A formulation based on the cognitive-behavioural model of BDD — mapping self-focused processing, distorted self-image, rumination, and safety behaviours.
BDD is maintained by a cycle of self-focused attention on appearance, a distorted mental image of the perceived flaw, rumination about its meaning, and safety behaviours (checking, camouflaging, avoiding). Map each component with your therapist.
Use in the initial assessment and formulation phase of CBT for BDD. Veale's cognitive-behavioural model maps the maintenance cycle including selective attention, distorted mental imagery, rumination, safety behaviours, and avoidance.
Collaboratively build the formulation, starting with a recent triggering situation. Help the client map how internal focus, negative appraisals, and safety behaviours create a vicious cycle that maintains preoccupation with perceived appearance defects.
For clients with delusional-intensity BDD beliefs, do not challenge the belief directly at the formulation stage — focus on mapping the cycle and its functional impact. For those with comorbid eating disorders, clarify which appearance concerns relate to BDD versus eating disorder psychopathology.
If the client is seeking cosmetic surgery imminently, discuss the evidence that cosmetic procedures typically do not resolve BDD symptoms before proceeding with formulation. If there is active suicidal risk (BDD carries high suicide risk), prioritise safety planning.
Pay particular attention to the role of mental imagery — many BDD clients have a distorted felt sense of how they look that differs from their actual appearance. Identify whether the client processes their appearance from an observer perspective (seeing themselves as if from outside) versus a field perspective, as this affects intervention planning.
Suitable for clients working with bdd, body dysmorphic disorder, formulation, veale, cbt, self-image, appearance. 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.
Build a hierarchy of appearance-related situations you avoid, ranked by distress, to guide graded exposure.
Track BDD episodes — triggers, preoccupation with the perceived flaw, rituals, and mood impact.
Compare your mental image of yourself with photographic evidence to test whether the perceived flaw is as visible as you believe.