Mirror, Mirror on the Wall, Who Is the Ugliest of Them All?

The Psychopathology of Mirror Gazing in Body Dysmorphic Disorder

(2001)

Veale, Riley

BackgroundBody Dysmorphic Disorder

A somatoform disorder• A mental illness in which a person has

symptoms of a medical illness, but these can’t be explained by an actual physical disorder.

People with BDD are preoccupied with an imagined physical defect or a minor defect that others often cannot see. Sometime called “imagined ugliness”

Background: BDD

Also known as dysmorphophobia, the fear of having a deformity

Shares certain traits with anorexia nervosa and OCD

Affects men & women equally

It usually begins during the teen years or early adulthood

Background: BDD

The most common areas of concern for BDD patients:

• Skin imperfections: wrinkles, scars, acne, and blemishes

• Hair: head or body hair or absence of hair • Facial features: Very often this involves

the nose, but it also might involve the shape and size of any feature

• Body weight: Sufferers may obsess about their weight or muscle tone

Heidi Montag may have BDD

Background: BDD Symptoms Engaging in repetitive and time-consuming

behaviors, such as mirror gazing, picking at the skin, and trying to hide or cover up the perceived defect

Constantly asking for reassurance that the defect is not visible or too obvious

Repeatedly measuring or touching the perceived defect

Background: BDD Symptoms Experiencing problems at work or school, or

in relationships due to the inability to stop focusing about the perceived defect

Feeling self-conscious, not wanting to go out in public, feeling anxious when around other people

Repeatedly consulting with medical specialists, such as plastic surgeons or dermatologists, to find ways to improve his or her appearance

Lil’ Kim may have BDD

Background: BDD CausesThe exact cause of BDD is not known

• Having biological relatives with body dysmorphic disorder

• Having another psychiatric disorder, such as anxiety or depression

• Experience of traumatic childhood events

• Low self-esteem

• Parents & others who were critical of the person's appearance

• Pressure from peers & society that equates physical appearance with beauty and value

Background: BDD TreatmentMedications

• Antidepressants

Cognitive behavioral therapy. This is a type of therapy with several steps. With the help of a therapist:

• The patient enters social situations without covering up the "defect."

• The patient stops doing the compulsive behaviors to check the defect or cover it up

• The patient changes the false beliefs about their appearance

Background

This study was prompted by a patient with (BDD) who reported to one of the authors that he had just spent 6 hours staring at himself in front of a series of mirrors.

Questions that arose:• What exactly did the behavior consist of?

• What was the function of the behavior?

• What maintained this behavior? (especially when he reported feeling worse after gazing in the mirror)

Mirror Gazing

The most common behavior related to BDDOccurs in about 80% of patients while others

tend to avoid mirrors (covering or removing them)

Motivations might be: • Hoping to look different

• A desire to know exactly how they look

• Reassurance that their efforts at camouflage have worked

• Belief that they will feel worse if they resist

AIMTo better understand of the

psychopathology of mirror gazing in order to better define BDD & develop new strategies for cognitive behavioral therapies for BDD patients

Who is the population?

Subjects52 patients with BDD who reported

mirror gazing to be a feature of their problem were recruited to complete a “Mirror gazing questionnaire”

A group of 55 controls were recruited from personal contacts• The groups were age and sex matched

What is this design called?

Method/procedureSelf-report mirror gazing questionnaire.

• Instructions informed them that the researchers were interested in the feelings that they had in front of a mirror during the past month

• The subjects were asked if they had a long session in front of a mirror on most days of the past month (Longest amount of time a person spends in front of the mirror, e.g. Getting ready for the day) If yes, then they were asked a series of questions about

a typical long session in front of a mirror

• The same questions were asked about a typical short session in front of a mirror (e.g. Checking their appearance)

Questionnaire

Length of time mirror gazing in the last month• Average duration of a “long” session in

minutes

• The estimated maximum amount of time on any one occasion spent in front of a mirror in hours/minutes.

