Author's Accepted Manuscript

Body Dysmorphic Disorder: The functional

and evolutionary context in phenomenology
and a compassionate mind
D. Veale, P. Gilbert

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PII: S2211-3649(13)00084-5
DOI: http://dx.doi.org/10.1016/j.jocrd.2013.11.005
Reference: JOCRD122

To appear in: Journal of Obsessive-Compulsive and Related Disorders

Cite this article as: D. Veale, P. Gilbert, Body Dysmorphic Disorder: The
functional and evolutionary context in phenomenology and a compassionate
mind, Journal of Obsessive-Compulsive and Related Disorders, http://dx.doi.org/
10.1016/j.jocrd.2013.11.005

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 Body Dysmorphic Disorder: the functional and evolutionary context in

phenomenology and a compassionate mind

Veale, D.a,b Gilbert, P. c

a
The Institute of Psychiatry, King's College London SE5, United Kingdom
b
South London and Maudsley NHS Foundation Trust, London SE5, United Kingdom
c
Mental Health Research Unit, Kingsway Hospital Derby, DE22, United Kingdom

Address for correspondence: David Veale, Centre for Anxiety Disorders and Trauma,

The Maudsley Hospital, 99 Denmark Hill, London, SE5 8AZ. UK. Tel: +44 203 228

4146 Fax: +44203 228 5215 Email: [email protected]

Abstract

The descriptive phenomenology of Body Dysmorphic Disorder (BDD) is well

known in terms of the content of the beliefs, the attentional biases and the nature of

the repetitive behaviors. Less has been written about the function of BDD symptoms

in relationship to a perceived threat of a distorted body image and past aversive

experiences. This article therefore explores the functional and evolutionary contexts

of the phenomenology of BDD as part of threat based safety strategies. The

attentional bias and checking are discussed in terms of threat detection and

monitoring. Behaviors such as comparing self with others and camouflaging

appearances have the function of monitoring and avoiding social threats such as social

contempt, shame, rejection and ridicule from others. These fears may be rooted in

early aversive emotional memoires. People with BDD may find it difficult to engage

in therapy if they do not have a good understanding of the context and function of

their behaviors and if the memories of past aversive experiences (e.g., of rejections

and shame) have not been emotionally processed. In addressing these social threats

we discuss how the mammalian attachment and affiliation based emotions need to be
recruited as part of the therapeutic process. These affiliative processing systems

underpin a compassionate orientation to working with people with BDD and their

capacity for engaging in the change process.

Keywords: body dysmorphic disorder; functional analysis; compassionate mind;

attachment;

Introduction

Much is now known about the descriptive phenomenology of Body

Dysmorphic Disorder (BDD). The preoccupation and distress in BDD are most

commonly around the face (especially the nose, facial skin, hair, eyes, eyelids, mouth,

lips, jaw, and chin) (Neziroglu & Yaryura-Tobias, 1993; Phillips, McElroy, Keck,

Pope, & Hudson, 1993; Veale, Boocock, et al., 1996). However, any part of the body

may be involved and the preoccupation is frequently focused on several body parts.

Sometimes the complaints are non-specific as in feeling ugly or “not right”.

BDD is now grouped in DSM-5 in the section for Obsessive-Compulsive and

related disorders, partly on the similarity in the phenomenology of obsessions and

compulsions to BDD, and the comorbidity and family history of Obsessive-

Compulsive Disorder (OCD). However, Storch, Abramowitz, & Goodman (2008)

highlight how the phenomenology of OCD does not fit neatly into the two categories

of obsessions and compulsions. Factor analysis of the Yale Brown Obsessive-

Compulsive Scale (YBOCS) in OCD reveals just one factor score, in which the

resistance and control items do not meaningfully contribute to the total severity

(Deacon & Abramowitz, 2005). Storch et al. (2008) further argue that repetitive and

compulsive behavior, per se, is not the defining feature of OCD. Rather, repetition is

simply one of the several means by which people with OCD respond to a threat and
that the term “compulsivity” has become a way of describing a whole range of

behaviors. We shall consider how this observation is just as relevant for BDD in

which behaviors are also conceptualised as “compulsions” in the BDD-YBOCS

(Phillips et al., 1997).

DSM-5 has added “repetitive behaviors” as a characteristic feature of BDD at

some point during the disorder. The emphasis in DSM-5 is on the form rather than a

functional understanding of the phenomenology. The term “behavior” in BDD is,

however, interpreted broadly in DSM-5 in terms of how a person responds to a

perceived defect(s). It includes cognitive processes such as comparing and

scrutinising others (which could also be conceptualised as part of the preoccupation in

BDD). In the same manner, ruminating about a perceived defect could be part of the

preoccupation and part of the response. Thus like OCD the phenomenology of BDD is

unlikely to fit into two distinct categories of obsessions and repetitive behaviors.

Overt “repetitive behaviors” in BDD include: checking in mirrors or reflective

surfaces (or checking directly without a mirror); taking photos of oneself; touching

the body part or contour of one’s skin; seeking reassurance or questioning others

about their appearance; changing and re-arranging clothes; excessive exercise or

weight-lifting; excessive make-up, tanning or grooming; seeking of cosmetic and

dermatological procedures; altering position of the body or using clothing such as hats

to camouflage; or skin-picking (Lambrou, Veale, & Wilson, 2012; Perugi et al., 1997;

Phillips et al., 2006; Phillips & Diaz, 1997). An integral feature of BDD is avoidance

of social or public situations or intimacy, or avoidance of specific cues that trigger

appearance-related anxiety (for example photos or video taken by someone else,

looking in certain mirrors or being in certain lighting). Some of the behaviors

described above, such as repeated seeking of reassurance, may be more “compulsive-

like” in that they are largely involuntary: a person feels driven to perform them, they

are repetitive (one act immediately after another) and are seldom resisted. In addition

an individual with BDD may have a criterion to terminate a compulsion such as

mirror gazing by wanting to feel “comfortable” or “just right” (Baldock, Anson &

Veale, 2012). Other behaviors such as obtaining a cosmetic procedure or altering

body position to camouflage a feature are difficult to conceptualise as compulsions.

Functional relationships in BDD

This article goes beyond the descriptive phenomenology of BDD (that focuses

on the content of the beliefs about being ugly and descriptions of the behavior as

compulsions in response to an obsession) and focuses on a functional and contextual

understanding of BDD. Partly because individuals with BDD are very sensitive to

shame, it is important to be cautious about language that implies some kind of

deficit/error within the self, and therefore to avoid the language of thinking

errors/distortions, dysfunctional/maladaptive beliefs, or brain defects. Instead we will

use language (e.g., “better safe than sorry”) that recognizes threat and negativity

biases as normal to human processing systems (Baumeister, Bratslavsky, Finkenauer,

& Vohs, 2001). Moreover, threat focused styles of attending and thinking canbe very

functional and understandable, and can track evolutionarily important concerns

(Tobena, Marks, & Dar, 1999). We agree too that like OCD, not all behavior in BDD

has to be conceptualised as a compulsion just because it is repetitive (Storch et al,

2008).

