Mirror exposure in women with bulimic symptoms: How do thoughts
and emotions change in body image treatment?
Monika Trentowska*, Caroline Bender, Brunna Tuschen-Caffier
Department of Clinical Psychology and Psychotherapy, Albert-Ludwigs-University Freiburg, Engelbergerstrasse 41, 79106 Freiburg, Germany
a r t i c l e i n f o
Received 7 November 2011
Received in revised form
14 March 2012
Accepted 19 March 2012
a b s t r a c t
Mirror exposure is an efficient treatment for body image problems in eating disorders. Although
habituation processes and cognitive changes are postulated to be underlying mechanisms, evidence
is scarce, especially during repeated mirror exposure treatment. Fourteen participants with eating
disorders not otherwise specified (EDNOS) and five with bulimia nervosa (BN) composed the bulimic
group (BG), and 19 healthy women without any mental disorder composed the healthy controls group
(HC). The participants were treated by four standardized mirror exposure sessions. Subjective distress
was assessed five times during each session. Both negative and positive emotions and negative thoughts
were assessed after each session. The patients in the BG reported significantly higher levels of negative
emotions and cognitions than did those in the HC in all measures and across all sessions. In both groups,
subjective distress increased significantly within each session and decreased toward the end of each
session. Only in the subjects of the BG group did both distress and negative thoughts and emotions
decrease significantly from session to session, whereas positive emotions increased. The patterns of
change differed between the BG and the HC, suggesting that habituation between sessions occurred only
in the BG. Our findings suggest that the additional underlying cognitiveeaffective processes merit further
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Body image dissatisfaction is a core feature in eating disorder
psychopathology (American Psychiatric Association, 1994) and
a risk factor for the development of eating disorders (Jacobi,
Hayward, de Zwaan, Kraemer, & Agras, 2004; Stice & Shaw, 2002).
specified (EDNOS), body dissatisfaction is an essential factor for
maintenance (Bohon, Stice, & Burton, 2009; Fairburn & Cooper,
2003; Ricciardelli, Tate, & Williams, 1997; Stice & Shaw, 2002) and
a risk factor for relapse (Fairburn & Cooper, 2003; Freeman, Beach,
Davis, & Solyom, 1985). EDNOS is the most frequently assigned
diagnosis among eating disorders (Fairburn et al., 2007), and
treatments of body image disturbances are equally indicated
(Farrell, Shafran, & Lee, 2006) because body image dissatisfaction is
high in both this group and in those with BN (Grilo et al., 2009).
Effective cognitive-behavioral therapies for eating disorders
& Wilson, 2010; Key et al., 2002; Tuschen-Caffier, Pook, & Frank,
2001; Vocks, Legenbauer, Troje, & Schulte, 2006). In this context,
mirror exposure is a promising technique in the treatment of body
image disturbance (Delinsky & Wilson, 2006; Hilbert & Tuschen-
Caffier, 2004; Key et al., 2002; Tuschen-Caffier, Vögele, Bracht, &
Hilbert, 2003). For example, Tuschen-Caffier et al. (2001) imple-
in a university service setting, encouraging patients with eating
disorders to describe their physical appearance in a detailed and
realistic way while standing in front of a mirror. Mirror exposure
improved the body dissatisfaction of patients with BN significantly
(Cohen’s d after therapy: d ¼ 1.36; one year follow-up: d ¼ 1.63). It
has been postulated that mirror exposure activates a negative body
schema, which includes the negative emotions of fear and disgust
(Tuschen-Caffier et al., 2003), as well as self-deprecating cognitions
(Vocks, Legenbauer, Waechter, Wucherer, & Kosfelder, 2007). It is
assumed that the negative emotions habituate and that the self-
deprecating cognitions change during prolonged repeated mirror
exposure (Delinsky & Wilson, 2006; Vocks et al., 2007). These
Model (EPM) of Foa and Kozak (1986). The authors postulate that
existing schemata are activated by specific stimuli and can be
restructured through prolonged exposure and the integration of
new incoherent information into the schema network. Foa and
* Corresponding author. Tel.: þ49 761 2039446; fax: þ49 761 2033122.
