European Journal of Psychological

Assessment
The Appearance Intrusions Questionnaire: A Self-Report
Questionnaire to Assess the Universality and
Intrusiveness of Preoccupations About Appearance
Defects
Martha Giraldo-O’Meara and Amparo Belloch
Online First Publication, June 28, 2017. http://dx.doi.org/10.1027/1015-5759/a000406

CITATION
Giraldo-O’Meara, M., & Belloch, A. (2017, June 28). The Appearance Intrusions Questionnaire: A
Self-Report Questionnaire to Assess the Universality and Intrusiveness of Preoccupations About
Appearance Defects. European Journal of Psychological Assessment. Advance online
publication. http://dx.doi.org/10.1027/1015-5759/a000406
Multistudy Report

The Appearance Intrusions

Questionnaire
A Self-Report Questionnaire to Assess the Universality
and Intrusiveness of Preoccupations About Appearance
Defects
Martha Giraldo-O’Meara and Amparo Belloch

Department of Personality Psychology, Research Unit for Obsessive-Compulsive and Related Disorders, I’TOC,
Universidad de Valencia, Spain

Abstract: This study aims to examine whether Body Dysmorphic Disorder (BDD) related preoccupations might consist of unwanted intrusive
cognitions, and if so, their degree of universality, its dimensionality from normality to BDD psychopathology, and their associations with
symptom measures. The Appearance Intrusions Questionnaire (AIQ) was designed to assess intrusive thoughts related to appearance defects
(AITs). A sample of 410 undergraduate university students completed a former 54-item version of the AIQ. Principal Components Analyses
(PCA) and Parallel Analysis yielded a five-factor structure and a reduction to 27 items. The 27-items AIQ was examined in a new sample of 583
non-clinical community participants. Confirmatory Factor Analyses (CFAs) grouped the AITs in five factors: Defect-related, Others-related,
Concealment, Bodily functions, and Urge to do something. Up to 90% of the participants experienced AITs. The AIQ scores were more
associated with BDD, Obsessive-Compulsive Disorder (OCD), and body image measures than with worry, suggesting that AITs are closer to
obsessional intrusions than to worries. The new AIQ might be a valid and reliable measure of AITs and would help to reliably detect individuals
at risk for BDD in nonclinical populations using a brief self-report.

Keywords: Body Dysmorphic Disorder, intrusive thoughts, Obsessive-Compulsive Disorder, appearance defect-related intrusive thoughts,
Appearance Intrusions Questionnaire

Body Dysmorphic Disorder (BDD) is a disabling disorder in
which patients are highly distressed by preoccupations
about nonexistent or slight defects in physical appearance.
These appearance-related preoccupations are difficult to
resist or control and time-consuming (DSM-5, American
Psychiatric Association [APA], 2013). Patients are reluctant
to discuss their appearance concerns. Although they
may seek treatment for comorbid disorders, they tend to
conceal their BDD symptoms, even to clinicians (Bjornsson,
Didie, & Phillips, 2010; Wilhelm, Buhlmann, Hayward,
Greenberg, & Dimaite, 2010). The preoccupations can be
about any particular area of the body, although over the
course of the disorder, some patients may be concerned
with every body area (Wilhelm, Phillips, & Steketee,
2013), whereas other patients may feel that their general
physical appearance is “ugly” or deformed. Appearance
preoccupations are not usually based on genuine or real
defects, and if the defect does exist, it would not be
especially noticeable to others.
Preoccupations about appearance defects and body
image concerns are nearly universal, and they are probably
a consequence of social normative pressures about one’s
figure and appearance (Striegel-Moore & Bulik, 2007).
These pressures are quite relevant during adolescence; in
fact, BDD typically begins in early adolescence (Phillips
et al., 2006). The universality of preoccupations about
physical appearance defects suggests a dimensionality of
these thoughts (Wilhelm & Neziroglu, 2002) on a contin-
uum ranging from normality to BDD psychopathology.
Preoccupations with defects in physical appearance are
the main diagnostic criterion for BDD in the DSM-5 (i.e.,
Criterion a). However, “preoccupation” is a term that
should be better operationalized (Phillips et al., 2010).
It can refer to rumination (Nolen-Hoeksema, Wisco, &
Lyumbomirsky, 2008), worry (Wells, 1999), or obsessions
(Phillips et al., 2010), the key thought processes defining
depression, generalized anxiety, and Obsessive-Compulsive
Disorder (OCD), respectively. Phillips et al. (2010) argued

