Journal of Abnormal Psychology

The Role of Aesthetic Sensitivity in Body Dysmorphic

Disorder
Christina Lambrou, David Veale, and Glenn Wilson
Online First Publication, January 31, 2011. doi: 10.1037/a0022300

CITATION
Lambrou, C., Veale, D., & Wilson, G. (2011, January 31). The Role of Aesthetic Sensitivity in
Body Dysmorphic Disorder. Journal of Abnormal Psychology. Advance online publication. doi:
10.1037/a0022300
Journal of Abnormal Psychology © 2011 American Psychological Association
2011, Vol. ●●, No. ●, 000 – 000 0021-843X/11/$12.00 DOI: 10.1037/a0022300

The Role of Aesthetic Sensitivity in Body Dysmorphic Disorder

Christina Lambrou, David Veale, and Glenn Wilson

King’s College London

Individuals with a higher aesthetic sensitivity may be more vulnerable to developing body dysmor-
phic disorder (BDD). Aesthetic sensitivity has 3 components: (a) perceptual, (b) emotional, and (c)
evaluative. Individuals with BDD (n ⫽ 50) were compared with a control group of individuals with
an education or employment in art and design related fields (n ⫽ 50) and a control group of
individuals without aesthetic training (n ⫽ 50). A facial photograph of each participant was
manipulated to create a 9-image symmetry continuum. Presented with the continuum on a computer,
participants were required to select and rate the image representing their self-actual, self-ideal, idea
of perfect, most physically attractive, most pleasure, and most disgust. Control symmetry continua
examined the specificity of the disturbance. As predicted, BDD participants displayed no distortion
in their perceptual processing but were disturbed in their negative emotional/evaluative processing
of their self-image. A significant discrepancy between their self-actual and self-ideal, resulting from
an absent self-serving bias in their self-actual (a bias exhibited by controls) appears to be the source
of their disturbance. They also overvalued the importance of appearance and self-objectified. These
aesthetic evaluations may predispose individuals to BDD and/or maintain the disorder.

Keywords: body dysmorphic disorder, aesthetic sensitivity, body image, self-serving bias, depression

The wish to be attractive is a normal desire. Many express
dissatisfaction, to some degree, with at least one facet of their
appearance. For those with body dysmorphic disorder (BDD),
however, the concern with an imagined or slight defect in their
appearance is excessive, causing them significant distress and/or
impairment in their social and/or occupational functioning. Etio-
logical understanding of BDD is still in its infancy, and it remains
enigmatic. That individuals with BDD appreciate art and beauty to
a greater degree than comparative psychiatric groups is suggested
by their choice of occupation and/or education (Veale, Ennis, &
Lambrou, 2002), which raises an interesting question about the
definition of BDD as a preoccupation with an imagined defect or
a minor physical anomaly. Perhaps individuals with BDD are more
aesthetically sensitive than the mental health professionals who
diagnose them and who are therefore unable to appreciate art and
beauty to the same degree (Veale & Lambrou, 2002).
Aesthetic Sensitivity Model
Aesthetic sensitivity can be defined as an awareness and appre-
ciation of beauty and harmony. Individuals with BDD may be
more aware of subtle differences in facial asymmetry or the size of
secondary sexual facial characteristics, or they may be better at
evaluating harmony and balance in appearance. This relates to the
concept of aestheticality, a term coined by Harris (1982) to de-
scribe an innate sensitivity to aesthetic perception, an attribute that
varies among individuals; a high aestheticality would augment an
individual’s self-consciousness and distress over any defect in
their appearance, such that they seek cosmetic surgery. Veale et al.
(1996) suggested that being more aesthetically sensitive was a
possible risk factor in the development of BDD. To our knowl-
edge, this is the first study to investigate whether aesthetic sensi-
tivity may play such a role. As well as expanding on the original
theory by Harris (1982) and applying the ideas to BDD, we used
novel techniques to test the hypotheses formulated.
Akin to the perceptual and affective/attitudinal components of
body image, this study proposed that aesthetic sensitivity has three
components: (a) perceptual (the ability to differentiate variations in
aesthetic proportions); (b) emotional (the degree of emotion expe-
rienced when presented with beauty or ugliness); and (c) evalua-
tive (aesthetic standards, values, and identity). The question is
whether those with BDD exhibit a perceptual distortion and/or an
emotional/evaluative disturbance.
Components of Aesthetic Sensitivity

Aesthetic Perceptual Sensitivity

Christina Lambrou, David Veale, and Glenn Wilson, Department of
Psychology, Institute of Psychiatry, King’s College London, London,
United Kingdom.
This study is part of a doctoral dissertation by Christina Lambrou.
Correspondence concerning this article should be addressed to Christina
Lambrou, Department of Psychology, Box PO77, Institute of Psychiatry,
King’s College London, De Crespigny Park, London SE5 8AF, United
Kingdom. E-mail: christina.lambrou@kcl.ac.uk
Aesthetic perceptual sensitivity has two components: (a) per-
ceptual understanding/awareness (i.e., idea of perfect) and (b)
perceptual accuracy (i.e., self-actual). Although research on per-
ceptual understanding/awareness was not available prior to this
study, limited empirical research was available for perceptual
accuracy. Mainstream opinion is that self-perception in those with
BDD is distorted. However, consistent with the hypothesis of this
study, Thomas and Goldberg (1995) found that individuals with