We want first to focus on the principle that the ways of responding in BDD are

highly understandable given the way that humans like many other animals have

evolved to respond to threat rapidly in order to protect themselves and that this

rapidity often works on a ‘better safe than sorry’ principle (Gilbert, 1998a; Marks,
1987). Thus we will argue that it is important at an assessment not just to make a

diagnosis of BDD and go through a detailed checklist of behaviors, but also (a) to

make a developmental formulation as a means of engagement and begin to understand

how past experiences shape a person’s view of their own appearance as a threat, and

(b) to provide a functional and evolutionary context by normalising how the ways of

responding are very understandable in terms of trying to keep the person safe.

Rapid, physiological threat response (the flush of anxiety) helps to deal with

actual threat but is unhelpful in the absence of any concrete external threat. Moreover,

threat sensitivity is easily developed from previous learning and conditioning.

Emotionally conditioned memories of threat can fuel rumination and in BDD is

focused on •Šƒ‡(Kim, Thibodeau, & Jorgensen, 2011) and in particular body

shame (Veale, 2002). Ways of responding in BDD echo those of other anxiety

disorders: when under threat it makes sense to think in black and white terms or give

selective attention to a threat - this is how the threat system is setup (LeDoux, 1998).

The response is similar to that in other body image disorders where there is marked

shame and self-criticism.

Central to our argument is the importance of understanding both threat

processing itself (LeDoux, 1998) and the regulators of threat processing, particularly

the way mammalian social behavior has come to regulate threat; for example, the

presence of a parent can calm a distressed child or encourage a youngster to engage

with things that scare him or her (Mikulincer & Shaver, 2007). Feeling supported by

others can stimulate courage (Gilbert, 2009). Recent research into the functional

analysis of emotions and emotional regulation suggest that distinct emotion regulation

systems underlie feelings of threat and safeness (Depue & Morrone-Strupinsky, 2005;

Gilbert, 2009). Three types of emotion regulation system have evolved, each with a
different function and triggered in different contexts. These three systems interact and

are depicted in Figure 1 below.

-------------------------FIGURE 1 ABOUT HERE ----------------------------

(1) Threat and self-protection-focused system. This system is focused on

the detection of threat, attention processing, and response to threats. Threat-based

emotions include anxiety, disgust, shame, anger and hatred and are associated with a

range of behaviors such as fight, flight, freeze and the motivation for specific safety-

seeking behaviors that aim to prevent harm coming to an individual (for example,

escaping from a predator, averting the gaze from a dominant-other as social threat).

The threat system enables individuals to detect and monitor a possible threat with

increased sensitivity (“hyper-vigilance”); narrowing of one’s attention (“selective

attention”); rapid decision-making when a potential threat is detected (“black and

white thinking”) or using emotion to act fast (“emotional reasoning”). Therefore

individuals may respond to threats not (only) because of dysfunctional beliefs or

“thinking errors” but from the use of evolved mechanisms and heuristics (Baumeister

et al., 2001; Gilbert 1998a)

The threat system typically evolved for rapid response using the “better safe

than sorry” heuristics. Slow responders would be at risk of dangerous delay in

defensive manoeuvres. For example, an animal grazing calmly may be easily alarmed

by audible, visual or somatic cues indicative of a predator nearby, and will take flight.

Subordinate animals are highly vigilant to potential threats from dominants (Gilbert &

Bailey, 2000). Threat-response can often be made on the basis of a ‘false alarm’ – the

animal runs away, but in reality no threat was imminent. If you watch birds feeding
on a lawn, you will see how rapidly they give up food in favour of escape. But false

alarms are not a serious problem: missing a positive just means delayed gratification,

but missing a threat or danger could spell serious injury or fatality. So threat systems

are designed to allow many ‘false alarms’ such that rapid access to emotion and

‘anticipate the worst’ thinking rather than logical reasoning are common in humans.

Such sensitivity, however, is problematic for humans who often ruminate or criticise

themselves and amplify what are essentially false alarms when they have emotional

memories of a threat. In addition, threat activation tends to suppress positive

emotion; it is important to lose interest in feeding or any other positive activity when

confronted by threat.

The main defensive behaviors to threat involve fight, flight/escape, avoidance,

freezing and in social contexts, submissive behavior. Threats can include physical

harm but more often nowadays involves social threats such as potential rejection,

humiliation or social isolation (Barkow, 1989). Safety-seeking and repetitive

behaviors are observed across all anxiety disorders and take many different forms

(and not just obsessive compulsive and related disorders). Even when threats are no

longer in the sensory field, animals and humans can still ‘scan and check’ for them –

which in humans involves ‘monitoring’. For example, monitoring and checking heart

rate for someone with panic disorder has the function of monitoring physical threat;

being hyper-vigilant for cues and checking for danger in Post-Traumatic Stress

Disorder (PTSD) are designed to monitor whether something traumatic is about to

happen again as the cues for threat have lost their context. The threat-system therefore

involves an attentional system that locks onto and monitors a potential threat by a

narrowing of attention (Baumesiter, et al., 2001). In BDD this is self-focused

attention.
 Behaviors such as checking in OCD have the function to detect a potential

threat (“Is it safe to proceed?”) or to monitor a possible threat that has already been

detected (“Is the threat as severe as I think it could be?”). Szechtman and Woody

(2004) refer to this as the “security motivational system” and propose that the

termination of the behavior is induced by an internally generated “feeling of

knowing” and that this would normally signal task completion. However in OCD,

they suggest that problem is repetition of security-related behavior in an attempt to

overcome a dysfunctional feedback mechanism and to eventually dampen the driving

motivation. Boyer and Liénard (2006) developed the idea further in a model of a

Precaution System geared to the detection of and reaction to inferred threats to fitness.

This system does not supply negative feedback to the appraisal of potential threats,

resulting in doubts about the proper performance of precautions, and repetition of

action. Normally automatized actions are submitted to cognitive control. This

“swamps” working memory, an effect of which is temporary relief from intrusions

coupled with their long-term reinforcement.

Within the threat system, once a significant threat is detected, it then activates

the Fear Module or system that motivates the individual to escape from the situation

with “flight”, submission or “fight”. In OCD, there are magical ways for the person to

avoid threat by “undoing” it (for example by compulsive washing, “wiping it clean”

or some types of mental neutralizing). We will describe below how the threat system

for fear is activated in BDD and the typical responses.

Note that the threat system also includes the emotions of anger and disgust. An

increased sensitivity to disgust has been identified in BDD (Neziroglu, Hickey, &

McKay, 2010) and self-disgust is part of the subjective experience of shame (Lewis,

1971). Hatred or loathing may be focused on the self especially in more severe cases
of BDD. Self-hatred is conceptualised as a combination of disgust and anger directed

against the self. It motivates a desire to get rid of or to destroy and may be a factor in

a desire for skin-picking, cosmetic procedures and suicide. Alternatively, the hatred

may be directed against others (for example, towards a cosmetic surgeon whose

handiwork has not changed the body part in a way that achieves the desired effect or

has ‘made the feature worse’).

