD physical abuse. Andrews (1995, 1997) conducted
is regarded a being on the spectrum of either OCD lengthy interviews that covered attitudes and current
( Hollander, 1993 ; Neziroglu & Yaryura-Tobias, 1993 ) or past life experiences. In a study with younger
or affective disorders ( Phillips, McElroy, Hudson, & women, early abuse was associated with disordered
Pope, 1995 ). Therefore, any study on risk factors needs eating and bulimia. In a study with older women,
to include both non-clinical controls and those with body shame mediated the relationship between early
depression and OCD. The onset of BDD is in adoles- abuse and episodes of chronic or recurrent depres-
cence and therefore particular attention will need to sion. In the absence of bodily shame, the relationship
be given to risk factors preceding the onset. For exam- between early abuse and chronic or recurrent depres-
ple, not all individuals who have experience of being sion was lost. There was no structured interview for
teased about their appearance develop BDD and one the diagnosis of BDD and it is possible that some of
aim of future research is to determine which factors (or the subjects in both studies had BDD.
combination of factors) predict future persistence of There is other preliminary evidence for the role of
extreme self-consciousness so that interventions may childhood abuse in BDD. Neziroglu, Khemlani-Patel,
be devised for those at risk. I will review some of the and Yaryura-Tobias (personal communication) com-
hypothesised risk factors especially during childhood pared 50 OCD and 50 BDD patients. Abuse was
and adolescence. reported by 19 (38%) BDD patients compared to
7 (14%) of OCD patients. This was predominantly
Genetic factors emotional abuse in 14 (28%) BDD and 1 (2%) OCD
patients but also sexual abuse in 11 (22%) BDD and
As in most psychiatric disorders, genes are likely 3 (6%) of OCD and physical abuse in 7 (14%) BDD
to predispose an individual when they interact with and 4 (8%) OCD.
environmental stresses. As yet there are no genetic In the study by Osman et al. (2003 ) 15 (88.33%)
studies in BDD and both twin and adoption studies BDD patients and 2 (13.3%) control participants
are required. In this regard it will be important to de- identified their images to be closely associated to a
122 D. Veale / Body Image 1 (2004) 113–125

particular memory during adolescence. Typical themes uals and places a greater value on the importance of
include being teased and bullied at school for at least appearance in their identity. Secondly, some BDD pa-
a third, e.g. “I was 10 years old and never got on with tients may have greater aesthetic perceptual skills and
this boy in school. I remember one day I asked him this is manifested in their education or training in art
why he didn’t like me and he said it’s because you’re and design. Lastly, individuals with BDD may hold
ugly”. higher aesthetic standards than the rest of the popula-
Sexual abuse was linked in 11% of images. These tion, which is a factor in the appearance comparison
may occur after looking in a mirror either during or described in the model above. The role of aesthetics
after a rape. For example, a patient reported that at in BDD has been discussed in previous papers ( Veale
the age of 15 she felt pretty before a rape. However & Lambrou, 2002 ; Veale et al., 1996b ) and the exper-
during a rape she looked in a mirror and saw her face imental evidence is now required. In brief, we tend
putrefying and decaying and this image from an ob- to value beauty because it may confer other qualities,
server perspective remained with her and became her which have no other physical markers. Evolutionary
view of herself. psychology might argue that because attractiveness is
There is some evidence that repeated childhood ad- important for reproduction and social acceptance, then
versity such as bullying and abuse can be internalised some individuals will idealise the importance of at-
as negative self-criticism. This in turn can lead to tractiveness for reproduction, which then becomes a
changes in brain functioning such as decreased activ- factor in the development of BDD.