1
2 LAMBROU, VEALE, AND WILSON
BDD were more accurate in assessing their facial proportions than
controls or individuals seeking cosmetic surgery. Note that they
explored accuracy in ability, which is not necessarily the same as
accuracy in perception.
Mirror gazing heightens self-awareness and accuracy (Jerome,
1992) and reduces attractiveness ratings of one’s own face (Mulk-
ens & Jansen, 2009) in those dissatisfied with their appearance.
When viewing their appearance in the mirror (a common compul-
sive behavior in BDD), those with BDD may selectively attend to
specific features. This may explain their accuracy and the main-
tenance of their symptoms (Veale, 2004). Depression is the most
common comorbid disorder in BDD (e.g., Gunstad & Phillips,
2003). The relationship with depression may account for their
perceptual accuracy. The premise of this study, which is based on
the idea of depressive realism (Alloy & Abramson, 1979), was that
mildly to moderately depressed individuals (this would likely
include most individuals with BDD) would be more accurate in
their self-actual perception. In contrast, nondepressed individuals
would display a self-serving bias.
The accurate self-estimations reported by Thomas and Goldberg
(1995) may be tapping the perceptual component of body image,
which may not be distorted in BDD. In contrast, the perceptual
distortion described by some clinicians may be an account of their
response to their internal body image (e.g., Osman, Cooper, Hack-
mann, & Veale, 2004), which involves the emotional/evaluative
component of body image and may be disturbed in BDD.
Aesthetic Emotional Sensitivity
Harris (1982) suggested that a consequence of increased aes-
theticality is that an individual reacts with a greater emotional
response to beauty or ugliness. Individuals with BDD experience
more aversion to their face than controls (Feusner et al., 2010).
When rating their own face or body, the emotional response for
those with BDD may be a mixture of self-disgust (e.g., when
viewing themselves in a mirror), depression at the failure to
achieve an aesthetic standard, and anxiety about the future conse-
quences of being ugly (Veale & Lambrou, 2002).
This study assessed the emotional experience in relation to
pleasure and disgust to reveal the precise nature of the hypothe-
sized emotional disturbance in BDD. Because of their heightened
aestheticality, individuals with BDD may recognize beauty or
ugliness on a perceptual level. However, on an emotional level,
they may exhibit a negative bias, experiencing less pleasure and
more disgust than those without BDD when viewing attractive and
unattractive versions of their own face, respectively.
Aesthetic Evaluations
Individuals with BDD may hold certain dysfunctional aesthetic
evaluations, which interact with aesthetic perceptual and emotional
sensitivity to predispose them to and/or maintain the disorder.
Aesthetic evaluations divide into three broad categories: (a) aes-
thetic standards, (b) aesthetic values, and (c) aesthetic identity.
Aesthetic standards. There are three types of standards:
personal, aesthetic, and attractiveness.
Personal standard (self-ideal and self-discrepancy). Perhaps
individuals with BDD evaluate their appearance negatively be-
cause they are perfectionists (Buhlmann, Etcoff, & Wilhelm,
2008), who have higher beauty standards than the rest of the
population and demand perfection in themselves as an ideal (Veale
& Lambrou, 2002). Relative to controls, those with BDD display
a greater discrepancy between their self-actual and their self-ideal
(Veale, Kinderman, Riley, & Lambrou, 2003). The question that
needs to be addressed is the source of their self-discrepancy. Is it
due to a distorted self-actual, an exaggerated self-ideal, or both?
Aesthetic standard. The discrepancy between an individual’s
idea of perfect and their ideal personal standard represents their
aesthetic standard. Individuals with BDD may display a minimal
discrepancy between their self-ideal and their idea of perfect
because they are demanding perfection in their appearance.
Attractiveness standard. By the nature of their disorder, indi-
viduals with BDD may value attractiveness more than the rest of the
population (e.g., Buhlmann, Teachman, Naumann, Fehlinger, & Rief,
2009). This may partly explain why they are more stringent when
rating their own attractiveness (e.g., Buhlmann et al., 2008).
Aesthetic values. Not everyone who believes they are ugly or
that they have a defect in their appearance develops BDD. Indi-
viduals with BDD may place a greater value on the importance of
appearance in their identity, which would predispose them to
and/or perpetuate the disorder.
Aesthetic identity. Veale (2004) posited that those with BDD
are more likely to judge themselves almost exclusively by their
appearance and view the self as an aesthetic object. This process,
known as self-objectification, leads to an assiduous engagement in
appearance enhancing behaviors, self-consciousness, and body
shame (Fredrickson & Roberts, 1997), which characterize BDD.
Present Study
The aim of the present study was to investigate three proposed
components of aesthetic sensitivity (perceptual, emotional, and
evaluative) to determine whether for those with BDD, their views
of their appearance are due to a perceptual distortion and/or an
emotional/evaluative disturbance. The central premise was that
rather than having a distortion in their perceptual processing,
individuals with BDD would have an enhanced understanding of
aesthetic proportions and an increased accuracy in their self-actual
estimation. The source of their disturbance would be in their
emotional/evaluative processing, which is specific to the self.
Individuals with an interest in art and beauty, such as those with an
education or employment in art and design related fields, might have
developed an enhanced understanding or appreciation of aesthetic
proportions compared with individuals without aesthetic training.
Therefore, art and design controls as well as non-art controls were
used. Conceptualized as the reference group, the selection of art and
design controls was based on the expectation that they would resem-
ble individuals with BDD in their perceptual processing, expressed as
an increased understanding of aesthetic proportions, and that they
would resemble non-art controls in their emotional/evaluative pro-
cessing. Each of the three proposed components of aesthetic sensitiv-
ity has a perceptual and emotional/evaluative element to illustrate the
dichotomy. For instance, in the assessment of aesthetic emotional
sensitivity, participants selected the images that gave them the most
pleasure and the most disgust (perceptual) and reported their pleasure
and disgust ratings (emotional/evaluative).
Two control conditions (other face and building) were included
to test whether the hypothesized emotional/evaluative disturbance
 ROLE OF AESTHETIC SENSITIVITY IN BDD
in those with BDD is specific to their own face. The hypothesized
increased perceptual understanding would generalize to other faces
(facial control condition) and inanimate objects in the general
surroundings, represented by a building (nonfacial control condi-
tion). In the control conditions, individuals with BDD would be
indistinguishable from art and design controls.
Method
Participants
The study sample comprised 150 participants in three groups:
(a) 50 individuals with BDD (test group), (b) 50 art and design
controls (nonclinical control group), and (c) 50 non-art controls
(nonclinical control group). Male and female adults ages 18
through 40 were recruited. This age group was selected because it
is representative of the time when individuals are more commonly
and most affected by BDD. The groups were age and gender
matched.
The inclusion criteria for the BDD group were (a) a primary
diagnosis of BDD based on the Diagnostic and Statistical Manual
of Mental Disorders (4th ed., DSM–IV; American Psychiatric
Association, 1994); (b) a total score of at least 20 on the Yale–
Brown Obsessive–Compulsive Scale modified for BDD (BDD-
YBOCS; Phillips et al., 1997), including a score of at least 2 on
Item 1 (1–3 hr per day of preoccupation with the perceived defect);
and (c) facial concerns as the main preoccupation, because partic-
ipants were rating their faces and facial concerns are the most
common concerns in BDD. Most participants (88%) had multiple
concerns, with facial concerns being the main for each BDD
participant. Concerns with skin (70%), whole face (44%), eyes
(38%), and nose (38%) were the most common. Aside from their
primary BDD diagnosis, as confirmed by the Structured Clinical
Interview for DSM–IV (First, Spitzer, Gibbon, & Williams, 1997),
their comorbid disorders were major depression (n ⫽ 21), delu-
sional disorder (n ⫽ 19), social phobia (n ⫽ 5), obsessive–
compulsive disorder (n ⫽ 4), alcohol misuse (n ⫽ 2), adjustment
disorder (n ⫽ 1), and bulimia nervosa (n ⫽ 1). Participants with
BDD were either individuals receiving treatment at the Priory
Hospital North London or individuals who had contacted a BDD
support group.
The two nonclinical control groups excluded (a) those who
responded yes to “Have you ever been diagnosed with a psychi-
atric disorder?” and/or “Are you currently suffering with a psy-
chiatric disorder?” and (b) those who had excessive appearance
concerns defined by a total score of 20 or above on the BDD-
YBOCS, including a score of at least 2 on Item 1. The only
difference between the control groups was the additional inclusion
criterion of an education or occupation in art and design, necessary
for the art and design group. This included a current or completed
education (at least advanced level) or training in art, fine art, art
history, architecture, or design or an occupation as an artist, an art
teacher, an architect, or a graphics, fashion, or textile designer. To
classify a participant, both current and past occupation, training,
and education in art and design were used. For instance, a partic-
ipant with an art degree but working as a waiter qualified for the
art and design group. The two control groups were recruited by (a)
advertisements in a local newspaper, (b) email circulars in 11
