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Mirror gazing in body dysmorphic disorder and healthy controls: Effects of duration of gazing
Abstract
Cognitive-behavioural models of body dysmorphic disorder (BDD) suggest that mirrors can act as a trigger for individuals with BDD, resulting in a specific mode of cognitive processing, characterised by an increase in self-focussed attention and associated distress. The aim of the current study was to investigate these factors experimentally by exposing participants with BDD (n=25) and without BDD (n=25) to a mirror in a controlled setting. An additional aim was to ascertain the role of duration of mirror gazing in the maintenance of distress and self-consciousness by manipulating the length of gazing (short check vs. long gazing). Findings demonstrated that contrary to what was predicted, not only participants with BDD, but also those without BDD experienced an increase in distress and self-focused attention upon exposure to the mirror. In addition, people without BDD, unlike those with BDD, experienced more distress when looking in the mirror for a long period of time as opposed to a short period of time. This lends some support to the idea that, for people with BDD, gazing in a mirror, regardless of duration, might act as an immediate trigger for an abnormal mode of processing and associated distress, and that this association has developed from past excessive mirror gazing. Further theoretical implications of these findings, as well as subsidiary research questions relating to additional cognitive factors are discussed.
Supplementary resource (1)
Data
February 2013
... Specifically, they tend to focus intensely on distinct features, such as the eyes, nose, or mouth (local processing: focusing on specific, small-scale details rather than overall picture) at the expense of considering their facial features or body as a whole (global or holistic processing: attending to overall features and broad organizational aspects of a complex figure; Beilharz et al., 2017;Feusner et al., 2010b;Johnson et al., 2018;Kerwin et al., 2014). This tendency for local processing leads to selffocused attention, characterized by individuals' examination of perceived flaws in the mirror or another reflective surface Grocholewski et al., 2012;Windheim et al., 2011), but also reflects underlying neural dynamics. Individuals with BDD exhibit impairments in brain connectivity related to visual processing, particularly in balancing global versus detailed information (Li et al., 2015;Wong et al., 2021Wong et al., , 2022. ...
... Support for this hypothesis comes from findings that individuals with BDD are more prone to interpreting appearance-related situations negatively, exhibiting a significant bias toward negative appearance-related interpretations when compared to social and generalized anxiety disorders . Further studies reveal that individuals with BDD exhibit strong automatic associations linking "attractive" with "competent" and "self" with "bad" on the Implicit Association Test (Buhlmann et al., 2009;Windheim et al., 2011). These associations reflect maladaptive core beliefs, predicting symptom severity and distress during mirror-checking rituals (Buhlmann et al., 2009;Windheim et al., 2011). ...
... Further studies reveal that individuals with BDD exhibit strong automatic associations linking "attractive" with "competent" and "self" with "bad" on the Implicit Association Test (Buhlmann et al., 2009;Windheim et al., 2011). These associations reflect maladaptive core beliefs, predicting symptom severity and distress during mirror-checking rituals (Buhlmann et al., 2009;Windheim et al., 2011). Interpretation biases and related maladaptive coping mechanisms, such as mirror-checking and avoidance, have been shown to, in turn, further increase sadness, anger, and negative body-related cognitions (Kollei & Martin, 2014), as well as self-focused attention (Windheim et al., 2011). ...
Body dysmorphic disorder (BDD) is an underrecognized, challenging illness with
severe comorbidities, demanding urgent advancements in treatment strategies. This
state-of-the-science review describes current research on existing BDD treatments,
beginning with a detailed discussion of cognitive-behavioral therapy (CBT), the primary
psychosocial intervention for BDD, and its foundational theories. We emphasize the
significant progress in the field, including the efficacy of face-to-face CBT, the
promising outcomes of digital interventions for broadening access to care, and
emerging treatments that warrant further exploration. The review also addresses the
critical gap of targeted interventions for youth, considering the diseases’ typical onset
during adolescence. Our review also sheds light on the significant gap in research
dedicated to testing these treatments in underserved communities, stressing the
importance of including these populations in research and culturally informed and
adapted, if necessary, care. The review concludes with recommendations for future
directions, outlining areas for ongoing treatment development and research to expand
the scope and efficacy of interventions for BDD.
... Folgt man dem kognitiv-behavioralen Modell der Körperdysmorphen Störung (Veale et al., 2010), so initiiert die Konfrontation mit dem eigenen Spiegelbild einen Zyklus mit mehreren Rückkopplungsschleifen. Die Konfrontation mit dem Spiegelbild trägt dazu bei, dass die Selbstaufmerksamkeit ansteigt Veale et al., 2010;Windheim et al., 2011). Mit der Selbstaufmerksamkeit gehen unter anderem aversive Erinnerungen wie beispielsweise Hänseleien in der Vergangenheit einher, die an negative Affekte gekoppelt sind (Ingram, 1990, zitiert nach Veale, 2004Osman et al., 2004;Veale, 2004, Veale et al., 2010. ...