E-mail address: firstname.lastname@example.org (M. Trentowska).
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Behaviour Research and Therapy 51 (2013) 1e6
Kozak (1986) define three indicators for a successful restructuring
process during exposure therapy for anxiety disorders: (a) the
maximal initial activation of the emotional schemata, (b) the
decrease of cognitiveeaffective reactions within one session
(within-habituation) and (c) the decrease of cognitiveeaffective
reactions from one session to the next (between-habituation).
Only a few studies have investigated these processes in body
image treatment for eating disorders. Tuschen-Caffier et al. (2003)
studied the emotional response of women with BN and healthy
controls, confronting them with their own bodies in a video or via
their imagination. The results indicated that figure exposure elicits
negative emotions in both groups. However, this response is more
pronounced in BN, especially during the video task. Similar results
single mirrorexposure session. Not only negative emotions but also
negative cognitions increased more strongly in eating disordered
women compared to healthy controls. In both groups, negative
emotions and cognitions decreased throughout the session,
whereas the group differences remained. Hilbert, Tuschen-Caffier,
and Vögele (2002) showed that women with Binge Eating
Disorder (BED) rated the intensity of their emotional reactions as
less distressing in a second exposure session. Finally, Delinsky and
Wilson (2010) report considerable decreases of distress within
exposure sessions and from session to session in a BN case example
with three repeated mirror exposures. In summary, these studies
strongly suggest that the processes underlying the habituation of
fear and the improvement of a negative body image schema are
processes occurring in only one or three sessions. Little is known
about processes that appear following a repeated and prolonged
treatments (Tuschen & Bents,1995; Tuschen-Caffier & Florin,2002).
Therefore, the aim of this study is a close investigation of these
processes during a four-session treatment for women with body
image disturbances and severe bulimic symptoms.
The following hypothesizes were asserted:
a) Mirror exposure activates negative body image schemata,
which are experienced by the person as distress, negative
thoughts and emotions.
b) The level of distress decreases within a single session (within-
habituation) and from one session to the next (between-
c) Negative thoughts and emotions decrease from one session to
the next (between-habituation).
Sample and recruiting procedures
and 19 in the healthy control group (HC); the groups were matched
which is characterized by fulfilling all of the BN criteria except the
3 months (APA,1994). Women in the HC had to be free of current or
for at least five years. For the entire sample, the exclusion criteria
included the presence of substance abuse or addiction, current or
past psychosis, schizophrenia, bipolar disorder, current suicidal
ideation or self-harming behavior, current post traumatic stress
disorder symptoms caused by sexual abuse, pregnancy or lactation
and current or past therapies using mirror exposure. Participants
were recruited via newspaper announcements, public notices, and
announcements on disorder-specific web pages and within female
ethics committee. Women in theHC were paid V45 for participating
therapy unit of the university.
Women interested in the study were screened by phone inter-
view by trained post-graduate psychologists. If they fulfilled the
inclusion criteria, they were invited to the Department of
Psychology for diagnostic sessions. In the BG, women were diag-
nosed using the Eating Disorder Examination Interview (EDE;
Cooper & Fairburn, 1987; German version: Hilbert & Tuschen-
Caffier, 2006b) and the Structured Clinical Interview for DSM-IV
Axis I (SCID-I; Spitzer, Williams, Gibbon, & First, 1992; German
version: Wittchen, Zaudig, & Fydrich, 1997).
The Body Shape QuestionnairedBSQ (Cooper, Taylor, Cooper &
Fairburn, 1987; German version: Waadt, Laessle, & Pirke, 1992) is
a 34-item questionnaire that assesses body dissatisfaction on a 6-
point frequency scale, ranging from 1 ¼ never to 6 ¼ always, and
that indicates the frequency of body-related behavior during the
previous month. The German version has been established as
a valid measure for discriminating body dissatisfaction among
bulimic and healthy women and is sensitive to therapeutic changes
(Pook, Tuschen-Caffier, & Brähler, 2008). The internal consistency
in this sample is high (BG: a ¼ .94; HC: a ¼ .93).