A factor that may be crucial to the acquisition of threat sensitivity and threat

response is an innate disposition often needs to be coupled with a social process and

this may be important for BDD. For example ™‹Ž†‘‡›••‡‡–‘Šƒ˜‡ƒ‹ƒ–‡

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–‘–”‹‰‰‡”‹‰–Š‹•ˆ‡ƒ”Ǥ ƒ‘™ Žƒ••‹ •‡”‹‡•‘ˆ•–—†‹‡•ǡCook & Mineka (1989)

ˆ‘—†–Šƒ–Žƒ„‘”ƒ–‘”›‘‡›•ȋ™Š‘Šƒ˜‡‡˜‡”•‡‡ƒ•ƒ‡Ȍ•‡‡‡†–‘Žƒ –Š‹•

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•ƒ‡•ǡ–Š‡ƒÃ˜‡‘‡›•“—‹ Ž›†‡˜‡Ž‘’‡†ƒˆ‡ƒ”‘ˆ•ƒ‡•‹ Ž—†‹‰–‘›•ƒ‡•Ǥ

ƒ– Š‹‰‘–Š‡”‘‡›••Š‘™ˆ‡ƒ””‡•’‘•‡•–‘ˆŽ‘™‡”•†‹†‘–‹ ‘–”ƒ•– ”‡ƒ–‡

ƒˆ‡ƒ”‘ˆˆŽ‘™‡”•Ǥ˜‡–Š‘—‰Š–Š‡ƒÃ˜‡‘‡›•Šƒ†‘––Š‡•‡Ž˜‡•‡š’‡”‹‡ ‡†

ƒ›–Š‹‰„ƒ†Šƒ’’‡‹‰ˆ”‘ƒ•ƒ‡–Š‡›Šƒ†Ž‡ƒ”‡†ǡ„›•‘ ‹ƒŽ”‡ˆ‡”‡ ‹‰

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‹• ‘’Ž‡–‡Ž›ƒ—–‘ƒ–‹ ƒ††‘‡•‘– ‘‡ˆ”‘ ƒ”‡ˆ—Ž ‘‰‹–‹˜‡’”‘ ‡••‡•‘”

”‡ˆŽ‡ –‹‘ȋ•‡‡ƒŽ•‘ ƒŽŽ›ͳͻͺ͹ˆ‘”ƒ”‡˜‹‡™ȌǤ

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ƒ†”‡Œ‡ –‹‘‹‘–Š‡”•Ǥ ‘™‡˜‡”ǡ‹–‹•’‘••‹„Ž‡–Šƒ––Š‡•‡–Š”‡ƒ–†‡–‡ –‹‘•›•–‡•

”‡“—‹”‡•‘ ‹ƒŽŽ‡ƒ”‹‰–‘–”‹‰‰‡”–Š‡ˆ—ŽŽ›Ǥ•ˆ‘”–Š‡‡šƒ’Ž‡‘ˆ•ƒ‡ƒ “—‹”‡†

’Š‘„‹ƒ•ǡ™‡•—‰‰‡•––Šƒ–‹‹†‹˜‹†—ƒŽ•ƒ›†”ƒ™‘„‘–Š†‹”‡ –’‡”•‘ƒŽ

‡š’‡”‹‡ ‡•‘ˆ–Š”‡ƒ––‘„‘†›ƒ’’‡ƒ”ƒ ‡ƒ†ˆ— –‹‘‹‰‹–Š‡ˆ‘”‘ˆ•Šƒ‡

‘˜‡”ƒ’’‡ƒ”ƒ ‡(Buhlmann, Cook, Fama, & Wilhelm, 2007Ȍƒ†Ȁ‘”–Š‡

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‘•‡“—‡–ˆ‡ƒ”ƒ†•ƒˆ‡–›•–”ƒ–‡‰‹‡•Ǥ †‡‡†ǡ–Š‡Žƒ––‡”‘„•‡”˜ƒ–‹‘ƒŽ’”‘ ‡••ƒ›

„‡•—ˆˆ‹ ‹‡––‘•‡•‹–‹œ‡–Š‡‡ Šƒ‹•‹•‘‡’‡‘’Ž‡Ǥ–Š‹•‘”‡”‡•‡ƒ” Š‹•

‡‡†‡†Ǥ

(2) Drive, seeking and acquisition-focused system. This system enables the

individual to pay attention to advantageous resources. An experience of pleasure is

associated with pursuing and securing resource. The drive system leads to positive

emotion only in the case of achievement, so the person’s sense of well-being is

contingent on frequent achievements. The issue here is that the drive system interacts

with the threat system. The drive system influences and regulates the threat system

and vice versa. Thus if the drive system alone is used to regulate threat-based

emotions (for example by distraction with constant stimulation and keeping “busy” or

a constant drive to seek a cosmetic procedure) then the person remains vulnerable and

will eventually re-experience the sense of threat. The drive system can also be abused

with stimulants such as cocaine or behavioral addictions such as gambling.

These are important insights into understanding how the drive system provides

another way of responding to threat. Therapists should beware that an individual with

BDD may use their drive system in the short term to keep themselves “busy” or to

distract themselves and superficially appear to be making progress. Others reinforcing

behaviours in that emanate from the drive system include actual appearance changes
such as building muscle mass or having a cosmetic procedure such as breast

augmentation that may be associated with increased attention.

Activation of the threat system (by whatever means) will tend to suppress

positive emotion. Over time, the threat system may be constantly activated and

overwhelm the drive system -or drives become primarily in the service of safety

strategies and threat avoidance. This will lead to deficits in the drive system and over

time to co-morbid depression, which is extremely common in BDD. The main

psychological therapy that targets the drive system is behavioral activation. The client

focuses on what he is avoiding and on his values in life. In addition drives need to be

focused on genuine positive behavior and rewards/pleasures not the avoidance of

threats. So this requires a good functional analysis of the activity and not just keeping

“busy” or avoiding potential conflict or situations associated with possible rejection

(Dimidjian et al., 2006).

(3) Contentment, soothing and affiliative-focused system. This system is

associated with a distinct positive affect to that associated with the drive system. It is

experienced as peacefulness or well-being, and occurs when individuals are no longer

threat-focused or seeking resources and are satisfied. The soothing system and the

drive system play distinct roles on threat-regulation. Conversely, threat-regulation

through activation of the soothing system can be longer-term and is not contingent on

achievement. One of the major ways mammals and especially humans create a sense

of safeness is through social relationships that activate the parasympathetic system

(Porges, 2007) and can release oxytocin that impacts on the threat system (Heinrichs,

Baumgartner, Kirschbaum & Ehlert, 2003; Kirsch, Esslinger, Chen et al., 2005).

There is growing evidence that feeling socially safe with others in general is a better

predictor of vulnerability than ‘excitement-based’ positive emotion (Gilbert et al.,

2008) and a better predictor than general positive or negative affect and social support

(Kelly, Zuroff, Leybman, & Gilbert, 2012).

Only limited research has been done on the insecure attachment that might

occur in BDD (Coles et al., 2006) or OCD (Doron, Moulding, Kyrios, Nedeljkovic,

& Mikulincer, 2009). There is a significant body of evidence that an anxious or

avoidant attachment system is an important factor in developing rigid or defensive

methods of emotion avoidance or regulation, or in more extreme cases of emotional

disorganization. Furthermore, interventions designed to increase a secure attachment

have beneficial effects on mental health, prosocial behavior, and intergroup relations

(Mikulincer & Shaver, 2007).

