Veale (2004) · Body dysmorphic disorder
Veale (2004)
Trigger
A trigger that brings appearance to mind — catching sight of yourself in a mirror or reflection, a photo, a comment, or entering a situation where you feel looked at.
Negative Image & Beliefs
A distorted mental image of the feature, viewed from an observer's perspective, with attention zooming in on the perceived defect. Processed against exacting internalised standards about appearance and its importance — 'my nose is huge and deformed', 'if I look flawed I'm worthless and will be rejected'.
Distress
Painful emotions — shame, disgust, anxiety and low mood — driven by the appraisal of the feature and what it is taken to mean about the self.
Rumination / Checking
Self-focused attention, rumination and checking — mirror gazing, comparing the feature with other people's, mentally going over it, and seeking reassurance. Checking and comparing amplify the distortion and keep the feature salient.
Avoidance / Concealment
Safety behaviours, concealment and avoidance — camouflage with make-up, hair, clothing or posture, grooming rituals, skin picking, pursuit of cosmetic procedures, and avoiding mirrors, photos or social situations. These prevent disconfirmation and maintain preoccupation and distress.
The published model, shown for reference. Switch to “Blank” to see the empty template you complete with a client.
Most of us have parts of our appearance we'd change, but in body dysmorphic disorder (BDD) a perceived flaw takes over — it feels glaringly obvious and deeply distressing, even when others can't see a problem. This model shows how BDD keeps itself going.
A trigger — often a mirror, a photo, or a comment — brings appearance to mind. Up comes a distorted internal picture of the feature, seen as if through someone else's eyes, with attention zooming in on the part that feels wrong. Held up against very high standards for how you 'should' look, it seems ugly or abnormal.
That brings painful feelings — shame, disgust, anxiety, low mood — and a strong pull to do something about it.
So people check mirrors, compare themselves with others, go over the flaw in their mind, and try to hide or fix it with make-up, grooming, clothing or procedures, while avoiding situations where they feel exposed. These responses ease the distress briefly but keep attention locked on the feature, strengthen the distorted image, and stop you finding out that others aren't reacting as you fear — so the preoccupation continues.
How to introduce the model, guided-discovery questions, treatment targets and a behavioural experiment are available to signed-in therapists.
This diagram is a reconstruction of the published model for clinical and educational use, grounded in the sources above.
Formulate provides educational CBT resources for use with a qualified therapist. They are not a substitute for professional assessment, diagnosis, or crisis care.
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