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Spontaneously occurring images and early memories in people with body dysmorphic disorder

Selen Osman and Myra Cooper University of Oxford, Warneford Hospital, Oxford, UK

Ann Hackmann University of Oxford, and Institute of , London, UK

David Veale University of London, UK

A semi-structured interview assessing the presence and characteristics of spontaneous appearance-related images was designed and administered. A total of 18 patients with body dysmorphic disorder BDD) and 18 normal controls took part. The BDD patients were found to have spontaneously occurring appearance- related images that were significantly more negative, recurrent, and viewed from an observer perspective than control participants. These images were more vivid and detailed and typically involved visual and organic internal body) sensations. The study also found that BDD images were linked to early stressful memories, and that images were more likely than verbal thoughts to be linked to these memories. Implications for theory and clinical practice are discussed.

Horowitz 1970) defined images as contents of autobiographical memories. For example, the consciousness that possess sensory qualities, as presence of mental imagery has been found to be a opposed to those that are purely verbal or general predictor of memory specificity Williams, abstract. While the visual modality is most Healy, & Ellis, 1999). Intrusive memories invol- prominently represented within mental imagery, ving recall of event specific knowledge ESK) images can, and often do, have qualities associated Conway & Pleydell-Pearce, 2000) are core with any of the senses. In addition to this, images symptoms of post-traumatic disorder can also be divided into different types and cate- PTSD; American Psychiatric Association, 1994). gories. They may occur spontaneously, be delib- These often manifest as images. Cognitive the- erately generated, transformed, or suppressed. ories of PTSD e.g. Brewin, Dalgleish, & Joseph, They may reflect past, present, or future per- 1996) typically include reference to imagery, and spectives and may be literal or symbolic. Com- link it to autobiographical memory and emotional pared to verbal thoughts, images may sometimes processing. provide direct access to a holistic network of Research examining the nature and meaning of beliefs underlying emotional responses that may imagery in different psychological disorders, and be difficult to identify through questioning alone links to early memories, has grown in recent years. Hackmann, 1998). For example, patients with social Hack- There is also evidence to suggest that an mann, Surawy, & Clark, 1998) have been shown to important relationship exists between images and report experiencing significantly more spon-

Requests for reprints should be sent to Myra J. Cooper, Isis Education Centre, Warneford Hospital, Oxford, OX3 7JX, UK. EMail: [email protected]