universities and colleges, (c) leaflets delivered to 1,000 homes, and
3
(d) snowball sampling. The ethics committees of the Institute of
Psychiatry and the Priory Hospital North London approved the
study protocol.
Computer Graphic Techniques
We investigated the three proposed components of aesthetic
sensitivity by manipulating a digital photograph of each partici-
pant’s face, the control faces, and the building, using Adobe
Photoshop 7.0 and Ulead MorphStudio 1.0 to create nine image
symmetry continua. Participants viewed the images in SuperLab
on a laptop.
Generation of individual test photographs. The first author
took a digital colored photograph of each participant’s face under
standardized conditions. Each participant sat upright in front of a
white background, with a light source positioned on either side to
reduce shadowing. A 3.0 mega-pixel digital camera, placed on a
tripod and positioned a constant distance of 0.6 m from the
participant, was used to take the frontal view photographs. To
eliminate emotional expression as a possible confounding variable,
participants received instructions to look directly at the camera and
display a neutral facial expression.
The male and female individuals recruited to represent the two
control facial images were selected because they matched the age
criteria of the participants and were judged by 10 volunteers to fall
within the average range of attractiveness. The first author took
their original digital colored photograph under the same standard-
ized conditions outlined for participants.
A building represented the nonfacial inanimate control stimulus
to compare with the faces because buildings are comparable with
faces in terms of visual complexity; buildings contain internal
features, have a global structure, and are, to some degree, sym-
metrical. The first author used a 3.0 mega-pixel digital camera,
placed on a tripod, to generate the original digital colored photo-
graph of the building. The building was Grovelands House, a
Grade I listed Regency mansion designed by the celebrated archi-
tect John Nash in 1797.
Definition of perfection. Empirical evidence implies that
attractiveness increases in male and female faces as symmetry is
enhanced and that attractiveness decreases as symmetry is reduced
(Rhodes, Proffitt, Grady, & Sumich, 1998). For the purposes of
this study, perfection was therefore defined by symmetry. To
simplify the design, the manipulations were limited to this one
dimension of beauty.
Symmetry continuum manipulations. The first author cre-
ated a symmetry continuum of nine images (one real image and
eight manipulated images) for each participant, for the male con-
trol facial image, for the female control facial image, and for the
building image. The real image, that is, the original digital photo-
graph, represented the midpoint on the symmetry continuum.
Creating the images representing symmetry and asymmetry.
The first author created the two extremes of the continuum, sym-
metry (most attractive) and asymmetry (least attractive), using
Adobe Photoshop 7.0. For all the manipulations, the feather was
set at 10 pixels to reduce the visibility of harsh lines in the image
from using the lasso or marquee tools to select isolated features or
larger sections of the image.
Symmetry. To create the facial and building images represent-
ing symmetry, the first step was to duplicate a layer of the real
4 LAMBROU, VEALE, AND WILSON
image to allow for the manipulations. Half of the facial or building
image was then flipped horizontally (with the edit, transform, and
flip horizontal commands). The first author used a randomized
process to determine whether to flip the left side or right side. This
involved tossing a coin. The randomized order matched across the
three groups.
To circumvent the technical problems reported in previous
research, the first author took care to ensure that, when creating the
symmetrical image, the image maintained the original widths of
the face and building, as well as the widths and positioning of the
internal features. By using the scale option in the edit tool, the
transform tool restored any slight deviations from the original.
Skin blemishes transferred to the other side of the face because of
the flipping, were removed with the cloning stamp and healing
brush tools. The final step was to flatten the layers and save the
image. The first author saved the images in a bitmap format
because it was the only format common to the software used in the
manipulation and in the presentation of the images.
Asymmetry. To create the facial and building images repre-
senting asymmetry, the first step was to duplicate a layer of the real
image to allow for the manipulations. For the facial images, one
side of the jaw line was pinched (with the filter, distort, and pinch
tools) by 30% to reduce the symmetrical proportions of the face.
To increase the asymmetry of the internal features, the same side
of the mouth was pinched by 30% to reduce the size on one side,
and the same side of the nose was pinched by ⫺30% to increase
the size on one side. For the building image, one side of the
building was pinched by 10% to reduce the symmetrical propor-
tions of the building. On the same side of the building, pinching
the outer window on the first floor by 20% and outer window on
the second floor by 20% increased the asymmetry of the internal
features. The final step was to flatten the layers and save the
images in a bitmap format.
The asymmetry manipulations occurred on either the left side or
the right side of the face and the building depending on the side
originally flipped to create the symmetry image. If, to create
symmetry, this entailed flipping the left side to the right side, then
the asymmetry manipulations were on the right side and vice versa.
Creating the images within the continuum. The first author
created the six images within the continuum, using Ulead
MorphStudio 1.0. In this software, an option is available to com-
pose an image by morphing two images to varying percentages.
The real image and symmetry were morphed to create three images
of varying symmetry: 25% symmetry, 50% symmetry, and 75%
symmetry. The real image and asymmetry were morphed to create
three images of varying asymmetry: 25% asymmetry, 50% asym-
metry, and 75% asymmetry.
Questionnaires
BDD-YBOCS. The BDD-YBOCS (Phillips et al., 1997), a
12-item semistructured interview was administered to assess the
severity of BDD symptoms during the past week. Total scores
range from 0 to 48 (mild: 20 –26; moderate: 27–34; severe: 35⫹).
Internal consistency was high in the present sample (Cronbach’s
␣ ⫽ .951).
Beck Depression Inventory (BDI). The BDI (Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961), a 21-item self-report inven-
tory, was used to assess the presence and severity of symptoms
related to depression. Total scores range from 0 to 63 (none or
minimal: ⬍10; mild to moderate: 10 –18; moderate to severe:
19 –29; severe: 30 – 63). Internal consistency was high in the
present sample (Cronbach’s ␣ ⫽ .948).
Values Scale. A simple scale specifically devised for the
study measured aesthetic values. Given a relative scale, respon-
dents are required to allocate 100 points to a choice of 10 values
(physical appearance, family, friends, health, academic/
occupational success, religion, art, music, money, scientific truth)
and to rate each one on degree of importance. Values that hold no
importance to them receive a zero rating. The final points yield a
total score of 100 for all respondents.
Self-Objectification Questionnaire. The Self-Objectification
Questionnaire (Noll & Fredrickson, 1998), a 10-item ranking scale
was used to measure aesthetic identity. Total scores range from
⫺25 to 25. A higher positive score indicates a greater emphasis on
appearance and, thus, a higher level of self-objectification.
Procedure
Participants met with the first author on two occasions. In the
first meeting, participants read the information form and had the
opportunity to ask questions. After consenting to the study, par-
ticipants had their photograph taken in preparation for the second
meeting, where they viewed the real image and the manipulated
versions of their image and the control images on a computer.
Participants were then administered the BDD-YBOCS and the
BDI.
In the second meeting, before the computer study commenced,
participants viewed the questions of the study. They received a
thorough explanation of the procedure with the opportunity to ask
questions for clarification.
Participants were then presented with the nine images of their
face (one real and eight manipulated) simultaneously on the com-
puter screen. They were required to select and rate, in the follow-
ing order, their actual self, their ideal self, their perfect face, the
most physically attractive image and give their attractiveness rat-
ing for their selected image (scale: 0 ⫽ extremely unattractive,
10 ⫽ extremely attractive), the image that gave them the most
pleasure and give their pleasure rating for their selected image
(scale: 0 ⫽ extreme disgust, 10 ⫽ extreme pleasure), and the
image that gave them the most disgust and give their disgust rating
for their selected image (scale: 0 ⫽ extreme pleasure, 10 ⫽
extreme disgust). Viewing and rating time was 1 min for each
selection question. A blank screen preceded each new selection
question and series presentation. A neutral instructional format
was used (i.e., “please select which image represents your actual
self”) to eliminate a possible instructional effect. Participants sub-
sequently completed the Values Scale and the Self-Objectification
Questionnaire.
Next, participants viewed and rated the images of the facial
control condition, followed by the nonfacial control condition. The
same procedure and question order used for the self-image condi-
tion applied, with two exceptions. First, to make their judgments
for actual other and actual building, participants viewed the real
image for 10 s. This image was followed by the nine images of the
symmetry continuum for 1 min for the image selection. Second, in
contrast to the facial image conditions, participants did not select
their most attractive building or rate its attractiveness. To reduce
 ROLE OF AESTHETIC SENSITIVITY IN BDD 5