European Journal of Psychological Assessment (2017) Ó 2017 Hogrefe Publishing

DOI: 10.1027/1015-5759/a000406
2 M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire
that neither obsessions nor worry can capture the maladap-
tive thought process in BDD, whereas rumination is
characterized as a chain of passive, catastrophizing, nega-
tive, and repetitive thoughts that usually take a verbal or
linguistic form, as occurs with worry (Clark & Rhyno,
2005). Other authors consider that BDD preoccupations
have an obsessive quality because they are distressing,
intrusive, time-consuming, unwanted, and difficult to resist
or keep under control (Abramowitz & Jacoby, 2015;
Wilhelm et al., 2013), the same characteristics present in
the OCD phenomenology.
The current inclusion of BDD in the OCD spectrum
disorders in the DSM-5 raises the question of whether
BDD preoccupations might consist of unwanted intrusive
thoughts, images, impulses, or sensations, and more impor-
tantly, whether these intrusions might be an etiological fac-
tor in the development of BDD, comparable to the role of
obsessional intrusive thoughts in the development of
OCD (Rachman, 1981). Unwanted and distressing intrusive
cognitions have been a main topic in the research on OCD
since the pioneering work by Rachman and de Silva (1978),
who postulated that obsessions were extreme variants of
normal unwanted thoughts, images, and impulses. Since
then, these unwanted cognitions have also been described
in other mental disorders, such as posttraumatic stress
disorder (e.g., Michael, Ehlers, Halligan, & Clark, 2005),
insomnia (e.g., Harvey, 2000), and eating disorders (e.g.,
Belloch, Roncero, & Perpiñá, 2016; Blackburn, Thompson,
& May, 2012; García-Soriano, Roncero, Perpiñá, & Belloch,
2014).
Several self-report measures and structured clinical
interviews have been designed for BDD screening,
assessment, and/or diagnosis. Examples are the Body
Dysmorphic Disorder Questionnaire (BDDQ; Phillips,
Atala, & Pope, 1995), Body Dysmorphic Disorder Examina-
tion (Rosen & Reiter, 1996), Dysmorphic Concern
Questionnaire (Oosthuizen, Lambert, & Castle, 1998),
Body Image Concern Inventory (Littleton, Axsom, & Pury,
2005), and Appearance Anxiety Inventory (Veale et al.,
2014). However, these self-reports do not assess whether
BDD preoccupations consist of appearance-related intru-
sive thoughts (AITs), defined as brief, discrete, sudden,
unintended, recurrent, difficult to control, interfering, and
unexpected thoughts that can also be experienced as
impulses, urges to do something, images, or sensations
and feelings (Clark & Rhyno, 2005; Rachman, 1981).
In sum, despite the importance of preoccupations about
physical appearance defects in BDD phenomenology, and
their functional similarities with the intrusive cognitions
found in OCD, to our knowledge no studies have specifi-
cally examined whether these preoccupations consist of
recurrent and unwanted intrusive thoughts, images,
impulses, and/or sensations about appearance defects.
Ó 2017 Hogrefe Publishing
Obtaining data about this possibility would help to under-
stand the escalation from normal but distressing intrusive
cognitions about appearance defects to clinically significant
BDD symptoms. Additionally, it would also help to better
understand the phenomenological and clinical similarities
between BDD and OCD. From this perspective, the first
step is to examine whether nonclinical individuals have
unwanted and distressing intrusive cognitions about
appearance defects, which was the objective of this study.
To this end, the following process was carried out. First, a
self-report was elaborated to specifically assess the pres-
ence, contents, and frequency of AITs in nonclinical indi-
viduals. Second, the structure of the new instrument was
validated in a new sample. Third, the associations of AITs
with different signs of psychopathology, both BDD and
non BDD-related, were examined. To approach the dimen-
sionality of AITs from normalcy to BDD psychopathology,
differences in the frequency of these thoughts between
individuals at risk of BDD and those with no risk were ana-
lyzed. These steps are presented through three consecutive
studies.
Study 1
The objective of this study was to explore whether
nonclinical individuals have distressing and unwanted
intrusive thoughts, impulses, images, and/or feelings about
appearance defects, and if so, how often. Therefore, a
specific self-report questionnaire, the Appearance Intrusions
Questionnaire (AIQ), was designed to assess distressing
intrusive cognitions about physical appearance defects,
and its internal structure and properties were examined
(Parallel and Principal Components Analyses, PCA).
Method
Participants
A group of 410 Spanish undergraduate university students
who attended introductory courses in Psychology or Speech
Therapy participated in the study. The majority were
women (75%), single (92%), and reported a medium socioe-
conomic level (70%). Their mean age was 23.50 years
(SD = 2.24).
Instrument
Appearance Intrusions Questionnaire (AIQ)
This is a self-report questionnaire designed by the authors,
based on the Revised Obsessional Intrusions Inventory
(ROII; Purdon & Clark, 1993) and the Obsessional Intrusive
Thoughts Inventory (OITI; García-Soriano, 2008; García-
Soriano, Belloch, Morillo, & Clark, 2011), to assess the
European Journal of Psychological Assessment (2017)
M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire
frequency of unwanted appearance defect-related intrusive
thoughts, images, impulses, and sensations. The items were
generated by the authors and four PhD Clinical Psycholo-
gists. Each of them individually wrote a list of at least 50
items, considering the most important contents of the
BDD phenomenology described in current diagnostic
systems and self-report measures and structured clinical
interviews widely used in the area. Next, the items had to
be clustered in the four scenarios most likely to trigger
the thought: For no reason at all – baseless, in front of
reflecting surfaces, in social situations with others, and
when in close contact with family, friends, or partners. A list
of 54 AITs was finally selected in a work session of the
research team, based on two conditions: their relevance
to the clinical description of BDD and the inclusion of the
item by at least three of the six researchers.
Similar to the ROII and the OITI, the AIQ includes initial
instructions providing a detailed definition of AITs to avoid
confusion between these thoughts and ruminations,
concerns, and/or worries. Additionally, as the items are
clustered in four scenarios, each item was preceded by a
reminder about what it actually refers to, that is, an
unwanted intrusive cognition: “For no special reason, pop
into my head unpleasant thoughts, images, feelings or urges
like. . .” “When I look at myself in the mirror or see my
reflection somewhere, pop into my head unpleasant thoughts,
images, feelings or urges like. . .” “When I’m with other
people, pop into my head unpleasant thoughts, images, feelings
or urges like. . .,” or “When I have physical contact with
someone close to me (family, friends, my partner, etc.),
pop into my head unpleasant thoughts, images, feelings or urges
like. . ..” Each item is rated on a 7-point Likert scale ranging
from 0 = I have never had this intrusion to 6 = I have this
intrusion frequently during the day.
The number and frequency of AITs reported by partici-
pants were computed as the average frequency of the
thoughts actually experienced by the subject at least once
in his/her life; that is, the AIQ total score and subscale
scores were divided by the number of items (total or
subscale) with a frequency  1.
Procedure
Participants were recruited by the authors from the students
who attended their lectures at the University. The students
were invited to voluntarily participate in a study on values
and beliefs about physical appearance. Those who explicitly
agreed to participate and provided informed written con-
sent were scheduled to attend an assessment session where
participants completed a socio-demographic data sheet and
the former pilot version of the AIQ. The assessment
sessions were conducted in groups of 25–35 individuals in
the presence of one of the authors. The study received
the approval of the University Ethics Committee.
European Journal of Psychological Assessment (2017)
3
Results
The factor structure of the AIQ-54 items was examined,
considering the data from participants who experienced
intrusions at least once in their lives (n = 377; 91.9% of
the sample). To determine the optimal number of factors
to retain in the PCA, a Parallel Analysis was conducted to
generate 100 random data sets from the 54-item AIQ
(Hayton, Allen, & Scarpello, 2004). The mean and 95th
percentiles of all eigenvalues from the generated random
data sets were compared to the actual eigenvalues from a
PCA conducted on the real data set. Only the first five
actual eigenvalues (i.e., 18.44, 2.83, 2.48, 1.98, 1.48) were
greater than the mean generated eigenvalues (i.e., 12.53,
1.48, 1.20, 1.21, 1.01), indicating that five factors were the
optimal number to retain in the factor analysis.
A PCA with promax rotation, constrained to five factors,
was then subsequently conducted on the 54-item AIQ
(Bartlett’s Test of Sphericity: w2 = 1,342.145; p = .0001;
Kaiser-Meyer-Olkin test of sampling adequacy = .553).
Twenty-seven items were deleted because they scored
below .40 through different factors. The five-factor solution
explained 68.675% of the total variance, and the factors
were easily interpretable. The first factor, composed of nine
items related to appearance defects, was the most impor-
tant, as it explained 52.710% of the variance. The second
factor, explaining 5.234% of the variance, was composed
of five items about how other people might evaluate the
respondent’s physical appearance, or about some way to
remove or diminish the defect. The third factor explained
4.240% of the variance and included only two items related
to defective bodily functions. The fourth factor, explaining
3.380% of the variance, was composed of six items about
the need/urge to conceal the defect. The fifth factor,
explaining 3.120% of the total variance, grouped five items
about the urge to do something about the appearance
defect. In sum, the factors clustered intrusions based on
their contents, but not the scenarios or triggers that activate
these intrusions.
Discussion
The AIQ structure was finally composed of 27 items
grouped in five factors. The first (“defect”) and fourth
(“bodily functions”) factors included AITs related to physi-
cal appearance defects, whereas factor two (“in contact with
others”) grouped intrusions people have about physical
appearance defects when they are with people and compare
themselves to others. By contrast, factors four (“conceal-
ment”) and five (“urge to do something”) include AITs
about the need to do something about the defect. The five
factors explained a large proportion of the variance. More
than 90% of the participants reported having had AITs.
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4 M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire
Study 2
The goal of this study was to confirm the structure of the
AIQ-27 items in a new sample. Moreover, the internal con-
sistency, basic psychometric properties, and differences in
the AIQ scores based on gender and age were examined.
Method
Participants
The initial sample consisted of 583 participants (71.6%
women) with a mean age of 29.80 years (SD = 13.23;
range = 18–60 years). The majority were single (64.5%)
or married (23.3%) and had a medium (67.1%) or medium-
low (21%) socioeconomic level. Regarding education, 25.7%
had completed high school (14 years of education), 45%
were undergraduate University students (between 15
and 18 years of education), and 29.3% had completed
University studies.
Procedure
The participants were recruited through advertisements on
the University Campus that requested voluntary participa-
tion in a study on beliefs and values about physical appear-
ance. Potential participants were invited to contact the
authors for an interview, where they were informed about
the study’s general purpose and assessment procedure
and asked for their explicit consent to participate in the
study. Once informed written consent had been obtained,
participants were scheduled to attend the assessment
session. In this session, they were provided a booklet
containing a socio-demographic data sheet, the 27-item
Appearance Intrusions Questionnaire obtained from the
PCA, and the other self-reports described in Study 3. The
assessment session was conducted in groups of 25–35 par-
ticipants in the presence of one of the authors. On the
demographic fact sheet, participants who reported having
mental health problems in the past 6 months, or who were
undergoing psychological or pharmacological treatment, or
were not in the 18–60-age range were not included in the
study. None of the Study 1 participants were included.
The study received the approval of the University Ethics
Committee.
Results
Confirmatory Factor Analyses of the 27-Item AIQ
Model parameters of CFA were estimated with software
package EQS 6.1, using a robust maximum likelihood
method to confirm the 27-item AIQ five-factor structure.
To conduct these analyses, only data from participants
who experienced intrusions at least once (n = 540;
Ó 2017 Hogrefe Publishing
92.62% of the sample) were considered. Following Sch-
weizer’s (2010) recommendations, several parameters were
used to assess the goodness-of-fit of the model: w2 p  .05;
normed w2  3; root mean square error of approximation
(RMSEA)  0.08; comparative fit index (CFI)  0.90;
and standardized root mean square residual
(SRMR)  0.10.
Average skewness and kurtosis values of the items were
found. Skewness values ranged between 0.960 and 1.418,
and kurtosis values ranged between 0.891 and 1.361.
Exceptions were items 2 (“I am deformed”; skew-
ness = 2.982) and 11 (“I have to find a plastic surgeon or
dermatologist to fix me up”; skewness = 2.627), whose con-
tents refer to a sort of “red line” that goes beyond normal
intrusive thoughts about appearance defects. Therefore,
they might serve as an index of potential severity, and so
we decided to keep them.
Four models were tested through CFA: a one-factor
model; a four-factor model considering the four scenarios
used to elaborate the items, corresponding to situations
and/or contexts where AITs were most likely to be trig-
gered according to the BDD literature; a second 4-factor
model merging the items in the fourth and five factors from
the PCA (urges to conceal and “do something” about the
defect) because these items refer to behaviors that BDD
patients display regarding their preoccupations about
appearance defects; and the five-factor solution from the
PCA. Goodness-of-fit indices (see Table 1) indicated that
the five-factor solution, compared to the other models, pro-
vided the best data fit. Nonetheless, the CFI values were
below the acceptable range. Table 2 shows the item factor
loadings and R2.
In summary, the 27-item AIQ was composed of five first-
order factors: Defect-related, Others-related, Concealment,
Bodily functions, and Urge to do something. Hence, these
five subscales will be used in the subsequent analyses.
A sample copy of the AIQ is available upon request to
authors.
Internal Consistency of the 27-Item AIQ
The Cronbach’s alphas for the AIQ total scale and sub-
scales and the item-total correlations were satisfactory:
Total scale: α = .96, r = .59 to .83; Defect-related: α =
.92, r = .55 to .70; Others-related: α = .84, r = .59 to .83;
Concealment: α = .90, r = .66 to .80, and Urge to do some-
thing: α = .86, r = .57 to .80. By contrast, the internal con-
sistency of the Bodily functions subscale was low (α = .71),
as expected, given that it only included two items. As Cron-
bach’s alpha depends on inter-item correlations and the
number of items, we also calculated the mean inter-item
correlation (MIC), which is independent from scale length
(Clark & Watson, 1995). The MIC obtained for the Bodily
functions subscale was .57, which is a satisfactory value.
European Journal of Psychological Assessment (2017)
M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire 5

