A preliminary exploration of metacognition in Body Dysmorphic Disorder (BDD) was undertaken. The study investigated how 18 patients with BDD controlled, corrected, regulated, and appraised their thinking, in relation to a mental image of their concerns with appearance. Verbal thoughts related to these concerns were also investigated. A semistructured interview was administered. Patients reported attempts to distract themselves from their (invariably distressing) images, which had few advantages and many disadvantages. Images increased self-consciousness and decreased self confidence. Some patients sought to counter their distress by recalling past positive memories. All patients made negative self-judgments as a result of having these images. They thought that they were unattractive, ugly, inferior, and worthless. Looking in the mirror was a common source of evidence for these judgments, together with reactions from others. Examination of the verbal thoughts produced similar findings. Some tentative implications are discussed.
Keywords: body dysmorphic disorder; metacognition; cognition
Body dysmorphic disorder (BDD) is a severe and extreme body image disorder. Patients have a preoccupation with an imagined defect in their appearance, or, if there is a slight physical abnormality, their concern is excessive (American Psychiatric Association, 1994). Patients are often very incapacitated by the disorder; it can affect most areas of their functioning and make normal, everyday life impossible (Philips, McElroy, Keck, Pope, & Hudson, 1993). Body dysmorphic disorder is difficult to treat, and patients can be very difficult to engage in treatment (Veale et al., 1996).
The most detailed cognitive-behavioral model of BDD has been developed by Veale (Veale, 2004; Veale et al., 1996). A cycle maintaining the disorder begins when an external representation of the person's appearance (e.g., looking in a mirror, looking at an old photograph) activates a distorted mental image. This is associated with selective attention and increased self-focused attention that functions to increase awareness of the image and the deficits perceived in the image. Negative appraisal of the mental image (e.g., I'm inadequate, abnormal, etc.), which often includes comparison with an "ideal" self-image (Veale et al., 1996), leads to rumination, mood changes, and the use of safety behaviors designed to prevent feared catastrophes (e.g., camouflaging the skin with excessive makeup to prevent other people noticing perceived facial flaws). These features also function, in a series of vicious circles, to maintain the distorted mental image (Veale, 2004). Of particular note, Veale (2004) suggests that metacognition may contribute to the maintenance of the vicious circles involved in BDD.
Metacognition refers to " knowledge about your own thoughts and the factors that influence your thinking " ( Encarta World English Dictionary, 1999). It has become an important construct in cognitive theories of anxiety disorders, where it has formed the basis for " metacognitive " theories, for example, of generalized anxiety disorder and obsessive compulsive disorder (OCD) (for a summary, see Wells, 2000). High levels of metacognitive beliefs or strategies have been identified as characteristic of those with OCD-related symptoms (e.g., Wells, 2000). To date, however, metacognition has rarely been investigated in BDD despite the presence of high levels of anxiety, including many OCD symptoms (e.g., rumination, checking until the person feels "just right") and high OCD comorbidity (e.g. Neziroglu, McKay, Todaro, & Yaryura Tobias, 1996).
Wells (2000) has identified three important aspects of metacognition. First, metacogni-tive knowledge is the beliefs and theories that individuals hold about their own cognitions (e.g. "worry is bad/dangerous for me"). Second, metacognitive experiences are appraisals of the meanings of specific cognitive and mental events (e. …