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ORIGINAL ARTICLERepetitive, Safe, and Automatic: The Experience of AppearanceRelated Behaviours in Body Dysmorphic DisorderAlissa Oakes, James Collison, and Jo Milne-HomeSchool of Social Sciences and Psychology, Western Sydney UniversityObjective: Body dysmorphic disorder (BDD) entails a preoccupation with a perceived appearance defect, which causes distress and/or functionalimpairment. The individual must also perform repetitive behaviours in response to these concerns (e.g., mirror checking, excessive grooming).Prior research has focused primarily on preoccupation, and behaviours have rarely been examined. As such, there is limited insight regarding howthese activities are perceived by the sufferer. This study therefore examined how individuals with BDD experience these behaviours.Method: Eight individuals diagnosed with BDD completed a 60-min, semi-structured interview. Inductive thematic analysis was employed toinvestigate semantic themes within the data.Results: Three themes emerged: “Routine and repetitive”, “Safety through control,” and “Natural and automatic.” These findings portray a complexexperience of distressing activities that may also provide comfort and safety, in time coming to embodying what “normal” constitutes for the individual.Conclusions: The experience of BDD behaviour is complex. Camouflaging and using make-up provided a sense of relief and/or reassurance,whereas other behaviours were reported as distressing and likely to promote further concerns. Ironically, participants were seemingly dissatisfied with these symptoms, while also drawing comfort and a sense of identify from them. This inconsistent pattern of reward and punishment supports existing conceptual models of BDD, and may explain why these symptoms are so difficult to manage and/or change (i.e., vianegative reinforcement). It also suggests that different types or categories of behaviour may exist for BDD (e.g., checking vs fixing behaviours), reflecting different functions and/or underlying motivations among individuals.Key words: appearance-related behaviour; BDD behaviour; body dysmorphic disorder; qualitative investigation; thematic analysis.What is already known on this topic1 Appearance-related behaviours are a common clinical featureof body dysmorphic disorder (BDD) and a newly added symptom in DSM-5 nosology.2 BDD behaviours are thought to be distressing and cause functional impairment (American Psychiatric Association, 2013).3 The only previous qualitative study on BDD reported on theexperience of BDD, but did not explore its behavioural symptoms in detail.What this paper adds1 Some BDD behaviours are negatively reinforcing(e.g., camouflaging), while others are positively punishing(e.g., mirror checking).2 The lived experience of BDD behaviour is multi-faceted. Theseactivities may provide reassurance and a sense of identity, butthey are also distressing and cause significant functionalimpairment.3 BDD behaviour is complex and may not follow the anxietyreduction mechanisms seen in obsessive-compulsive disorder.This finding is consistent with existing literature, and conceptualmodels of BDD should reflect this. When treating, BDD cliniciansshould recognise the complex relationship an individual may havewith their behaviours and the notable reluctance participantsreported about giving them up.Body dysmorphic disorder (BDD) is a debilitating psychiatriccondition (Phillips, 2005). It is characterised by a distressingpreoccupation with a perceived defect in one’s appearance,repetitive appearance-related behaviours (e.g., mirror checking,skin picking), and/or cognitions (e.g., imaginal surgery), andsubsequent functional impairment in social and occupationalCorrespondence: James Collison, School of Social Sciences and Psychology, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751,Australia.Email: [email protected] for publication 20 July 2016doi:10.1111/ap.12247bs_bs_bannerAustralian Psychologist 52 (2017) 433–441© 2016 The Australian Psychological Society433settings (American Psychiatric Association, APA, 2013).Appearance preoccupations commonly extend to the face, skin,nose, and hair (Allen & Hollander, 2004; Phillips et al., 2010),and often involve multiple body parts (Hart & Phillips, 2013).They are experienced as unwanted and persistent thoughts,consuming some 3–8 hr per day (Phillips, Gunderson, Mallya,McElroy, & Carter, 1998).BDD typically begins in adolescence, and tends to have achronic and continuous course when left untreated (Bjornssonet al., 2013; Phillips, Menard, Fay, & Weisberg, 2005). Individuals experience high levels of distress, poorer