the risk of overtesting, male participants viewed only the male
control face, and female participants viewed only the female
control face. All participants were screened to ensure they were not
familiar with the control face.
There were two presentation orders for the position of the
images on the screen, with the allocation of the order randomized
by tossing a coin. Participants viewed the same presentation, in
either the first or the second order, across the three conditions. The
numbers viewing each presentation were equal across the three
groups. At the conclusion of the study, each participant was
debriefed.
Statistical Analysis
Multivariate analyses of variance (MANOVAs) were conducted
to confirm the body image components. A series of one-way
analyses of variance (ANOVAs) were conducted on each variable.
When variances were considered heterogeneous (variance ratio ⬎
3:1), a Brown–Forsythe F* test was selected. Significant main
effects were followed up with planned comparisons designed
accordingly to test each specific prediction. A post hoc Tukey
honestly significant difference test followed up an unexpected
outcome. Cohen’s f (for ANOVAs) or Pearson’s correlation coef-
ficient r (for planned comparisons) were calculated to measure
effect sizes (small: f ⫽ 0.10, r ⫽ .10; medium: f ⫽ 0.25, r ⫽ .30;
large: f ⫽ 0.40, r ⫽ .50). Correlational analyses were performed to
assess the depressive realism explanation. The following coding
system was used in the analyses for the images selected from the
symmetry continuum: symmetry ⫽ 4; 75% symmetry ⫽ 3; 50%
symmetry ⫽ 2; 25% symmetry ⫽ 1; real image ⫽ 0; 25% asym-
metry ⫽ ⫺1; 50% asymmetry ⫽ ⫺2; 75% asymmetry ⫽ ⫺3;
asymmetry ⫽ ⫺4. In light of the multiple comparisons, a Bonfer-
roni corrected alpha level was set at .001 for all analyses.
Results
Demographic and Clinical Characteristics
Relative to control participants, BDD participants scored signif-
icantly higher on the BDD-YBOCS ( p ⬍ .0001, r ⫽ .86) and the
BDI ( p ⬍ .0001, r ⫽ .85). Control groups did not differ. The
groups were equivalent in age and gender ratio (see Table 1).
Aesthetic Perceptual Sensitivity
Table 2 presents the group means, standard deviations, test
statistics, significance values, and effect sizes for the variables of
aesthetic perceptual sensitivity. The findings were consistent with
expectations.
Perceptual understanding/awareness (idea of perfect).
BDD participants and art and design controls (who did not differ)
selected a significantly more symmetrical self-image for their idea
of perfect than did non-art controls ( p ⬍ .0001, r ⫽ .62). Their
perceptual superiority relative to non-art control participants ex-
tended to the control conditions (other face: p ⬍ .0001, r ⫽ .31;
building: p ⬍ .001, r ⫽ .29).
Perceptual accuracy. BDD participants were significantly
more accurate in perceiving their actual self than were control
participants ( p ⬍ .0001, r ⫽ .59). The groups did not differ in their
accuracy for the control conditions.
Effects of mirror checking. BDD participants checked their
appearance in a mirror significantly more frequently on a weekly
basis than did control participants, t(147) ⫽ 5.992, p ⬍ .0001, r ⫽
.44 (BDD: M ⫽ 3.9, SD ⫽ 1.0; art and design: M ⫽ 2.9, SD ⫽ 1.0;
non-art: M ⫽ 2.8, SD ⫽ 1.0). However, mirror checking did not
influence the self-actual estimation results. When it was included
as a covariate, the pattern of results did not change.
Depressive realism. There was a significant negative corre-
lation between self-actual estimation and depression (BDI total
score; r ⫽ ⫺.52, p ⬍ .0001). Participants with mild-to-moderate
depression were the most accurate. Participants with minimal or no
depression showed the greatest positive distortion. Of the BDD
group, 90% were at least mildly depressed. When we controlled
for BDD severity (BDD-YBOCS total score), the significant as-
sociation ceased (r ⫽ ⫺.16, p ⫽ .058). There was a significant
negative correlation between self-actual estimation and BDD se-
verity (r ⫽ ⫺.54, p ⬍ .0001). BDD participants with moderate
BDD were the most accurate. BDD participants with severe BDD
showed the greatest negative distortion. A significant positive corre-

