David Veale and Susan Riley (2000)

1. Mirror, mirror on the wall, who is the ugliest of them all?The psychopathology of mirror gazing in body dysmorphicdisorder David Veale and Susan Riley (2000)

2. BodyDysmorphicDisorder (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

3. BodyDysmorphicdisorder • Hiddendisorder: usuallydon’taskforhelp depressionor social phobia • Mirrorgazingissecretive: nottobeseen as vainornarcissistic. Itisshameful. • Mirrorgazingalsoappears in schizophrenicswhentheyhavesudden look changes

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

5. 1. Backround and context • Thisstudywaspromptedby a patientwith BDD thatspent 6 hourslooking at himself in mirrors • 80% of patientswith BDD presentmirrorgazing. Therestavoidmirrors. • Mainquestion: whatismirrorgazing and whatisitsmainfunction? Whatmantainedthisbehaviour?

6. Backround and context • Mirrorgazing has beencomparedtocompulsivechecking in OCD compulsions are repeatedbecausethey reduce anxiety in the short term • Authorsthinkthatmirrorgazingishardertoresistthancompulsivechecking. • From a cognitivebehaviouralperspective: itachievestomantainpreoccupationwithone’sappearance, and magnifiesperception of defects. • Therapeuticalindication: notto look in themirror hardtoachieve. A betterunderstanding and new therapeuticalstrategies are needed.

7. 2. Method • 52 patientsdiagnosedwith BDD (DSM-IV) whoreportedmirrorgazinganswered a “mirrorgazingquestionnaire”. • 55 control participantsalsoanswered. • Groupswereaged and sex matched. • Pilotstudy therewere 2 types of mirrorgazing: longperiod (usually in themornings) and shorterperiodsduringtheday • Controls lesslikelytoreport a longsession.

8. 2.1 Procedure • Self-reportmirrorgazingquestionnaire: instructionsreportedinterest in thefeelingstheyhad in front of themirrorduringthepastmonth • Askedforreports of longsessions in thepastmonth, defined as thelongest time duringthedaythatthepersonspends in front of themirror + example

9. 2.1 Procedure • Iftheparticipantreportedlongsessions, thenquestionsaboutlongsessionswereasked. • Thesamewith short sessions explanation + example and questionsabout short sessions.

10. 2.2 Length of themirrorgazing • Subjectswereasked: • Averageduration of a “long” session in minutes (duringlastmonth) • Theestimatedmaximumamount of time onanyoneoccasionthat he orshehadspent in front of a mirror in hours/minutes • Theaverageduration (in minutes) and thefrequency of a short session in front of a mirrorduringthelastmonth.

11. 2.3 Motivationbeforelooking in themirror • Subjectswereaskedtoratethestatementsfor a longsessionlistedontable 2 with: • 1: stronglydisagree • 2: disagree • 3: neitherdisagreeoragree • 4: agree • 5: stronglyagree

12. Table 2

13. 2.4 Focus of attention • Subjectswereaskedthelocation of theirconcentration in front of themirrorforboth short and longsessions. • 9 pointanalogue visual scalebetween +4 and -4 • -4: I’mentirelyfocusedon my reflection in themirror • +4: I’mentirelyfocusedonanimpressionorfeelingthat I getaboutmyself.

14. 2.5 Distressbefore ad afterlooking in front of mirror • Subjectswereaskedtoratethedegree of distress visual analoguescalebetween 0 and 10 were 0= no at alldistressed and 10= extremelydistressed. • Theywereaskedtoratetheirdistress: • A) beforetheylookedfor a longsession • B) Inmediatelyafterlooking in themirror • C) Afterresistingthe urge to look in themirror Samequestionsfor short sessions *Mistake: not rating distressafterresisting urge for a short session

15. 2.6 Behaviour in front of themirror • Theywereaskedwhatactivitiestheydid in front of a mirrorfor a long and short sessions and weregiven a list of options. • Theyhadtoratethe % of time spent in each. Theyhadtoaddto 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.