Table 1. Goodness-of-fit indices of the Appearance Intrusions Questionnaire factor models analyzed (n = 540)
Models
Indices One-factor Four-factor (1st) Four-factor (2nd) Five-factor
w2 1,148.9976 951.3770 930.8717 848.1053**
Degrees of freedom 324 318 318 314
Normed w2 3.54 2.99 2.97 2.70
Comparative fit index 0.796 0.843 0.848 0.868
RMSEA 0.069 0.061 0.060 0.056
SRMR 0.057 0.052 0.052 0.052
Notes. RMSEA = Root mean square error of approximation; SRMR = standardized root mean square residual. **p < .001.

Table 2. Appearance Intrusions Questionnaire (AIQ) items, factor loadings, and R2 in AIQ subscales
Subscale/Factor Item number Item content Factor loading R2
Defect 1 Something of my appearance makes me horrible .753 .567
Defect 2 I am deformed .590 .348
Defect 6 My look is horrible .674 .455
Defect 7 I have a horrible, disgusting physical flaw (nose, mouth, hair, genitals, skin, .783 .614
muscles, ears. . .)
Defect 8 My flaw is very noticeable (nose, ears, hands, sweat, spots, greasy look. . .) .821 .675
Defect 9 With this defect, I can’t be in any picture .665 .442
Defect 13 Any of these people has a better appearance than mine .717 .514
Defect 14 My flaw is very noticeable (nose, mouth, hair, skin, muscles, ears, .879 .772
genitalia. . .)
Defect 19 I can’t do anything to camouflage my defect .809 .655
Others 10 I would like to know how to retouch my pictures to cover up my defect .608 .369
Others 15 I would like to ask how I look .659 .434
Others 16 They are staring at my flaw .848 .718
Others 17 They are talking about my appearance .766 .586
Others 18 I would like to ask what they do to improve their appearance .643 .413
Concealment 20 I must cover myself up to hide my defect .729 .531
Concealment 21 My flaw is very noticeable (nose, mouth, hair, genitalia, skin, muscles, .863 .745
ears, . . .)
Concealment 22 He/she is staring my defect, is noticing it .824 .679
Concealment 23 I need to stay away .750 .562
Concealment 24 I can’t do anything to camouflage my defect .707 .500
Concealment 26 I must find a position that hides my flaw .766 .587
Bodily functions 3 My body is not working properly in some way (e.g., excessive body odor, .631 .398
bad breath, flatulence, grease on my face, my hands, my hair. . .)
Bodily functions 25 They are noticing that something in my body is not working properly in .874 .764
some way (e.g., excessive body odor, sweat, bad breath, grease on
my face. . .)
Urge to do 4 I need to camouflage or hide this defect by any means (applying makeup, .730 .532
changing clothes, going to the hairdresser. . .)
Urge to do 5 I must find a position that hides my flaw .762 .580
Urge to do 11 I must find a plastic surgeon or dermatologist to fix me up .601 .362
Urge to do 12 I have to do something to get rid of this defect .822 .676
Urge to do 27 I can’t go on like this. I have to do something to get rid of this defect .768 .590

AIQ Descriptive Statistics and Gender Differences
As mentioned above, more than 90% of respondents
reported having had at least one of the 27 AITs. The mean
number of intrusions experienced by this sample was 12.36
(SD = 8.24), and the frequency of these intrusions was low
(M = 1.98, SD = 0.94). The highest frequency was found for
the urge to do something subscale (M = 2.23, SD = 1.20).
The lowest mean was .43 (SD = 1.026) for item 2, and
the highest (M = 1.78, SD = 1.60) was for item 13 (see
Table 2 for a description of items).

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6 M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire

Table 3. Descriptive statistics and gender differences in the frequency of appearance defect-related intrusive thoughts assessed with the
Appearance Intrusions Questionnaire (AIQ)
AIQ Total sample (n = 540) Men (n = 145) Women (n = 395) t (df = 359) Cohen’s d
Defect (9 items) 2.00 (1.01) 1.80 (.94) 2.07 (1.03) 2.62* (495) .27
Others (5 items) 2.07 (1.07) 1.86 (.95) 2.15 (1.11) 2.75* (450) .28
Concealment (6 items) 1.92 (1.05) 1.61 (.79) 2.01 (1.10) 3.81* (391) .41
Bodily functions (2 items) 2.02 (1.15) 1.71 (1.02) 2.13 (1.18) 3.08* (346) .38
Urge to do (5 items) 2.23 (1.20) 2.09 (1.21) 2.29 (1.19) 1.41 (429) –
Total (27 items) 1.98 (1.94) 1.76 (0.87) 2.06 (0.96) 3.22* (526) .32
Notes. Data are means (SD); *p  .01.