... Diese umfassen Angst, Anspannung, Ekel, Frustration, psychische Belastung, Scham, Unsicherheit und Trauer (Hilbert et al., 2002;Kollei et al., 2014;Neziroglu et al., 2010;Servián-Franco et al., 2015;Trentowska et al., 2013;Trentowska et al., 2017;Vocks et al., 2007;Vocks et al., 2008b). Im Vergleich zu Kontrollgruppen weisen diese Gruppen dabei zu jedem Zeitpunkt eine deutlich höhere Ausprägung an negativen Affekten auf (Hilbert et al., 2002;Kollei et al., 2014;Servián-Franco et al., 2015;Trentowska et al., 2013;Trentowska et al., 2017;Vocks et al., 2007;Vocks et al., 2008b;Windheim et al., 2011 (Cannon, 1927;LeDoux, 1989LeDoux, , 1996LeDoux, , 2001Schachter et al., 1962). Da diese Reize eine potentielle Bedrohung darstellen, gehen sie mit den prototypischen Kampf-und Fluchtreaktionen oder einer Angststarre einher (Azevedo et al., 2005;Blanchard et al., 1986;Choi et al., 2009;Koolhaas et al., 1999;Lovallo, 2005;Shields, 1993). ...
... Ferner ist eine erhöhte Selbstaufmerksamkeit mit einer höheren Herzrate assoziiert (Lacey et al., 1963). Wirft man einen Blick auf vorliegende Befunde, so ist der Spiegelblick mit negativen Emotionen behaftet und steigert die Selbstaufmerksamkeit (Brohede et al., 2016;Kollei et al., 2014;Veale et al., 2001;Veale et al., 2004;Veale et al., 2010;Windheim et al., 2011). Die Konfrontation mit ...
Die vorliegende Abschlussarbeit untersucht die Wirkung einer Spiegelexposition auf affektive und physiologische Veränderungen im Vergleich von Personen mit und ohne körperdysmorphe Symptomatik. Ferner sollte erfasst werden, ob hinsichtlich emotionaler Zustände Habituationseffekte zu beobachten sind. Insgesamt wurden 55 Personen zu zwei Terminen im Abstand von einer Woche (± einem Tag) eingeladen. Diese wurden mit Hilfe eines VorabScreening-Fragebogens in zwei Gruppen unterteilt: Personen mit (N = 26) und ohne körperdysmorphe Symptomatik (N = 29). Zur Registrierung physiologischer Veränderungen wurde die Herzrate mittels physiologischer Messinstrumente erfasst. Die affektiven Zustände Angst, Anspannung und Scham wurden per Fragebogen während und nach der Konfrontation mit dem eigenen Spiegelbild erhoben. Im Anschluss an die Körperbildexposition berichteten die Probanden mit körperdysmorpher Symptomatik im Vergleich zur Kontrollgruppe eine höhere Ausprägung von Angst, Anspannung und Scham. Hinsichtlich der Herzrate konnten keine signifikanten Unterschiede zwischen den beiden Subgruppen ausfindig gemacht werden. Die affektiven Zustände Angst, Anspannung und Scham erfuhren innerhalb der Gruppe mit körperdysmorpher Symptomatik eine Reduktion von der ersten zur zweiten Sitzung. Abschließend lässt sich somit eine höhere affektive Reaktivität seitens der Personen mit körperdysmorpher Symptomatik bei Spiegelexpositionen feststellen. Über mehrere Sitzungen hinweg können Habituationseffekte hinsichtlich emotionaler Zustände ausfindig gemacht werden und liefern Implikationen für mögliche Behandlungsmethoden.
This thesis analyzes the effect of mirror exposure on affective and physiological changes, comparing subjects with and without body dysmorphic symptoms. Furthermore, it aimed at verifying if affective states habituate. In total 55 people were invited to two appointments in a temporal distance of one week (± one day). Using a pre-screening-questionnaire they were divided into two groups: subjects with (N = 26) and without body dysmorphic symptoms (N = 29). To detect physiological changes, heart rate was measured by physiological measuring instruments. The affective states fear, aversive tension and shame were identified by a questionnaire during and following a confrontation with their reflection in the mirror. After body image exposure, participants with body dysmorphic symptoms reported a higher level of fear, aversive tension and shame compared to the control group. Regarding heart rate, no significant differences between the two subgroups could be identified. The affective states of fear, aversive tension and shame decreased from the first to the second session in the group with body dysmorphic symptoms. Thus, a higher affective reactivity by the subjects with body dysmorphic symptoms could be observed during mirror exposures. Between sessions, habituation effects regarding affective states have been identified and yield implications for possible treatment methods.