16. 2.7 Type of light preferred • Theywereaskedwetherthetype of light wasimportanton a scalefrom “natural day-light” to “artificial light”. • Theywereaskediftheyused a series of mirrorsfordifferentprofilesoranyotherreflectivesurface (eg. Back of CD) forgazing 2.8 Type of reflectivesurfaces

17. 2.9 Mirroravoidance 2.10 Statistics • Subjectswereaskediftheyavoidedcertaintypes of mirrors and thesituations in whichthisoccurred. • Data wereanalysedwith SPSS usingAnovaforparametric and Chi-squaredfor ordinal data.

18. 3. Results • No significantdifferences in age and sex between BDD patients and controls. • Reportedtohavelongsessionseachday: 84,6% of BDD; 29,6% controls. • Of theoneswhoreportedlongsessions, BDD’slongsessionswerelonger.

19. 3. Results • Oneor more short sessions: 86,5% of BDD; 79,6% controls. • BDD checked more frequentlyfor short sessions. • No differencebetween BDD and controls in duration of short sessions.

20. 3. Results 3.1 Motivationforlooking in a mirror • BDD were more likelyto endorse allthebeliefslisted in table 2. Controlswere more interested in makingthemselves look presentable. • Resultswerethesamefor short sessions • BDD were more likelyto use themirrorwhenfeelingdepressed • BDD retainedsomeinsightintotheirbehaviour

21. 3. Results 3.2 Behaviour in front of mirror • Forlongsessions • BDD wereequalthancontrols in terms of make up, stylinghair, picking spots and feelingskinwithfingers. • Controlswere more likelyto use ittoremovehair/shave. • BDD were more likelyto: compare whattheyseewith a mental image; try toseesomethingdifferent in themirror.

22. 3. Results Behaviour in front of mirror For short sessions: • BDD were more likelyto: tocheckmake up, practicebest position to show in public, compare whaytheyseewith mental image. • Controlswere more likelyto use itforshaving • BDD reported “others”: washingrituals, combingeyebrows, studyeffect of stress oraging in face, pullingfacetoseehowsurgerywould look like, putugly faces toprovehowdisgusting I am, etc…

23. 3. Results 3.3 Distressbefore, afterorresisting a check • Forbothlong and short, BDD ratedthemselvesretrospectively as significantly more distressedthancontrolsbeforeanygazing. • Forlong, BDD more distressedthancontrolsaftergazing. • BDD: More distressifresistinggazing, thancontrols.

24. After a longsession, BBD increase in distress • Afterresisting no significantincrease in distress as believed • Reportedsignificanthandicapsfrommirrorgazing: frombeing late toappointments, to car accidents.

25. 3. Results 3.4 Focus of attention in mirror • Long session: BDD more likelythancontrolstofocusoninternalfeelingsratherthanreflection, butnotfor a short session. • BDD more likelytofocusonspecificparts of theirappearanceduring a longsession, ratherthanthewhole.

26. 3. Results 3.5 Preferencefor natural light • No significantdifferencebetween BDD and controls. 3.6 Types of mirrors • Long session: BDD more likelyto use a series of mirrorscomparedtocontrols. • Shop windowswereusedbyboth in short checks, but BDD used a lot more surfaces.

27. 3. Results 3.7 Mirroravoidance • Somepatientsreportedavoidingintentionallymirrors at certain times, becausetheythoughtitwas time consumingordistressing. • 67% of BDD avoidedonlycertaintypes of mirrors, comparedtoonly 14% of controls

28. 3. Results • 3.7 Mirroravoidance In BDD patients, therewere 4 type of mirroravoidance: 1. Looking at a specific “defect” in themirror ie. Onlyusinghandmirrorstoavoidseeingnose 2. Avoidance of specificmirrors: avoiding “bad” or “unsafe” mirrors basedonpreviousexperience.

29. 3. Results 3. Onlyusingmirrors in private, butavoidingmirrorsorreflectivesurfaces in social orpublicsituationstopreventfeelingupset. 4. Use onlyanobscuredmirror: not full reflection can beseen. *Somepatientsflipbetweenavoidance and gazing.