# 0000 Press Ltd http://www.tandf.co.uk/journals/pp/09658211.html DOI: 10.1080/09658210444000043 2 OSMAN ETAL. taneously occurring images in anxiety-provoking social phobia). However, this has not been social situations than non-patient controls. These empirically investigated, nor has the possible images are typically negative in content, involve input from memory. seeing oneself from an observer perspective i.e., The hypotheses in this study were as follows: from an external viewpoint), and are perceived as 1) People with BDD will report having more at least partially distorted when considered after spontaneously occurring images that are negative the event Hackmann et al., 1998). and recurrent) when asked about their appear- The images of people with social phobia also ance, compared to control participants. 2) The appear to be recurrent and involve sensory com- sensory modality characteristics of BDD images, ponents in a variety of modalities. For example, and the perspective from which they are observed, Hackmann, Clark, and McManus 2000) found will differ to those of the control group. 3) that bodily sensations occurred as an aspect of Spontaneously occurring images in people with imagery almost as often as visual sensations. BDD will be linked to early memories and Importantly, the reported recurrent spontaneous experiences. 4) Images in people with BDD are images were linked to particular memories of more likely to be associated with stressful early events that occurred close in time to the onset of memories than verbal thoughts. the social phobia. Images and associated mem- ories were well matched with regard to their sen- METHOD sory content in the various modalities. Similar findings have been reported in other disorders Participants e.g., health anxiety, Wells & Hackmann, 1993: , Day, Holmes, & Hackmann, 2004 A total of 18 patients with BDD 9 men and 9 this issue). women) and 18 control participants 9 men and 9 While research examining the nature and women) aged between 17 and 49 years took part in meaning of imagery in psychological disorders has the study. The mean age in years was 27.50 SD = grown in recent years, most of this work has 7.02) for the BDD group and 26.83 SD = 6.67) for focused on anxiety disorders, with little research the control group. Patients with BDD were exploring the existence of imagery in other recruited from The Priory Hospital, North Lon- psychological conditions. It might be hypothesised don, through their consultant psychiatrist. All from a clinical perspective that mental imagery gave their informed consent for the study. Those would be implicated in disorders of , with concurrent /organic brain disorder, which include the eating disorders anorexia ner- , , substance vosa and ), and a more specific misuse, and those with a primary diagnosis of an disorder of body image concern, known as body were excluded. dysmorphic disorder BDD). This paper is con- Clinically there is some overlap in typical cerned with examining the nature and content of symptoms in BDD and eating disorders. There- imagery in BDD. fore, to confirm that participants had a primary A key criterion for the diagnosis of BDD in diagnosis of BDD and did not have a co-morbid DSM-IV Diagnostic and statistical manual of eating disorder, all were screened with the BDD mental disorders, American Psychiatric Associa- and eating disorder modules of the Structured tion, 1994) is ``a preoccupation with a defect in Clinical Interview for DSM-IV SCID), Spitzer, appearance . . . the defect is either imagined, or, if Williams, & Gibbons, 1996). a slight physical abnormality is present, the indi- The control participants non-clinical) were vidual's concern is markedly excessive'' p. 466). recruited by requesting volunteers from among Cognitive behavioural models have been hospital staff and colleagues. developed for the understanding and treatment of BDD Veale et al, 1996). Veale 2002) subse- quently hypothesised that BDD patients have Measures idealised values about the importance of appear- ance and tend to view themselves as an aesthetic The interviewer rated BDD patients on the Yale- object. Clinical experience suggests that patients Brown Obsessive Compulsive Scale Y-BOCS) suffer from extreme self-consciousness, with modified for BDD Phillips, Hollander, Rasmus- negative images of themselves, viewed mainly sen, Arnowitz, DeCaria, & Goodman, 1997). This from an observer perspective similar to images in is a short 12-item semi-structured interview used IMAGES IN PEOPLE WITH BDD 3 to assess the severity of BDD symptoms. All is the image/impression of yourself in your mind's participants also completed the Beck eye?''), with participants rating their responses on Inventory-II BDI-II; Beck, Steer, & Brown, a 101-point scale e.g., 0 = not at all vivid, 100 = 1996), Rosenberg Self-Esteem Inventory RSE; extremely vivid). Rosenberg, 1965), Fear of Negative Evaluation The perspective from which each participant Scale FNE; Watson & Friend, 1969), and The observed their image/impression was rated on a 7- Body Consciousness Questionnaire BCQ; Miller, point scale. Scores ranged from +3 observer Murphy & Buss, 1981). perspective: seeing myself completely from an external viewpoint, as if from another person's vantage point) to 73 observing myself com- Semi-structured interview pletely through my own eyes, as if looking in a mirror). This scale contrasted the observer per- The semi-structured interview was adapted from spective not with the field perspective as in Wells, Q1 Hackmann et al. 2000, 1998) and comprised two Ahmad, & Clark, 1998), but with a variant of the sections, one investigating spontaneously occur- field perspective, in which the subject is viewing ring imagery and one investigating thoughts. The their self through their own eyes, as if in a mirror. interview was piloted on eight volunteers two This was because pilot work suggested that many men and two women from each group). No mod- control subjects described their image in this way. ifications were made to the schedule and the pilot A 7-point scale was also used by participant and data were thus included in the main analysis. interviewer independently) to rate the emotional tone of the image/impression from 73 extremely Spontaneous imagery section of negative) to +3 extremely positive). interview Participants were then asked when in their life they had first experienced the sensations, In this section participants were asked to think thoughts, and feelings they had in the image/ about a recent time when they had felt really impression, and if there was a particular memory worried and anxious about their appearance. They that seemed closely linked to it. They were asked were asked if they had ever experienced any to evoke a relevant memory, which was then spontaneous images using Horowitz's 1970 defi- explored, as with the image, in terms of its content nition) at such times. If no images were reported, and sensory qualities. They also rated the extent participants were asked if they had ever experi- to which the memory resembled the image in enced an impression of the way they thought they terms of its sensory qualities, emotional sig- looked, or how others might see them at such nificance, and interpersonal meaning. Again, 0± times. This was to capture sensory impressions 101-point scales were used for these ratings e.g., 0 other than visual pictures, should the participants = not at all similar, 100 = extremely similar). have understood this to be a distinction. They were also asked if any of the images or impres- Verbal thoughts section of interview sions were recurrent. Participants were asked to recreate and describe the content of one of these In this section participants' appearance-related images or impressions. They were asked about thoughts were explored in the same way as rele- each of the sensory modalities in the image/ vant aspects of their images. impression in the following order: visual ``Can you see anything in your image?''), auditory ``Can you hear anything in the image?''), kinaesthetic Procedure ``Are you performing any acts in the image?''), cutaneous ``Do you notice any sensations of touch Participants were interviewed individually by the or pressure upon your skin, from an external first author SO). The semi-structured interview source?''; ``Are you touching anything in the took between 45 and 120 minutes and the two image?''), organic or internal bodily sensations sections were administered in counterbalanced ``Do you notice any sensations inside your order. All interviews were audio taped with par- body?''), gustatory ``Do you notice any sensations ticipants' permission. Four participants from each of taste?''), and olfactory ``Do you notice any group agreed to repeat the interview for test± sensations of smell?''). The characteristics of each retest purposes. All repeat interviews took place modality were explored in detail e.g., ``How vivid within 4 weeks of initial administration. 4 OSMAN ETAL.