quality of life(Marques et al., 2011), and greater functional impairment(Didie, Menard, Stern, & Phillips, 2008). For example, approximately 30% are unable to work or attend school because oftheir symptoms, while most avoid virtually all social and occupational activities (Didie et al., 2008; Phillips, McElroy, Keck, &Pope, 1993). Comorbid depression is therefore common, withsuicidal ideation present in some 78–81% of all cases, while24–28% report lifetime rates of attempted suicide (Phillips,2007; Phillips, Coles, et al., 2005). BDD is prevalent in about1.7–2.4% of community and university samples (Buhlmannet al., 2010; Koran, Abujaoude, Large, & Serpe, 2008; Rief,Buhlmann, Wilhelm, Borkenhagen, & Brähler, 2006),1.8–54.3% of psychiatric outpatients (Grant, Kim, & Eckert,2002; Nierenberg et al., 2002; Semiz et al., 2008), and approximately 16.0% of psychiatric inpatient facilities (Conroy et al.,2008; van der Meer et al., 2012).Despite its relative severity, BDD remains an under-researchedcondition that is commonly misdiagnosed and misunderstood(Neziroglu & Santos, 2013). One area that has garnered attention recently is BDD behaviour. The Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition (DSM-5; APA, 2013)classifies BDD as an “obsessive compulsive and related disorder,”noting that virtually every individual reports appearance-relatedbehaviour. Commonly occurring activities include mirror checking or mirror avoidance, comparing one’s appearance to others,camouflaging, repetitive or excessive grooming, covering up orhiding the perceived imperfection, exercising, and investigating/undertaking cosmetic or dermatological procedures (Hraboskyet al., 2009; Phillips & Hollander, 2008; Phillips, Menard, et al.,2005). Many behaviours can also be highly idiosyncratic, meaning there may be limitless variation among individuals (Veale &Neziroglu, 2010). Like the appearance preoccupations, thesebehaviours are time consuming and repetitive, occurring frequently throughout the day and occupying much of an individual’s time (Phillips, 2005).BDD behaviours are difficult to resist or control (Phillips,1996; Phillips, Menard, et al., 2005) and are thought toreduce/prevent the distress associated with the perceiveddefect. They are subsequently regarded as key maintaining factors in the disorder’s ongoing presentation. For example, existing behavioural (Neziroglu, Khemlani-Patel, & Veale, 2008),cognitive (Wilhelm & Neziroglu, 2002), and cognitivebehavioural (Phillips, 2005; Veale & Neziroglu, 2010) modelsall conceptualise appearance-related behaviours as attempts tocope with intrusive and/or negative thoughts about appearance, which ironically serve to increase self-awareness andintensify the appearance preoccupation. That is, any shortterm reduction in distress is negatively reinforcing,maintaining the behaviour over time (Chance, 2009; Nezirogluet al., 2008). By comparison, activities that confirm one’s negative beliefs are positively punishing, promoting additionalbehaviours and increasing the desire to engage with one’sappearance. These behaviours may subsequently be a “doubleedged sword,” fostering preoccupation and distress regardlessof the outcome. However, investigations of BDD behaviourhave been infrequent and empirical research is sparse. Themotivations underlying these activities are therefore poorlyunderstood, and many components of these models have yetto be tested.Just five studies have explored BDD behaviour in any detail,and only three have involved clinical samples. No study hasexamined behaviours beyond mirror checking/avoidance orexplored what the experience is like for the individual, nor hasany study adopted an open-ended or qualitative design. Mirrorgazing and mirror avoidance are the most researched behaviours, being present in approximately 80% (checking) and20% (avoiding) of individuals, respectively (Veale & Riley,2001). Using retrospective methods and forced-choiceresponses, Veale and Riley (2001) compared BDD (n = 52) andcontrol (n = 55) participants on mirror gazing, finding theformer were motivated by the “desire to know what theylooked like,” the “hope that this would be different to whatthey expected,” and a belief that “they would feel worse if theydid not.” They also revealed a positive correlation betweenamount of time spent gazing and self-consciousness and negative self-perceptions, while BDD participants were more likelythan controls to feel distress both before and after mirrorchecking.In a live study, Windheim, Veale, and Anson (2011) reportedthat both BDD (n = 25) and control (n = 25) participants experienced elevated distress after gazing for a short period of time,but