Descriptive statistics for the AIQ subscales and gender Method

differences are shown in Table 3. Women scored
significantly higher than men on the AIQ total scale and
subscales, except for the urge to do something subscale.
Correlations between the AIQ total scale and subscales
and age were significant, ranging from r = .24 to
r = .50 (p  .01 to .0001).
Discussion
The AIQ contains 27 items grouped in four scenarios
where the AITs are most likely to be triggered: for no rea-
son at all – baseless, in front of reflecting surfaces, in
social situations with others, and when in close contact
with family, friends, or partners. The CFA confirmed the
5-factor model found in the PCA. The five factors showed
good internal consistency. The contents of these factors
correspond well with the clinical picture of BDD, as postu-
lated by experts in the area (e.g., Phillips et al., 2006;
Veale, 2009; Wilhelm et al., 2013). Interestingly, as
research shows that these intrusive cognitions tend to be
concealed (Bjornsson et al., 2010; Wilhelm et al., 2010),
the fact that one of the AIQ factors captures the conceal-
ment of AITs would help to detect them in nonclinical
populations.
Participants
The participants were those described in Study 2. Only data
from participants who experienced intrusions with a
frequency  1 were considered for analyses (n = 540).
Instruments
In addition to the AIQ-27 items described in Study 2,
the participants completed the following self-report
questionnaires:
Body Dysmorphic Disorder Questionnaire
(BDDQ; Phillips et al., 1995)
This screening measure for BDD, based on DSM-IV diag-
nostic criteria, can be completed either as a self-report
or by an interviewer. In this study, the BDDQ was applied
as a self-report questionnaire. It includes 12 items with vari-
ous response formats (yes/no, open-ended, and multiple
choice). A BDD diagnosis requires positive answers to the
first two questions and to at least one of the questions from
5 to 10, and at least 1 hr/day thinking about the perceived
defect. To perform correlation analyses, the sum of the first
two questions was scored from 0 to 2; the remaining three
yes/no items (except the item related to weight) and the
multiple-choice item (related to the time spent) were scored
from 0 to 7 (items 5, 6, 8, 10, 12), obtaining a composite score
for distress and interference due to dysmorphic concerns.

Study 3 Multidimensional Body-Self Relations

After verifying that unwanted intrusive cognitions about
appearance defects were experienced by most of the non-
clinical people, and that the AIQ was a reliable self-report
to assess these thoughts, it was necessary to examine
whether AITs were more associated with BDD measures
than with other different signs of psychopathology. This
was the main aim of this study. Additionally, as an approach
to the putative dimensionality of AITs from normalcy to
BDD psychopathology, the differences in their number
and frequency between individuals at risk of BDD and
those with no risk were analyzed.
Questionnaire-Appearance Scales (MBSRQ-AS 34;
Brown, Cash, & Mikulka, 1990; Cash, 2000; Spanish
version: Roncero, Perpiñá, Marco, & Sánchez-Reales,
2015)
This 34-item self-report measure assesses evaluative,
cognitive, and behavioral components of body image. It is
composed of five subscales: Appearance Evaluation,
Appearance Orientation, Overweight Preoccupation, Self-
Classified Weight, and Body Areas Satisfaction. Each item
is scored on a 5-point scale. In the current study, the Cron-
bach’s alpha ranged from α = .75 to α = .88 for the different
subscales.

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M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire 7

Table 4. Relationships (partial correlations) of the Appearance Intrusions Questionnaire (AIQ) with BDD-related measures (n = 540)
Multidimensional Body-Self Relations Questionnaire
Appearance Appearance Body areas Overweight Self-classified
AIQ BDDQ evaluation orientation satisfaction preoccupation weight
Defect .457** .430** .173* .489** .320** .257**
Others .413** .237** .326** .372** .281** .086
Concealment .467** .347** .185* .466** .236** .267**
Bodily functions .278** .090 .199* .229* .196* .116
Urge to do .441** .259** .200* .433** .310** .269**
Total .500** .373** .234** .493** .330** .259**
Notes. BDDQ = Body Dysmorphic Disorder Questionnaire. *p  .01; **p  .001.

Obsessive-Compulsive Inventory-Revised (OCI-R;
Foa et al., 2002; Spanish version: Belloch et al., 2013)
This 18-item self-report questionnaire assesses distress
associated with various obsessive-compulsive symptoms.
The OCI-R provides a total score (ranging from 0 to 72)
and scores on six subscales: washing, checking, ordering,
obsessing, hoarding, and neutralizing. Internal consistency
values in this study ranged from α = .67 (neutralizing
subscale) to α = .88 (total scale).
Clark-Beck Obsessive-Compulsive Inventory
(C-BOCI; Clark, Beck, Antony, & Swinson, 2005.
Spanish Adaptation: Belloch, Reina, García-Soriano,
& Clark, 2009)
The C-BOCI is a 25-item self-report questionnaire that
assesses the frequency and severity of obsessive and com-
pulsive symptoms. It uses a graded response format and
contains a total score and obsession and compulsion sub-
scales. Internal consistency of the C-BOCI scores in this
study was satisfactory: α = .86, α = .83, and α = .90, for
obsessions, compulsions, and total scale, respectively.
Depression Anxiety Stress Scale-Short Version
(DASS-21; Lovibond & Lovibond 1995; Spanish Version:
Bados, Solanas, & Andrés, 2005)
This 21-item self-report questionnaire assesses the occur-
rence of three types of symptoms during the past week:
depression, anxiety, and stress, using a 4-point scale. The
Spanish version has satisfactory internal consistency in
current study (anxiety: α = .77; stress: α = .79; depression:
α = .87).
Penn State Worry Questionnaire (PSWQ; Meyer, Miller,
Metzger, & Borkovec, 1990; Spanish Version: Sandin,
Chorot, Valiente, & Lostao, 2009)
This 16-item self-report inventory assesses the individual’s
tendency to experience worry. Each item is rated on a
5-point scale. The internal consistency in the present study
was excellent (α = .90).
Positive and Negative Affect Scale (PANAS; Watson,
Clark, & Tellegen, 1988; Spanish Adaptation: Sandin
et al., 1999)
This 20-item self-report questionnaire assesses positive and
negative affect on a 5-point scale. The internal consistency
for both subscales in this study was good: PA: α = .88, NA:
α = .89.
Procedure
Participants’ recruitment and procedure were the same as
in Study 2. In the assessment session, participants were
given a booklet containing a socio-demographic data sheet,
the 27-item AIQ, and the other self-report instruments.
The order of the self-reports in the booklet was randomized
to avoid or minimize order effects.
Results
Relationships of the AIQ With Symptom Measures,
Both BDD-Related and Non BDD-Related
All correlations were performed controlling for gender and
age, due to the gender differences found on the AIQ
subscales and their relationships with age in Study 1. Table 4
shows the results. The AIQ total scale’s correlations with
both the BDDQ and body image (MBSRQ) measures
ranged between moderate and high. The size of the correla-
tions was significantly higher for the BDDQ and MBSRQ-
body areas satisfaction than for MBSRQ-Appearance
orientation, MBSRQ-Overweight preoccupation, and
MBSRQ-Self-classified weight (all z’s p  .05). Moreover,
the correlation with the BDDQ was positive, whereas it
was negative with MBSRQ-body areas satisfaction. As for
the AIQ subscales, a similar pattern of associations was
found: the correlations of each subscale with the BDDQ
and with MBSRQ-body areas satisfaction were significantly
higher than with the other MBSRQ subscales (all z’s
p  .05), except for AIQ-others and MBSRQ-Appearance
orientation, which did not differ from the correlations
between this subscale and the remaining MBSRQ subscales.