RESULTS .001), had lower self-esteem RSE: U = 4.50, p < .001), and had higher fear of negative evaluation Analysis for normality Kolmogorov-Smirnov by others FNE: U = 24.00, p < .001) than the Test) and equality of variance Levene's Test for control participants. Participants in the BDD Equality of Variance) was carried out on the data. group were also more conscious of their internal Parametric tests e.g., independent t-test) were body sensations BCQ private body conscious- used where the assumptions for such testing was ness: U = 66.50, p = .002) and external appearance met. In all other cases, non-parametric equivalents BCQ public body consciousness: U = 55.00, p = were employed to assess between group differ- .001). No significant between-groups difference ences e.g., Mann-Whitney Test, Chi-square Test, was found on the BCQ body competence sub- Fisher's Exact Test) and within group differences scale BCQ body competence: U = 132.00, p= Wilcoxon Signed Ranks Test). .36).

Descriptive data Reliability of the semi-structured interview Demographic data. The median number of years in full time education for each group, and Test±retest reliability. Test±retest reliability inter-quartile ranges IQR) were 14.00 IQR = was assessed for the participants who repeated 12.00±15.00) and 15.00 IQR = 13.75±16.00) the interview) item-by-item using the Wilcoxon respectively. There were no significant between- Signed Ranks Test. No significant between-group group differences for age t = .29, df = 34, p=.77) differences for the images/impressions were or years in education U = 117.00, p=.16). observed at retest for any of the sensory mod- alities. Clinical characteristics.The mean age of onset of BDD was 14.50 years SD = 7.68) and mean length of time in treatment was 7.92 months Frequency of spontaneous images/ SD =9.62). For women, typical features of con- sensory impressions cern were their skin, eyes, hair, teeth, and geni- talia. For the men, eyes, hair, and genitalia were All of the BDD patients reported experiencing also common concerns, as well as their nose and either spontaneous images n = 17, 94%) or other head size. On the Y-BOCS modified for BDD, the sensory impressions n =1,6%) when worried or patients had a mean score of 34.06 SD = 8.28), anxious about their appearance. Of the control indicating that they had relatively severe symp- participants, 15 83%) reported either sponta- toms. Medians and IQR) for the self-report neous images n =6,33%) or sensory impressions questionnaires for both groups are presented in n =9,50%). Images and sensory impressions Table 1. were collapsed into one category and are reported According to questionnaire scores the BDD as images/impressions for the remainder of the patients were more depressed BDI-II: U =8,p < analyses. There was no difference between the

TABLE 1 Medians and IQR) for BDD and control participants on the self-report measures

BDD group Control group Scale n = 18) n = 18)

BDI-II 30.50 16.50±46.25) 2.50 0±6.25) RSE 30.00 28.00±36.00) 15.50 11.00±19.50) FNE 28.50 26.75±30.00) 14.50 7.75±19.50) BCQ subscales Private body consciousness 16.00 11.75±18.00) 9.00 7.75±12.00) Public body consciousness 20.00 15.50±22.00) 12.00 10.50±14.25) Body competence 8.00 6.75±9.00) 6.50 6.00±10.00)