Table 1
Demographic and Clinical Characteristics of BDD and Control Participants

Art and design

BDD participants controls Non-art controls
(n ⫽ 50) (n ⫽ 50) (n ⫽ 50)
Effect size
Variable M n SD M n SD M n SD Test statistic p Cohen’s f

Demographic characteristic
Age 27.7 6.9 26.2 6.5 26.3 5.1 F(2, 147) ⫽ 0.988 .375 0.11
Gender
Male 18 16 18
Female 32 34 32 ␹2(2) ⫽ 0.235 .930
Clinical characteristic
BDD-YBOCS 29.6aⴱ 6.3 8.2b 5.7 8.4b 6.1 F(2, 147) ⫽ 209.218 ⬍.0001 1.67
BDI 24.4aⴱ 10.6 4.9b 4.7 4.9b 4.5 Fⴱ(2, 86.546) ⫽ 121.431 ⬍.0001 1.27

Note. Means in the same row that do not share subscripts differ at p ⬍ .001 in planned comparisons. BDD ⫽ body dysmorphic disorder; BDD-YBOCS ⫽
Yale–Brown Obsessive–Compulsive Scale modified for body dysmorphic disorder; BDI ⫽ Beck Depression Inventory.
ⴱ
p ⬍ .0001.
6 LAMBROU, VEALE, AND WILSON

Table 2
Group Differences in Aesthetic Perceptual Sensitivity

Art and
BDD design Non-art
participants controls controls
(n ⫽ 50) (n ⫽ 50) (n ⫽ 50)

Variable and condition M SD M SD M SD Test statistic: F(2, 147) p Effect size Cohen’s f

Perceptual understanding
Self 3.4aⴱ 0.7 3.2aⴱ 0.7 1.9b 1.1 46.452 ⬍.0001 0.79
Other 2.9aⴱ 0.9 2.9aⴱ 1.0 2.1b 1.5 7.983 ⬍.001 0.33
Building 3.3a 0.7 3.2a 0.8 2.7b 1.2 7.351 ⬍.001 0.31
Perceptual accuracy
Self ⫺0.4aⴱ 1.0 0.9b 0.9 1.3b 1.0 41.154 ⬍.0001 0.74
Other 0.3 1.1 0.3 1.5 0.4 1.7 0.119 .888 0.04
Building 0.4 1.1 0.6 1.8 0.6 2.1 0.183a .833 0.05

Note. Means in the same row that do not share subscripts differ at p ⬍ .001 in planned comparisons. BDD ⫽ body dysmorphic disorder; self ⫽ self-image
condition; other ⫽ other face condition; building ⫽ building condition.
a ⴱ
F (2, 121.279).
ⴱ
p ⬍ .0001.

lation was observed between depression and BDD severity (r ⫽ .82,
p ⬍ .0001).
Aesthetic Emotional Sensitivity
Table 3 presents the group means, standard deviations, test
statistics, significance values, and effect sizes for the variables of
aesthetic emotional sensitivity. The outcomes were as predicted.
Pleasure. BDD participants and art and design controls (who
did not differ) selected a significantly more symmetrical self-
image than did non-art controls to represent the image that gave
them most pleasure ( p ⬍ .0001, r ⫽ .48). When rating their
selected self-image, BDD participants experienced significantly
less pleasure than did control participants ( p ⬍ .0001, r ⫽ .63).
Control groups did not differ. The perceptual superiority in BDD
participants and art and design controls extended to the control

Table 3
Group Differences in Aesthetic Emotional Sensitivity

BDD Art and design Non-art

participants controls controls
(n ⫽ 50) (n ⫽ 50) (n ⫽ 50)
Variable and
condition M SD M SD M SD Test statistic: F(2, 147) p Effect size Cohen’s f