ity of the serotonergic system and increases in corti- Harris (1982) has suggested that individuals seeking
sol production ( Gilbert, 2000a ). This may be a link cosmetic surgery are more aesthetically sensitive and
with the modest benefits accorded by SSRIs ( Phillips, that aesthetic sensitivity may have two components—
2002; Phillips et al., 2002 ). one related to perception and the other an emotional
response. For increased aesthetic sensitivity in per-
History of dermatological or other physical stigmata ception, BDD patients may be particularly aware of
subtle differences in facial asymmetry or the size of
Many patients report a past history of dermatolog- secondary sexual facial characteristics or may be bet-
ical disorder (e.g. acne) or other physical stigmata as ter at evaluating harmony in appearance. An objective
an adolescent. Such stigmata may either be minor or measure of aesthetic perception is required to test the
noticeable and may have attracted teasing. However, hypothesis. The problem is that the “gold standard”
the stigmata are usually long since resolved as an adult of aesthetic perception is usually a composite rating
but the imagery of their previous appearance and as- by a group of artists for works of art, or by cosmetic
sociated teasing remains. surgeons for the human form and are therefore too
subjective.
Sexual identity For the emotional component of anestheticality,
there may be greater emotional response to beauty or
In our clinical experience, we have noted that young ugliness in BDD. If this is the case then, it may be
homosexual men are at greater risk perhaps because of related to idealised values about the degree of impor-
an increased social pressure to look attractive within tance that one attaches to attractiveness ( Veale, 2002 ).
the gay community. There may be other communities Wilhelm, Buhlmann, Etcoff, Savage, and Jenike
with similar societal or cultural pressures that lead to (2001) found that BDD patients rated attractive faces
an increased incidence of BDD. as more attractive compared to normal controls and
OCD patients. Interestingly, one might predict that
Aestheticalit BDD patients would be more averse to unattractive
y faces but there was no difference between BDD and
It is proposed that BDD patients may be more aes- OCD patients and healthy controls in their rating of
thetically sensitive (an attribute like being musical, neutral and unattractive faces.
which varies in different individuals). This results in a Another component of aesthetic sensitivity may
greater emotional response to more attractive individ- be indirectly related to BDD individuals’ interests or
 D. Veale / Body Image 1 (2004) 113–125 123

skills in art and design. We hypothesized that BDD in press ) that will expand upon on this model that
patients were more likely than comparative groups of it is hoped will lead to a RCT that compares CBT
psychiatric patients to have had an education or oc- against an attentional control treatment with equal
cupation in art and design ( Veale, Ennis, & Lambrou, credibility.
2002 ). We extracted data on the higher education,
training or occupation from the case notes of 100
consecutive patients with BDD and compared them References
to 100 consecutive patients with a major depressive
episode, 100 consecutive patients with obsessive com- Allan, S., & Gilbert, P. (1995). A social comparison scale:
pulsive disorder (OCD) and 100 consecutive patients Psychometric properties and relationship to psychopathology.
Personality and Individual Differences, , 293–299.
with post-traumatic stress disorder (PTSD). We found 19S., & Gilbert, P. (1997). Submissive behaviour and
Allan,
that 20% of the BDD patients had an education or psychopathology. British Journal of Clinical Psychology, ,
occupation in art or design compared to 4% in the 467–488. 36
depressed group, 3% in the OCD group and 0% in the American Psychiatric Association (1994). Diagnostic and
PTSD group. This was highly statistically significant. statistical manual of mental disorders (4th ed.) Washington,
DC: APA.
The differences between the BDD group and the three
Andrews, B. (1995). Bodily shame as a mediator between abusive
comparative groups are relatively large and the rate in experiences and depression. Journal of Abnormal Psychology,
the three comparative groups is similar. It suggests that 104 , 277–285.
the association between an occupation or education Andrews, B. (1997). Bodily shame in relation to abuse in childhood
in art and design and BDD was relatively robust and and bulimia. British Journal of Clinical Psychology, , 41–
50. 36
deserves further investigation in a prospective study.