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8 M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire

Table 5. Relationships (partial correlations) of the Appearance Intrusions Questionnaire (AIQ) with non BDD-related symptom measures (n = 540)
DASS-21 PANAS CBOCI
AIQ Stress Anxiety Dep. PA NA PSWQ OCI-R Obs. Comp. Total
Defect .210** .255** .353** .186** .207** .193** .260** .341** .284** .342**
Others .248** .264** .336** .138* .177** .197** .275** .325** .251** .316**
Concealment .167** .219** .324** .158* .148* .098 .253** .288** .212** .275**
Bodily functions .219** .256** .198** .124 .183** .176** .235** .317** .282** .327**
Urge to do .138* .215** .307** .209** .131* .134* .313** .366** .275** .352**
Total .217* .269** .371** .197** .198** .181** .314** .382** .302** .375**
Notes. DASS-21 = Depression Anxiety and Stress Scale; PANAS = Positive and Negative Affect Scales; PSWQ = Penn State Worry Questionnaire;
OCI-R = Obsessive-Compulsive Inventory-Revised; CBOCI = Clark-Beck Obsessive-Compulsive Inventory. *p  .05; **p  .01.

The associations between AIQ and non BDD-related
measures (see Table 5) were low and moderate, except
AIQ-Concealment and worry (PSWQ), and AIQ-Bodily
functions and PANAS-Positive affect, where no correla-
tions were observed. The AIQ total scale was more
correlated with OCD measures than with worry (PSWQ)
(all z’s p  .05). The association between AIQ total scale
and C-BOCI total score was significantly higher than for
DASS-stress and PANAS-negative affect (all z’s p  .05),
but DASS-Depression and DASS-anxiety showed no dif-
ferences. The AIQ subscales presented the same pattern
of associations as the total score (Table 5).
Predictive Power of BDD, OCD, and Other Symptom
Measures on the AIQ Scores
To examine the contribution of the OCD symptoms,
depressive and anxiety symptoms, worry, affect, body
image, and distress and interference due to dysmorphic
concern, a series of hierarchical regression analyses were
performed with the AIQ subscale and total scale frequency
scores as the dependent variables. In the first step, the
scores on the DASS-21, PANAS, and PSWQ were entered,
with gender and age as covariates. In the second step, the
OCI-R and C-BOCI total scores were included. In the final
step, MBRSQ-Body areas satisfaction and BDDQ were
entered. Results are given in Table 6.
The BDDQ score predicted all AIQ subscales and the
total scale, beyond OCD, depression, anxiety, and worry
symptom measures, which did not enter as significant
predictors in the final equation models, except the
AIQ-Concealment subscale, which was also predicted
by gender and the score on the OCI-R. MBSRQ-Body
areas satisfaction also contributed to the AIQ’s variance,
except AIQ-Others and AIQ-Bodily functions, where
BDDQ was the only predictor. The percentage of vari-
ance explained by the symptoms (i.e., anxiety, depres-
sion, worry, OCD, affect, BDD, and body image) was
low (3%–6.7%).
Group Differences Between Subjects at Risk of BDD
and Subjects With No Risk on the Appearance
Intrusions Questionnaire and Symptom Measures
A subgroup of 77 participants who met the BDDQ criteria
for BDD was extracted from the sample, which means that
14.25% of individuals met the criteria for BDD. The BDD-
risk group (BDD-R; 81.6% women) had a mean age of
22.59 years (SD = 5.5; range = 18–56 years), whereas the
no-BDD-risk group (BDD-NR; 463 participants; 70%
women) had a mean age of 30.91 years (SD = 13.71;
range = 18–60 years). The BDD-risk group was significantly
younger than the no-BDD risk group, t(253, 1) = 9.51,
p = .001, but no differences were observed in the gender
distribution between the two groups.
As expected, differences between the BDD-R and the
BDD-NR groups were found on all the symptom measures,
including the AIQ total score and subscales (Table 7). The
BDD-R group obtained higher scores, except on PANAS-
Positive affect and the MBSRQ-Body areas satisfaction
and Appearance evaluation subscales, where the BDD-NR
group scored higher. Especially relevant was the signifi-
cantly higher number of AITs experienced by the BDD-R
group. The effect sizes of between-group differences ranged
from moderate to high, and the highest values were for
AIQ-total score, C-BOCI-Obsessions, the BDDQ composite
score, and the three MBSRQ subscales.
Given the previously observed differences between the
two groups on age, all the aforementioned analyses were
conducted again with age as covariate (analyses of covari-
ance, ANCOVAs). The results obtained did not change,
suggesting that age did not influence the observed differ-
ences between subjects at risk of BDD and those with no
risk on the study variables.
Discussion
The results indicate that appearance intrusions were consis-
tently more associated with BDD symptoms (BDDQ), body

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M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire 9

Table 6. Predictors of the Appearance Intrusions Questionnaire (AIQ) total score and subscales in the final steps of the regression models
(n = 540)
Independent variables* Adj. R2 ΔR2 B SE B β t p ΔF (df) p
DV: AIQ total score
.316 .03 8.558 (5,189) .004
BDDQ .250 .048 .385 5.185 < .001
MBSRQ – body areas satisfaction .042 .014 .203 2.925 .004

DV: AIQ – defect

.266 .042 10.963 (5,186) .001
BDDQ .236 .057 .324 4.175 < .001
MBSRQ – body areas satisfaction .055 .017 .240 3.311 .001

DV: AIQ – others

.167 .067 15.229 (5,183) .0001
BDDQ – distress and Interference .220 .056 .292 3.902 < .001

DV: AIQ – concealment

.279 .033 7.874 (5,167) .006
Gender .530 .189 .182 2.806 .006
OCI-R – total .015 .007 .157 2.200 .029
BDDQ .245 .058 .326 4.182 < .001
MBSRQ – body areas satisfaction .051 .018 .211 2.806 .006

DV: AIQ – bodily functions

.119 .030 5.072 (4,145) .026
BDDQ .163 .072 .202 2.252 .026

DV: AIQ – urge to do

.208 .028 6.193 (5,173) .014
BDDQ .262 .067 .318 3.885 < .001
MBSRQ – body areas satisfaction .050 .020 .193 2.488 .014
Notes. *Only significant predictors in final equations are shown on the table. BDDQ = Body Dysmorphic Disorder Questionnaire; MBSRQ = Multidimensional
Body-Self Relations Questionnaire-Appearance Scales; OCI-R = Obsessive-Compulsive Inventory-Revised.

image concerns (MBSRQ), and OCD measures, and espe-
cially with obsessions (C-BOCI), than with worry (PSWQ).
These results suggest that BDD preoccupations are closer
to obsessions than to worries, and they provide additional
support for the current consideration of BDD as an
OC-spectrum disorder.
The high associations found with the BDDQ support the
construct validity of the AIQ. Additionally, the low percent-
age of variance in the AIQ total score explained by the
BDDQ indicates that the two measures are assessing differ-
ent aspects of BDD. First, the AIQ assesses unwanted
intrusive thoughts, images, and impulses about appearance
defects in nonclinical people, whereas the BDDQ assesses
clinical symptoms following DSM-IV criteria. Therefore,
the AIQ might be helpful in understanding the BDD phe-
nomenology, just as the research about intrusive thoughts
with obsessional contents has advanced the current under-
standing and treatment of OCD. Second, the AIQ assesses
the concealment of symptoms and the different contexts
and/or situations where the symptoms are triggered.
This could be especially important in the early detection
of the disorder, given that people with BDD, and presum-
ably also people at risk of the disorder, tend to conceal
the symptoms and/or not be aware that they could be at
risk of developing a devastating mental disorder like BDD.
Associations between the AIQ and the body image mea-
sure (MBSRQ), and especially the body areas satisfaction
subscale, also support the construct validity of the AIQ
for BDD. The highest association was observed with the
body areas satisfaction subscale, compared to the two sub-
scales that assess more Eating Disorder-related aspects of
body image (Overweight preoccupation and Self-classified
weight). Nonetheless, the predictive power of the body
image measure on the frequency of AITs was low, suggest-
ing that the AIQ and MBSRQ are assessing different aspects
of body image and appearance concerns.
The results showing the higher number and frequency of
AITs in individuals at risk of BDD, compared to those with