BDI-II = Beck Depression Inventory-II; RSE = Rosenberg Self-Esteem Inventory; FNE = Fear of Negative Evaluation Scale; BCQ = Body Consciousness Questionnaire. IMAGES IN PEOPLE WITH BDD 5 patients and controls in reported frequency of features that took up a greater proportion of the spontaneous images/impressions Fisher's Exact whole image U = 39.50, p = .01) than control Test, p = .11). participants. The BDD images/impressions also involved organic sensations that were more vivid Characteristics of spontaneous U =6.00, p = .002) and intense U = 8.50, p = images/impressions .005). Median scores and IQR) for both groups can be seen in Table 2. Of those experiencing spontaneous images/ impressions, 17 94%) in the patient group and 7 The observer/mirror perspective 46%) in the control group reported these to be recurrent. The difference was significant Fisher's The median ratings for perspective of the images/ Exact Test, p = .002). impressions were 3.00 viewing myself completely from an external viewpoint, as if through the eyes Sensory modality characteristics of another, IQR = 3.00 to 3.00) for the BDD group and 73.00 viewing myself completely from my The median number of modalities reported for the own eyes, as if in a mirror, IQR = 73.00 to 73.00) images/impressions was 2.00 IQR = 1.00±2.00) for the control group. It is notable that the scale for the patient group and 1.00 IQR = 1.00±2.00) could have been collapsed, as participants used it for the control group. This difference was sig- as a categorical measure rather than a continuum, nificant U = 98.50, p = .04). utilising only extreme ends of the scale. All BDD The visual modality was the most commonly participants saw themselves from an observer reported sensory modality for both patients and perspective, while all control participants reported controls, followed by the organic modality. The the mirror perspective. latter consisted of feelings of anxiety, such as tingling sensations in the body part of concern and a feeling of butterflies in the stomach. No parti- Emotional tone of the images/ cipants reported gustatory or olfactory sensations. impressions

Differences between groups in The median participant ratings of the emotional imagery characteristics tone of their images/impressions were 73.00 IQR = 73.00 to 72.75) for the patient group and The BDD group reported images/impressions that 71.00 IQR = 71.00 to 71.00) for the control were visually more vivid U = 0.00, p < .001), group. BDD patients' ratings were significantly brighter U = 42.50, p = .02), more detailed U = more negative U = 28.50, p <.001) than the 32.50, p = .004), and involved facial and bodily control groups' ratings.

TABLE 2 Medians and IQR) of sub-modalities for the BDD and control groups

Characteristics BDD group Control group Significance level

n = 15, 83%) n = 12, 80%)

Visual Vividness 90.00 85.00±100.00) 10.00 7.50±17.50) **** Brightness 60.00 40.00±70.00) 35.00 10.00±50.00) * Detail 90.00 60.00±100.00) 60.00 12.50±68.75) *** Proportion of whole image 80.00 70.00±95.00) 50.00 40.00±60.00) *

n = 13, 72%) n =5,33%)

Organic internal sensations) Vividness 90.00 52.50±95.00) 12.50 8.75±51.25) *** Intensity 90.00 55.00±100.00) 37.50 17.50±56.25) *

*= p < .05, ** = p < .01, *** = p < .001. 6 OSMAN ETAL.

Characteristics of early memories The median number and IQR) of modalities associated with images/impressions reported for the BDD group early memories was 2.50 IQR = 0.75±4.00). As for images/impres- Of the 18 BDD patients who reported sponta- sions, the visual modality was the most frequently neous images/impressions, 15 88%) reported that reported sensory modality, followed by the they were associated with a particular stressful organic sensation modality. These memories were memory. The median age in years associated with also mainly viewed from an observer perspective the event that occurred in the memory was 11.50 median = 3, IQR = 2.00±3.00). Again, no patients IQR = 10.00±21.50). Typical themes included: reported the presence of gustatory or olfactory being teased and bullied at school e.g. ``I was 10 sensations. There was no difference between the years old and never got on with this boy in school. I median number of modalities reported in the remember one day asking him why he didn't like BDD groups' spontaneous images/impressions me and he said `it's because you're ugly'.'') and and early memories Z = 71.31, p = .19). self-consciousness about appearance changes Mean sensory similarity reported between the during adolescence e.g. ''I was very tall for my age spontaneous image/impressions and the asso- and I remember queuing up in the playground after ciated memories was 60%, mean emotional simi- break time one day and seeing my reflection in the larity was 65%, and mean interpersonal similarity hall window. My whole face and body seemed out was 71%. Inspection of the data suggested that of proportion and I was about two heads taller than there was generally a close match between everyone else.''). Inspection of the themes sug- reported modalities, i.e., patients who experi- gested that all the early memories could be placed enced a particular modality in their images/ in one or both) of these two categories. impressions were also likely to experience that Of the 15 control participants who reported modality in the associated memory. spontaneous images/impressions, only 2 13%) reported these to be closely linked to a particular Characteristics of early memories memory. The median age in which the memory accessed through verbal thoughts occurred was 13.00 IQR = 10.50±5.50). Sig- nificantly more BDD patients reported a parti- A total of 11 BDD participants 61%) and 2 cular memory associated with their images, x21) = control participants 11%) reported early mem- 14.07, p < .001, than control participants. ories associated with thoughts. This difference was Table 3 illustrates the number and percentage) significant, x21) = 6.48, p = .04. The median age of of BDD patients reporting each sensory modality the participants within the memories reported by represented within the associated early memories/ the BDD participants was 15.00 years IQR = experiences. One patient did not wish to discuss 10.00±22.50). This was not significantly higher their memory. The characteristics of the early than the median age 11.50, 10±21.50) in the memories reported thus relate to the remaining 14 reported early memories associated with images/ patients. For ease of comparison, the relevant data impressions Z = 71.65, p = .86). for images/impressions are also reproduced in this Finally, the images/impressions of the BDD table. participants were more likely than thoughts to be linked to stressful early memories, x21) = 3.74, p= .05. TABLE 3 Number and percentage) of BDD patients reporting sensory modalities within their images and associated memories DISCUSSION