Secure attachments from childhood are therefore powerful in developing an

affiliative orientation to self and others effective at regulating the threat system. There

is evidence now that genetic expressions are influenced - for both good and ill - by

our early affectionate relationships (Belsky & Pluess, 2009). The soothing system is

linked to affiliative interactions, social connectedness, and safeness as conferred by

the presence and social support of others. These of course are the exact emotions that

many people with BDD are not able to access or feel. Although there is much overlap

between different types of positive emotion, Depue & Morrone-Strupinsky, (2005Ȍ

”‡˜‹‡™‡†ƒ™‡ƒŽ–Š‘ˆ•–—†‹‡•‹†‹ ƒ–‹‰–Šƒ–social emotions and behaviors linked

to competiveness and achievements are rooted in sympathetic and dopaminergic

systems, whereas calming-affiliative positive affects are linked to the endorphins

(Dunbar, 2010), oxytocin (Carter, 1998; MacDonald & MacDonald, 2010),

serotonergic systems (Insel & Winslow, 1998) and parasympathetic activity (Porges,

1995). We shall discuss below how the contentment, soothing and affiliative-focused
system can be enhanced to assist in the regulation of threat by the use of

compassionate mind approaches.

The Threat System in BDD

There is now general agreement that many fears track evolutionarily important

themes, such as animal, spider and snake phobias are to do with potential injury or

social anxiety is linked to fear of others (McNally 1987). Many animals have

developed specialized attentional mechanisms to track (the threat of encountering)

disease and deformity in others and so avoid them (Oaten, Stevenson, & Case, 2009).

Not surprisingly then, appearance and aesthetics are salient domains of human

monitoring and judgment; attractive people tend to fare better than unattractive ones

(Etcoff, 1999). Moreover, physical appearance is one of the most common dimensions

for shame (Gilbert & Miles, 2002). This threat sensitive attention process, which is a

kind of monitor for aesthetic sensitivity is likely to be involved in BDD is some way

(Deckersbach, Otto, Savage, Baer, & Jenike, 2000; Feusner et al., 2010; Feusner,

Townsend, Bystritsky, & Bookheimer, 2007; Veale, Gournay et al 1996). People with

BDD have frequently been shaped by social experiences that are often characterised

by being shamed, rejected or humiliated (for example poor attachment; emotional

neglect and sexual abuse, being criticised by a caregiver; being bullied or teased by

peers)(Buhlmann, Cook, Fama, & Wilhelm, 2007; Neziroglu, Khemlani-Patel, &

Yaryura-Tobias, 2006). We also know that people can acquire fears by observing the

behaviors of others and certainly physical appearance is something that in Western

society has a high focus of attention (Ectoff, 1999). In addition, appearance may have

been one of the most salient factors that was positively reinforced or regarded as

important and was a focus of attention in childhood (Neziroglu, Khemlani-Patel, &

Veale, 2008). These experiences may over-sensitize people’s ability to monitor their
physical appearance and function to reinforce the value of appearance over

competence (e.g., comments such as ‘You were wonderful on stage and you looked so

good,’’ rather than, “You played the flute so well during the school concert”). Others

may be reinforced as children or adolescents for a particular body part, or for height,

poise, or body shape, elements of which may for example have had a role in early

dating success.

Rachman (1980, 2001) first described the failure to emotionally process events

as an explanatory concept with relevance to anxiety disorders. He defined emotional

processing as: “a process whereby emotional disturbances are absorbed, and decline

to the extent that other experiences and behavior can proceed without disruption”.

Rachman argued that if emotional experiences were incompletely processed then

certain signs of this failure would be manifested such as the return of fear and

obsessions. Furthermore, he suggested that excessive inhibition or prolonged

experiential avoidance of such events would lead to the maintenance of fear. People

with BDD commonly experience a distorted image or “felt impression” of their

appearance usually in the visual modality from an observer perspective but also from

physical sensations (Osman, Cooper, Hackmann, & Veale, 2004). These are

commonly associated with emotional memories that are associated with a current

sense of threat as they have lost their context and have not been emotionally

processed. Osman et al (2004) found that people with BDD were more likely than

controls to experience intrusive appearance related images that were rated as

significantly more negative, vivid and distressing. The images were associated with

early aversive memories (for example being teased or bullied, or being self-conscious

about changes during adolescence.). Imagery and sensory impressions may be

experienced with a time perspective or context rather than being memories from the
past (similar to a model of trauma). When the memories are emotionally processed

and cognitively appraised as related to a past experience, it will be easier to test the

theory that a body image problem is present by the use of behavioral experiments - for

example to test the effect of altering the attentional system so that a client can focus

on the environment as a whole (and not on the self as in self-focused attention nor

comparing against others). Thus as part of the engagement of a person with BDD in

therapy, one might emphasize a developmental understanding of such memories.

Furthermore, the threat system is especially prone to making associations with

emotional memories and it may be possible to assist the processing of such memories

and contextualizing them by imagery re-scripting (Holmes, Arntz, & Smucker, 2007)

or stimulus discrimination, that is identifying the similarities and differences between

an emotional memory being activated compared to a current experience.

Higher order functioning

In addition to our basic mammalian motivational systems (e.g., avoiding harm

in threat, contesting resources, and developing status hierarchies in the drive system),

humans have evolved cognitive competencies such as anticipating and imagining that

allow us to engage in these tasks with more insight, and the ability to be creative and

to plan. Not only could humans imagine, plan, anticipate and think systemically, and

use symbols and language, they also developed the capacity for objective self-

awareness. No other animal can think about itself, its ambitions in life, and its body -

including rating whether it is too fat or thin, or rank its reputation against others in the

group. This capacity to experience oneself as an object opens the doors to negative

evaluation of self and the experience of shame. Thus the experience of a distorted

body image in BDD that defines the self is known as “the self as aesthetic object”

(Veale, Gournay et al, 1996) and is essentially a trigger for the threat system and
experience of shame, because of the way the self is defined through a perception of

ugliness and anticipated rejection or humiliation (Veale, 2002).

Therefore, animals can experience anxiety and even depression but not, one

would assume, BDD because it depends upon viewing the “self” as an object and

defining identity through appearance. These new cognitive competencies are

colloquially referred to as “new brain” and are associated with slow and analytical

processing (Gilbert, 2009). However, the “new brain” also means that individuals

struggle when they trigger their own threat system by their imagination and worries.

The “new brain” is utilised in cognitive therapy, and may be used to question the “old

brain” about its “irrationality” in its “thinking errors”, such as over-estimation of

threat in the old brain, and to motivate the individual to do exposure. “New brain” is

also the part that is self-critical (“labelling”); demanding (“ ‘should’ statements”), and

anticipating the worst possible outcome (“catastrophizing”). All these strategies

further activate the threat system and are clearly unhelpful in the ruminative processes

between old brain and new brain – hence the need to focus on the unintended

consequences of responding to an internal threat and having an alternative

understanding of the problem. However, while the new brain competencies and the

ability to experience ‘self as object’ are central to BDD, the emotional drivers are

very much old brain and linked to issues of loss of status inferiority, and vulnerability

to rejection or even attack.