Pleasure
Perceptual selection
Self 2.9aⴱ 0.9 2.6aⴱ 1.0 1.5b 1.2 23.146 ⬍.0001 0.55
Other 2.6aⴱ 1.1 2.4aⴱ 1.1 0.9b 1.9 20.330 ⬍.0001 0.52
Building 2.7aⴱ 1.4 2.8aⴱ 1.2 1.9b 1.4 6.951 ⬍.001 0.30
Rating
Self 2.8aⴱ 1.8 5.2b 1.3 5.3b 1.3 47.308 ⬍.0001 0.79
Other 5.6 1.4 5.8 1.2 6.0 1.3 0.942 .392 0.11
Building 6.1 1.8 6.5 1.6 6.1 1.5 1.252 .289 0.13
Disgust
Perceptual selection
Self ⫺2.9aⴱ 1.0 ⫺2.8aⴱ 0.9 ⫺1.9b 1.2 12.562 ⬍.0001 0.40
Other ⫺3.0aⴱ 1.0 ⫺2.9aⴱ 1.1 ⫺1.6b 1.7 16.748 ⬍.0001 0.47
Building ⫺3.1aⴱ 0.9 ⫺2.8aⴱ 1.1 ⫺1.6b 1.6 21.111a ⬍.0001 0.53
Rating
Self 8.0aⴱ 1.7 5.9b 1.5 5.4b 1.5 36.035 ⬍.0001 0.69
Other 5.0 1.7 4.6 1.3 4.4 1.5 2.177 .117 0.17
Building 5.8 1.9 5.3 1.7 4.9 1.7 3.384 .037 0.21

Note. Means in the same row that do not share subscripts differ at p ⬍ .001 in planned comparisons. BDD ⫽ body dysmorphic disorder; self ⫽ self-image
condition; other ⫽ other face condition; building ⫽ building condition.
a ⴱ
F (2, 113.275).
ⴱ
p ⬍ .0001.
 ROLE OF AESTHETIC SENSITIVITY IN BDD 7

conditions (other face: p ⬍ .0001, r ⫽ .46; building: p ⬎ .0001,
r ⫽ .29). The groups did not differ in their pleasure rating for the
control conditions.
Disgust. BDD participants and art and design controls (who
did not differ) selected a significantly less symmetrical self-image
than did non-art controls to represent the image that gave them
most disgust ( p ⬍ .0001, r ⫽ .45). When rating their selected
self-image, BDD participants experienced significantly more dis-
gust than did control participants ( p ⬍ .0001, r ⫽ .57). Control
groups did not differ. The perceptual superiority in BDD partici-
pants and art and design controls extended to the control condi-
tions (other face: p ⬍ .0001, r ⫽ .43; building: p ⬎ .0001, r ⫽ .55).
The groups did not differ in their disgust rating for the control
conditions.
Aesthetic Evaluative Sensitivity
Table 4 presents the group means, standard deviations, test
statistics, significance values, and effect sizes for the variables of
aesthetic evaluative sensitivity. With the exception of personal and
aesthetic standard, the results were as predicted.
Personal standard. There were no significant differences
between the groups in their self-ideal selections. Contrary to ex-
pectations, BDD participants were not demanding a higher self-
ideal standard than were control participants. However, there were
significant group differences in the degree of self-discrepancy (see
Figure 1). Consistent with our prediction, BDD participants ex-
pressed a greater discrepancy between their self-actual and self-
ideal than did control participants ( p ⬍ .0001, r ⫽ .62). Control
groups did not differ. The groups did not diverge in their ideal
standard or their actual/ideal discrepancy for the control condi-
tions.
Aesthetic standard. There was a significant group effect in
the discrepancy between their self-ideal and perfect self. Contrary
to expectations, planned comparisons revealed that BDD partici-
pants and control participants did not differ ( p ⫽ .011, r ⫽ .21),
and control groups did diverge ( p ⬍ .0001, r ⫽ .45). A post hoc
Tukey honestly significant difference test identified the source of
the significant group effect. BDD participants and art and design
controls (who did not differ) expressed a greater discrepancy
between their self-ideal and perfect self than did non-art controls
( ps ⬍ .0001). The groups did not differ in their aesthetic standard
for the control conditions.
Attractiveness standard. Relative to non-art controls, BDD
participants and art and design controls (who did not differ)

Table 4
Group Differences in Aesthetic Evaluative Sensitivity

Art and
BDD design Non-art
participants controls controls
(n ⫽ 50) (n ⫽ 50) (n ⫽ 50)

Variable and condition M SD M SD M SD Test statistic: F(2, 147) p Effect size Cohen’s f

Aesthetic standards
Personal standard
Ideal
Self 2.2 0.9 1.9 1.2 1.9 1.2 1.701 .186 0.15
Other 2.5 1.2 2.4 1.2 2.2 1.4 1.036 .357 0.12
Building 2.7 1.1 2.5 1.5 2.3 1.5 1.076 .343 0.12
Actual/ideal discrepancy
Self 2.6aⴱ 1.3 1.0b 1.0 0.6b 1.0 48.028 ⬍.0001 0.80
Other 2.2 1.3 2.1 1.8 1.8 1.7 1.170 .313 0.12
Building 2.3 1.2 1.9 1.9 1.7 2.2 1.426a .243 0.14
Aesthetic standard (perfect vs. ideal)
Self 1.2aⴱ 1.2 1.3aⴱ 1.2 0.0b 0.9 22.104 ⬍.0001b 0.48
Other 0.4 1.0 0.5 1.1 ⫺0.1 1.4 2.959 .055 0.20
Building 0.6 0.9 0.7 1.1 0.3 1.1 1.978 .142 0.16
Attractiveness Standard
Perceptual selection
Self 2.8aⴱ 0.8 2.5aⴱ 1.3 1.6b 1.2 15.852c ⬍.0001 0.46
Other 2.6aⴱ 1.0 2.4aⴱ 1.2 1.3b 1.9 12.316d ⬍.0001 0.41
Rating
Self 3.3aⴱ 2.1 5.1b 1.2 4.8b 1.5 16.636 ⬍.0001 0.47
Other 5.2 1.6 5.6 1.3 5.8 1.5 1.769 .174 0.15
Aesthetic values
Values Scale–physical appearance 28.8aⴱ 16.7 8.6b 4.6 9.1b 5.6 60.073e ⬍.0001 0.89
Aesthetic identity
ⴱ
Self-Objectification Questionnaire 8.7 a 11.2 ⫺2.5b 9.9 ⫺2.1b 11.3 17.032 ⬍.0001 0.48

Note. Means in the same row that do not share subscripts differ at p ⬍ .001 in planned comparisons. BDD ⫽ body dysmorphic disorder; self ⫽ self-image
condition; other ⫽ other face condition; building ⫽ building condition.
a
Fⴱ(2, 126.940). b A post hoc Tukey honestly significant difference test identified the source of the significant group effect. c Fⴱ(2, 133.473). d Fⴱ(2,
108.377). e Fⴱ(2, 67.935).
ⴱ
p ⬍ .0001.
8 LAMBROU, VEALE, AND WILSON

-4 -3 -2 -1 0 1 2 3 4

|_____|_____|_____|_____|_____|_____|______|_____|

100% 75% 50% 25% RI 25% 50% 75% 100%

AS AS AS AS S S S S

BDD participants

Art and design controls

Non-art controls

Figure 1. Group differences in self-actual versus self-ideal discrepancy. AS ⫽ asymmetry; RI ⫽ real image;
S ⫽ symmetry; BDD ⫽ body dysmorphic disorder.