• The average duration (in minutes) & frequency of a short session in front of a mirror

Results

More BDD patients reported that they had a “long session” in front of the mirror each day• And BDD patients used a mirror for far longer

87% of BDD patients 80% of controls reported that they had one or more “short sessions” • However there was no difference between BDD

patients and controls for the duration of each short session

BDD patients checked mirrors more frequently

Questionnaire

Motivation before looking in a mirror (handout)• Rate the strength of agreement with the

statements for a long session listed in Table 2 before looking in front of a mirror on a scale between “1” to “5” (1=“strongly disagree”, 5=“strongly agree”). (What is this called?)

• At the end there was the option to write anything else that motivated them to use the mirror (Why?)

• None of the items were reversed.

• The questions were repeated for short sessions

Results

BDD patients • more likely to support the beliefs listed in Table 2

(handout)

• more likely to use the mirror if they were feeling depressed

BDD patients did have some insight into their behavior. They were more likely to agree with the statements: • “Looking in a mirror so often and for so long distorts

my judgment about how attractive I am”

• “Every mirror I look in I see a different image”

Questionnaire/Results

Behavior in front of mirror (Handout)

BDD patients were more likely: • to compare what they

see in front of a mirror with an image in their mind of how they think they should ideally look

• try to see something different in the mirror

Questionnaire/ResultsBehavior in front of mirror (Handout)For short session BDD patients were more

use the mirror: • for checking their make-up • practicing the best position/ face to show in public • comparing what they saw in front of a mirror with

how they think they would ideally look BDD patients listed a range of other

behaviors while in front of the mirror• washing rituals, studying my eyes hair and skin to

observe the effect of stress on the ageing process, pulling my features or squashing my nose to see how I’d look if I had plastic surgery, make ugly faces to prove how disgusting I am, etc (What sort of data is this?)

Questionnaire/Results

Distress before, after or resisting a check• For both short & long mirror sessions,

BDD patients were significantly more distressed than before any gazing

• For long mirror sessions, the BDD patients were more distressed after mirror gazing

• BDD patients were more distressed if they resisted gazing in the mirror

Questionnaire/Results

Focus of attention in mirrorFor long sessions BDD patients were

more likely to focus their attention on an internal impression or feeling (rather than their external reflection) • This was not true for short sessions

BDD patients more likely to focus their attention on specific parts of their appearance

Questionnaire/Resultss

Preference for natural light• No significant difference was found

Types of mirrors• For short sessions, both BDD patients and

controls used shop windows • For long sessions, BDD patients were more likely

to use a series of mirrors with different profiles• However, BDD patients spontaneously reported

using a wide variety of reflective surfaces (car mirrors, windows, car bumpers, cutlery, TV screens, reflective table tops, glass watch faces, the back of CDs, etc)

Questionnaire/ResultsMirror avoidance BBD patients found mirror gazing time consuming &

distressing & avoided all mirrors at times BDD patients reported that they avoided only certain

mirrors Four types of selective avoidance of mirrors

• Selective avoidance of looking at a specific “defect” in the mirror

• Selective avoidance of specific mirrors • Using mirrors only in private but avoiding mirrors or reflective

surfaces in public • Flipping between avoidance and gazing

(A patient who picked his skin would stay inside checking his skin until it healed. When he was satisfied he would go out, but then he would avoid mirrors. Finally the urge to check in the mirror & pick his skin would overwhelm him and the cycle would begin again)

Conclusions

BDD patients • have hope that they will look different from their

internal body image • are uncertain about their body image & demand

to know exactly how they look• believe they will feel worse if they resist gazing• are driven by a desire to camouflage their

appearance or excessively groom to make themselves look their best or to feel ‘comfortable’

• use an “internal impression of how they feel” when they look in the mirror

Outcomes

As a result of this study, therapeutic strategies have been changed to help BDD patients to stop mirror gazing

Analysis

What are some strengths of this study?• Controls?

What are some of the weaknesses of this study?

What are some useful outcomes of this study?

Questions?

Vocabulary

Body Dysmorphic Disorder Psychopathology: The manifestation of

a mental or behavioral disorder Mirror gazing

Sources

http://www.webmd.com/mental-health/mental-health-body-dysmorphic-disorder?page=2 http://www.mayoclinic.com/health/body-dysmorphic-disorder/DS00559 http://www.bddsupport.org.uk/modules.php?op=modload&name=HomePages&file=preview&id=4

Veale, D. and Riley, S. (2001), Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder. Behaviour Research and Therapy. 39. pp. 1381–1393