Modality Images Early memory In line with the hypotheses, BDD patients were n = 18) N = 14) found to have significantly more spontaneously Visual 15 83%) 14 100%) occurring appearance-related images/impressions Organic internal) 13 72%) 12 85%) that were negative, recurrent, and viewed from an Auditory 1 6%) 8 57%) observer perspective, than control participants. Kinaesthetic 1 6%) 6 43%) These images/impressions were also more vivid Cutaneous 1 6%) 5 36%) and detailed, and typically involved a greater Gustatory 0 0 Olfactory 0 0 number of sensory modalities, the most common of which were visual and organic. Analysis IMAGES IN PEOPLE WITH BDD 7

revealed that these imagery characteristics could that may contribute to the development of BDD be reliably assessed over time. Given the sugges- symptoms, and that fail to update. Three pro- tion that people with BDD tend to selectively cesses suggested by Hackmann et al., 2000, in attend to interoceptive information Veale et al., relation to social phobia) might help to explain 1996), and the notion that visual imagery is the this phenomenon in BDD. The first is an atten- most common type of imagery Marks, 1973), the tional bias, and relates to the increased self- current finding that visual and organic sensations focused attention observed in BDD patients when predominate is not surprising. Other modalities negative appearance-related images arise e.g., in may predominate in other clinical populations front of a mirror, Veale & Riley, 2001). Second, consistent with the content of the disorder and BDD patients frequently avoid situations in which hypothesised psychological processes). For negative evaluation of appearance) by others is example, a recent study has indicated that the anticipated or, if such situations are not avoided, kinaesthetic and visual modalities were important subtle in-situation safety behaviours e.g., in people anxious about spiders Pratt, Cooper, & camouflage) are employed. Both of these pro- Q2 Hackmann, in press). cesses may prevent patients from noticing infor- Thus, while the occurrence of spontaneously mation that might correct their distorted negative occurring appearance-related images/impressions self-images. Third, when patients do receive was similar in both groups implying that the positive feedback about their appearance, this presence of such imagery is in fact common in usually occurs in verbal form and, as a con- both clinical and non-clinical populations), the sequence, may be poorly suited to modifying findings suggest that it is the quality of these visual images Hackmann et al., 2000). In addition images, rather than their presence, that differ- to these processes, information from others may entiates individuals with, and those without, be discounted as untrue by BDD patients e.g., BDD. ``they are only saying it to be nice to me'') or may The BDD patients reported more images/ not be considered of value, as some patients may impressions viewed from an observer perspective be more concerned with failure to achieve their than controls. Clark and Wells' 1995) model of own aesthetic ideals, than the demands of others social phobia suggests that observer perspective Veale, Kinderman, Riley, & Lambrou, 2003). imagery is partly constructed from interoceptive The observer perspective found in the images information. In BDD as in social phobia, part of of people with this disorder may be viewed as one the input may also be from memory of previous possible consequence of maladaptive attentional stressful experiences, where individuals have processes. Thus, it is conceivable that treatment come under scrutiny perceived as critical. Thus strategies aimed at the alleviation of dysfunctional imagery may be unlikely to convey an accurate self-focused attention might modify biased ima- impression of actual appearance. Interestingly gery in BDD. Wells and Papageorgiou 1998) Veale and Riley 2001) note that negative images demonstrated that exposure plus externally arise when BDD patients attempt to look in a focused attention produced greater reductions in mirror. They may avoid close scrutiny of the anxiety and negative beliefs than exposure alone actual reflection, and thus images do not get in people with social phobia. Moreover, the updated. By contrast participants without BDD, attention condition resulted in a significant shift who are presumably not over-worried about their from the observer to the field perspective in appearance, can and do look in mirrors. Memories imagery, while the exposure alone condition did may be