Monitoring and responding to threat

The ways of responding to threat can be broadly divided into threat-

monitoring and avoidance by the use of safety-seeking or submissive behaviors (see

Table 1). The Table lists some of the possible motivations and unintended

consequences of the behaviors. Classical way of responding to a threat is with

behavioral inhibition and avoidance. Conditioning theories of anxiety treat

compulsions in OCD as active avoidance behavior, maintained by a reduction in

anxiety that follows them (or negative reinforcement). Thus some of the repetitive

behaviors in BDD may function as a form of avoidance but are designed to keep the

individual safe.

(a) Attentional bias in BDD

For threat-monitoring, there is evidence of attentional bias of visual stimuli in

BDD – thus there is a bias for detailed rather than holistic processing of visual stimuli

(Deckersbach et al, 2000; Feusner et al., 2010; Feusner et al, 2007). Individuals with

BDD focus in a mirror on their perceived flaws rather than on the rest of their

appearance or on features that may be regarded as positive (Grocholewski, Kliem, &

Heinrichs, 2012). Furthermore, a person with BDD will be excessively self-focused,

trying to detect and monitor exactly how they look on the basis of their image and

whether their appearance is as bad as they think it is. This attentional bias makes

perfect sense in detecting threat but has the unintended consequence of increasing

awareness of possible defects. In general the more fixed the attentional system on the

self, the more the person will obtain information from their “inner” world of threat

and not their current experience of what they “see” in the mirror; or what others say or

how they act (and be regarded as “delusional”).

Thus self-focused attention on an image, repeatedly touching the skin or

checking in reflective surfaces may all have the function of threat detection and

monitoring. Such ways of responding have the unintended consequence of increasing

the preoccupation and distress of BDD. Thus, in order for people with BDD to

consciously redirect their attention externally, it is important for them to understand

why their mind is self-focused by default and why it can be difficult to refocus their
attention externally because their mind is doing what it is programmed to do for good

evolutionary reasons in terms of detection of threat and trying to keep them safe.

(b) Comparing

Over many millions of years the process of competing for social status and rank

have given rise to a whole range of evolved mechanisms for monitoring of the self in

relation to others by social comparison (Barkow, 1989; Gilbert, Price & Allan, 1995Ȍ.

Humans spend a lot of time monitoring their relative social standing in comparison to

others (Boksem, Kostermans, Milivojevic, & De Cremer, 2012; Gilbert, 1992). In BDD,

comparing a perceived defect is designed to alert others to threat and indicate defensive

actions; this may interact with the drive system. All forms of social communication can

be viewed as forms of displays of qualities of the self. Sexual attractiveness, for

example, is based upon sexual display. In most species those who have poor displays

may fail to reproduce or be wanted as ‘mates’. Humans are highly focused on selection

according to attraction of friends, employees and lovers. Etcoff (1999) called it “the

survival of the prettiest.” One of the significant changes over human evolution has been

the shift from competition by aggression to competition by displays of attraction - with

the desire to be desired. Monitoring one's attractiveness to others has been referred to as

social attention holding potential - that is, our ability to monitor and evaluate the kinds of

attention we can elicit from others and hold (Gilbert, 1997, 2007). Barkow (1989) has

outlined the way social status via attractiveness is highly linked to ‘displays’ and thus

why humans spend so much attention on dress, body make-up and so forth. Tiggemann,

Martins, and Churchett (2008) have highlighted how the displays in men are different to

those of women. Thus heterosexual men are primarily concerned about body weight,

penis size and height compared to women who are more concerned by weight and shape.

However in BDD, the preoccupation is primarily focused on the face and there is
evidence that animals and humans seek symmetry, perhaps because it advertises

biological quality and serves to attract individuals to partners resistant to developmental

disruptions and the absence of infections (Veale, Gournay, et al., 1996). Thus people

with BDD may have greater aesthetic sensitivity (Lambrou, Veale, & Wilson, 2011;

Veale, Ennis, & Lambrou, 2002).

However, while some people are worried about being average and enhancing

their attractiveness, people with BDD are more preoccupied with being ugly and

undesirable and not fitting in. The experience of an ‘unattractive self’ gives rise to the

experience of shame (Gilbert, 1998b; Gilbert, 2007; Veale, 2002) and shame can drive

the ruminations of self-criticism, self-disgust, and even self-hatred (Gilbert, in press).

Comparing the attractiveness and appearance of one's perceived defect and

appearance to others is probably linked into an evolutionary-based monitoring

mechanism, which has become overly self-focused. Observing others in a non-

judgemental manner without ranking is difficult for a person with BDD but may become

easier once he or understands both the function of comparison - to keep a person safe,

for example, the unintended consequences of comparing and the way it may lead to

ruminating and submissive behavior.

(c) Safety seeking behaviors

The basis of threat in BDD is “I see myself as defective. Others reject people

who are defective and diseased – therefore if I create disgust in my mind and the

mind of others, and are seen as undesirable, inferior I will be ridiculed, avoided or

rejected.” Clearly, the emotions associated with being ridiculed avoided or rejected

are intense for BDD whereas other individuals might be more able to tolerate the

potential for rejection. So the challenge is avoidance of creating these affects in the

minds of others and the consequent social outcomes. Individuals with BDD resort to
safety seeking behaviors with a high degree of self-monitoring with specific

submissive and concealing behaviors. The term “safety-seeking behaviors” is widely

used in the anxiety disorder literature and has a functional meaning. It refers to any

action that aims to prevent a catastrophe in a feared situation and reduce harm

(Salkovskis, 1991). Safety seeking behaviors therefore include a broad range of

responses that overlap with the concept of “submissive behaviors”. Safety-seeking

behaviors usually occur in social situations where people with BDD may keep their

head down, alter their posture, employ excessive make up or padding, or use their hair

to camouflage the perceived defect. Such behaviors are often lumped together as

“compulsive” behaviors. However, these behaviors have a function of reducing threat:

attempts to camouflage or prevent others from seeing a defect are designed to prevent

rejection or humiliation. However, such behaviors also carry unintended

consequences. First, this submissive and concealing way of relating is indeed

unattractive to others (Gilbert, 2001). Friendships are built from affiliative signaling,

open faces and postures and taking an interest in each other. With their avoidance

behaviors, people with BDD are doing exactly the opposite. Others may treat them as

somewhat unattractive and reject them precisely because of these behaviors, which in

turn confirms their negative self-image. Moreover, highly submissive individuals

have an understanding that submissive behaviors are unattractive to others, but find it

very difficult to override the anxiety that triggers such behaviors. In addition, people

with BDD may use considerable mental energy in planning how to camouflage or

alter their appearance, and in monitoring whether the behaviour is “working” or how

to respond if it stops working. This will further contribute to the degree of

preoccupation and distress and does not promote affiliative behavior such as taking an

interest in others and express friendly signals.

(d) Ruminating

Ruminating may be a response to a memory of an image in an attempt to

verify exactly how one looks or “problem-solve” the wrong problem of trying to solve

an appearance problems. To understand the function of the rumination, it is important

to identify the motivation. It may be by suppressing emotion of say the sadness that is

associated with feelings of loneliness and rejection and replacing it with a focus on

body attention that causes difficulty because it has many unintended consequences

(Nolen-Hoeksema, 1991Ȍ– for example it increases depression, enhances negative

thinking, impairs problem solving, and erodes social support (Nolen-Hoeksema,

Wisco, & Lyubomirsky, 2008). In BDD, rumination is likely to increase the

preoccupation and distress and avoidant behavior.