selected a significantly more symmetrical self-image for their most
physically attractive image ( p ⬍ .0001, r ⫽ .41). BDD participants
rated their selected self-image significantly lower in attractiveness
than did control participants ( p ⬍ .0001, r ⫽ .53). Control groups
did not differ. The perceptual superiority in BDD participants and
art and design controls extended to the other face condition ( p ⬍
.0001, r ⫽ .46). The groups did not differ in their attractiveness
ratings for the control other face.
Aesthetic values. BDD participants were significantly more
likely to value the importance of physical appearance than were
control participants ( p ⬍ .0001, r ⫽ .75). Control groups did not
differ.
Aesthetic identity. BDD participants reported a significantly
higher positive self-objectification score than did control partici-
pants ( p ⬍ .0001, r ⫽ .43). Control groups did not differ.
Confirmation of Body Image Components: Perceptual
and Emotional/Evaluative
We postulated that the following variables assessed the percep-
tual component of body image: (a) perfect, (b) pleasure perceptual
selection, (c) disgust perceptual selection, and (d) physical attrac-
tiveness perceptual selection. MANOVAs conducted with these
variables revealed, as expected, a significant group effect for the
self-image condition, F(8, 290) ⫽ 11.896, p ⬍ .0001, for the other
face condition, F(8, 290) ⫽ 6.788, p ⬍ .0001, and for the building
condition, F(6, 292) ⫽ 7.281, p ⬍ .0001.
In addition, we postulated that the following variables would
assess the emotional/evaluative component of body image: (a)
actual, (b) pleasure rating, (c) disgust rating, (d) ideal, (e) actual/
ideal discrepancy, (f) physical attractiveness rating, (g) aesthetic
values, and (h) aesthetic identity. MANOVAs conducted with
these variables revealed, as expected, a significant group effect for
the self-image condition, F(14, 284) ⫽ 11.650, p ⬍ .0001, but not
for the other face condition, F(10, 288) ⫽ 0.922, p ⫽ .513, or for
the building condition, F(8, 290) ⫽ 1.700, p ⫽ .089.
Influence of the BDD Concerns
Of the BDD group, 52% were preoccupied with at least one of
the facial features altered in the manipulations. However, this did
not influence the results. There were no significant differences
between the two BDD subgroups for any variable in this study
( ps ⬎ .05).
Discussion
It was hypothesized that a higher aesthetic sensitivity contrib-
utes to the development and maintenance of BDD. This study
examined the central premise that rather than being distorted in
their perceptual processing, those with BDD have an enhanced
understanding of aesthetic proportions and an increased accuracy
in their self-actual estimation. We expected the source of their
disturbance to be in their emotional/evaluative processing, which is
specific to the self. This would manifest in art and design controls
resembling BDD participants in their superior perceptual understand-
ing of aesthetic proportions and non-art controls in their emotional/
evaluative processing. Overall, the findings corroborate these hypoth-
eses. Effect sizes for these key findings were medium to large.
Individuals with BDD and art and design controls seemed to
have a clearer idea of the criteria of attractiveness levels defined by
symmetry. They displayed a greater awareness of their aesthetic
facial proportions relative to non-art controls, and this extended to
another person’s face and a building. This reinforces the idea that
individuals with BDD possess a more critical eye and appreciation
of aesthetics, which they then apply to their own appearance
(Veale & Lambrou, 2002).
BDD participants were also more accurate in perceiving their
actual self compared with controls. According to Thomas (1990),
the body image of each healthy member of the population tends to
mirror their position within the attractiveness distribution. Dissat-
isfaction arises when there is a mismatch between perceived ap-
pearance and actual appearance. However, the results of this study
suggest that individuals with BDD, who are particularly dissatis-
fied, present a closer match between perceived appearance and
actual appearance. On average, they displayed only a slight neg-
ative bias in their estimation of themselves. Hence, they did not
display a distortion in their perceptual processing. Rather this
study substantiates preliminary evidence (Thomas & Goldberg,
1995) that individuals with BDD are superior in their discrimina-
tory abilities. In contrast, control participants expressed a pro-
 ROLE OF AESTHETIC SENSITIVITY IN BDD
nounced positive bias toward symmetry, overestimating the attrac-
tiveness of their actual self. In other words, control participants
were looking at themselves through rose-tinted spectacles.
Control participants’ overestimation of attractiveness was spe-
cific to their own face and is consistent with previous findings.
Jansen, Smeets, Martijn, and Nederkoorn (2006) observed that,
contrary to eating-symptomatic participants who expressed a real-
istic view of their attractiveness, control participants overestimated
their own independently rated attractiveness. Similarly, Noles,
Cash, and Winstead (1985) reported that, although depressed stu-
dents underestimated their attractiveness (akin to the slight nega-
tive distortion in the BDD group), they were nevertheless more
accurate in their self-appraisals than nondepressed students, who
positively exaggerated their level of attractiveness. Consistent with
the depressive realism explanation, those with mild-to-moderate
depression in the present study were the most accurate in their
self-perception. Participants with minimal or no depression
showed the greatest positive distortion.
The findings suggest that overestimating personal attractiveness
may be important for psychological well-being, providing protec-
tion from developing body image conditions and depression. Self-
perceived facial appearance correlates positively with global self-
worth (Pope & Ward, 1997). The present results imply that
individuals with BDD are not using a self-serving bias when
evaluating their physical appearance. Thus, their minor imperfec-
tions disappoint them, and they experience negative emotions,
such as depression. Future studies could examine whether individ-
uals with BDD also fail to use self-serving attributional biases to
assess self-relevant information unrelated to physical appearance.
There was no perceptual accuracy in the severely depressed, all
of whom were BDD participants. The situation is probably made
more complex by the fact that clinicians have described individ-
uals with BDD who clearly display distortion in their self-portraits.
Severity of the BDD condition may play an important role. Per-
haps at some point on the BDD severity scale, individuals with
BDD become exclusively preoccupied with their internal body
image. Presumably, at this stage they have a grossly distorted
internal body image because of the limited validation with objec-
tive reality. The present study provides preliminary support for this
idea, because those with severe BDD showed the greatest negative
distortion in their self-actual estimation. Participants with moderate
BDD were the most accurate. Although BDD severity ranged from
mild to severe in the present BDD sample, most BDD participants had
moderate BDD, which may account for their lack of distortion.
It is important to disentangle the effects of the BDD symptom-
atology and of depression on participants’ self-actual estimations.
Replication with a sample of depressed and nondepressed BDD
participants will determine whether depression influences percep-
tual accuracy over and above the effects accounted for by BDD.
Future research could also compare BDD participants with de-
pressed participants. Aesthetic values and identity could be the key
factors separating them. Only those with BDD will overvalue the
importance of appearance and self-objectify, which may promote
BDD symptomatology.
Although BDD participants checked their appearance in the
mirror more often than controls, this did not account for their
perceptual accuracy. The quality of the mirror-checking experi-
ence may be more important than the quantity of checks (e.g.,
Mulkens & Jansen, 2009). To enhance ecological validity, an eye
9
tracker could register participants’ eye movements when they are
looking at themselves in the mirror to examine how they scan their
face. Individuals with BDD display visual processing and frontos-
triatal abnormalities when viewing their own face, which imply a
bias for detail encoding and analysis rather than holistic processing
(Feusner et al., 2010). It is therefore likely that individuals with BDD
approach the mirror with a more analytical eye, deliberately assessing
features and focusing on their perceived defects. This approach
heightens their self-perception and reinforces their dissatisfaction.
The increased perceptual accuracy in the BDD group was spe-
cific to their own faces. The groups did not differ in the control
conditions. Thus, BDD participants did not display impairments in
their face- or object-recognition abilities, further substantiating the
idea that there is no perceptual deficit. Indeed, Stangier, Adam-
Schwebe, Müller, and Wolter (2008) found that individuals with
BDD were more accurate than control participants in recognizing
aesthetic alterations to other faces. The accuracy may not extend to
other body image conditions. Individuals with eating disorders
were less accurate than controls at detecting the facial flaws of
others (Legenbauer, Kleinstäuber, Müller, & Stangier, 2008). The
outcome might have been different had these authors assessed the
body, because weight and shape are the concerns in eating disor-
ders. The role of facial versus body concerns on aesthetic sensi-
tivity needs to be investigated.
The emotional sensitivity results confirm the main hypothesis that
individuals with BDD are superior in their perceptual processing and
disturbed in their emotional processing. BDD participants and art and
design controls were perceptually superior to non-art controls. They
selected a more symmetrical face to represent the self-image provid-
ing the most pleasure and a less symmetrical face to represent the
self-image providing the most disgust. Crucially, when rating their
selected self-image for most pleasure and most disgust, BDD partic-
ipants experienced less pleasure and more disgust, respectively, than
either control group. Surprisingly, although the insula, one of the main
regions implicated in self-recognition, plays a role in the experience of
emotions such as disgust, insula hyperactivity is not evident in those
with BDD (Feusner et al., 2010).
The perceptual superiority observed in BDD participants and art
and design controls extended to another person’s face and a
building. The emotional ratings were the pivotal difference be-
tween the self-image and the control conditions. In contrast to their
self-image, where they exhibited a marked negative emotional
bias, BDD participants resembled controls in their pleasure and
disgust ratings for the other face and the building. This corrobo-
rates the premise that the emotional disturbance in those with BDD
is specific to their own face.
The aesthetic evaluations component of aesthetic sensitivity is
subdivided into standards, values, and identity. Contrary to the
commonly held view and our prediction, individuals with BDD did
not demand a higher standard of beauty for themselves compared
with individuals from the healthy population. BDD participants
and controls did not differ, with each selecting a modest self-ideal.
Of interest, Silver and Reavey (2010) reported that for some with
BDD, their ideal self was an idealized version of their perceived
childhood self. The groups were also analogous in their modest
ideal standard for another person’s face and for a building.
In line with Veale et al. (2003), the key difference between the
groups was the self-discrepancy. As a result of overestimating their
actual attractiveness, controls expressed only a marginal difference
10 LAMBROU, VEALE, AND WILSON
between their actual self and their ideal self, suggesting that they
were satisfied with their perceived appearance. Korabik and Pitt
(1980) observed that individuals with a high self-concept tended to
see themselves as closer to the ideal than they actually were.
Relative to controls, BDD participants expressed a greater discrep-
ancy between their perceived actual self and their desired ideal
self, because of an absent self-serving bias in their self-actual
estimation. Thus, the crucial determining factor for those with
BDD, and probably the source of their disturbance, is that a
discrepancy exists between their actual and ideal, rather than that
they possess an unrealistic ideal or a distorted actual self.
According to Higgins (1987), individuals displaying a discrep-
ancy between their actual self and their ideal self are vulnerable to
dejection-related emotions, such as depression. This may explain
the increased depressive symptomatology in the present BDD
sample. As they did not differ from controls in their self-ideal
standards, treatment strategies that aim to develop self-serving
biases, such as those evident in controls, may prove effective in
reducing the self-discrepancy in those with BDD and, conse-
quently, may alleviate their symptomatology.
BDD participants resembled control participants in their dis-
crepancy between actual and ideal for the control conditions. Their
significant actual versus ideal discrepancy was therefore unique to
their self-image. This further attests to the idea that for those with
BDD, the source of their disturbance is the specific discrepancy
between their perceived actual self and their desired ideal self.
Contrary to expectations, BDD participants expressed a discrep-
ancy between their perfect and ideal self. They selected a more
symmetrical self-image for their perfect self than for their ideal
self, verifying the earlier observation that most do not desire
perfection in their appearance. Indeed, they chose images analo-
gous to those chosen by art and design controls.
On a perceptual level, BDD participants and art and design
controls displayed a higher attractiveness standard, probably the
result of their increased understanding of aesthetic proportions.
They were superior to non-art controls in selecting a more sym-
metrical self-image to represent their most physically attractive
image. This perceptual superiority extended to the control other
face. Akin to the trend observed for emotional sensitivity, what
differentiated the BDD group was their self-rating. They rated the
attractiveness of only their chosen self-image markedly lower than
both control groups. There were no group differences when rating
the attractiveness of the control other face. This did not concur in
Buhlmann et al.’s (2008) study, in which they found that partici-
pants with BDD rated attractive faces as more attractive compared
with participants with obsessive– compulsive disorder and control
participants. However, participants in the present study rated the
image they perceived as the most physically attractive as opposed
to rating images classified by others as attractive.
This study did not include the objective rating of the partici-
pants’ actual attractiveness. Should research unequivocally show
individuals with BDD to be less attractive than the general popu-
lation and than others with a psychiatric disorder, this would raise
some questions regarding the validity of the BDD diagnosis.
Thomas and Goldberg (1995) provided modest support for the
possibility of those with BDD being less attractive, but they did not
assess symmetry or include a control psychiatric group. Buhlmann
et al. (2008), however, reported that BDD, obsessive– compulsive
disorder, and control groups did not differ in their independently rated
attractiveness. Perhaps for BDD participants in the present study, their
appearance dissatisfaction and negative self-appraisals were, to some
extent, justified, as a panel in Jansen et al. (2006) found in an
eating-symptomatic group. Alternatively, perhaps BDD participants
and controls did not differ in their actual attractiveness; the discrep-
ancy in their ratings may have been merely a reflection of control
participants overestimating their attractiveness to maintain their pos-
itive self-concept. These issues need to be addressed.
Physical appearance was the most important value only for BDD
participants. They valued its importance three times more than control
participants did, implying that they may be valuing appearance to a
dysfunctional degree. Consistent with the physical attractiveness ste-
reotype, Buhlmann et al. (2009) reported that BDD participants at-
tached more meaning and consequences to thoughts about the impor-
tance of appearance (e.g., attractive people are more competent).
Valuing the importance of appearance is likely to reinforce processing
of the self as an aesthetic object (Veale, 2004). BDD participants were
more likely to self-objectify than controls. It is reasonable to hypoth-
esize that these aesthetic evaluations predispose an individual to
BDD, as well as maintaining the condition.
One must interpret the present outcomes in light of several limita-
tions. The main limitation was the unavoidable selection bias in the
BDD group. Only those who were willing to view and rate their image
agreed to participate. BDD participants were also preselected for
their predominant facial concerns and for falling within a restricted
age range of 18 to 40 years. Further studies would verify whether
the results generalize to those who refused to participate, those
primarily concerned with nonfacial features, or those ages above
40 or below 18. Given that BDD usually begins in adolescence,
prospective longitudinal studies based on young vulnerable sam-
ples may elucidate whether a high aesthetic sensitivity predisposes
an individual to BDD and/or is a consequence of the disorder.
Comorbidity was present in the BDD group. Although this is
typical in BDD, the question does arise as to whether the comorbid
disorders partially influenced the outcomes. Comparing a BDD
group without comorbidities with related clinical control groups,
such as groups with eating disorders, depression, obsessive–
compulsive disorder, and social phobia, would address issues
regarding a possible degree of overlap in the pathogenesis of BDD
and these comorbid disorders. Future investigations could use
electroculography to measure how BDD and comparative groups
differentiate and/or resemble one another in their strategies when
viewing, selecting, and rating the images. It would have been
preferable for participants to view both the male and female
control images to allow comparisons of cross-gender differences,
but there was a risk of overtesting. In addition, the order in which
the three conditions were presented should have been randomized.
The present study explored the role of aesthetic sensitivity in BDD.
Results support the distinction between perceptual and emotional/
evaluative modalities of body image. Results also substantiate the
underlying premise of the study that, rather than suffering from a
perceptual deficit, individuals with BDD possess an increased under-
standing of aesthetic proportions, which extends to other faces and a
building, and a superior accuracy in their self-actual estimation. The
source of the disturbance is in their emotional/evaluative processing
when viewing their self-image. Such findings hold clear implications
for treatment. Rather than engaging in a debate with them about the
existence of their perceived defects, it may be more effective for
clinicians to focus on their emotional/evaluative processing.
 ROLE OF AESTHETIC SENSITIVITY IN BDD 11

