Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder

Patients with Body Dysmorphic Disorder (BDD) may spend many hours in front of a mirror but little is known about the psychopathology or the factors that maintain the behaviour. A self-report mirror gazing questionnaire was used to elicit beliefs and behaviours in front of a mirror. Two groups were compared, which consisted of 55 controls and 52 BDD patients. Results: Prior to gazing, BDD patients are driven by the hope that they will look different; the desire to know exactly how they look; a belief that they will feel worse if they resist gazing and the desire to camouflage themselves. They were more likely to focus their attention on an internal impression or feeling (rather than their external reflection in the mirror) and on specific parts of their appearance. They were also more likely to practise showing the best face to pull in public or to use “mental cosmetic surgery” to change their body image than controls. BDD patients invariably felt worse after mirror gazing and were more likely to use ambiguous surfaces such as the backs of CDs or cutlery for a reflection. Conclusion: Mirror gazing in BDD consists of a series of complex safety behaviours. It does not follow a simple model of anxiety reduction that occurs in the compulsive checking of obsessive–compulsive disorder. The implications for treatment are discussed.     

Differential outcomes of skill training,group counseling,and individual cognitive therapy for persons with acquired visual impairment

As part of the Living Skills Training Program, group counseling and individual cognitive therapy were implemented to decrease psychological distress for adults with acquired visual impairment. This quasi‐experimental design study compared the outcomes of a 6‐month skill training program combined with a group counseling program (n = 37), with (n = 9) or without (n = 10) individual cognitive therapy, and with a control group (n = 42). The outcome measures were the Profile of Mood States and the Nottingham Adjustment Scale Japanese Version. The results showed that participants with low psychological distress decreased anxiety and increased acceptance of disability, even when they did not participate in group counseling. However, among the participants with high distress, they did not show any improvement without group counseling or individual therapy. The participants with high distress who engaged in group counseling showed an improving trend in attitudes toward others. Moreover, the participants who chose to engage in individual therapy in addition to group counseling showed decreased tension‐anxiety, depression, and fatigue, and significantly improved acceptance of disability. These results suggest that group counseling, combined with individual cognitive therapy, can be an effective part of rehabilitation treatment for clients who have high psychological distress.     

Perceived teasing experiences in body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are excessively concerned about imagined or slight defects in their appearance (e.g., asymmetrical facial features). Cognitive-behavioral models of BDD propose that several factors, including dysfunctional appearance-related beliefs and life experiences, such as teasing, contribute to the avoidance behaviors or rituals (e.g., mirror checking, grooming) characteristic of BDD. Previous research has demonstrated an association between perceived teasing and body dissatisfaction. In the current study, we examined whether individuals with BDD (n = 16) report to have been teased more often than do mentally healthy controls (n = 17). The group comprising individuals with BDD reported more appearance- and competency-related teasing than did control participants. This study provides preliminary evidence for the association between perceived teasing and BDD.     

Facial asymmetry detection in patients with body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) propose that individuals with BDD may possess a better or more developed sense of aestheticality than do individuals without BDD. Evidence for this proposition, however, is limited. One perceptual process that could contribute to heightened aestheticality is the ability to detect differences in symmetry. In this experiment we tested whether individuals with BDD (n = 20), relative to individuals with obsessive compulsive disorder (OCD; n = 20) and healthy controls (n = 20), show an enhanced ability to detect differences in the symmetry of others’ faces, symmetry of dot arrays, and/or show a greater preference for symmetrical faces. Individuals with BDD were not significantly more accurate in detecting differences in facial symmetry or dot arrays relative to individuals with OCD and healthy controls. Individuals with OCD took longer to make facial symmetry judgments than did individuals in the other two groups. All participants, regardless of diagnostic group, preferred more symmetrical faces than nonsymmetrical ones. Taken together, our results do not support a heightened perceptual ability or evaluative preference for symmetry among individuals with BDD.     

Strange-face illusions during inter-subjective gazing

In normal observers, gazing at one’s own face in the mirror for a few minutes, at a low illumination level, triggers the perception of strange faces, a new visual illusion that has been named ‘strange-face in the mirror’. Individuals see huge distortions of their own faces, but they often see monstrous beings, archetypal faces, faces of relatives and deceased, and animals. In the experiment described here, strange-face illusions were perceived when two individuals, in a dimly lit room, gazed at each other in the face. Inter-subjective gazing compared to mirror-gazing produced a higher number of different strange-faces. Inter-subjective strange-face illusions were always dissociative of the subject’s self and supported moderate feeling of their reality, indicating a temporary lost of self-agency. Unconscious synchronization of event-related responses to illusions was found between members in some pairs. Synchrony of illusions may indicate that unconscious response–coordination is caused by the illusion–conjunction of crossed dissociative strange-faces, which are perceived as projections into each other’s visual face of reciprocal embodied representations within the pair. Inter-subjective strange-face illusions may be explained by the subject’s embodied representations (somaesthetic, kinaesthetic and motor facial pattern) and the other’s visual face binding. Unconscious facial mimicry may promote inter-subjective illusion–conjunction, then unconscious joint-action and response–coordination.     

