Mirror, mirror on the wall, who is the ugliest of them all?

The psychopathology of mirror gazing in body dysmorphic disorder

David Veale and Susan Riley (2000)

Body Dysmorphic Disorder (DSM-V)

• A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. 

• B. At some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing their appearance with that of others) in response to the appearance concerns.

• C. The preoccupations cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• D. The preoccupations are not attributable to another medical condition

• E. The appearance preoccupations are not better accounted for by concerns with body fat or weight in an Eating Disorder.

• Specify if:• Muscle dysmorphia form of body dysmorphic disorder (the belief that one’s body build is too small or is

insufficiently muscular). (note: this specifier can be used even if other body areas are a focus of concern.)

Indicate whether beliefs about appearance are currently characterized by:• Good or fair insight: The individual recognizes that BDD beliefs are definitely or probably not true, or that

they may or may not be true• Poor insight: The individual thinks BDD beliefs are probably true• Absent insight (i.e., delusional beliefs about appearance): The individual is completely convinced BDD

beliefs are true

Body Dysmorphic disorder•Hidden disorder: usually don’t ask for

help depression or social phobia

•Mirror gazing is secretive: not to be seen as vain or narcissistic. It is shameful.

•Mirror gazing also appears in schizophrenics when they have sudden look changes

Body Dysmorphic disorder

• http://www.youtube.com/watch?v=ZTaQ-hEMMew• http://www.youtube.com/watch?v=RlX1TXYr01M&feature

=related

1. Backround and context• This study was prompted by a

patient with BDD that spent 6 hours looking at himself in mirrors

• 80% of patients with BDD present mirror gazing. The rest avoid mirrors.

• Main question: what is mirror gazing and what is its main function? What mantained this behaviour?

Backround and context• Mirror gazing has been compared to

compulsive checking in OCD compulsions are repeated because they reduce anxiety in the short term

• Authors think that mirror gazing is harder to resist than compulsive checking.

• From a cognitive behavioural perspective: it achieves to mantain preoccupation with one’s appearance, and magnifies perception of defects.

• Therapeutical indication: not to look in the mirror hard to achieve. A better understanding and new therapeutical strategies are needed.

2. Method • 52 patients diagnosed with BDD (DSM-IV) who reported mirror gazing answered a “mirror gazing questionnaire”.

• 55 control participants also answered.• Groups were aged and sex matched.

• Pilot study there were 2 types of mirror gazing: long period (usually in the mornings) and shorter periods during the day

• Controls less likely to report a long session.

2.1 Procedure• Self-report mirror gazing

questionnaire: instructions reported interest in the feelings they had in front of the mirror during the past month

• Asked for reports of long sessions in the past month, defined as the longest time during the day that the person spends in front of the mirror + example

2.1 Procedure•If the participant

reported long sessions, then questions about long sessions were asked.

•The same with short sessions explanation + example and questions about short sessions.

2.2 Length of the mirror gazing• Subjects were asked:(a) Average duration of a “long”

session in minutes (during last month)

(b) The estimated maximum amount of time on any one occasion that he or she had spent in front of a mirror in hours/minutes

(c) The average duration (in minutes) and the frequency of a short session in front of a mirror during the last month.

2.3 Motivation before looking in the mirror•Subjects were asked to rate the

statements for a long session listed on table 2 with:▫1: strongly disagree▫2: disagree▫3: neither disagree or agree▫4: agree▫5: strongly agree

Table 2

2.4 Focus of attention• Subjects were asked the location of

their concentration in front of the mirror for both short and long sessions.

• 9 point analogue visual scale between +4 and -4▫-4: I’m entirely focused on my

reflection in the mirror▫+4: I’m entirely focused on an

impression or feeling that I get about myself.

2.5 Distress before ad after looking in front of mirror• Subjects were asked to rate the degree of

distress visual analogue scale between 0 and 10 were 0= no at all distressed and 10= extremely distressed.

• They were asked to rate their distress:▫ A) before they looked for a long session▫ B) Inmediately after looking in the mirror▫ C) After resisting the urge to look in the

mirror

Same questions for short sessions

*Mistake: not rating distress after resisting urge for a short session

2.6 Behaviour in front of the mirror• They were asked what activities they did in front of a

mirror for a long and short sessions and were given a list of options.