during an extended gazing session, controls actuallyreported higher levels of distress. This finding suggests that mirror behaviour does not follow an anxiety-reduction process,since the presence of distress both before and after gazingshould decrease the behaviour (Chance, 2009). That group differences were only evidenced in one condition would also indicate that some other phenomenon may mediate therelationship between mirror checking and distress. Indeed, topersist with an emotionally distressing behaviour would likelyrequire some internalised or cognitive motivation, sufficient forthe individual to tolerate emotional discomfort. To investigatethis, Baldock, Anson, and Veale (2012) retrospectively compared the stopping criteria for mirror gazing among BDD(n = 21) and control (n = 18) participants. Using a speciallydesigned measure involving forced-choice responses, theyfound that BDD patients were more strongly motivated byinternal goals (e.g., being satisfied with their make-up),whereas Non-BDD participants were more strongly motivatedby external ones (e.g., seeing if the make-up was correctlyapplied). However, the termination criteria among BDD participants were not aligned with their internal goals, instead corresponding with feelings of distress and frustration, as well astime constraints. Mirror behaviour is subsequently a morecomplex set of activities than may appear, and it seems likelythat these behaviours reflect more than a simple desire toreduce one’s distress by confirming their appearance.BDD behaviour A Oakes et al.434 Australian Psychologist 52 (2017) 433–441© 2016 The Australian Psychological SocietyBeyond mirror behaviour, Grant, Menard, and Phillips(2006) and Phillips, Conroy, et al. (2006) have reported on theprevalence and distribution of pathological skin picking andexcessive tanning, while several others have broadly reportedon the presence/absence of certain behaviours (e.g., mirrorchecking, reassurance seeking, grooming, camouflaging,appearance comparisons; Albertini, Phillips, & Guevremont,1996; Cansever, Uzan, Donmez, & Ozsahin, 2003; Fontenelleet al., 2006; Grant et al., 2006; Perugi et al., 1997). However,no study has explored the pathology of any other behaviour,and it is entirely unclear whether mirror behaviours are aunique set of activities or whether the processes reported previously are generic ones. Likewise, studies have yet to investigatewhat motivates an individual to perform the variety of otherBDD behaviours reported in the literature, or what the experience of living with these actions and their consequences maybe like. Indeed, what little research is available has been gathered via retrospective methods, self-report surveys with forcechoice responses, and/or closed interviews, and there is subsequent need for inductive investigations to better understandBDD’s new behavioural symptoms.Aims of the Current StudyBDD behaviours are largely understudied and additionalresearch is required (Kollei, Rauh, De Zwaan, & Martin, 2013)particularly into activities beyond mirror gazing and/or avoidance. The available research portrays a complex picture ofsafety behaviours that do not adhere to simple models ofreward and punishment. However, these data are limited in itsreliance on retrospect self-report, as no studies involving qualitative methods have been conducted. In fact, there has beenjust one qualitative investigation of BDD to date (i.e., see Silver & Reavey, 2010 and Silver, Reavey, & Fineberg, 2010), andthere is a major dearth of such research. As such, little isknown about the experience of BDD behaviour and/or themotives that underlie such activities, and we retain only a limited understanding of how these symptoms are experienced.This study therefore aimed to explore the lived experience ofBDD behaviour, in order to better understand the nature ofthese complex symptoms.MethodParticipantsTwenty-two community volunteers completed an online survey and consented to a follow-up interview. Twelve were notcontacted for interview after reporting a diagnosis other thanBDD in the initial survey, while two participants were contacted regarding an interview but did not respond. Thus, thereported interview data were collected from eight individuals(five female, Mage = 35 years, SD = 9.41, range = 27–46).Each reported a diagnosis of BDD and screened positively forthe disorder via a self-report measure. Existing diagnoses weremade between 2002 and 2015, with three participants theirdiagnosis from a psychiatrist and five from a clinical psychologist. All but one reported some comorbid condition in theirlifetime, including depression (n = 4), the eating disorders(n = 