& Beglin, 1994; German version: Hilbert & Tuschen-Caffier, 2006a)
measures the specific pathology of eating disorders. The 36 items of
the questionnaire focus on the occurrence of core eating disorder
symptoms during the last 28 days and can be organized into four
scales: Restraint, Eating Concern, Weight Concern and Shape
Concern. Individuals respond to the items in a 7-point response
format ranging from 0 ¼ on no days or not at all to 6 ¼ every day or
markedly. The study sample shows an acceptable level of internal
consistency (BG: a ¼ .74 (Restrained); a ¼ .79 (Eating Concern);
a ¼ .55 (Weight Concern); a ¼ .84 (Shape Concern); HC: a ¼ .78
(Restrained); a ¼ .61 (Eating Concern); a ¼ .70 (Weight Concern);
a ¼ .87 (Shape Concern)). A high discriminant and convergent val-
idity is reported for the German version (Hilbert, Tuschen-Caffier,
Karwautz, Niederhofer, & Munsch, 2007).
Body image treatment
Before the treatment began, an individualized cognitive-
behavioral model of body image development and its associations
with eating disorder symptoms was established (according to Cash,
2008; Tuschen-Caffier & Florin, 2002). Based on that etiological
were explained and participants were given time to ask questions
and decide whether they would like to begin the body image
treatment. Finally, written informed consent forms were signed by
Body exposure was conducted according to the manual of
Tuschen-Caffier and Florin (2002) (also described by Tuschen &
Bents, 1995) and delivered in individual sessions by one of two
post-graduate psychologists. The participants, who were wearing
a beige-colored set of underwear during all of the exposure
sessions, were asked to look in a full-length mirror with double-
winged doors, which allowed a good view from all perspectives.
The therapist stood outside the participant’s view and asked her to
describe her own bodyas precisely as possible in a realistic manner,
as if she were describing it to a blind painter whowas attempting to
draw a picture of her body. The therapist’s instructions guided the
M. Trentowska et al. / Behaviour Research and Therapy 51 (2013) 1e6
participant’s attention to five different parts of her body: head,
torso (including neck, chest, stomach, back and bottom), legs, arms
and overall appearance: starting with the head and ending with
a description of the overall appearance of the body. The partici-
pant’s attention was led to different details of her body areas, for
example, color, texture, proportion and shape, and the participant
was asked to describe each of these details. The participants were
allowed to express their feelings (e.g., shame, disgust) toward their
body and to describe in detail what triggered each of the emotions
they felt. Regarding their overall appearance, the women were
asked to describe themselves in a holistic and natural way (e.g.,
what type of figure they had and the impression they would have of
a person “like this” approaching them). Each session lasted 50e
60 min. Additionally, all of the women were asked to complete
ratings of the thoughts and emotions they had directly after the
exposure session. Women were debriefed after each session and
encouraged to practice looking at themselves in a holistic way at
home. All of the sessions followed the same protocol and were
administered at a frequency of 1e2 sessions per week over the
course of 14 days.
After each body area description, the therapist asked the partic-
ipant to rate the level of distress experienced on a subjective units of
distress scale (SUD), ranging from 0 ¼ not distressing at all to
10 ¼ extremely distressing. To ensure that the participants focused
on their experienced distress, the therapist asked them to describe
To monitor the cognitive and affective processes during the
body image treatment, two measures were administered during
each exposure session. The participants were asked to rate their
cognitions and emotions before and after each session to control
the impact of the mirror exposure on their thoughts and feelings.
