BDD Formulation (Veale)

When to Use

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.

How to Introduce

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.

Adaptations

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.

Clinical Tips

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.