• They had to rate the % of time spent in each. They had to add to 100.

(a) Trying to hide my defects or enhance my appearance by the use of make-up;(b) Combing or styling my hair;(c) Trying to make my skin smooth by picking or squeezing spots;(d) Plucking or removing hairs or shaving;(e) Comparing what I see in the mirror with an image that I have in my mind;(f) Trying to see something different in the mirror;(g) Feeling the skin with my fingers;(h) Practising the best position to pull or show in public;(i) Measuring parts of my face.

2.7 Type of light preferred• They were asked wether the type

of light was important on a scale from “natural day-light” to “artificial light”.

• They were asked if they used a series of mirrors for different profiles or any other reflective surface (eg. Back of CD) for gazing

2.8 Type of reflective surfaces

•Subjects were asked if they avoided certain types of mirrors and the situations in which this occurred.

•Data were analysed with SPSS using Anova for parametric and Chi-squared for ordinal data.

2.9 Mirror avoidance

2.10 Statistics

•No significant differences in age and sex between BDD patients and controls.

•Reported to have long sessions each day: 84,6% of BDD; 29,6% controls.

•Of the ones who reported long sessions, BDD’s long sessions were longer.

3. Results

3. Results•One or more short sessions:86,5% of BDD; 79,6%

controls.

•BDD checked more frequently for short sessions.

•No difference between BDD and controls in duration of short sessions.

3. Results3.1 Motivation for looking in a mirror- BDD were more likely to endorse all the

beliefs listed in table 2. Controls were more interested in making themselves look presentable.

- Results were the same for short sessions- BDD were more likely to use the mirror

when feeling depressed- BDD retained some insight into their

behaviour

3. Results3.2 Behaviour in front of mirror- For long sessions

- BDD were equal than controls in terms of make up, styling hair, picking spots and feeling skin with fingers.

- Controls were more likely to use it to remove hair/shave.

- BDD were more likely to: compare what they see with a mental image; try to see something different in the mirror.

3. ResultsBehaviour in front of mirrorFor short sessions:

- BDD were more likely to: to check make up, practice best position to show in public, compare whay they see with mental image.

- Controls were more likely to use it for shaving

- BDD reported “others”: washing rituals, combing eyebrows, study effect of stress or aging in face, pulling face to see how surgery would look like, put ugly faces to prove how disgusting I am, etc…

3. Results3.3 Distress before, after or resisting a

check- For both long and short, BDD rated

themselves retrospectively as significantly more distressed than controls before any gazing.

- For long, BDD more distressed than controls after gazing.

- BDD: More distress if resisting gazing, than controls.

- After a long session, BBD increase in distress

- After resisting no significant increase in distress as believed

- Reported significant handicaps from mirror gazing: from being late to appointments, to car accidents.

3. Results3.4 Focus of attention in mirror

- Long session: BDD more likely than controls to focus on internal feelings rather than reflection, but not for a short session.

- BDD more likely to focus on specific parts of their appearance during a long session, rather than the whole.

3. Results3.5 Preference for natural

light- No significant difference

between BDD and controls.

3.6 Types of mirrors- Long session: BDD more

likely to use a series of mirrors compared to controls.

- Shop windows were used by both in short checks, but BDD used a lot more surfaces.

3. Results3.7 Mirror avoidance- Some patients reported

avoiding intentionally mirrors at certain times, because they thought it was time consuming or distressing.

- 67% of BDD avoided only certain types of mirrors, compared to only 14% of controls

3. Results• 3.7 Mirror avoidanceIn BDD patients, there were 4

type of mirror avoidance:1. Looking at a specific “defect” in the mirror ie. Only using hand mirrors to avoid seeing nose

2. Avoidance of specific mirrors: avoiding “bad” or “unsafe” mirrors based on previous experience.

3. Only using mirrors in private, but avoiding mirrors or reflective surfaces in social or public situations to prevent feeling upset.

4. Use only an obscured mirror: not full reflection can be seen.

*Some patients flip between avoidance and gazing.

3. Results

4. Conclusions• First study on mirror gazing in

BDD

• Findings: BDD patients have problematics beliefs and behaviours in mirror use compared to controls.