Body-related thoughts were assessed using the German trans-
lation of the “Thoughts Checklist” (TCL) (Cooper & Fairburn, 1992;
German version: Vocks et al., 2007). The checklist consists of 17
items that assess the self-deprecating automatic thoughts that
eating disordered women have when looking at their body (e.g., “I
am so fat” or “I look disgusting”). Two items with bulimia-specific
content were added: “I would like to throw up” and “I would like
to jog.” Participants were asked to rate how often these thoughts
occurred to them on a 6-point scale ranging from 1 ¼ not at all to
for each session and entered into the analysis. The internal consis-
tency of the TCL was veryhigh for the BG (a ¼ .86) and moderate for
emotions that might occur while viewing one’s own body. Based on
previous studies (Hilbert et al., 2002; Tuschen-Caffier et al., 2003;
Vocks et al., 2007), five negative emotional reactions were chosen:
sad, disgusted, anxious, distressed, and insecure. By expert recom-
mendation, three additional negative emotions were included:
angry, ashamed and frustrated. Moreover, three positive emotions
exposure session, all of the participants were asked to rate on a 6-
point scale, ranging from 1 ¼ not at all to 6 ¼ very much, how
strongly they experienced the listed emotions during the mirror
exposure. Two separate scores were calculated from the emotion
rating list: a mean score of the negative emotions for each session
and a mean score of the positive emotions.
The data analysis was carried out using Predictive Analytics
Software (PASW, SPSS 2009). Differences between the group
characteristics at the beginning (age, BMI and psychological
measures) were analyzed using two-sample t tests. For the cate-
gorical data, Chi-Square tests were applied. SUD mean scores were
computed for each zone of the body in each session; the TCL and
emotion (negative and positive) mean scores were computed over
all items and for each session. Missing values were adjusted for
using the last carried forward method. The mean scores were
analyzed using a two-way analysis of variance (ANOVA) with the
factor time (SUDs for zone and time, and TCL and emotion ratings
for time) and comparing the factor group (BG vs. HC). For the SUDs,
zone was added as an additional factor. Post-hoc analyses (t tests or
ANOVA) were calculated for the significant main effects of time or
for the interaction effects. In all of the analyses, the significance
level was p ¼ .05.
There were 14 women with EDNOS (7 had a BN diagnosis in the
past and 7 had never been diagnosed with BN) and 5 with BN in the
BG and 19 healthy women in the HC group. Groups did not differ in
average age (F(1, 36) ¼ .001; p ¼ .979; BG: M ¼ 27.1, SD ¼ 6.2; HC:
M ¼ 27.0, SD ¼ 5.8) nor BMI (F(1, 36) ¼ .281; p ¼ .599; BG: M ¼ 23.5,
SD ¼ 3.2; HC: M ¼ 22.9, SD ¼ 3.1), and there were no significant
differences in the socio-demographic variables, such as partner-
ship, maternal status or employment (p’s > .55). There were,
however, significant group differences with regard to educational
level (Chi-Square at p < .05; A-levels: BG: 78.9%; HC: 52.6%;
university degree: BG: 5.3%; HC: 42.1%). In the BG, two women had
a comorbid diagnosis of major depression and two presented
comorbid anxiety disorders; three women were in current
psychotherapeutic treatment, six women had previously been in
a clinic or psychotherapy treatment because of theireating disorder
and ten had never before received psychotherapy.
Furthermore, as expected, the number of binges over the last
four weeks was significantly higher (F(1,35) ¼ 13.74; p ¼ .001) in
the BG (M ¼ 7.4; SD ¼ 7.6) compared to the HC (M ¼ .7; SD ¼ 1.2).
Similarly, the use of compensatory behavior over the past four
weeks was significantly higher (F(1,35) ¼ 14.54; p ¼ .001) in the BG
(M ¼ 8.3; SD ¼ 9.2) than in the HC (M ¼ .0; SD ¼ .0). Participants in
the BG had significantly higher scores in all of the eating disorder-
specific measures (p’s < .001).