3), obsessive-compulsive disorder (OCD) (n = 1), socialanxiety disorder (n = 2), bipolar disorder (n = 1), posttraumatic stress disorder (n = 1), borderline personality disorder (n = 1), and agoraphobia (n = 1).Countries of residence included the United Kingdom (n = 4),United States of America (n = 2), Australia (n = 1), and India(n = 1). One participant was married, two were in new relationships of 3 months or less, and the remaining five were single. Three participants were being treated with some form ofmedication (e.g., sertraline, citalopram), two were currentlyengaged in cognitive-behaviour therapy, and two reported nomedical or therapeutic intervention at present. One participantwas undertaking “counselling” while also receiving medicationfor their BDD. Six participants had received some form of medication and/or cognitive-behaviour therapy in the past, reporting these to be “not effective.” Two participants reported nopast interventions of any kind, prior to their current treatment.All participants were at least 18 years old.MaterialsDemographic questionnaireEight questions gathered relevant demographic data regardingage, gender, occupation, relationship status, education, andaddress. Information was also gathered on current and/or pastpsychiatric diagnoses, and the nature and type of any currentor previous treatments. Participants were also asked to describeany appearance-related behaviours they currently performed.Body dysmorphic disorder questionnaireThe body dysmorphic disorder questionnaire (BDDQ; Phillips,Atala, & Pope, 1995) was used to support/confirm reporteddiagnoses of BDD. The BDDQ is a widely used, four-item selfreport diagnostic screen for BDD. Psychometric properties havebeen investigated in several studies, with a reported specificityof 100% and a sensitivity ranging from 89% to 93% amongstpsychiatric outpatient and inpatient settings (Dufresne, Philips,Vittorio, & Wilkel, 2001; Grant, Kim, & Crow, 2001; Phillipset al., 1995). The BDDQ’s brevity makes it useful across varioussettings (e.g., Baldock et al., 2012; Conrado et al., 2010; Conroyet al., 2008), and it is arguably the most frequently employeddiagnostic screen for BDD (Veale & Neziroglu, 2010).Interview scheduleA series of open-ended questions was derived to form a semistructured interview, starting with an item that exploredand/or confirmed the individual’s diagnos

is (i.e., “How did youcome to be diagnosed with BDD?”). Questions were administered in a semi-structured fashion from this point, with participants free to discuss whatever themes they felt relevant. Thus,the researcher progressed to additional items only after the participant had seemingly exhausted their interest for any givenquestion, and/or displayed no interest in continuing to discussthat question. The interview explored a number of topicsrelated to BDD behaviour, such as what (if any) appearancerelated activities were present for each individual (i.e., “Do youA Oakes et al. BDD behaviourAustralian Psychologist 52 (2017) 433–441© 2016 The Australian Psychological Society435do anything about your body part, or have you done anythingto change it?”), whether any particular reasons or motivationdrove those behaviours (i.e., “Can you give me some reasonswhy you do this?”), and how the individual felt about not carrying out these behaviours (i.e., “How would you feel aboutstopping this behaviour?”). Using other prompts and unstructured questions, participants were encouraged to discuss theirbehaviours in an open and non-judgemental fashion, with theoverall purpose to understand the lived experience of thesenewly designated symptoms.ProcedureInitial contact was made via a flyer that was distributedthrough the Western Sydney University (WSU) PsychologyClinics, local psychologists, and traditional/online media. Theflyer was also made available to participants from a previousstudy on BDD at WSU, who had indicated their desire toengage in any future research. The flyer invited participants tocomplete an online survey, which collected demographic dataand information about BDD behaviour. The survey also invitedparticipants to be contacted by the researcher for an interviewabout their symptoms. Consent for the survey was gatheredprior to its completion and stored separately to participantresponses. Participants who elected to be interviewed werethen provided with a participant information sheet, before providing informed consent via email. The researcher also prepared emergency contacts for each participant prior to theirinterview (e.g., details of local hospitals), in the event of significant distress or concerns. Interviews were conducted via Skypeand lasted