(e) Cosmetic procedures

Altering appearance by a cosmetic procedure has some functional similarity to

compulsive washing in which a person is trying to “undo” their feeling of

contamination. Cosmetic procedures or skin picking holds the prospect of feeling

better either by wiping the slate clean or because of a memory of improvement

following a previous procedure. Such behaviors may share the function of compulsive

washing in OCD, in that the motivation is to purify or eradicate the disgust and start

afresh.

Evidence for threat monitoring and avoidance

There is some evidence for the distinction of threat monitoring and avoidance

in a new scale that has been validated in people with BDD, the Appearance Anxiety

Inventory (AAI) (Veale, Eshkevari, Ellison, Costa, & Werner, 2013). A group with

BDD found that the AAI had good internal consistency with Cronbachs ǩ = .86. The

AAI was significantly correlated with the BDD-Yale Brown Obsessive Compulsive
Scale (BDD-YBOCS) (Phillips et al., 1997) with a moderate coefficient between the

AAI and symptoms of BDD (r = 0.55). There was also a significant moderate

correlation with the Patient Health Questionnaire (PHQ-9) (Kroenke & Spitzer, 2002)

of 0.58 and with the Generalised Anxiety Disorder assessment (GAD-7) (Spitzer,

Kroenke, Williams, & Lowe, 2006) (r = 0.55), showing that higher scores on the AAI

are associated with greater symptoms of anxiety and depression. The AAI also shared

a moderate negative correlation (r = -0.54) with the quality of life affected by body

image (BIQLI) (Cash & Fleming, 2002; Hrabosky et al., 2009). Lastly, it is sensitive

to change during treatment. For the purpose of this discussion, it has two factors. One

factor on the AAI is threat monitoring and includes the following four items: the

checking of appearance in an attempt to verify exactly how one looks; excessive self-

focus: the checking of image against that seen in a mirror or reflective surface; and

rumination or questioning of others, perhaps in an attempt to verify exactly how one

looks and to set up problem solving.

There are six items on the avoidance factor of the AAI. These refer to

avoiding cues that might trigger negative evaluation by self or others, trying to

camouflage the self or avoiding any reminders of appearance. Understanding the

function and context of the behavior (including cognitive processes) and the

motivation behind them as one of threat monitoring, avoidance or “undoing” can be

clinically helpful in the discussion with a client. Thus, some behaviors (for example

trying to follow the contour of the skin over one’s nose) may have several functions,

such as (a) threat monitoring to verify whether the contour is as bad as it feels, (b)

trying to alter the contour and rub the bone down. Thus the aim is for a client to

reflect on their behavior, and to carry out their own functional analysis on how their

mind is trying to ‘find a route to safety and the resolution of fear.’ However, these
routes have many unintended consequences particularly if clients follow the theory

that the problem is with the appearance of their nose (as opposed to following the

alternative theory in therapy that they have a body image problem). The key is to

connect the self-monitoring with underlying fears of rejection and aloneness, together,

often, with past experiences and aversive memories. Indeed, there is increasing

interest in how different types of symptomatology, including voice hearing, can

represent unprocessed or overwhelming fears (Gumley, Gillham, Taylor &

Schwannauer, 2013)

The process of comparing a feature on the AAI is partly a complex factor as it

loads on both the factor of avoidance and to a lesser extent that of threat monitoring.

This makes sense as comparing may consist of (a) threat monitoring – here the person

with BDD ranks himself against others, and, having established that he is ranked

lower than another person (b) enacting submissive behavior and social avoidance.

This may also be expressed in meta-cognitive beliefs regarding the motivation behind

the cognitive process and behavior.

All these ways of responding make perfect sense when they are discussed in

terms of trying to keep a person safe. We suggest that the reason why it may be

difficult for a client to engage in therapy is they do not have a good understanding of

the function and evolutionary context in which their behavior occurs; with memories

of past aversive experiences not yet emotionally processed or appropriately appraised,

they persist as a current threat.

Clinical implications

We therefore predict that using new brain and “cognitive restructuring” is

helpful when there is cognitive flexibility and lower levels of threat and arousal.

However one might also reach a stage in therapy with the client saying, “I can see the
logic but I don't feel any better” or “I know (logically) that I am not ugly but I still

feel ugly”. This is a recognised difficulty in CBT for a range of emotional disorders

(Stott, 2007). Cognitive restructuring of the content of beliefs will be less effective

when the sense of threat is marked or is associated with aversive memories that make

the person feel as if the experience is still occurring as in Post-Traumatic Stress

Disorder. Therefore, the desire to avoid and take action to escape from a potential

threat is normal and adaptive. This in turn leads to the “new brain” ruminating in an

effort to solve the “appearance problem” rather than the underlying social fear. This

inevitably leads to further preoccupation, frustration and distress. Equally being self-

critical or catastrophizing is regarded as helpful in self-improvement or preventing

threat and giving it up as dangerous. The problem of cognitive restructuring in BDD

is therefore that it is rarely believable and that clients do not want to give up strategies

that are designed to keep them safe at least until they have a better understanding of

the problem and develop a different perspective of their body image. Furthermore,

just focusing on the irrationality of BDD or the unimportance of appearance could

potentially increase preoccupation similar to questioning the content of an obsession

in OCD and increase the sense of shame flowing from the inability to get over the

problem. Moreover, the inner emotional tone for this rumination is threat-based (e.g,

“Why did you get that surgery done by that surgeon, you stupid idiot?”), not curious

or supportive. It may reduce therapeutic alliance as the therapist is viewed as not

understanding. Equally conducting surveys and collecting data to disprove the content

of the beliefs may be unhelpful.

We believe there is greater benefit to identifying the motivation and

unintended consequences behind processes such as ruminating and self-focused

attention. It is possible to identify processes such as “labelling” or being self-critical

but only if it encourages self-reflection and the ability to distance oneself from such

thoughts. Thus it is important to have a credible alternative understanding of the

problem to be tested out in therapy so that the person can begin to reflect on the

nature of his or her self without a deep sense of shame.

Compassionate Focused Therapy (CFT

CFT began very simply. Gilbert (2000, 2009) noted that many depressed

people could generate ‘alternative’ thoughts but this did not always help them, partly

because of the emotional textures of those thoughts. For example, an individual might

have the thought of “When laying in bed I tend to ruminate which makes me feel

worse. If I get up and do things, even make a cup of tea, I will get myself going and

will feel better.” However, Gilbert (2000) noted the emotional tone was commonly,

“You know, just laying here ruminating makes you feel worse, it's your own stupid

fault, get out of bed you lazy toad and make a cup of tea.” So the first CFT

intervention was simply to practice creating a warm voice, as if talking to a friend,

and really try to feel the impact of that kind voice. It turned out that many depressed

patients struggled to do this or were resistant; or that ‘feelings of kindness’ started a

grief process (Gilbert & Irons, 2005). Over subsequent years, CFT built on other

aspects of compassion such as the capacity for empathy for distress, distress tolerance,

and creation of genuine compassionate motivation to work with distress. Generating

alternative thoughts and most behavioural practices had to meet the compassion test

‘where the intervention (e.g., alternative thoughts) are experienced as helpful, kind,

supportive and validating.’ One of the reasons this may be difficult for some people is

because their affect system, which underpins the experience of kindness and

compassion, is not easily accessible or is associated with trauma memories.