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10 M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire

Table 7. Group differences on Appearance Intrusions Questionnaire (AIQ) and symptom measures between individuals at risk for BDD and no-risk
individuals
Study measures BDD-Risk (n = 77) No-BDD (n = 463) t (df) Cohen’s d
AIQ – Defect 2.88 (1.26) 1.84 (.87) 6.81 (501)* 0.96
AIQ – Others 2.85 (1.21) 1.92 (.97) 6.30 (456)* 0.84
AIQ – Concealment 2.63 (1.28) 1.75 (.91) 5.59 (395)* 0.79
AIQ – Bodily functions 2.71 (1.42) 1.86 (1.03) 4.48 (349)* 0.68
AIQ – Urge to do 3.15 (1.28) 2.04 (1.09) 6.95 (435)* 0.93
AIQ – Total frequency 2.89 (1.09) 1.83 (0.82) 8.08 (533)* 1.09
AIQ – Total number of intrusions 20.65 (5.50) 11.10 (7.86) 13.30 (581)* 1.40
DASS-21 – Stress 6.66 (3.90) 3.74 (2.96) 6.27 (550)* 0.84
DASS-21 – Anxiety 6.56 (3.66) 4.24 (2.98) 5.27 (557)* 0.69
DASS-21 – Depression 6.12 (4.80) 2.88 (2.89) 5.66 (553)* 0.81
PANAS – Positive affect 29.51 (8.31) 32.27 (7.18) 2.68 (542)* 0.35
PANAS – Negative affect 26.10 (8.89) 21.56 (7.85) 4.52 (550)* 0.54
PSWQ 58.15 (11.60) 50.04 (11.41) 5.67 (547)* 0.70
OCI-R – Total 21.65 (12.87) 13.70 (9.82) 4.98 (527)* 0.60
CBOCI – Obsessions 14.13 (7.03) 7.81 (5.25) 7.55 (553)* 1.05
CBOCI – Compulsions 10.42 (6.08) 5.64 (4.61) 6.44 (555)* 0.88
CBOCI – Total 25.03 (12.03) 13.44 (8.97) 7.89 (543)* 1.09
BDDQ 2.45 (0.95) 1.35 (1.14) 7.36 (240)* 1.04
MBSRQ – Appearance evaluation 17.04 (4.26) 20.52 (4.09) 6.84 (563)* 0.83
MBSRQ – Appearance orientation 49.39 (5.44) 40.38 (7.33) 12.74 (561)* 1.39
MBSRQ – Body areas satisfaction 25.03 (4.64) 29.76 (4.82) 8.00 (563)* 0.99
MBSRQ – Overweight preoccupation 14.00 (3.69) 9.75 (3.37) 10.09 (565)* 1.20
MBSRQ – Self-classified weight 6.66 (1.63) 6.40 (1.32) 1.32 (564)* 0.17
Notes. BDD = Body Dysmorphic Disorder; DASS-21 = Depression Anxiety and Stress Scale; PANAS = Positive and Negative Affect Scales; PSWQ = Penn State
Worry Questionnaire; OCI-R = Obsessive-Compulsive Inventory-Revised; CBOCI = Clark-Beck Obsessive-Compulsive Inventory; BDDQ = Body Dysmorphic
Disorder Questionnaire; MBSRQ = Multidimensional Body-Self Relations Questionnaire-Appearance Scales. Data are Means (SD); *p  .01.

no risk, support the dimensionality of AITs because a higher
number and frequency of distressing intrusive cognitions
about appearance defects accompanied an increased risk
of BDD. The large effect size of the between-groups
difference on the AIQ total scale indicates that the new
self-report questionnaire has good construct validity, and
supports its potential usefulness for detecting subclinical
and/or prodromal forms of BDD in the general population.
Moreover, as expected, the two groups of individuals dif-
fered on all the study measures.
General Discussion
Preoccupations about defects in physical appearance play a
key role in the functional phenomenology of BDD (Veale &
Gilbert, 2014; Wilhelm & Neziroglu, 2002) and constitute
the main diagnostic criteria for the disorder. However, to
the best of our knowledge, there are no studies that
specifically address the phenomenology of these cognitive
products, in terms of their intrusive, discrete, and unwanted
nature, in a similar way to the intrusive thoughts, images,
and impulses analogous to obsessions. In order to achieve
this aim, a specific self-report questionnaire, the Appear-
ance Intrusions Questionnaire (AIQ), was constructed to
assess the frequency of unwanted appearance defect-
related intrusive thoughts (AITs) and their putative univer-
sality in nonclinical participants. The results confirmed the
five-factor structure of the AIQ in two different samples of
individuals, and these factors capture the phenomenology
of BDD.
The results also support the universality of thoughts,
images, urges, and feelings about defects in physical appear-
ance, which were experienced as intrusive and distressing
by more than 90% of participants in Study 1 and Study 2.
These results are comparable to those found by Onden-
Lim and Grisham (2013), where 84.6% of nonclinical partic-
ipants reported experiencing recurrent intrusive imagery
about their appearance. Regarding gender, women reported
more AITs than men, which coincide with higher rates of
BDD reported in women compared to men (Bjornsson
et al., 2013). The universality of AITs is comparable to what
is found in most studies on obsessional unwanted intrusive
thoughts using nonclinical samples in different cultural
contexts (e.g., Clark et al., 2014; Radomsky et al., 2014).

Ó 2017 Hogrefe Publishing European Journal of Psychological Assessment (2017)