Anson, M., Veale, D., & De Silva, P. (2003). Social evaluative
We do not have any evidence for a causal relation- concerns and processes in body dysmorphic disorder. In
ship between BDD and an occupation or education in Proceedings of the Paper Presented at Conference
art and design. The onset of BDD is usually gradual Innovation
in Cognitive Behaviour Therapy for BDD , London, UK.
during adolescence and an interest in art and design Arntz, A., & Weertman, A. (1999). Treatment of childhood
memories: Theory and Behaviour Research Therapy,
may be a contributory factor to the development of practice.
37 , 715–740.
the disorder in some patients. Patients might develop Beck, A. T. (1976). Meaning and emotions. In A. T. Beck (Ed.),
a more critical eye and appreciation of aesthetics, Cognitive therapy and the emotional disorders (pp. 47–75).
which is then applied to their own appearance. London: Penguin.
BDD is greatly under-researched compared to other Bogels, S. M., Mulkens, S., & De Jong, P. J. (1997). Task
concentration training and fear of Clinical
body image disorders such as eating disorders. It is blushing. Psychology
and Psychotherapy, 4 , 251–258.
only now beginning to attract interest. Many of the Bohne, A., Wilhelm, S., Keuthen, N. J., Florin, I., Baer, L., &
suggested risk factors remain very speculative. It is Jenike, M. (2002). Prevalence of body dysmorphic disorder in
worth emphasising that potential risk factors are likely a German college student Psychiatry Research, 109 ,
sample.
101–104.
to be additive and interact with genetic predispositions
Bulik, C. M., Devlin, B., Bacanu, S. A., Thornton, L., Klump, K.
to then lead to the final pathway of maintaining factors
L., & Fichter, M. M. et al., (2003a). Significant linkage on
in the cognitive behavioural model. chromosome 10p in families with bulimia Genetics
nervosa.
72 , 200–207. ,
Evidence for cognitive behaviour therapy Bulik, C. M., Tozzi, F., Anderson, C., Mazzeo, S. E., Aggen,
S., & Sullivan, P. F. (2003b). The relation between eating
disorders and components of perfectionism. American Journal
The efficacy of CBT for BDD has recently been
of Psychiatry, 160 , 366–368.
reviewed ( Neziroglu & Khemlani-Patel, 2002 ). There Cash, T. F., & Szymanski, M. L. (1995). The development and
are only two randomised controlled studies, both validation of the body image ideals Journal of
of which used a waitlist comparison group ( Rosen, questionnaire.
Personality Assessment, 64 , 466–477.
1995; Veale et al., 1996b ). There are also case control Cash, T. F., & Pruzinsky, T. (Eds.) (2002). Body image: A handbook
of theory, research, and clinical . New York: Guilford
studies ( Geremia & Neziroglu, 2001 ) and case series practice
Press.
( Wilhelm, Otto, Lohr, & Deckersbach, 1999 ). A treat- Cash, T. F., Melnyk, & Hrabosky, J. I. (in press). The assessment
ment manual is in preparation ( Veale & Neziroglu, of body image investment: An extensive revision of the
124 D. Veale / Body Image 1 (2004) 113–125

appearance schemas inventory Journal of Ingram, R. E. (1990). Self-focused attention in clinical

international.
Disorders . Eating disorders:
Review and a conceptual Psychological Bulletin, ,
Clark, D. M., & Wells, A. (1995). A cognitive model of social model.
156–176. 107
phobia. In R. G. Heimberg, M. R. Liebowitz, D. Hope, & F. Jerome, L. (1992). Body dysmorphic disorder: A controlled study
R. Schneier (Eds.), Social phobia—diagnosis, assessment, and of patients requesting cosmetic American Journal
treatment (pp. 69–93). New York: Guilford Press. rhinoplasty.
of Psychiatry, 149 , 577–578 [letter].
Cromarty, P., & Marks, I. (1995). Does rational roleplay enhance Layden, M. A., Newman, C. F., Freeman, A., & Morse, S. B.
the outcome of exposure therapy in dysmorphophobia? A case (1993). Cognitive therapy of borderline personality disorder .
study. British Journal of Psychiatry, 167 , 399–402. Needham Heights, MA: Allyn & Bacon.