Subjective distress changes over the course of the body image
Between the sessions, significant group (F(1, 29) ¼ 62.54,
p < .001), time (F(3, 87) ¼ 34.74; p < .001) and group ? time effects
(F(3, 87) ¼ 4.81; p ¼ .004) were detected. In all of the sessions, the
groups differed significantly on the SUD level, with the BG consis-
tently reaching higher SUD scores than the HC (F(1, 36) ¼ 35.46,
p < .001). Within the sessions, there was a significant zone (F(4,
116) ¼ 14.40; p < .001) and zone ? group effect (F(4, 116) ¼ 4.59;
p < .001) but no significant time ? zone (F(12, 348) ¼ 1.07; p ¼ n.s.)
or time ? zone ? group effect (F(12, 348) ¼ 1.20; p ¼ n.s.) (Fig.1). As
revealedbythepost-hoct tests,theSUDscores increasedfromhead
to upper body, from upper body to legs and decreased from legs to
arms in both groups and in all sessions (BG: t (18) ¼ 2.75e7.19;
P ¼ .01 e<.001; HC: t (18) ¼ 4.0e5.48; P ¼ .001 e< .001). In addi-
tion, there was a significant difference in the mean SUD scores from
head to overall appearance (F(1, 36)< 71.86, p’s < .001) (Fig. 1).
Changes in negative thoughts over the course of the body image
The TCL results reveal significant group (F( 1, 35) ¼ 45.30;
p< .001), time(F(3,105) ¼33.61;p <.001) andtime ?groupeffects
M. Trentowska et al. / Behaviour Research and Therapy 51 (2013) 1e6
(F(3, 105) ¼ 14.63; p < .001) (Fig. 2). As shown in Fig. 2, negative
thoughts in both groups decreased from the first to the last session
(F(1, 36)>27.761, p’s < .001). Over the course of the treatment,
negative thoughts in the BG decreased significantly from the first to
the second and from the second to the third session (all p’s < .05),
but not from the third to the fourth session (p ¼ .113). Corre-
spondingly, negative thoughts decreased significantly in the HC
from the first to the second (p < .05), but not from the second to the
third or from the third to the fourth session (p > .131).
Changes in emotions over the course of the body image treatment
According to the ANOVA, there were effects of group (F(1,
36) ¼ 52.83; p < .001), time (F(3, 108) ¼ 41.12; p < .001) and
time ? group interaction (F(3, 108) ¼ 18.43; p < .001) on the
negative emotion scores. Regarding the positive emotion scores,
a significant group (F(1, 34) ¼ 81.42; p < .001), time (F(3,
102) ¼ 15.75; p < .001) and a marginally significant time ? group
interaction effect (F(3, 102) ¼ 2.94; p ¼ .059) was found (Fig. 2). In
both groups, negative emotions decreased and positive emotions
increased from the first to the last session. Negative emotions
to the third session (p < .05), but not from the third to the fourth
(p ¼ .124), whereas in the HC, negative emotions decreased only
from the first to the second session (p < .05). The positive emotions
increased in the BG fromthe first tothe second and fromthe second
to the third session (p’s < .05), but not from the third to the fourth
session (p ¼ .182). The HC group showed no significant changes
from session to session (negative emotions; F(1, 36)>22.209,
p < .001; positive emotions; F(1, 36) > 17.782, p < .001) (Fig. 2).
It has been shown in this study that subjective distress, negative
cognitions and emotions toward one’s own body improved during
body image treatment with repeated mirror exposure sessions in
Kozak, 1986), an increase followed by a decrease in subjective
distress during an exposure session is essential for emotional pro-
Fig. 2. Mean ratings of frequency of (a) negative thoughts measured by the thoughts Check List (TCL), (b) negative emotions and (c) positive emotions in each session in the bulimic
group (BG) and in the healthy controls (HC).