Consequently, many people with BDD may not have access to one of the most
important regulators of threat - affiliate emotion. As we have noted, they are

preoccupied by shame and rejection rather than the ability to create support, kindness

and understanding in themselves and others.

CFT is integrated with traditional approaches to, and recent research on,

compassion. So today compassion is commonly defined as “a sensitivity to the

suffering of the self and others with a deep commitment to try to alleviate and to

prevent it” (Gilbert & Choden, 2013). This simple definition speaks to two very

different psychologies: 1) The ability to engage with suffering and difficulty (which

depends upon motivation, attention, capacities to be emotionally attuned with, but

also to tolerate, distress, and to mentalize and have empathic understanding of the

causes of your suffering in an non-judgemental way) and 2. developing the insights

and wisdom to try to prevent and alleviate suffering (Gilbert, 2009; GilbertƬ

Š‘†‡ǡʹͲͳ͵). The second psychology is action focused. For example, if one wants

to be a doctor then the motivation to attend to suffering, and be able to tolerate and

make sense of it is important but insufficient. One also has to train for some years to

understand the nature of suffering and to develop the skills of healing and

intervention. Central to CFT is recognizing that developing access to affiliative

processing helps in a whole range of compassion therapy tasks such as developing

distress tolerance, empathic insight and the courage to work with memories that are

frightening. Moreover, learning to approach these difficulties with a kind, validating

and empathic inner orientation makes the task a lot easier than it would be with a

hostile, constantly critical or threat focused voice.

One of the key compassion interventions is psycho-education that highlights

the way in which the evolved human brain is often tricky and easily creates loops

around evolutionary fears. The focus here is that “much of what goes on in our minds
is not of our design nor of our choosing and is not our fault” For some people this de-

shaming and de-personalising process can be a very moving experience because self

blame and feelings of there being “something wrong with me” can lie the heart of

these difficulties. Crucially however it is our responsibility to change. So CFT makes

a big distinction between blaming and shaming and the processes by which we

develop the courage to take responsibility for change and then engage the change

processes - all the time keeping an eye on the affiliative experience during the process

of change.

So a key message to someone with BDD is that the way their brain has been

shaped is an evolutionary problem of being human and internal threats, and that BDD

symptoms are designed to keep them safe from perceived social exclusion or

rejection. This offers a different rationale for therapy. One may help the person realize

how old and new brain create loops and how becoming more mindful of those loops

and taking the compassionate but also rational evidence-based stance can help one

breakout of those loops. The focus in this approach is on communicating empathically

that people are not to blame for their BDD and making sure the client has a good

developmental understanding of the problem. This is why one does not use the

language of cognitive distortions, dysfunctional beliefs or maladaptive schemas

because shame-prone clients may process this as “it's my fault because I'm thinking

wrongly.” Thus a therapist might say: “It is very understandable that after you were

teased and bullied as a teenager, you felt different from your peers. You told me that

you felt alone and rejected and that the onset of the “felt impression” of how you look

began at around this time.” From here it is possible to engage in the guided discovery

process, for example, “How might there be an emotional link between the image you

have of your features and some of those difficult early memories”? “Is it possible that
those fears of rejection and that sense of loneliness and emptiness were drivers for this

focus on your appearance? I wonder what would happen if we could help you with the

difficult memories that are still painful to you, and the feelings of rejection, aloneness

and shame that haunt you? ”.

In CFT a person with BDD has responsibility for change, learning how to

empathically understand the roots of the difficulties, tolerate distress and test out an

alternative explanation: that they have a body image problem with memories that need

updating rather than an appearance problem. Compassion allows them to shift

attention to, and begin to tolerate, the deeper underlying fears of unlovability, the

feelings of undesirability and the self as rejectable (e.g, because of creating disgust in

oneself and in the minds of others) and sense of separation/difference and aloneness.

In CFT it is important to work with these feelings of aloneness and separateness

because they are symptomatic of a very dysfunctional affiliative system. These

insights point to the kind of social environment and therapeutic relationship that needs

to be created for a person with BDD who finds feeling safe difficult. It means not just

appealing to the rational “new brain” to do exposure. It harnesses the new brain for a

behavioral experiment to test out an alternative understanding of the problem and to

reduce self-focused attention (which is the source of the threat). This also means

trying to prevent unnecessary activation of the threat system by one’s inner critic and

the use of mindfulness and compassionate imagery practices to try to stimulate the

compassionate pathways and to feel safe.

Compassionate Mind Research

There is increasing interest in, and evidence for, helping people to develop

compassion for themselves and others as a way to significantly alleviate a range of

mental health problems (Germer & Siegel, 2012;Hoffmann, Grossman, & Hinton
2011). Indeed compassion practices have been shown to have a range of physiological

effects on frontal cortex and immune systems, for example (Lutz, Brefczynski-Lewis,

Johnstone, & Davidson, 2008; Klimecki, Leiberg, Lamm, & Singer, 2012; Rein,

Atkinson, & McCraty, 1995). A number of slightly different compassion trainings and

practices for the general population have been shown to be highly effective in

increasing well-being (Neff & Germer, 2012;Jazaieri, Jinpa, McGonigal et al; 2012).

CFT however was designed for clinical populations with high shame and self

criticism. Recent evidence suggests that CFT reduces depression and anxiety in people

presenting to community mental health teams (Judge, Cleghorn, McEwan, & Gilbert,

2012). Laithwaite, O'Hanlon, Collins, Doyle, Abraham, Porter & Gumley, (2009)

found that CFT significantly reduced depression, anxiety, shame, and self-criticism in

patients in high security psychiatric settings. CFT has been found to significantly reduce

anxiety, depression, shame and self-criticism for people with chronic personality

disorders (Gilbert & Procter, 2006; Lucre & Corten, 2012) and eating disorders (Gale,

Gilbert, Read, & Goss, 2012). CFT has been shown to be helpful for people with

psychosis (Mayhew & Gilbert, 2007; Braehler, Gumley, Harper et al., 2013; Braehler

Harper and Gilbert 2013) and can significantly reduce paranoid ideation in a non-

clinical population (Lincoln, Hohenhaus, Hartmann, (2012). Ashworth, Gracey, &

Gilbert (2011) found CFT to be valuable addition to standard therapies for people

with acquired brain injury. Kuyken, et al., (2010) found that increasing self-

compassion was a significant mediator between a mindfulness intervention and

recovery in depression. Schanche, Stiles, McCullough, Svartberg, and Nielsen (2011)

found that self-compassion was an important mediator of reduction in negative

emotions associated with cluster C personality disorders and recommended self-

compassion as a target for therapeutic intervention.

 The evidence base is of course still to be developed, particularly with well-

controlled trials, but there is sufficient data now to recommend integrating

compassion approaches into Cognitive Behaviour Therapy (CBT) for BDD.