Clinical Application of a Behavioral Model for the Treatment of Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is characterized by an obsessive concern over a perceived flaw in bodily appearance. If a minor flaw does exist, the patient displays unwarranted distress. This preoccupation typically leads to compulsive behaviors, such as mirror checking or mirror avoiding, camouflaging, and seeking reassurance from others regarding one’s appearance or the perceived “flaw.” Although some theorists have outlined important maintaining mechanisms of the disorder, a full model of the etiology and maintenance of this disorder has only recently been articulated in the literature (Neziroglu, Roberts, & Yaryura-Tobias, (2004). A behavioral model for body dysmorphic disorder. Psychiatric Annals, 34, 915–920.). The aim of the present article is to review this model and demonstrate its application to the successful treatment of BDD via a case presentation.     

Dispositional and induced optimism lead to attentional preference for faces displaying positive emotions: An eye-tracker study

The aim of this study was to examine whether dispositional optimism and induced optimism are associated with an attentional bias for positive stimuli. Fifty-six healthy participants performed an eye-tracking task twice, while their gazing time at faces displaying joy, anger, pain, or a neutral expression was measured. Participants scoring high on dispositional optimism tended to gaze longer at joy faces during the first face-presentation trial compared to participants scoring lower on optimism, and this correlation became significant during the second face-presentation trial. In between the two presentations, participants received either an optimism manipulation or a control manipulation. There was no effect of type of manipulation on gazing behavior but post hoc analyses demonstrated that participants showing an increase in state optimism displayed a significant decrease in gaze duration for anger faces and a nearly significant increase in gaze duration for joy faces.     

Perceptual and cognitive biases in individuals with body dysmorphic disorder symptoms

Given the extreme focus on perceived physical defects in body dysmorphic disorder (BDD), we expected that perceptual and cognitive biases related to physical appearance would be associated with BDD symptomology. To examine these hypotheses, participants (N=70) high and low in BDD symptoms completed tasks assessing visual perception and cognition. As expected, there were significant group differences in self-relevant, but not other-relevant, cognitive biases. Perceptual bias results were mixed, with some evidence indicating that individuals high (versus low) in BDD symptoms literally see themselves in a less positive light. Further, individuals high in BDD symptoms failed to demonstrate a normative self-enhancement bias. Overall, this research points to the importance of assessing both cognitive and perceptual biases associated with BDD symptoms, and suggests that visual perception may be influenced by non-visual factors.     

Nonverbal self-accuracy in interpersonal interaction

Four studies measure participants' accuracy in remembering, without forewarning, their own nonverbal behavior after an interpersonal interaction. Self-accuracy for smiling, nodding, gazing, hand gesturing, and self-touching is scored by comparing the participants' recollections with coding based on videotape. Self-accuracy is above chance and of modest magnitude on average. Self-accuracy is greatest for smiling; intermediate for nodding, gazing, and gesturing; and lowest for self-touching. It is higher when participants focus attention away from the self (learning as much as possible about the partner, rearranging the furniture in the room, evaluating the partner, smiling and gazing at the partner) than when participants are more self-focused (getting acquainted, trying to make a good impression on the partner, being evaluated by the partner, engaging in more self-touching). The contributions of cognitive demand and affective state are discussed.     

Advances in a cognitive behavioural model of body dysmorphic disorder

Body dysmorphic disorder (BDD) is the most distressing and handicapping of all the body image disorders. A cognitive behavioural model of BDD is discussed which incorporates evidence from recent studies and advances in the author’s 1996 conceptual model. The model aims to understand the maintenance of symptoms in BDD, to assist in the process of engagement of therapy and to guide the strategies to use. At the core of BDD is an excessive self-focussed attention on a distorted body image, the negative appraisal of such images leading to rumination, changes in mood and the use of safety behaviours. Evidence for possible risk factors in the development of BDD is also discussed.     