Dryden, W. (1998). Developing self- . Chichester: Lazarus, A. (1977). Towards an egoless state of being. In A. Ellis,
acceptance Wiley.
Faravelli, C., Salvatori, S., Galassi, F., Aiazzi, L., Drei, C., & & R. Grieger (Eds.), Handbook of rational emotive therapy
Cabras, P. (1997). Epidemiology of somatoform disorders: A (vol. 1, pp. 113–118). New York: Springer.
community survey in Florence. Social & Psychiatri Mansell, W., Clark, D., Ehlers, A., & Chen, Y. (1999). Social
Epidemiology, , 24–29. Psychiatry c
anxiety and attention away from emotional Cogntion
32 L. (1954). A theory of social comparison processes.
Festinger, faces.
and Emotion, 13 , 673–690.
Human Relations, 7 , 117–140. Mansell, W., Clark, D. M., & Ehlers, A. (2003). Internal versus
Geremia, G. M., & Neziroglu, F. (2001). Cognitive therapy in the external attention in social anxiety: An investigation using
treatment of body dysmorphic disorder. Clinical anovel paradigm. Behaviour Research and Therapy, 41 , 555–
and Psychotherapy, 8 , 243–251. Psychology
572.
Gilbert, P. (2000a). Social mentalities—internal “social” con
Neziroglu, F., & Yaryura-Tobias, J. A. (1993). Body dysmorphic
ict and the role of inner warmth and compassion in
disorder: Phenomenology and case descriptions. Behavioura
cognitive
therapy. In P. Gilbert, & K. Bailey (Eds.), Genes on the couch
Psychotherapy, 21 , 27–36. l
(pp. 118–150). London: Hover.
Neziroglu, F., & Khemlani-Patel, S. (2002). A review of cognitive
Gilbert, P. (2000b). Varieties of submissive behaviour. In L.
and behavioral treatment for body dysmorphic disorder. CNS
Sloman, & P. Gilbert (Eds.), Subordination and defeat: An
Spectrums, 7 , 464–471.
evolutionary approach to mood disorders and their therapy
Neziroglu, F., McKay, D., Todaro, J., & Yaryura Tobias, J. A.
(pp. 3–45). Hillsdale, NJ: Lawrence Erlbaum.
(1996). Effects of cognitive behavior therapy on persons with
Gilbert, P., Price, J. S., & Allan, S. (1995). Social comparison,
body dysmorphic disorder and comorbid axis II diagnoses.
social attractiveness and evolution: How might they be
Behavior Therapy, 27 , 67–77.
related?
New Ideas in Psychology, 13 , 149–165.
Neziroglu, F., Khemlani-Patel, S., & Yaryura-Tobias, J. A. (in
Hackmann, A. (1998). Working with images in clinical psychology.
press). Incidence of abuse in body dysmorphic disorder.
In A. S. Bellack, & M. Hersen (Eds.), Comprehensive
clinical Osman, S., Cooper, M., Hackmann, M., & Veale, D. (2003).
psychology (pp. 301–318). Amsterdam: Elsevier.
Imagery in people with body dysmorphic disorder: A study
Hackmann, A., Surawy, C., & Clark, D. M. (1998). Seeing
of its characteristics, and links to early beliefs and
yourself through other’s eyes: A study of spontaneously
memories., in press.
Memory
occurring images in social phobia. Behavioural and
Cognitive Otto, M. W., Wilhelm, S., Cohen, L. S., & Harlow, B. (2001).
Psychotherapy, 26 , 3–12.
Prevalence of body dysmorphic disorder in a community
Harper, R.C. (1985). Power, dominance and nonverbal behaviour:
sample of women. American Journal of Psychiatry, 158 , 2061–
An overview. In S. L. Ellyson, & J. F. Dovidio (Eds.),
2063.
Power, dominance and nonverbal behavior . New York:
Springer-Verlag. Partridge, J. (1990). Changing faces: The challenge of
facial
disfigurement . London: Penguin.