A higher aesthetic sensitivity may contribute to an explanation profile self perception. Journal of Applied Social Psychology, 10, 482–
of why a small defect in their appearance severely disturbs those 489. doi:10.1111/j.1559-1816.1980.tb00727.x
with BDD. As predicted, participants with BDD responded the Legenbauer, T., Kleinstäuber, M., Müller, T., & Stangier, U. (2008). Are
same way as art and design controls in the control conditions. It is individuals with an eating disorder less sensitive to aesthetic flaws than
healthy controls? Journal of Psychosomatic Research, 65, 87–95. doi:
therefore important to understand what differentiates these groups.
10.1016/j.jpsychores.2008.02.014
This will not only aid the development of effective treatment Mulkens, S., & Jansen, A. (2009). Mirror gazing increases attractiveness in
strategies but also contribute to the prediction of which individuals satisfied, but not in dissatisfied women: A model for body dysmorphic
are vulnerable to BDD. Differences in personality and psycholog- disorder? Journal of Behavior Therapy and Experimental Psychiatry,
ical factors, such as the experience of shame, may be pivotal to 40, 211–218. doi:10.1016/j.jbtep.2008.10.001
appreciating the idiosyncratic pathways of BDD. Noles, S. W., Cash, T. F., & Winstead, B. A. (1985). Body image, physical
The promising outcomes of this study highlight that aesthetic attractiveness, and depression. Journal of Consulting and Clinical Psy-
sensitivity plays a role in BDD and indicate potential therapeutic chology, 53, 88 –94. doi:10.1037/0022-006X.53.1.88
strategies. With the development of research methods and the ques- Noll, S. M., & Fredrickson, B. L. (1998). A mediational model linking
tions generated from this study, future research on self-perception in self-objectification, body shame, and disordered eating. Psychology of
Women Quarterly, 22, 623– 636. doi:10.1111/j.1471-6402.1998.tb00181.x
BDD may unlock the mysteries of this enigmatic disorder.
Osman, S., Cooper, M., Hackmann, A., & Veale, D. (2004). Spontaneously
occurring images and early memories in people with body dysmorphic
disorder. Memory, 12, 428 – 436. doi:10.1080/09658210444000043
References
Phillips, K. A., Hollander, E., Rasmussen, S. A., Aronowitz, B. R., De-
Caria, C., & Goodman, W. K. (1997). A severity rating scale for body
Alloy, L. B., & Abramson, L. Y. (1979). Judgment of contingency in
dysmorphic disorder: Development, reliability, and validity of a modi-
depressed and nondepressed students: Sadder but wiser? Journal of
fied version of the Yale–Brown Obsessive–Compulsive Scale. Psycho-
Experimental Psychology: General, 108, 441– 485. doi:10.1037/0096-
pharmacology Bulletin, 33, 17–22.
3445.108.4.441
Pope, A. W., & Ward, J. (1997). Self-perceived facial appearance and
American Psychiatric Association. (1994). Diagnostic and statistical man-
psychosocial adjustment in preadolescents with craniofacial anomalies.
ual of mental disorders (4th ed.). Washington, DC: Author.
Cleft Palate Craniofacial Journal, 34, 396 – 401. doi:10.1597/1545-
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961).
1569(1997)0342.3.CO;2
An inventory for measuring depression. Archives of General Psychiatry,
Rhodes, G., Proffitt, F., Grady, J. M., & Sumich, A. (1998). Facial
4, 561–571.
symmetry and the perception of beauty. Psychonomic Bulletin & Re-
Buhlmann, U., Etcoff, N. L., & Wilhelm, S. (2008). Facial attractiveness
view, 5, 659 – 669.
ratings and perfectionism in body dysmorphic disorder and obsessive–
Silver, J., & Reavey, P. (2010). “He’s a good-looking chap aint he?”: Narrative
compulsive disorder. Journal of Anxiety Disorders, 22, 540 –547. doi:
and visualisations of self in body dysmorphic disorder. Social Science &
10.1016/j.janxdis.2007.05.004
Medicine, 70, 1641–1647. doi:10.1016/j.socscimed.2009.11.042
Buhlmann, U., Teachman, B. A., Naumann, E., Fehlinger, T., & Rief, W.
Stangier, U., Adam-Schwebe, S., Müller, T., & Wolter, M. (2008). Dis-
(2009). The meaning of beauty: Implicit and explicit self-esteem and
crimination of facial appearance stimuli in body dysmorphic disorder.
attractiveness beliefs in body dysmorphic disorder. Journal of Anxiety
Journal of Abnormal Psychology, 117, 435– 443. doi:10.1037/0021-
Disorders, 23, 694 –702. doi:10.1016/j.janxdis.2009.02.008
843X.117.2.435
Feusner, J. D., Moody, T., Hembacher, E., Townsend, J., McKinley, M.,
Thomas, C. S. (1990). Stress and facial appearance. Stress Medicine, 6,
Moller, H., & Bookheimer, S. (2010). Abnormalities of visual processing
299 –304. doi:10.1002/smi.2460060408
and frontostriatal systems in body dysmorphic disorder. Archives of General
Thomas, C. S., & Goldberg, D. P. (1995). Appearance, body image and
Psychiatry, 67, 197–205. doi:10.1001/archgenpsychiatry.2009.190
distress in facial dysmorphophobia. Acta Psychiatrica Scandinavica, 92,
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1997).
231–236. doi:10.1111/j.1600-0447.1995.tb09574.x
Structured Clinical Interview for DSM–IV Axis I Disorders: Clinician
Veale, D. (2004). Advances in a cognitive behavioural model of body
Version. Washington, DC: American Psychiatric Association.
dysmorphic disorder. Body Image, 1, 113–125. doi:10.1016/S1740-
Fredrickson, B. L., & Roberts, T. (1997). Objectification theory: Toward
1445(03)00009-3
understanding women’s lived experiences and mental health risks. Psy-
Veale, D., Ennis, M., & Lambrou, C. (2002). Possible association of body
chology of Women Quarterly, 21, 173–206. doi:10.1111/j.1471-
dysmorphic disorder with an occupation or education in art and design.
6402.1997.tb00108.x
American Journal of Psychiatry, 159, 1788 –1790. doi:10.1176/
Gunstad, J., & Phillips, K. A. (2003). Axis I comorbidity in body dysmor-
appi.ajp.159.10.1788
phic disorder. Comprehensive Psychiatry, 44, 270 –276. doi:10.1016/
Veale, D., Gournay, K., Dryden, W., Boocock, A., Shah, F., Willson, R.,
S0010-440X(03)00088-9
& Walburn, J. (1996). Body dysmorphic disorder: A cognitive behav-
Harris, D. L. (1982). Cosmetic surgery—where does it begin? British
ioural model and pilot randomised controlled trial. Behaviour Research
Journal of Plastic Surgery, 35, 281–286.
and Therapy, 34, 717–729. doi:10.1016/0005-7967(96)00025-3
Higgins, E. T. (1987). Self-discrepancy: A theory relating self and affect.
Veale, D., Kinderman, P., Riley, S., & Lambrou, C. (2003). Self-
Psychological Review, 94, 319 –340. doi:10.1037/0033-295X.94.3.319
discrepancy in body dysmorphic disorder. British Journal of Clinical
Jansen, A., Smeets, T., Martijn, C., & Nederkoorn, C. (2006). I see what
Psychology, 42, 157–169. doi:10.1348/014466503321903571
you see: The lack of a self-serving body-image bias in eating disorders.
Veale, D. M., & Lambrou, C. (2002). The importance of aesthetics in body
British Journal of Clinical Psychology, 45, 123–135. doi:10.1348/
dysmorphic disorder. CNS Spectrums, 7, 429 – 431.
014466505X50167
Jerome, L. (1992). Body dysmorphic disorder: A controlled study of
patients requesting cosmetic rhinoplasty. American Journal of Psychia- Received November 8, 2009
try, 149, 577–578. Revision received August 3, 2010
Korabik, K., & Pitt, E. J. (1980). Self concept, objective appearance, and Accepted August 4, 2010 䡲