Eye'm lovin' it! The role of gazing awareness in mimetic desires

Recent studies showed that people evaluate objects more favorably when these objects are gazed-at by others, an effect coined as “mimetic desire”. In two studies, we tested whether mimetic desire stems from an automatic form of learning by examining one dimension of automaticity, i.e., people's awareness of the object-gaze association. Participants saw 6 neutral art paintings associated with a female gazing toward two of the paintings, away from two of the paintings, and closing her eyes with respect to the last two paintings. After the exposition phase, participants evaluated the paintings and performed a contingency-awareness test. Importantly, participants' responses on this test were genuinely driven by memory and not by inferences from liking. Results show that participants preferred objects that were gazed-at but only when they were aware of the object-gaze association. Hence, despite the adaptive function of joint attention, its impact on valence acquisition does not seem to qualify as an implicit learning process.     

Case Conceptualization and Treatment of Comorbid Body Dysmorphic Disorder and Bulimia Nervosa

Body dysmorphic disorder (BDD) and eating disorders often co-occur and share some clinical features. In addition, the co-occurrence of BDD and an eating disorder may be associated with greater impairment in functioning. Furthermore, clinical impressions suggest that this comorbidity may be more treatment resistant than either disorder alone. The current article discusses the treatment of a 48-year-old female diagnosed with BDD and comorbid bulimia. We attempted to address these co-occurring disorders in a strategic, formulation-based manner using a variety of cognitive-behavioral strategies such as cognitive restructuring, rational disputation, exposure with response prevention, and mirror retraining. Despite the complexity of this case, results suggest that comorbid BDD and bulimia nervosa can be effectively managed with cognitive behavioral therapy.     

Reality monitoring in patients with body dysmorphic disorder

Patients with body dysmorphic disorder (BDD) typically have very poor insight into their disorder. Their conviction in their ugliness is often of delusional intensity. Reality monitoring is the ability to distinguish in memory between things that one has imagined and things that one has perceived. Deficits in reality monitoring have been associated with the development of other delusional beliefs. Therefore, in the present study we investigated whether individuals with BDD (n = 20) demonstrate impairments in reality monitoring relative to individuals with obsessive-compulsive disorder (OCD; n = 20) and healthy controls (n = 20). This hypothesized impairment might predispose people with BDD to confuse memories of how they imagine themselves to appear (i.e., ugly) with memories of how they actually appear (i.e., normal). All participants completed a memory task assessing reality-monitoring ability for verbal stimuli. The BDD patients did not exhibit a reality-monitoring deficit despite elevated levels of focal delusionality. The results suggest that impairments in reality monitoring do not contribute to the development or maintenance of appearance-related beliefs in BDD.     

Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder

Body dysmorphic disorder (BDD) continues to challenge professionals due to symptom severity, co-morbidity, suicidal ideation, and overvalued ideation. Despite the disorder's severity, little research exists. Clinical observation suggests a noteworthy history of abuse; therefore the present study investigated the reported rate of physical, sexual, and emotional abuse in BDD patients. OCD patients were chosen as a comparison group because BDD is considered to be an obsessive-compulsive spectrum disorder. A group survey design was used (N = 50 for each group). Results show significantly higher levels of emotional and sexual abuse in the BDD sample versus the OCD sample. No significant differences were found in physical abuse. Abuse may be a contributing factor in BDD, but not in OCD.     

Efficacy of Cognitive Therapy for Body Dysmorphic Disorder: A Randomized Controlled Pilot Trial

Dysfunctional cognitive processes and maladaptive interpersonal patterns have been postulated to maintain body dysmorphic disorder (BDD). The present trial evaluated CT for BDD (CT-BDD), which includes modules targeting maladaptive cognitive processing in BDD, as well as elements of schema therapy related to interpersonal problems. We investigated whether (a) CT-BDD is effective, as compared with a wait-list (WL) group at Week 12; (b) outcome of CT-BDD is maintained at posttreatment and 3- and 6-months follow-up; and (c) whether changes in shame and insight mediate changes in BDD symptom severity. Forty adults with BDD were randomized to 36 weeks immediate CT-BDD (n = 21), or to 12-week WL (n = 19). At Week 12, immediate CT-BDD was significantly superior to WL in clinician-rated BDD symptom severity, insight, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. Changes in outcomes were associated with moderate to large effect sizes at Week 12. Reductions in shame and increase in insight separately mediated changes in BDD symptom severity during treatment at Week 12. From baseline to posttreatment, significant improvements occurred within CT-BDD in clinician-rated symptom severity, insight, depression, global functioning, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. At posttreatment, improvements were associated with large effect sizes and were maintained at 3- and 6-month follow-up. Preliminary results support the efficacy of CT-BDD. Addressing interpersonal problems in addition to cognitive dysfunctions may increase the benefit of CBT for BDD patients.     