Harris, D. L. (1982). Cosmetic surgery—where does it begin?
British Journal of Plastic Surgery, 35 , 281–286. Phillips, K. A. (1991). Body dysmorphic disorder: The distress
Heinberg, L. J., & Thompson, J. K. (1992). Social comparison: of imagined ugliness. American Journal of Psychiatry, 148 ,
Gender, target importance ratings, and relation to body 1138–1149.
image
disturbance. Journal of Social Behavior and Personality, , Phillips, K. A. (1996). Body dysmorphic disorder: Diagnosis and
335–344. 7 treatment of imagined Journal of Clinical
ugliness.
57 , 61–64. Psychiatry,
Higgins, E. T. (1987). Self-discrepancy: A theory relating self and
affect. Psychological Review, , 319–340. Phillips, K. A. (2000). Quality of life for patients with body
94
Higgins, E. T., Bond, R. N., Klein, R., & Strauman, T. dysmorphic disorder. Journal of Nervous & Mental Disease,
(1986). Self-discrepancies and emotional vulnerability: 188 , 170–175.
How
magnitude, accessibility and type of discrepancy in Phillips, K. A. (2002). Pharmacologic treatment of body
uence
affect. Journal of Personality and Social Psychology, , 5–15. dysmorphic disorder: Review of the evidence and a
Hollander, E.51
(1993). Obsessive–compulsive spectrum disorders: recommended treatment CNS Spectrums, 7 , 453–463.
An overview. Psychiatric Annals, 23 , 355–358. approach.
Phillips, K. A., & Diaz, S. F. (1997). Gender differences in body
Horowitz, M. J. (1970). Image formation and cognition . New York: dysmorphic disorder. Journal of Nervous & Mental Disease,
Appleton Century Crofts. 185 , 570–577.
 D. Veale / Body Image 1 (2004) 113–125 125

Phillips, K. A., McElroy, S. L., Keck Jr., P.E., Pope Jr., H.G., Stopa, L. (2003). Observer perspective in imagery. In Proceedings
& Hudson, J. I. (1993). Body dysmorphic disorder: 30 cases of the Paper Presented at Conference on Innovation
of imagined ugliness. American Journal of Psychiatry, 150 , in
Cognitive Behaviour Therapy for BDD , London, UK.
302–308. Veale, D. (2002). Overvalued ideas: A conceptual analysis.
Phillips, K. A., McElroy, S. L., Hudson, J. I., & Pope Jr., H.G. Behaviour Research and Therapy, 40 , 383–400.
(1995). Body dysmorphic disorder: An obsessive–compulsive Veale, D., & Riley, S. (2001). Mirror, mirror on the wall, who
spectrum disorder, a form of affective spectrum disorder, or is the ugliest of them all? The psychopathology of
both? Journal of Clinical Psychiatry, , 41–51. mirror
gazing in body dysmorphic disorder. Behaviour Research and
56 Hollander, E., Rasmussen, S. A., Aronowitz, B.
Phillips, K. A., Therapy, 39 , 1381–1393.
R., DeCaria, C., & Goodman, W. K. (1997). A severity rating Veale, D. M., & Lambrou, C. (2002). The importance of aesthetics
scale for body dysmorphic disorder: Development, in body dysmorphic disorder. CNS Spectrums, 7 , 429–431.
reliability,
and validity of a modified version of the Yale-Brown Obsessive Veale, D., & Neziroglu, F. (in press). Body dysmorphic disorder—
Compulsive Scale. Psychopharmacology Bulletin, , 17–22. A treatment manual . Chichester:
Phillips, K. A., Dufresne Jr., 33
R.G., Wilkel, C. S., & Vittorio, C. Wiley.K., Dryden, W., Shah, F., &
Veale, D., Boocock, A., Gournay,
C. (2000). Rate of body dysmorphic disorder in dermatology Willson, R. (1996a). Body dysmorphic disorder. A survey of
patients. Journal of the American Academy of Dermatology, fifty cases. British Journal of Psychiatry, 169 , 196–201.