formed of times when they occasionally not. see images discrepant with their usual appearance. The current study provides some empirical Images/impressions in the BDD group were evidence for the role of imagery in BDD, and thus typically considered to be linked to early stressful some preliminary support for Veale's 2002) memories. The age of BDD participants in these hypothesis that BDD patients view themselves as memories and the themes that emerged from an aesthetic object with extreme self-conscious- them provide support for models that identify ness. Existing cognitive models of BDD Veale et typical symptom onset in early adolescence e.g., al., 1996) have been revised to acknowledge the Rosen, Reiter, & Orosan, 1995; Veale et al., 1996). importance of these findings Veale, in press). Q3 The link between appearance-related images There are a number of limitations to this study. and early stressful experiences suggests that some An important conceptual limitation relates to the people may develop negative self-images early on vague and all-encompassing definitions of ima- 8 OSMAN ETAL. gery within the literature. As a result of this, other Clark, D. M., & Wells, A. 1995). A cognitive model sensory impressions were placed within the same of social phobia. In R. Heimburg & D. A. Liebo- category as images as in the study reported by witz Eds.), Social phobia: Diagnosis, assessment, and treatment, pp. 69±93). New York: Guilford Hackmann et al., 1998). This raises some impor- Press. tant empirical questions. Are ``images'' and Conway, M. A., & Pleydell-Pearce, C. W. 2000). The ``impressions'' considered by participants to construction of autobiographical memories in the denote similar phenomena, or are they seen as self-memory system. Psychological Review, 1072), qualitatively different, with the latter perhaps 261±288. Day, S. J., Holmes, E. A., & Hackmann, A. 2004). referring to a milder, less distressing type of ima- Occurrences of imagery and its link with early gery? Within the current study, participant num- memories in agoraphobia. Memory. bers were too small to allow for a comparison Hackmann, A. 1998). Working with images in clinical between images and impressions, and as a result, psychology. In A. S. Bellack & M. Hersen Eds), this is an important conceptual issue that requires Comprehensive , 6, 301±317. Amsterdam: Elsevier. further investigation. Hackmann, A., Clark, D. M., & McManus, F. 2000). The current study relied on verbal self- Recurrent images and early memories in social reporting as the main method of data collection. phobia. Behaviour Research and Therapy, 38, 601± However, describing one's cognitive processes 610. and conveying them accurately is not always Hackmann, A., Surawy, C., & Clark, D. M. 1998). Seeing yourself through others eyes: A study of straightforward and can be especially problematic spontaneously occurring images in social phobia. in the case of imagery Kendall & Korgeski, 1979). Behavioural and Cognitive Psychotherapy, 26, 3±12. Furthermore, while this study identified a link Horowitz, M. J. 1970). Image formation and cognition. between spontaneously occurring imagery and New York: Appleton Century Crofts. early memories, it would be presumptuous to Kendall, P. C., & Korgeski, G. P. 1979). Assessment and cognitive-behavioural interventions. Cognitive assume causality. More detailed qualitative and Therapy and Research, 3, 1±21. quantitative analysis is needed to clarify the pos- Lang, P. J. 1985). The cognitive psychophysiology of sible mechanisms involved. Future research emotion: Fear and anxiety. In A. H. Tuma & J. D. exploring imagery in BDD would benefit from a Maser Eds.), Anxiety and the anxiety disorders larger sample size, recruited from multiple set- pp. 131±170). Hillsdale, NJ: Lawrence Erlbaum Associates Inc. tings. The psychometric properties of the semi- Marks, D. F. 1973). Visual imagery differences in the structured interview also require further investi- recall of pictures. British Journal of Psychology, 64, gation. At present, studies of imagery within the 17±24. psychological disorders tend to be disorder- Miller, L. C., Murphy, R., & Buss, A. H. 1981). Con- specific. However, the observed link between the sciousness of body: Private and public. Journal of Personality and Social Psychology, 41, 397±406. observer perspective and social-evaluative con- Phillips, K. A., Hollander, E., Rasmussen, S. A., cern in both social phobia and BDD suggests that Arnowitz, B. R., DeCaria, C., & Goodman, W. 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