• Mirror gazing: different to OCD compulsions (to reduce anxiety) more complex

4. Conclusions•“Series of idiosyncratic and complex

safety behaviours, designed to prevent a feared outcome in which the patient is seeking safety”

•Feared outcome: internal aversion about one’s appearance, social anxiety, beliefs about rejection

4. Conclusions• BDD’s motivations and behaviours:

▫1. Eternal hope that they will look different to internal body image, or feel comfortable with their appearance

▫ intermittently reinforced because sometimes they feel better.

▫ gazing becomes counter-productive because it becomes more frequent: increases distress

4. Conclusions▫ 2. Uncertainty about body image and

demand to know exactly how they look.

▫ may be rewarded when gazing, but when not looking at the mirror

▫ focus is on mental representation and uncertainty returns.

▫ gazing creates confusion in patients: sometimes they see “a good face” and sometimes “a bad face” that makes them stay housebound.

4. Conclusions▫3. Belief that they will

feel worse if they resist gazing. But results showed that this doesn’t occur.

▫ Probably they don’t resist it because of other factors: hope to look different, wanting to know exactly how they look.

4. Conclusions▫ 4. BDD are driven by a desire to

camouflage their appearance or excessively groom to make themselves look their best or feel comfortable.

▫ Controls: use mirrors for more functional reasons.

▫ Some BDD are trying to to change their internal body image to see something different. “mental cosmetic surgery” reinforced by good image of the past.

4. Conclusions• BDD are more likely to report

using an “internal impression of how they feel” when gazing.

• They are more likely to focus on internal representations for long periods, rather than reflection, and compare.

• Confusion is increased by using ambiguous reflective surfaces.

Selectively attend unstable internal

body image: emotioal reasoning

4. ConclusionsUse of

reflective surfaces:

ambiguous reflection

CONFUSION

Urge to gaze and

know how they

look

If the patient feels ugly or defective reasons that it must be a fact and assume that others can also see them as ugly

4. Conclusions• Adaptation of therapeutic

strategies to help BDD patients to stop mirror gazing. They monitor:▫ A. Time taken for longest session▫ B. Frequency of short sessions

• If patient can reduce grooming, short sessions will be reduced and time in long sessions too.

• This is not possible at early stages of therapy

4. Conclusions• Preparation is required:

less grooming= comments from others

• Some patients hide or cover mirrors. This may cause avoidance problems so the authors reject this strategy. It doesn’t solve the distortion problem.

• Patients need to learn to use mirrors in a healthy way negotiated time limits

4. ConclusionsPatients are encouraged to develop goals:• 1. To use mirrors at a slight distance or ones that are large enough to incorporate most of their

body.

• 2. To deliberately focus attention on their reflection in the mirror rather than an internal impression of how they feel;

• 3. To only use a mirror for an agreed function (e.g. shaving, putting on make-up) for a limited period of time;

• 4. To use a variety of different mirrors and lights rather sticking to one which they “trust”;

• 5. To focus attention on the whole of their face or body rather than a specific area;

• 6. To suspend judgement about one’s appearance and distance oneself from automatic thoughts about being ugly or defective;

• 7. Not to use mirrors that magnify their reflection;

• 8. Not to use ambiguous reflections (for example windows, the backs of CDs or cutlery or mirrors that are dusty or cracked);

• 9. Not to use a mirror when they feel have the urge but to try and delay the response and do other activities until the urge has diminished.

4. Conclusions• This study demonstrated

problematic beliefs prior to looking in a mirror:▫ Assumption of “what you see is

what you get” in front of a mirror.

▫ Helpful to change that belief to “What you see is what you construct” as a result of: Selective attention to specific

aspects of appearance Internal representation of body

image related to the meaning and value of physical appearance, ideal and mood

4. Conclusions• Help the patient to question the

usefulness of such beliefs evaluate more realistic alternatives.

• Difficult when the patient has an idealised value about physical appearance

• Better to take a pragmatic approach: cost-benefit analysis on advantages and disadvantages of the value about the importance of appearance, perfectionism and social acceptance by the use of reverse role-plays.

4. Conclusions•Last resort when everything

else has failed: response-cost

•Patient nominates their most hated organisation and agrees to pay a sum of money to it for each check in the mirror

•Requires a very compliant patient.