Conclusions

We suggest that CBT for BDD can be improved by 1) developing a functional

analysis of the functions and contexts of behavior in BDD, 2) linking the fears that are

focused on the body to more underlying fears associated with rejection, separation,

isolation and loneliness, 3) linking these, where appropriate, to emotional memories

and working with re-scripting, 4) providing an evolutionary context that de-shames

and de-personalises the process of the BDD and highlights how attention mechanisms

can get trapped in particular threat monitoring systems; in addition, providing

information about how disease and deformity monitoring mechanisms can operate and

get locked in, 5) addressing shame and self-criticism directly, 6) ensuring that during

the process of therapy clients have access to, and learn to cultivate, the affiliative

emotion processing system for self-to-self and self-to-other. Without access to the

affiliative emotion systems clients may struggle to be able to counteract the

underlying fears of separation, difference and rejection, and it will be more difficult

for them to develop the courage to engage in some of the exposure work, 7)

developing many of the competencies for compassionate relating in terms of empathic

understanding, mindfulness and distress tolerance, and courageous behavior.

This approach to BDD seeks to root its understanding and practice in what we

currently know about how the brain evolved, the role of specialist attention

monitoring systems, the central dimension of attractiveness to human social relating,

and how the evolution of affiliative emotion is a major regulator of threat. Building

these insights into current therapies may offer new ways for helping people with
BDD.

Acknowledgements

DV would like to acknowledge salary support from the National Institute for

Health Research (NIHR) Biomedical Research Centre for Mental Health at South

London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, King’s

College London. This paper presents independent research funded by the National

Institute for Health Research (NIHR). The views expressed are those of the author and

not necessarily those of the NHS, the NIHR or the Department of Health.

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ƒ„Ž‡ͳExamplesofmotivations,andunintendedconsequencesofsafetyǦseeking
andsubmissivebehaviours

FUNCTION RESPONSE POSSIBLE POSSIBLE
MOTIVATION UNINTENDED
CONSEQUENCE
Threat detection Checking feature in To determine if the Increasing preoccupation,
and monitoring mirror or reflective feature is as bad as it distress and handicap and
surface feels it is or feel more different
To know exactly how Increases uncertainty
one looks

Touching feature with To determine if the Increases awareness of

fingers feature is as bad as it flaws, increases/maintains
feels it is or attention bias toward
To know exactly how bodily sensations. Fuels
one looks magnification of flaw in
self-generated image.
Taking photos of self To determine if the Increases awareness of
for checking, feature is as bad as it flaws, increases/maintains
examining, feels it is or attention bias, feel more
comparing, or To know exactly how different
monitoring change. one looks

Ruminating about past To assess chance of Fuels preoccupation

events e.g. bullying or future humiliation lowers mood. Increases
teasing vigilance in social
situation.
Ruminating reasons To make sense of the Fuels preoccupation and
for my appearance problem lowers mood.
To solve the appearance
problem
Self-focussed attention To prevent one self Increasing preoccupation,
 on felt impression of from becoming distress and handicap and
feature complacent feel more different
Measuring a feature To find ‘objective’ Increases awareness of
measure of severity or flaws, increases/maintains
change in flaw. attention bias toward
bodily sensations. Fuels
magnification of flaw in
self-generated image.
Discuss feature or To gather Increases sense of
seek reassurance about evidence/support to hopelessness and
whether flaw is visible validate undertaking a helplessness if unable to
or has got worse cosmetic procedure. obtain procedure. Feel
more different
Compare feature To measure change in Increasing preoccupation,
against old photos flaw distress and handicap
Increases uncertainty and
feel more separate
Scrutinise against To determine where one Increasing preoccupation,
media pictures or stands in relation to distress and handicap
compare against others others Increases uncertainty.
I meet Increases self-
consciousness and
dissatisfaction and feel
more separate
Avoidance of threat Excessive make up or To reduce threat of Time consuming, cause
sunbeds to camouflage humiliation by hiding conflict in relationships,
perceived defect flaws feel more alone
Comparing feature to To determine where one Increases sense of
others stands in relation to discrepancy between
others current appearance and
‘ideal’, fuelling
dissatisfaction and feel
more separate
Mental planning how To bring relief that Increasing preoccupation
to camouflage feature threat can be reduced
Use objects/ posture/ To reduce threat of Increases self-
clothing/ hair to humiliation by hiding consciousness and
prevent people seeing flaws vigilance, feel more
feature separate
Grooming to To reduce threat of Requires maintenance,
camouflage humiliation by hiding increasing self-
flaws consciousness and
preoccupation
Looking at feature in To prevent self from Increasing preoccupation,
mirror forgetting how one self-consciousness,
looks and being caught distress and handicap
‘off guard’
Looking at photograph To prevent self from Increasing preoccupation,
or video of self forgetting how one self-consciousness,
looks and being caught distress and handicap,
‘off guard’ feeling more separate

Ruminating about the

problem
Avoid situations or To reduce threat of Reduce variety of
activities where humiliation or rejection activities, increased social
feature may be seen isolation
Cosmetic & To reduce threat by Dissatisfaction with
dermatological eliminating flaw result, increased shame if
treatments feels has made things
 worse
Undoing the threat Mental cosmetic To increase of sense of Increases sense of
surgery in front of hope that threat can be discrepancy between
mirror improved current appearance and
‘ideal’

Mental planning for To increase of sense of Increases sense of

cosmetic treatment hope that appearance discrepancy between
can be improved current appearance and
‘ideal’

Skin-picking Reduce chance of Can lead to increased

rejection by removing redness and fear that flaw
blemishes or ‘disgusting will be more noticeable
and feel more separate
Excessive grooming or Aim to reduce self- Time consuming, cause
adjusting hair until consciousness and conflict in relationships,
feels “just right|” improve social reduced engagement in
performance other activities and feel
more separate
Dieting, laxatives, Reduce chance of Fatigue, poor health,
diuretics, diet rejection or humiliation reduced engagement in
restriction, excessive by removing or relationships or activities,
exercise reducing flaw or feel more alone
compensating with
other areas of body
Changing clothing Reduce chance of Time consuming, fuels
rejection or humiliation preoccupation and
by reducing visibility of dissatisfaction
flaw or drawing
observers eye
Discuss feature or To gather Increases sense of
seek reassurance about evidence/support to hopelessness and
whether flaw is visible validate undertaking a helplessness if unable to
or has got worse cosmetic procedure. obtain procedure; feel
more separate

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x ––‡–‹‘ƒŽ„‹ƒ•ƒ† Š‡ ‹‰‹•†‡• ”‹„‡†‹–‡”•‘ˆ–Š”‡ƒ–†‡–‡ –‹‘

x ‘’ƒ”‹‰ƒ† ƒ‘—ˆŽƒ‰‹‰‹•†‡• ”‹„‡†‹–‡”•‘ˆƒ˜‘‹†ƒ ‡‘ˆ–Š”‡ƒ–

x Š‡—•‡‘ˆƒ ‘’ƒ••‹‘ƒ–‡‹†Šƒ•’‘–‡–‹ƒŽˆ‘””‡‰—Žƒ–‹‰–Š‡–Š”‡ƒ–
•›•–‡‹
Figure

Driven, excited, vitality Content, safe, connected

.
Non-wanting/
Incentive/resource- Affiliative-focused
focused
Wanting, pursuing, Safeness-kindness
achieving, consuming
Soothing
Activating Threat-focused

Protection and
safety-seeking

Activating/inhibiting

Anger, anxiety, disgust

Figure 1 Three Types of Affect Regulation System; Gilbert, (2009) reprinted with permission

from Constable & Robinson.