Fig. 1. Mean ratings of subjective units of distress (SUD) after each body zone during each session in the bulimic group (BG) and in the healthy controls (HC). OVA: Overall
M. Trentowska et al. / Behaviour Research and Therapy 51 (2013) 1e6
distress in each session, which was then followed by a decrease
within the session. The increase of distress can be interpreted as
In addition, the mean levels of subjective distress decreased
from session to session, which can be interpreted as a between-
habituation process. A decrease of negative emotions and nega-
tive thoughts toward one’s own body and an increase of positive
emotions over the first three sessions of the treatment were also
observed. These patterns reveal the expected habituation processes
and cognitiveeaffective changes achieved through repeated expo-
results do not explain the precise mechanisms at the core of the
habituation processes. However, this study shows that the level
of positive emotions rise during the treatment while negative
emotions and thoughts persist. This pattern could result from an
integration of additional information into the already existing
schemata, as suggested by the EPM and other network models
Another interesting finding involves the question of how many
sessions are needed to initiate the habituation process during
mirror exposure. Because negative thoughts and emotions in the
BG did not decrease significantly after the third session in this
study, the argument could be made that the fourth session is not
even necessary. We found a decrease in the variance of the negative
emotions and an increase in the variance of the positive emotions
in the BG in the fourth session, suggesting that some of the women
might be continuing to improve even at that point. It can be
concluded that a fourth session does not seem to be necessary for
most of the women, but it may be important for some. As a result,
the recommended number of sessions in a treatment should be
three or four.
The decrease of negativeemotionsand thoughts fromthe first to
the second session found in HC is in line with findings in previous
studies (Hilbert et al., 2002). However, the HC do not show the
same long-term pattern of increase and decrease in emotions and
negative thoughts toward their body as the BG. The HC, who are
without severe body image problems, experience subjective
distress during mirror exposure at a significantly lower level than
the BG. Onlythe decrease in negative emotionsand cognitions from
the first to the second session was found to be significant in the HC,
and the degree to which positive emotions were experienced
remained constant throughout. In terms of the EPM, the HC did not
therefore experience habituation processes over the course of the
body image treatment. These results suggest that the habituation
observed in the HC is mainly due to the novelty of the situation,
such as from looking at themselves in beige-colored underwear in
the presence of an unknown woman. In addition, the distress
pattern in both groups reveals that peak distress occurs while
looking at and describing the torso and legs. Because the belly,
bottom and thighs are known “problem areas” for many women,
this finding is not surprising. Consequently, a decrease in the SUD
scores in the HC was only observed between the first and second
sessions, whereas the SUD scores decreased continuously from
session to session in the BG.
There are limitations to this study. All of the women in the BG
felt stable enough and volunteered to take part in the treatment.
And half of the sample had previously undergone treatment for
their eating disorder. Therefore, a subsection of the women were
experienced inworking on overcoming their eating disorder, which
might result in higher self-efficacy. The rate of mirror exposures at
home was not recorded, so improvement might have been biased
by the amount of self-initiated practice. The average BMI and age
were higher in this study than in others; a generalization of the
results is therefore limited. Our findings do not indicate whether
habituation processes and patterns are the same in women with
severe eating disorders. Neither does this study clarify whether
mirror exposure is the treatment of choice for body image
improvement in EDNOS. Other techniques, such as cognitive
restructuring, might be as good or better for this group.
For that reason, future investigations of distress and cognitivee
affective processes in body image exposure treatment should
include participants with a range of eating disorder diagnoses, such
as BN, BED or Anorexia Nervosa. Future research should investigate
ongoing processes more closely, i.e., assess the cognitiveeaffective
variables during the sessions, test the postulated mechanisms, and
include psychophysiological assessment in repeated mirror expo-
sure research. Variations in the duration or the number of sessions
would also be of interest. In addition, studies should investigate the
long-term effects, the sustainability of body image exposure
treatments and the efficacy of mirror exposure compared to other
techniques. Furthermore, additional body image interventions
seem to be needed because the groups still differ at the end of the
mirror exposure treatment.
In summary, our study demonstrates that the patterns of change
found during mirror exposure treatment are comparable to fear
habituation processes. Repeated mirror exposure is a useful
method in the treatment of body image problems in eating disor-
dered women. Future direction studies should provide evidence
from other eating disordered groups and investigate the mecha-
nisms of habituation in detail.
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