42 , 436–444. Veale, D., Gournay, K., Dryden, W., Boocock, A., Shah, F., &
Phillips, K. A., Albertini, R. S., & Rasmussen, S. A. (2002). Willson, R. (1996b). Body dysmorphic disorder: A cognitive
A randomized placebo-controlled trial of uoxetine in behavioural model and pilot randomised controlled
body
dysmorphic disorder. Archives of General Psychiatry, 59 , 381– trial.
Behaviour Research and Therapy, 34 , 717–729.
388. Veale, D., Ennis, M., & Lambrou, C. (2002). Possible association
Pope Jr., H.G., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, of body dysmorphic disorder with an occupation or education
K. A. (1997). Muscle dysmorphia. An under recognized in art and design. American Journal of Psychiatry, 159 , 1788–
form of body dysmorphic disorder. Psychosomatics, 38 , 548– 1790.
557. Veale, D., Kinderman, P., Riley, S., & Lambrou, C. (2003).
Richards, C. H., & Salkovskis, P. M. (1995). The cognitive Self-discrepancy and body dysmorphic disorder. British
phenomenology of OCD repeated rituals. In Proceedings of Journal of Clinical Psychology, , 157–169.
World Congress of Behavioural and Cognitive Therapies , 42
Warwick, H., & Salkovskis, P. M. (1990). Hypochondriasis.
Copenhagen. Behaviour Research and Therapy, 28 , 105–117.
Rosen, J. C. (1995). The nature of body dysmorphic disorder and Wells, A. (1990). Panic disorder in association with relaxation-
treatment of with cognitive behaviour Cognitive induced anxiety: An attentional training approach to
therapy.
Behavioral Practice, , 143–166. and treatment. Therapy, 21
Behaviour , 273–280.
2
Salkovskis, P. M. (1991). The importance of behaviour in the Wells, A. (2000). Emotional disorders and metacognition:
maintenance of anxiety and Behavioural Innovative cognitive . Chichester:
panic.
19 , 6–19. Psychotherapy, therapy
Wilhelm, Wiley.
S., Otto, M. W., Lohr, B., & Deckersbach, T. (1999).
Salkovskis, P. M. (1996). The cognitive approach to anxiety: Threat Cognitive behavior group therapy for body dysmorphic
beliefs, safety-seeking behaviours and the special case of disorder: A case series. Behaviour Research and Therapy, 37 ,
health
anxiety and obsessions. In P. M. Salkovskis (Ed.), Frontiers of 71–75.
cognitive (pp. 48–74). New York: Guilford Press. Wilhelm, S., Buhlmann, U., Etcoff, N., Savage, C. R., & Jenike,
therapy
Salkovskis, P. M. (1999). Understanding and treating obsessive M. (2001). Ratings of facial attractiveness in body dysmorphic
compulsive disorder. Behaviour Research and Therapy, 37 , disorder. In Proceedings of the Association of Advancement
S29–S52. in (AABT)
Behavior Therapy .
Sarwer, D. B., Wadden, T. A., Pertschuk, M. J., & Whitaker, L. Woodruff-Borden, J., Brothers, A. J., & Lister, S. C. (2001). Self-
A. (1998). Body image dissatisfaction and body dysmorphic focused attention: Commonalities across
disorder in 100 cosmetic surgery patients. Plasti & Recons- psychopathologies
and predictors. Behavioural and Cognitive Psychotherapy, ,
tructive Surgery, 101 , 1644–1649. c 169–178. 29
Smucker, M. R., & Niederee, J. (1995). Treating incest related Yaryura-Tobias, J. A., & Neziroglu, F. (1997). Obsessive–com-
PTSD and pathogenic schemas through imaginal exposure and pulsive disorder spectrum: Pathogenesis, diagnosis and treat-
rescripting. Cognitive and Behavioural Practice, , 63–92. ment . Washington, DC: American Psychiatric Press.
2