Veale And Riley - Mirror Gazing (Bdd)

Front 1

Give uses of the mirror by body dysmorphic disorder(BDD)patients.

Back 1

• 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
  
• picking spots
  
• feeling skin
  
• combing/styling hair
  

Front 2

Outline pieces of qualitative data about behaviours from the body dysmorphic disorder (BDD) patients

Back 2

BDD patients listed a range of other behaviours that they engaged in whilst in front of the mirror. These included “washing rituals”; “combing my eyebrows”; “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”; “pull ugly faces to prove how disgusting I am” or “I try to permanently fix my image mentally”

Front 3

Describe conclusions from the study by Veale and Riley on mirror gazing.

Back 3

“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.”

BDD patients:

BDD patients hold a number of problematic beliefs and behaviours in their mirror use.

hope they will look different from their body image/will feel comfortable, but mirror gazing is counterproductive

are uncertain about their body image, so seek confirmation (although mirror gazing actually causes confusion)

believe they will feel worse if they resist mirror gazing, but still find it distressing

motivated to camouflage appearance by excessive grooming, accounting for excessive time in front of mirrors

Front 4

Describe quantitative data of this study.

Back 4

yes to long sessions: BDD: 44/52 (84.6%), controls 16/54 (29.6%) yes to short sessions: BDD: 45/52 (86.4%), controls 43/54 (79.6%)

Front 5

Identify and outline self report tools used with the body dysmorphic disorder (BDD) patients

Back 5

mirror gazing questionnaire: asked about feelings/behaviours in front of mirror; length of sessions, motivation (Likert scale), focus of attention (visual analogue scale, +4 to –4, in response to statements), distress before and after looking in mirror (visual analogue scale, 0 to 10, for different types of gazing session), list of other behaviours (type of light preferred, types of surfaces, mirror avoidance)

Front 6

Describe how the data about ‘motivation before looking in a mirror’ were gathered

Back 6

Likert scale/5 point scale/scale of strongly disagree to strongly agreein response to statements about reasonssuch as ‘I look in the mirror to see how I feel’Also was open-ended question: ‘At the end there was the option of writing down anything else that motivated them to use the mirror.’

Front 7

The experiment was based on the findings of a pilot study. What is the purpose of a pilot study?

Back 7

To refine the procedure of a study to ensure that study will collect valid/relevant data to ensure that data will be reliable

Front 8

Describe the pilot study

Back 8

A pilot study revealed that there were two types of mirror gazing:

• Many patients and controls tended to have one session a day which tended to be longer (for example putting on make up or shaving at the beginning of the day).
  
• The remainder of the mirror sessions consisted of shorter sessions during the day. Controls were however less likely to report a long session.
  

Front 9

Background

Back 9

• This study was prompted by a patient with Body Dysmorphic Disorder (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. The obvious questions were what exactly did the behaviour consist of, what was the function of the behaviour and what maintained his behaviour especially when he reported feeling worse after gazing in the mirror?
  
• Mirror gazing occurs in about 80% of patients with BDD while the remainder tend to avoid mirrors sometimes by covering them or removing them to avoid the distress of seeing their own image and the time wasted mirror gazing.
  
• When BDD patients do not seek help they may present symptoms of depression and social phobia and not reveal their main problem unless specifically questioned.
  
• Mirror gazing in BDD has been compared with compulsive checking with obsessive-compulsive disorder (OCD) where earlier analysis on compulsions such as washing and checking found that they were maintained because they reduce anxiety on the short term. But does mirror gazing in BDD follow the same model as compulsions in OCD?
  
• Mirror gazing might also occurs in obsessional slowness, in which patients perform complex rituals and safety behaviours such as grooming or bathing in a specific order. However in such patients it fails to reduce anxiety.
  

Front 10

Aim of the study

Back 10

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

Front 11

Describe participants

Back 11

• 52 patients with BDD who reported mirror gazing to be a feature of their problem.
  
• They were recruited to complete a “Mirror gazing questionnaire”
  
• All patients fulfilled DSM-IV diagnostic criteria for BDD
  
• A group of 55 controls that were chosen from personal contracts ( an opportunity sample)
  
• The groups were matched by age and sex (30.1 years compared with 33.4 years) and sex (40.4% male and 48% male).
  

Front 12

Describe Procedure

Back 12

• Subjects were given a self-report mirror gazing questionnaire.
  
• The instructions informed them that we were interested in the feelings that they had in front of a mirror during the past month.
  
• The subject was first asked if he or she had a long session in front of a mirror on most days of the past month.
  
• A long session was defined as the longest time during the day that the person spends in front of a mirror. An example was given of getting ready for the day.
  
• If the respondent said they had at least one long session in front of a mirror, then they were asked a series of questions about a typical long session in front of a mirror.
  
• Then repeated the same questions for a typical short session in front of a mirror and gave an example of checking their appearance.
  

Front 13

How was the data about length of mirror gazing obtained?

Back 13

Subjects were asked:

• The average duration of a “long” session in minutes.
  
• The estimated maximum amount of time on any one occasion that he or she had spent in front of a mirror in hours/minutes.
  