Something Distressing This Way Comes: The Effects of Trigger Warnings on Avoidance Behaviors in an Analogue Trauma Task

Avoidance is one of the purported benefits and harms of trigger warnings—alerts that upcoming content may contain traumatic themes. Yet, previous research has focused primarily on emotional responses. Here, we used a trauma analogue design to assess people’s avoidance behavior in response to stimuli directly related to an analogue trauma event. University undergraduates (n = 199) watched a traumatic film and then viewed film image stills preceded by either a trigger warning or a neutral task instruction. Participants had the option to “cover” and avoid each image. Apart from a minor increase in avoidance when a warning appeared in the first few trials, we found that participants did not overall avoid negative stimuli prefaced with a trigger warning any more than stimuli without a warning. In fact, participants were reluctant overall to avoid distressing images; only 12.56% (n = 25) of participants used the option to cover such images when given the opportunity to do so. Furthermore, we did not find any indication that trigger warning messages help people to pause and emotionally prepare themselves to view negative content. Our results contribute to the growing body of literature demonstrating that warnings seem trivially effective in achieving their purported goals.     

Intelligence in childhood and risk of psychological distress in adulthood: The 1958 National Child Development Survey and the 1970 British Cohort Study

Lower cognitive ability is a risk factor for some forms of severe psychiatric disorder, but it is unclear whether it influences risk of psychological distress due to anxiety or the milder forms of depression. The participants in the present study were members of two British birth national birth cohorts, the 1958 National Child Development Survey (n = 6369) and the 1970 British Cohort Study (n = 6074). We examined the association between general cognitive ability (intelligence) measured at age 10 (1970 cohort) and 11 years (1958 cohort) and high levels of psychological distress at age 30 (1970 cohort) or 33 years (1958 cohort), defined as a score of 7 or more on the Malaise Inventory. In both cohorts, participants with higher intelligence in childhood had a reduced risk of psychological distress. In sex-adjusted analyses, a standard deviation (15 points) increase in IQ score was associated with a 39% reduction in psychological distress in the 1958 cohort and a 23% reduction in the 1970 cohort [odds ratios (95% confidence intervals) were 0.61 (0.56, 0.68) and 0.77 (0.72, 0.83), respectively]. These associations were only slightly attenuated by further adjustment for potential confounding factors in childhood, including birth weight, parental social class, material circumstances, parental death, separation or divorce, and behaviour problems, and for potential mediating factors in adulthood, educational attainment and current social class. Intelligence in childhood is a risk factor for psychological distress due to anxiety and the milder forms of depression in young adults. Understanding the mechanisms underlying this association may help inform methods of prevention.     

"I feel fat": an experimental induction of body displacement in disordered eating

Body displacement, the theory that predicts that individuals with eating disorders will displace negative feelings about themselves onto their body, was tested experimentally in this study. Unrestrained eaters (n = 61), restrained eaters (n = 33), and individuals with eating disorders (n = 26) were randomly assigned to a control condition or an ineffectiveness induction. In the ineffectiveness condition participants were asked to recall and reflect on a past experience when they felt useless or incapable (i.e., ineffective). Results showed that individuals with eating disorders who were made to feel ineffective reported more implicit appearance/body concern than those in the control condition. Unrestrained and restrained eaters did not show this effect. This is the first experimental study to support body displacement theory. These data can be used clinically to educate and encourage patients with eating disorders to address thoughts and feelings related to ineffectiveness directly, instead of displacing this distress onto their body and potentially perpetuating their eating disorder.     

Experiential avoidance in body dysmorphic disorder

Experiential avoidance (i.e., the attempt to avoid certain internal experiences including bodily sensations, thoughts, emotions, memories, and urges) has been studied in various psychological disorders. However, research examining experiential avoidance in individuals with body dysmorphic disorder (BDD) is limited and inconsistent. The present study compared experiential avoidance in individuals with primary BDD (n = 23) to healthy controls (n = 22). Standardized measures were used to assess baseline clinical characteristics as well as experiential avoidance. Compared to healthy controls, individuals with BDD presented with significantly greater experiential avoidance (p < .001, d = −2.51). In BDD, experiential avoidance was positively correlated with depressive symptoms (p < .01) and avoidant coping strategies (p < .01). Clinician sensitivity to experiential avoidance may serve to improve the course of treatment for BDD.