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Build a hierarchy of appearance-related situations you avoid, ranked by distress, to guide graded exposure.
BDD leads to avoidance of situations where the perceived flaw might be noticed. List avoided situations, rate the distress, and plan a graded approach to facing them.
Introduce when the client is ready to begin systematic exposure to avoided situations. Build the hierarchy collaboratively, targeting situations avoided due to appearance concerns (social situations, bright lighting, close proximity, specific activities).
Explain that avoidance maintains BDD by preventing the client from learning that feared consequences don't occur and that distress is tolerable. Build the hierarchy together, rating each situation on a 0-100 distress scale, and plan to work through it gradually.
Include response prevention alongside exposure — the client should drop safety behaviours (camouflaging, checking, reassurance-seeking) during exposure tasks. For clients with agoraphobic avoidance secondary to BDD, start with lower-stakes social situations.
Do not rush the hierarchy or push clients into situations rated above their current tolerance. If exposure consistently fails to produce habituation or learning, reassess the formulation — there may be covert safety behaviours or the exposure may not be targeting the core fear.
BDD exposure hierarchies should target the specific feared consequence (e.g., 'people will stare at my skin') not just the avoided situation. Include both situational exposure (going to public places) and body-focused exposure (wearing clothes that don't camouflage). Monitor both distress and urge to ritualise.
Suitable for clients working with bdd, exposure hierarchy, avoidance, cbt, veale, body image. This tool can be used as a standalone worksheet or as part of a structured homework plan.
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Practise using mirrors differently — shifting from selective, critical zooming to a full, descriptive, non-judgemental observation of your whole body.
Track BDD episodes — triggers, preoccupation with the perceived flaw, rituals, and mood impact.
A formulation based on the cognitive-behavioural model of BDD — mapping self-focused processing, distorted self-image, rumination, and safety behaviours.
Compare your mental image of yourself with photographic evidence to test whether the perceived flaw is as visible as you believe.