• The average duration (in minutes) and the frequency of a short session in front of a mirror during the last month.
  

Front 14

How was the data focus of attention obtained?

Back 14

• Subjects were asked the location of their concentration in front of a mirror for both short and long sessions.
  
• They were presented with a 9-point visual analogue scale between “+4” and “-4” (where “-4” represented “I am entirely focused on my reflection in the mirror” and “+4” rep- resented “I am entirely focused on an impression or feeling that I get about myself”).
  

Front 15

Weaknesses

Back 15

• Low ecological validity because of the lab use.
  
• It could be argued that the matching process (of matched pairs) was not rigorous because the percentages were not that close.
  
• Veale and Riley describe the acquisition of the control group as i being recruited through ‘personal contacts' without any clarification of what this might be
  

Front 16

How was the data about distress before and after looking in the mirror obtained?

Back 16

Subjects were asked to rate the degree of distress on a visual analogue scale between 1 and 10, where “0” represented “not at all distressed” and “10” was “extremely distressed”.

They were asked to rate their distress :

• before they looked in a mirror for a long session
  
• immediately after looking in a mirror and
  
• after resisting the urge to look in a mirror.
  

The questions were subsequently repeated for short sessions in front of a mirror.

However, a mistake was made in the questionnaire in not rating the degree of distress after resisting the urge for a short session.

Front 17

How was the data for behaviour in front of a mirror obtained?

Back 17

They were asked what activities they did in front of a mirror for long and short sessions and were given a list of options.

They were asked to rate the percentage of time spent on each activity from the list below and ensure that the total added up to 100.

• Trying to hide my defects or enhance my appearance by the use of make-up;
  
• Combing or styling my hair;
  
• Trying to make my skin smooth by picking or squeezing spots;
  
• Plucking or removing hairs or shaving;
  
• Comparing what I see in the mirror with an image that I have in my mind;
  
• Trying to see something different in the mirror;
  
• Feeling the skin with my fingers;
  
• Practicing the best position to pull or show in public;
  
• Measuring parts of my face.
  

Front 18

How was the data for type of light preferred obtained?

Back 18

Subjects were asked whether the type of light was important for mirror gazing on a visual analogue scale between one extreme of “natural day-light” or at the other extreme of “artificial light”.

Front 19

How was the data about types of reflective surfaces obtained?

Back 19

They were asked if they used a series of mirrors for different profiles or any other reflective surface (for example the backs of CDs) for gazing.

Front 20

How was the data for mirror avoidance obtained?

Back 20

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

Front 21

Results for for length of time mirror gazing

Back 21

• No significant differences were found in age and sex between BDD patients and controls.
  
• 44 out of the 52 (84.6%) BDD patients and 16 out 54 (29.6%) control subjects reported that they had a “long session” in front of the mirror each day.
  
• Of those subjects that reported using a mirror for a long session, BDD patients used a mirror for far longer than controls. BDD participants spent an average of 72.5 minutes mirror gazing compared with 21.3 minutes for controls..
  
• 45 BDD patients (86.5%) and 43 controls (79.6%) reported that they had one or more “short sessions” in front of a mirror.
  
• BDD patients checked mirrors more frequently than controls for the short sessions.
  
• However there was no difference between BDD patients and controls for the average duration of each short session. BDD participants had an average of 14.6 short sessions (controls, 3.9) but BDD participants spend less time on these than the controls.
  

Front 22

Results for motivation before looking in the mirror

Back 22

Using a 5-point scale, on 10 out of the 12 belief statements, BDD participants were significantly more likely to Strongly agree or agree with the statements than were controls. On statement 11: ‘I need to see what I like about myself’ there was no significant difference and on statement 12: ’I can make myself look more presentable’ controls scored significantly higher than the BDD participants.

The results were the same for short sessions. BDD patients also spontaneously reported that they were more likely to use the mirror if they were feeling depressed.

Overall, BDD patients retained some insight into their behaviour. They were more likely than controls to agree with the statements “Looking in a mirror so often and for so long distorts my judgement about how attractive I am” and “Every mirror I look in I see a different image”.

Front 23

Results for focus of attention in mirror

Back 23

BBD participants were more likely to focus on an internal impression for long sessions (—0.49 compared with —2.2) but not for short sessions (—1.12 compared with -1.1S). BDD participants were more likely to focus on a specific part (70.5 compared with 44.5 on a scale of 0—100). These differences were significant.

Front 24

Results Distress before and after looking in front of a mirror

Back 24

• Long sessions: BBD participants were significantly more distressed, with a mean of 6.4 compared with 1.6 on a scale of 1—10 (p = 0.00).
  
• Short sessions: BBD participants were significantly more distressed, with a mean of 7.3 compared with 2.4 on a scale of 1—10 (p = 0.00).
  
• When trying to resist checking in a mirror, BDD participants were significantly more distressed (mean 6.82) compared with controls (mean 2.38), which was also very significant (p = 0.00).
  
• A number of patients reported significant handicaps from mirror gazing from being very late for appointments to having caused a road traffic accident after gazing in a car mirror.
  