M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire
The universality of the two contents of intrusive cognitions,
obsessional and BDD-related, indicates that OCD and BDD
share this modality of cognitions, which could help to
explain the high comorbidity rates between these two disor-
ders (Abramowitz & Jacoby, 2015; Altamura, Paluello,
Mundo, Medda, & Mannu, 2001; Phillips et al., 2010), the
clinical and phenomenological similarities between OCD
and BDD (i.e., Phillips, Gunderson, Mallya, McElroy, &
Carter, 1998), and the current consideration of BDD as an
OCD-spectrum disorder (APA, 2013).
Associations between the appearance intrusions assessed
with the AIQ and symptom measures, both BDD-related
and non BDD-related, indicate that BDD preoccupations
are closer to obsessions (i.e., C-BOCI score) than to worries
(i.e., PSWQ score), supporting the notion than these preoc-
cupations might consist of intrusive cognitions. Moreover,
the high associations between AIQ scores and BDD mea-
sures support the construct validity of the new questionnaire.
The current study has several limitations. First, the use of
nonclinical samples limits the generalizability of our results
to clinical settings. Nonetheless, the use of analog samples
to study intrusive thoughts is common. Moreover, our study
fits the requirements for using analog samples to draw
inferences about BDD clinical participants, that is,
prevalence of symptoms in the sample, dimensionality of
symptoms under study, qualitative similarities of symp-
toms, etiological continuity, and psychological variables
relevant to the disorder (Abramowitz et al., 2014). A second
limitation was the unequal gender distribution, which limits
the generalizability of the findings to broader settings.
Although BDD is mainly prevalent among women and
has a relatively early onset, a more representative sample
is needed in future studies. Finally, the questionnaire items
focus on intrusive thoughts, images, impulses, and feelings
or sensations. This does not exclude the possibility that
preoccupations about appearance defects would also take
the form of worry or rumination, which might have differ-
ent functional consequences. Future studies should exam-
ine whether BDD preoccupations consist of intrusive
cognitions closer to obsessions than to other cognitive
processes, such as worry and rumination.
In conclusion, this is the first empirical study to show that
unwanted and recurrent intrusive thoughts about appear-
ance defects are nearly universal, which is also the case
of intrusive thoughts analogous to obsessions. The AIQ
might be a valid, reliable, self-report measure of AITs that
would help to detect individuals at risk of BDD in nonclin-
ical populations. Future studies should investigate the AIQ’s
utility in clinical settings. Additionally, further research is
necessary to investigate whether unwanted intrusive cogni-
tions about appearance defects give rise to BDD in the long
term, which could contribute to the understanding and
treatment of BDD.
European Journal of Psychological Assessment (2017)
11
Acknowledgments
This study was funded by the Spanish Ministerio de Econ-
omía y Competitividad (MINECO-Grant PSI2013-44733-R)
and by the Conselleria d’ Educació, Cultura i Esport, Gen-
eralitat Valenciana, Spain (GV-PROMETEO/2013/066).
References
Abramowitz, J. S., Fabricant, L. E., Taylor, S., Deacon, B. J.,
McKay, D., & Storch, E. A. (2014). The utility of analogue
studies for understanding obsessions and compulsions.
Clinical Psychology Review, 34, 206–217. doi: 10.1016/j.cpr.
2014.01.004
Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive
and related disorders: A critical review of the new diagnostic
class. Annual Review of Clinical Psychology, 11, 165–186.
doi: 10.1146/annurev-clinpsy-032813-153713
Altamura, C., Paluello, M. M., Mundo, E., Medda, S., & Mannu, P.
(2001). Clinical and subclinical body dysmorphic disorder.
European Archives of Psychiatry and Clinical Neuroscience,
251, 105–108. doi: 10.1007/s004060170042
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA:
Author.
Bados, A., Solanas, A., & Andrés, R. (2005). Psychometric
properties of the Spanish version of Depression, Anxiety and
Stress Scales (DASS). Psicothema, 17, 679–683.
Belloch, A., Reina, N., García-Soriano, G., & Clark, D. (2009). El
Inventario Clark-Beck de Obsesión-Compulsión (C-BOCI):
Validación para su uso en población española [The Clark-Beck
Obsessive-Compulsive Inventory, C-BOCI: Validation for their
use in Spanish populations]. Revista de Psicopatología y
Psicología Clínica, 14, 95–105. doi: 10.5944/rppc.vol.14.num.2.
2009.4069
Belloch, A., Roncero, M., García-Soriano, G., Carrió, C., Cabedo, E.,
& Fernández-Álvarez, H. (2013). The Spanish version of the
Obsessive-Compulsive Inventory-Revised (OCI-R): reliability,
validity, diagnostic accuracy, and sensitivity to treatment
effects in clinical samples. Journal of Obsessive-Compulsive
and Related Disorders, 2, 249–256. doi: 10.1016/j.jocrd.2013.
05.001
Belloch, A., Roncero, M., & Perpiñá, C. (2016). Obsessional and
Eating Disorders-related intrusive thoughts: Differences and
similarities within and between individuals vulnerable to OCD
or to EDs. European Eating Disorders Review, 24, 446–454.
doi: 10.1002/erv.2458
Bjornsson, A. S., Didie, E. R., & Phillips, K. A. (2010). Body
dysmorphic disorder. Dialogues in Clinical Neuroscience, 12,
221–232.
Bjornsson, A. S., Didie, E. R., Grant, J. E., Menard, W., Stalker, E.,
& Phillips, K. A. (2013). Age at onset and clinical correlates in
body dysmorphic disorder. Comprehensive Psychiatry, 54,
893–903. doi: 10.1016/j.comppsych.2013.03.019
Blackburn, J. F., Thompson, A. R., & May, J. (2012). Feeling good
about being hungry: Food-related thoughts in eating disorders.
Journal of Experimental Psychopathology, 3, 243–257.
Brown, T. A., Cash, T. F., & Mikulka, P. J. (1990). Attitudinal body
image assessment: Factor analysis of the Body-Self Relations
Questionnaire. Journal of Personality Assessment, 55, 135–144.
doi: 10.5127/jep.018711
Cash, T. F. (2000). Multidimensional body-self relations
questionnaire (MBSRQ) users’ manual. Retrieved from http://
www.body-images.com
Ó 2017 Hogrefe Publishing
12 M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire
Clark, D. A., Abramowitz, J., Alcolado, G. M., Alonso, P., Belloch, A.,
Bouvard, M., . . . Wong, W. (2014). Part 3. A question of
perspective: The association between intrusive thoughts and
obsessionality in 11 countries. Journal of Obsessive-Compulsive
and Related Disorders, 3, 292–299. doi: 10.1016/j.jocrd.2013.
12.006
Clark, D. A., Beck, A. T., Antony, M. M., & Swinson, R. P. (2005).
Screening for obsessive and compulsive symptoms: Validation
of the Clark-Beck Obsessive-Compulsive Inventory. Psycholog-
ical Assessment, 17, 132–143. doi: 10.1037/1040-3590.17.
2.132
Clark, D. A., & Rhyno, S. (2005). Unwanted intrusive thoughts in
nonclinical individuals: Implications for clinical disorders. In
D. A. Clark (Ed.), Intrusive thoughts in clinical disorders: Theory,
research, and treatment (pp. 1–29). New York, NY: Guilford
Press.
Clark, L. A., & Watson, D. (1995). Constructing validity: Basic
issues in objective scale development. Psychological
Assessment, 7, 309–319. doi: 10.1037/1040-3590.7.3.309
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R.,
Hajcak, G., & Salkovskis, P. M. (2002). The Obsessive-
Compulsive Inventory: Development and validation of a short
version. Psychological Assessment, 14, 485–496.
García-Soriano, G. (2008). Obsessional intrusive thoughts inven-
tory. Retrieved from PsycTESTS. doi: 10.1037/t23131-000.
García-Soriano, G., Belloch, A., Morillo, C., & Clark, D. A. (2011).
Symptom dimensions in obsessive-compulsive disorder: From
normal cognitive intrusions to clinical obsessions. Journal of
Anxiety Disorders, 25, 474–482. doi: 10.1016/j.janxdis.2010.
11.012
García-Soriano, G., Roncero, M., Perpiñá, C., & Belloch, A. (2014).
Intrusive thoughts in obsessive-compulsive disorder and eating
disorder patients: A differential analysis. European Eating
Disorders Review, 22, 191–199. doi: 10.1002/erv.2285
Harvey, A. G. (2000). Pre-sleep cognitive activity: A comparison
of sleep-onset insomniacs and good sleepers. British
Journal of Clinical Psychology, 39, 275–286. doi: 10.1348/
014466500163284
Hayton, J. C., Allen, D. G., & Scarpello, V. (2004). Factor retention
decisions in exploratory factor analysis: A tutorial on parallel
analysis. Organizational Research Methods, 7, 191–205.
doi: 10.1177/1094428104263675
Littleton, H. L., Axsom, D., & Pury, C. L. S. (2005). Development of
the body image concern inventory. Behaviour Research and
Therapy, 43, 229–241. doi: 10.1016/j.brat.2003.12.006
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative
emotional states: Comparison of the Depression Anxiety Stress
Scales (DASS) with the Beck Depression and Anxiety
Inventories. Behaviour Research and Therapy, 33, 335–343.
doi: 10.1016/0005-7967(94)00075-U
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990).
Development and validation of the Penn State Worry
Questionnaire. Behaviour Research and Therapy, 28, 487–495.
doi: 10.1016/0005-7967(90)90135-6
Michael, T., Ehlers, A., Halligan, S., & Clark, D. M. (2005).
Unwanted memories of assault: What intrusion characteristics
are associated with PTSD? Behaviour Research and Therapy,
43, 613–628. doi: 10.1016/j.brat.2004.04.006
Nolen-Hoeksema, S., Wisco, B. E., & Lyumbomirsky, S. (2008).
Rethinking rumination. Perspectives on Psychological Science,
3, 400–424. doi: 10.1111/j.1745-6924.2008.00088.x
Onden-Lim, M., & Grisham, J. R. (2013). Intrusive imagery
experiences in a high dysmorphic concern population. Journal
of Psychopathology and Behavioral Assessment, 35, 99–105.
doi: 10.1007/s10862-012-9318-1
Ó 2017 Hogrefe Publishing
Oosthuizen, P., Lambert, T., & Castle, D. J. (1998). Dysmorphic
concern: Prevalence and associations with clinical variables.
Australian and New Zealand Journal of Psychiatry, 32, 129–132.
doi: 10.3109/00048679809062719
Phillips, K. A., Atala, K. D., & Pope, H. G. (1995). Diagnostic
instruments for body dysmorphic disorder. In American
Psychiatric Association. (Eds.), New research program and
abstracts. 148th meeting of the American Psychiatric Associa-
tion (p. 157). Miami, FL: American Psychiatric Association.
Phillips, K. A., Didie, E. R., Menard, W., Pagano, M. E., Fay, C., &
Weisberg, R. B. (2006). Clinical features of body dysmorphic
disorder in adolescents and adults. Psychiatry Research, 141,
305–314. doi: 10.1016/j.psychres.2005.09.014
Phillips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., &
Carter, W. (1998). A comparison study of body dysmorphic
disorder and obsessive-compulsive disorder. Journal of Clinical
Psychiatry, 59, 568–575. doi: 10.4088/JCP.v59n1102
Phillips, K. A., Wilhelm, S., Koran, L. R., Didie, E. R., Fallon, B. A.,
Feusner, J., & Stein, D. J. (2010). Body dysmorphic disorder:
Some key issues for DSM-V. Depression and Anxiety, 27,
573–591. doi: 10.1002/da.20709
Purdon, C., & Clark, D. A. (1993). Obsessive intrusive thoughts in
non-clinical subjects. Part I. Content and relation with depres-
sive, anxious and obsessional symptoms. Behaviour Research
and Therapy, 31, 713–720. doi: 10.1016/0005-7967(93)90001-B
Rachman, S. (1981). Part I. Unwanted intrusive cognitions.
Advances in Behaviour Research and Therapy, 3, 89–99.
doi: 10.1016/0146-6402(81)90007-2
Rachman, S., & de Silva, P. (1978). Abnormal and normal
obsessions. Behaviour Research and Therapy, 16, 233–248.
doi: 10.1016/0005-7967(78)90022-0
Radomsky, A., Alcolado, G. S., Abramowitz, J. S., Alonso, P.,
Belloch, A., Bouvard, M., . . . Wong, W. (2014). Part 1-You can
run but you can’t hide: Intrusive thoughts on six continents.
Journal of Obsessive-Compulsive and Related Disorders, 3,
269–279. doi: 10.1016/j.jocrd.2013.09.002
Roncero, M., Perpiñá, C., Marco, H., & Sánchez-Reales, S. (2015).
Confirmatory factor analysis and psychometric properties of
the Spanish version of the Multidimensional Body-Self
Relations Questionnaire-Appearance Scales. Body Image, 14,
47–53. doi: 10.1016/j.bodyim.2017.01.003
Rosen, J. C., & Reiter, J. (1996). Development of the body
dysmorphic disorder examination. Behaviour Research and
Therapy, 9, 755–766. doi: 10.1016/0005-7967(96)00024-1
Sandin, B., Chorot, P., Lostao, L., Joiner, T. H., Santed, M. A., &
Valiente, R. M. (1999). Escalas PANAS de afecto positivo y
negativo: Validación factorial y convergencia transcultural [The
PANAS scales of positive and negative affect: Factor-analytic
validation and cross-cultural convergence]. Psicothema, 11,
37–51.
Sandin, B., Chorot, P., Valiente, R. M., & Lostao, L. (2009).
Validación española del Cuestionario de Preocupaciones
PSWQ: Estructura factorial y propiedades psicométricas [Span-
ish validation of the PSWQ. Factor structure and psychometric
properties]. Revista de Psicopatología y Psicología Clínica, 14,
107–122. doi: 10.5944/rppc.vol.14.num.2.2009.4070
Schweizer, K. (2010). Some guidelines concerning the modeling of
traits and abilities in test construction. European Journal of
Psychological Assessment, 26, 1–2. doi: 10.1027/1015-5759/
a000001
Striegel-Moore, R. H., & Bulik, C. M. (2007). Risk factors for eating
disorders. American Psychologist, 62, 181–198. doi: 10.1037/
0003-066X.62.3.181
Veale, D. (2009). Body Dysmorphic Disorder. New York, NY: Oxford
University Press.
European Journal of Psychological Assessment (2017)
M. Giraldo-O’Meara & A. Belloch, Appearance Intrusions Questionnaire 13

