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.
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 and Yaryura-Tobias, 1993, Phillips et al., 1993 and Veale 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 conceptualized 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 scrutinizing others (which could also be conceptualized 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 et al., 2012, Perugi et al., 1997, Phillips et al., 2006 and Phillips and 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 conceptualize as compulsions.