an average 60–75 min. They were also limited toaudio to reduce any impact the researcher’s appearance mayhave had on the participant. Participants were debriefed at theend of each interview and thanked for their time. Participantswere recruited in this fashion until no new data emerged fromthe interview questions. This study was approved by the WSUHuman Research Ethics Committee (No: H11085).Data AnalysisInterview transcripts were analysed via an inductive thematicanalysis (Braun & Clarke, 2006), using an essentialist–realisttheoretical framework. This perspective was adopted as it islargely free of prior theoretical assumptions and allows forinterpretation of themes at a semantic level (i.e., where theresponse are taken at face value). Following Braun andClarke’s (2006) recommendations, each transcript was readseveral times for content familiarity prior to analysis. Transcripts were then coded, with codes collated into themes andsub-themes across the data. Each interview was then reviewedto ensure identified themes reflected the core experience, asdescribed by all participants. These themes were refined,defined, and named before extracts were selected that reflectedthese themes and the participants’ experience. All data werecollected, coded, and analysed by the same researcher. Pseudonyms are reported currently to protect each participant’sidentity.ResultsThree themes were identified from the analysis: (a) “Routineand Repetition,” (2) “Safety through Control,” and (3) “Automatic and Natural.” The full analyses for each participant areavailable from the authors upon request.Routine and RepetitionAll eight participants reported repetitive and ritualised behaviours related to their appearance concerns. Participantsendorsed anywhere from 3 to 15 separate behaviours, most ofwhich were performed on a daily basis and took several hoursto complete. The most frequently reported behaviours weremirror checking (n = 8), excessive camouflaging with clothes(n = 5), other forms of camouflaging (e.g., with make-up,hands, sunglasses) (n = 5), appearance comparisons (n = 5),mirror avoidance (n = 4), plastic surgery or dermatologicalinvestigations (n = 4), and body part touching (n = 3). Behaviours reported by one or two participants included skin picking, tanning, standing/positioning the body in a certain way,hair removal, avoiding viewing oneself naked, excessive weighing, excessive measuring of body parts, teeth brushing, excessive exercising, and avoiding photographs.While most participants generally differed from one anotherin the pattern of behaviours they endorsed, they shared a number of commonalities. Every participant endorsed mirror checking as a feature of their disorder, while six reported theirappearance-related behaviours were part of a daily routine thatneeded to be completed in order for them to feel comfortableabout their appearance.BC: “I spend a lot of time calculating and assessing what their skinlooks like in comparison to mine: ‘is their skin darker than mine, istheir skin lighter than mine, have they spent more time in the sunthan I have, have they got other distinguishing features that makethem look their age?’ and I normally come out worse.”JK: “When I wake up in the morning I look in the mirror face-on,and then I turn to the left to see how I look from the side, then theother side. Then I look at my individual body parts, for examplehow big my stomach might look, how big my arms might look, howbroad my shoulders might look … I always do it before I leave thehouse so as long as I’ve done it before I’ve left the house then findthat in my head that’s ok.”One exception to the routine was mirror checking and mirror avoidance, as several participants reported switching fromchecking to avoiding and vice versa. This change between thetwo contrasting behaviours depended on several different factors, such as the participant’s mood at the time, lighting, location, and the type of mirror.FE: “in the morning I would often spend just ages checking, in afull length mirror,” before adding “I’ll look in the mirror and becompletely disgusted and sometimes avoid it … I’ve seen myself inthe mirror and the reality of what I look like and decided that’ssomething I don’t want to see again.”ZT: “If I don’t like what I see I can stay in the mirror searching outfor something that, some redeeming feature,” but then added “thereBDD behaviour A Oakes et al.436 Australian Psychologist 52 (2017) 433–441© 2016 The Australian Psychological Societymight be a time on the previous day when I’ve looked in the mirrorand it hasn’t been a good experience and I kinda want to avoid itfor a bit.”Safety Through ControlSix of the