30. 4. Conclusions • Firststudyonmirrorgazing in BDD • Findings: BDD patientshaveproblematicsbeliefs and behaviours in mirror use comparedtocontrols. • Mirrorgazing: differentto OCD compulsions (to reduce anxiety) more complex

31. 4. Conclusions • “Series of idiosyncratic and complex safety behaviours, designedtoprevent a fearedoutcome in whichthepatientisseeking safety” • Fearedoutcome: internalaversionaboutone’sappearance, social anxiety, beliefsaboutrejection

32. 4. Conclusions • BDD’smotivations and behaviours: • 1. Eternal hope thattheywill look differenttointernalbodyimage, orfeelcomfortablewiththeirappearance •  intermittentlyreinforcedbecausesometimestheyfeelbetter. •  gazingbecomescounter-productivebecauseitbecomes more frequent: increasesdistress

33. 4. Conclusions • 2. Uncertaintyaboutbodyimage and demandtoknowexactlyhowthey look. •  mayberewardedwhengazing, butwhennotlooking at themirror •  focusison mental representation and uncertaintyreturns. •  gazingcreatesconfusion in patients: sometimestheysee “a goodface” and sometimes “a badface” thatmakesthemstayhousebound.

34. 4. Conclusions • 3. Beliefthattheywillfeelworseiftheyresistgazing. Butresultsshowedthatthisdoesn’toccur. •  Probablytheydon’tresistitbecause of otherfactors: hope to look different, wantingtoknowexactlyhowthey look.

35. 4. Conclusions • 4. BDD are drivenby a desiretocamouflagetheirappearanceorexcessively groom tomakethemselves look theirbestorfeelcomfortable. • Controls: use mirrorsfor more functionalreasons. • Some BDD are tryingtotochangetheirinternalbodyimagetoseesomethingdifferent. “mental cosmeticsurgery” reinforcedbygoodimage of thepast.

36. 4. Conclusions • BDD are more likelytoreportusingan “internalimpression of howtheyfeel” whengazing. • They are more likelytofocusoninternalrepresentationsforlongperiods, ratherthanreflection, and compare. • Confusionisincreasedbyusingambiguousreflectivesurfaces.

37. 4. Conclusions CONFUSION Use of reflectivesurfaces: ambiguousreflection Urge togaze and knowhowthey look Selectivelyattendunstableinternalbodyimage: emotioalreasoning Ifthepatientfeelsuglyordefective reasonsthatitmustbe a fact and assumethatothers can alsoseethem as ugly

38. 4. Conclusions • Adaptation of therapeuticstrategiestohelp BDD patientsto stop mirrorgazing. They monitor: • A. Time takenforlongestsession • B. Frequency of short sessions • Ifpatient can reduce grooming, short sessionswillbereduced and time in longsessionstoo. • Thisisnotpossible at earlystages of therapy

39. 4. Conclusions • Preparationisrequired: lessgrooming= commentsfromothers • Somepatients hideorcovermirrors. Thismay cause avoidanceproblems so theauthorsrejectthisstrategy. Itdoesn’tsolvethedistortionproblem. • Patientsneedtolearnto use mirrors in a healthyway negotiated time limits

40. 4. Conclusions Patients are encouragedtodevelopgoals: • 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 howtheyfeel; • 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.

41. 4. Conclusions • Thisstudydemonstratedproblematicbeliefs prior tolooking in a mirror: • Assumption of “whatyouseeiswhatyouget” in front of a mirror. • Helpfultochangethatbeliefto “Whatyouseeiswhatyouconstruct” as a result of: • Selectiveattentiontospecificaspects of appearance • Internalrepresentation of bodyimage relatedtothemeaning and value of physicalappearance, ideal and mood

42. 4. Conclusions • Helpthepatienttoquestiontheusefulness of suchbeliefs evaluate more realisticalternatives. • Difficultwhenthepatient has anidealisedvalueaboutphysicalappearance • Bettertotake a pragmaticapproach: cost-benefitanalysisonadvantages and disadvantages of thevalueabouttheimportance of appearance, perfectionism and social acceptancebythe use of reverse role-plays.

43. 4. Conclusions • Last resort wheneverythingelse has failed: response-cost • Patientnominatestheirmosthatedorganisation and agreestopay a sum of moneytoitforeachcheck in themirror • Requires a verycompliantpatient.