Veale, D., Eshkevari, E., Kanakam, N., Ellison, N., Costa, A., & Cognitive approaches to obsessions and compulsions: Theory,
Werner, T. (2014). The Appearance Anxiety Inventory: Validation assessment and treatment (pp. 203–214). Oxford, UK: Elsevier
of a process measure in the treatment of body dysmorphic Press.
Disorder. Behavioural and Cognitive Psychotherapy, 42, Wilhelm, S., Phillips, K. A., & Steketee, G. (2013). Cognitive-
615–616. doi: 10.1017/S1352465813000556 behavioral therapy for body dysmorphic disorder: A treatment
Veale, D., & Gilbert, P. (2014). Body dysmorphic disorder: The manual. New York, NY: Guilford Press.
functional and evolutionary context in phenomenology and a
compassionate mind. Journal of Obsessive-Compulsive and
Related Disorders, 3, 150–160. doi: 10.1016/j.jocrd.2013. Received March 15, 2016
11.005i Revision received September 15, 2016
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and Accepted October 14, 2016
validation of brief measures of positive and negative affect: The Published online June 28, 2017
PANAS scales. Journal of Personality and Social Psychology, 54,
1063–1070. doi: 10.1037/0022-3514.54.6.1063
Wells, A. (1999). A metacognitive model and therapy for Amparo Belloch
generalized anxiety disorder. Clinical Psychology and Departamento de Personalidad
Psychotherapy, 6, 86–95. doi: 10.1002/(SICI)1099-0879 Evaluación y Tratamientos Psicológicos
(199905)6:2<86::AID-CPP189>3.0.CO;2-S Facultad de Psicología
Wilhelm, S., Buhlmann, U., Hayward, L. C., Greenberg, J. L., & Universidad de Valencia
Dimaite, R. A. (2010). A cognitive-behavioral treatment Avenida Blasco Ibáñez, 21
approach for body dysmorphic disorder. Cognitive and Behav- 46010 Valencia
ioral Practice, 17, 241–247. doi: 10.1016/j.cbpra.2010.02.001 Spain
Wilhelm, S., & Neziroglu, F. (2002). Cognitive theory of body amparo.belloch@uv.es
dysmorphic disorder. In R. O. Frost & G. Steketee (Eds.),

European Journal of Psychological Assessment (2017) Ó 2017 Hogrefe Publishing