Front 25

Results for behaviour in front of a mirror

Back 25

For long mirror checking sessions: BDD patients did the same proportion of activities as controls in front of mirrors for: Using make up, Combing or styling their hair, Picking their spots, and Feeling their skin with their fingers.

The controls were more likely to use a mirror for removing hairs or shaving

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.
  

For short checks BDD patients were more likely than controls to use the mirror:

• For checking their make-up
  
• Practicing the best position or face to pull or show in public
  
• Compare what they see in front of a mirror with an image in their mind of how they think they would ideally look.
  
• Controls were more likely to use a mirror in a short session for shaving.
  

BDD patients listed a range of other behaviours that they engaged in whilst in front of the mirror. These included : “Washing rituals” “Combing my eyebrows” “Studying my eyes, hair and skin to observe the effect of stress on the aging process”; “Pulling my features or squashing my nose to see how I’d look if I had plastic surgery”; “Pull ugly faces to prove how disgusting I am” “I try to permanently fix my image mentally”.

Front 26

Results for type of light preferred

Back 26

There was very little difference (not significant) between BDD participants (38.5) and controls (41.6) in terms of preference for natural or artificial light.

Front 27

Results Types of reflective surface

Back 27

• For a long session, BDD patients were more likely to use a series of mirrors with different profiles compared to controls.
  
• For short checks, both BDD patients and controls admitted to using shop windows. However, BDD patients spontaneously reported using a wide variety of reflective surfaces including car mirrors, windows or bumpers on vehicles, cutlery, fish knifes, TV screens, reflective table tops, glass watch faces, washroom taps or the back of CDs.
  

Front 28

Results for Mirror avoidance

Back 28

Some patients reported that they had found mirror gazing too time consuming or distressing and had deliberately avoided all mirrors at certain times. This is similar to the mirror avoidance seen in anorexia nervosa.

67% of our BDD patients reported that they selectively avoided only certain mirrors compared to 14% of controls

Four types of selective avoidance of mirrors were noted in the BDD patients.

1. Looking at a specific “defect” in the mirror. An example of this was a patient who was preoccupied with the ugliness of his nose, so that he would only use a hand mirror to comb his hair by holding it above the line of his nose so that he avoided seeing his nose.
   
2. Specific mirrors: for example two patients reported avoiding mirrors that they regarded as “bad” or “unsafe” (as they were associated with a bad image and feeling distressed in the past) and only used “good” mirrors. Other patients reported only using mirrors that they trusted as being in the “right” light or if they were tilted correctly as other mirrors or lights were too distressing.
   
3. Using mirrors in private but avoiding mirrors or reflective surfaces in public or social situations to prevent themselves from feeling upset.
   
4. To use only a mirror that was obscured — for example one that was cracked, dusty or dirty so that a full reflection could not be seen. Another patient reported looking in a mirror with soap on her face so she did not see her skin.
   

Lastly some patients may flip between avoidance and gazing — for example a patient who picked his skin would remain housebound checking his skin many times during a week to see if his skin had healed. When he was satisfied that he could go outside, he would then avoid mirrors until the urge to check in the mirror and pick his skin would over- come him and the cycle would repeat itself.

Front 29

Conclusions

Back 29

• Mirror gazing in BDD does not follow a simple model of a compulsive checking in OCD in terms of a repetitive behaviour for anxiety reduction and is a more complex phenomenon.
  
• It is best conceptualised as a series of idiosyncratic and complex safety behaviours, that is designed to prevent a feared outcome and in which the patient is seeking safety. The feared outcome may be the internal aversion and disgust about one’s appearance (and in many patients social anxiety and beliefs about rejection).
  
• This study has demonstrated that
  
• BDD patients have a number of different motivations and behaviours in their use of mirrors:
  
• BDD patients have an eternal hope that they will look different to their internal body image or feel comfortable with their appearance.
  
• BDD patients are uncertain about their body image and demand to know exactly how they lookBDD patients believe they will feel worse if they resist mirror gazing.
  
• BDD patients have the need to camouflage by excessive grooming — what could be called mental cosmetic surgery.
  
• Another interesting difference from controls is the way BDD patients are more likely to report using an “internal impression of how they feel” when they look in the mirror.
  
• Based on the findings of the study, BDD patients can be helped to manage their mirror—gazing strategies, and the following recommendations are made:
  

1. Use mirrors so they show most of the body, or the whole of the face, rather than a specific part. Focus attention on reflection rather than internal impression of feelings, and do not make an automatic ‘ugly' judgement.
   
2. Use a mirror for a function, such as shaving or to do make—up.
   
3. Use different mirrors rather than the ‘trusted’ one and do not use magnifying mirrors or mirrors that give ambiguous reflections.
   
4. Do not use a mirror when they have the urge but to delay and do other things instead.
   

Front 30

Strengths

Back 30

• The experiment was controlled
  
• They asked the same questions to all participants
  
• Collected qualitative and quantitative data
  
• Participants were matched on age and sex this study is very useful. Not only does it give an understanding of the nature of mirror—gazing behaviour, but it also allows the author (David Veale) to recommend ways in which mirror—gazing can be managed when treating BDD patients.