eight participants reported that performingappearance-related behaviours led to a sense of comfort andsafety, providing positive emotional support in the face of theirperceived defect. This included safety from the judgement ofothers, as feeling judged for one’s perceived flaw is a key feature of BDD. For example, JJ reported that she felt “safer, protected, it’s like my security blanket … I’m just trying to protectmyself from being judged.” Connected to the benefit of feelingsafe or protected, the majority of participants also reported thattheir behaviours gave them a sense of control. They felt thatthey could not control the flaw itself, but could control itsappearance and whether others may see it.JK: “You can’t control it but what you can control is your makeup… I feel better and I feel more in control after I’ve got my makeupon. I feel more protected if that’s a good way of putting it.”LC: “They (behaviours) would always make me feel like I had asense of control, a sense that I could overcome this terrible physicalailment or disease or condition (the flaw) that I had.”Another positive effect that participants spoke of was usingtheir behaviours as a mask to hide themselves from being ondisplay. In particular, makeup and/or excessive clothing wasseen as a barrier or mask to hide them, with one participanteven attempting to hide her flaws from herself.BC: “If it was something that I’d tried to cover up, I’d tried to coverit up so that I couldn’t see it, I couldn’t experience it. So if I allowedanybody else to see it, it would mean that I had seen it or felt it orexperienced it and I didn’t want to. I was trying to hide it frommyself really.”JJ: “People can’t see all of me for who I am … they (behaviours)are hiding me from people. They are hiding the ugliness.”JK: “I don’t feel as vulnerable when I go out of the house or somebody comes around. I feel like it’s a barrier between me and whatother people might think of me or think of what I look like.”Natural and AutomaticFive participants reported that their behaviours felt natural andautomatic, and were carried out without hesitation or conscious thought. Several individuals reported their symptomshad become so fully internalised that they were no longer ableto conceptualise what behaving “normally” would involve. Forexample, JK reported that “I don’t even really think aboutwhat I’m doing. I’m aware that I’m doing it, but it’s just naturalto me now. It doesn’t feel weird or abnormal to me, it feels likeI’ve got to do it as it’s normal.” The majority of participants alsosaid that they did not wish to stop their behaviours, and thatthis was driven either by fear or their right to continue. Indeed,all participants had reportedly been offered psycho-educationregarding the unhelpful nature of their behaviours, but hadcontinued with their activities nonetheless. This may indicate adegree of resistance towards change and/or treatment, suggesting that in some instances participants would prefer to retaintheir behaviours despite the pain they cause.FE: “I don’t even know if I feel anything you know. I think it’salmost like I switch off.”JJ: “I just don’t even think about them. If a fly landed on your noseyou would brush it away. That’s just my kinda like breathing.Someone makes you happy you smile, someone looks at me, I coverup. I don’t know how I would stop … part of me wouldmiss them.”JK: “I’d feel lost if I wasn’t doing my mirror checks and putting onall my makeup and all the little things I do. I’d feel lost not doingthat because I’ve done it for so long.”BC: “If someone tried to stop me doing those behaviours, I wouldsee that as an affront because that is who I am and it is my entitlement to conduct my rituals for myself.”DiscussionThis is the first study to examine BDD’s behavioural symptomsfrom the experience of the individual and only the secondqualitative study on BDD. Consistent with Silver et al. (2010),the method was well accepted by participants, and severalexpressed gratitude at being afforded an opportunity to discusstheir experiences in a research context. There is a need foradditional qualitative investigations of BDD in the future.“Routine and Repetition” was the most common theme, witheach participant identifying at least three behaviours that wereperformed daily, accompanied by secondary behaviours thatwould occasionally vary. This is consistent with prior research,where the most frequently reported activities include mirrorchecking, comparing one’s appearance with others, andcamouflaging (Lambrou, Veale, & Wilson, 2012; Phillips,Menard, & Fay, 2006; Phillips, Menard, et al., 2005), but it isalso consistent with the notion that BDD behaviours can behighly idiosyncratic and varied. This is also congruent with theidea that appearance-related behaviours are an important clinical feature of the disorder (Phillips, Didie, et al., 2006), andsupports their inclusion as relevant diagnostic symptoms inDSM-5 (APA, 2013). There was also clear evidence for theintertwined nature of mirror checking and mirror avoidance, asthe majority of participants reported switching between theseactivities dependent on various factors, such as their mood atthe time, the type of mirror, lighting, or their last experiencewith the mirror. This supports previous reports that individualsmay fluctuate between behaviours over time (e.g., Neziroglu &Khemlani-Patel, 2003; Phillips, 1991), but is at odds with suggestions that people could be classified along categories of“checkers” or “avoiders” (e.g., Cassin & Rector, 2012).Interestingly, while most individuals reported the same typesof appearance-related behaviours, there was also notable variation in motivation and purpose. For example, JK reported mirror checking to ensure that she looked acceptable beforeleaving her house, as others would see her. Similarly, BC spokeof analysing her skin in comparison to others in order to see ifA Oakes et al. BDD behaviourAustralian Psychologist 52 (2017) 433–441© 2016 The Australian Psychological Society437hers was acceptable on several different factors, such as itslightness, sun-effects, and ageing. Here, two different behaviours shared a common underlying motivation (i.e., to ensureone’s appearance is acceptable in relation to others), suggestingthat seemingly disparate activities may actually reflect variations along the same theme. This is consistent with researchthat individuals have their own internal goals when performingsuch behaviours (Baldock et al., 2012), and supports Veale andNeziroglu’s (2010) notion that BDD behaviour could begrouped into categories based on their apparent function,rather than their descriptive features. Thus, behaviours such asmirror checking or reassurance seeking may serve to establishwhether the defect is acceptable, whereas camouflaging orgrooming may underscore a desire to hide or improve a defectthat is already acknowledged by the individual as unacceptablefor others to see. However, further research is required toestablish whether unique classes or groups of behaviour existfor BDD, in the way they do for other disorders. Future studiesmay therefore wish to explore this notion quantitatively, witha particular emphasis on developing measures that could assistclinicians in assessing BDD’s behavioural symptoms“Safety Through Control” encompassed the perceived benefits felt after performing appearance-related behaviours. Thistheme is consistent with the notion that BDD behaviours maybe negatively reinforcing (e.g., Neziroglu et al., 2008; Wilhelm & Neziroglu, 2002), serving to reduce uncertainty, distress, and anxiety. However, this finding was also unexpectedto a degree, as it runs counter to the notion that appearancerelated behaviours increase distress (e.g., APA, 2013; Baldocket al., 2012; Veale & Riley, 2001; Windheim et al., 2011). Thismay reflect the fact that this study assessed behaviours beyondmirror checking and/or avoidance, as several participants spokeof safety and control in regards to camouflaging and the use ofmake-up, but did not explicitly state whether this feelingextended to other activities. It may be that different behaviourselicit different outcomes, such that camouflaging is more likelythan mirror checking to promote a perception of safety andcomfort. For example, viewing one’s appearance is central tothe act of mirror checking, but can be optional for camouflaging. Perhaps, it is simply easier to satisfy the internal goals offeeling protected and safe through camouflaging than it isthrough mirror checking, as there are fewer triggers/cues todistressing appearance-related thoughts (Veale & Neziroglu,2010). Alternatively, this finding may reflect a latent differencein the beliefs that motivate each behaviour. For example, manyindividuals who engage in mirror checking report doing so inthe hope that their appearance may look acceptable (Phillips,2005). By comparison, those who camouflage have alreadyaccepted that a defect is present and are seeking to lessen itsimpact. Thus, camouflaging may be experienced as an activeattempt to cope with a very real and embarrassing physicalproblem, in turn promoting a more positive self-appraisal relative to activities such as mirror checking.It seems likely that BDD behaviours are both negatively reinforcing (Neziroglu et al., 2008) and positively punishing(Veale & Riley, 2001),