... Individuals with BDD are also more likely to notice deviations in beauty standards and use detailed, selective, and excessive processing rather than holistic processing, especially when presented with stimuli for long periods of time (Feusner, Moody et al., 2010). Even at greater distances, individuals with BDD exhibit increased selective self-focused attention following any duration of mirror gazing (Windheim, Veale, & Anson, 2011). Such findings may therefore support the idea that selective self-focused attention is a unique process that occurs in BDD (Feusner, Moody et al., 2010;Feusner, Neziroglu et al., 2010). ...
... Other studies suggest the effects of gazing may be common, rather than unique to BDD. For example, selective self-focused attention increases in both BDD and non-clinical populations following 10 min of mirror gazing (Windheim et al., 2011). This may occur because individuals without body image disturbances might be unlikely to naturally engage with the mirror for extended periods of time, meaning the increased time could elicit excessive processing that allows individuals to approach their body image in a more detailed and selective way (Windheim et al., 2011). ...
... For example, selective self-focused attention increases in both BDD and non-clinical populations following 10 min of mirror gazing (Windheim et al., 2011). This may occur because individuals without body image disturbances might be unlikely to naturally engage with the mirror for extended periods of time, meaning the increased time could elicit excessive processing that allows individuals to approach their body image in a more detailed and selective way (Windheim et al., 2011). Further supporting this idea, non-clinical participants who have low body satisfaction experience more dissatisfaction following mirror gazing than those who are satisfied (Mulkens & Jansen, 2009). ...
... Due to the characteristics and associated distress of gazing rituals, it is important to consider such rituals in the context of cognitive-behavioral models of BDD (e.g., Fang & Wilhelm, 2015;Veale, 2004;Wilhelm & Neziroglu, 2002). Gazing rituals are hypothesized to serve as a maintaining factor of the disorder (e.g., Fang & Wilhelm, 2015;Kollei, Brunhoeber, Rauh, de Zwaan, & Martin, 2012;Windheim, Veale, & Anson, 2011). Specifically, the aforementioned cognitive-behavioral models assume that rituals serve as a self-defeating coping strategy, which first decreases distressing emotions but second strengthens negative beliefs about one's own appearance as well as the salience of the perceived flaw. ...
... Two factors might account for the partly inconsistent results on effects of gazing on attractiveness evaluation, dissociation, and perceptual uncertainty: different gazing durations and the applied stimuli. Individuals with BDD report a wide range of gazing durations (e.g., Veale & Riley, 2001) and accordingly, the few studies that investigated gazing rituals used heterogeneous durations ranging from 25 s to 10 min (Mulkens & Jansen, 2009;Veale et al., 2016;Windheim et al., 2011). However, previous research does not allow to derive a threshold for critical gazing durations. ...
... Further, Coles, Radomsky, and Horng (2006) found memory distrust following OC-like checking to occur after only two to five times of checking. With respect to BDD gazing rituals however, Windheim et al. (2011) examined the effects of short and long durations of mirror gazing (25 s vs. 10 min) on selffocused attention and distress and found that gazing duration did not have a differential effect in individuals with (vs. without) BDD . ...
Gazing rituals and selective attention to perceived flaws during gazing are considered as maintaining factors in cognitive-behavioral models for body dysmorphic disorder (BDD). This study investigated different durations of BDD-like gazing at different facial stimuli (an unfamiliar face, the participant's own face, and the participant's own reflection in the mirror) with regard to effects on dissociation, attractiveness evaluations and perceptual uncertainty. The aim of this study was to examine the hypothesized causal effects of gazing rituals on appearance preoccupation.
We asked 115 females to complete a face gazing paradigm with three different facial stimuli and, depending on the condition, different gazing durations. We also examined the influence of BDD symptom severity on the reactions to different facial stimuli.
Five minutes of gazing significantly increased dissociation. Participants rated the attractiveness of self-relevant stimuli, especially the own photographed face, below average and lower than the unfamiliar face.
Limitations with regard to sample characteristics and experimental design are discussed.
Our findings support the cognitive-behavioral models for BDD and indicate that therapists may extend therapeutic interventions like mirror retraining by specific perceptual retraining with photographs of the patients.
... Individuals with BDD are also more likely to notice deviations in beauty standards and use detailed, selective, and excessive processing rather than holistic processing, especially when presented with stimuli for long periods of time (Feusner, Moody et al., 2010). Even at greater distances, individuals with BDD exhibit increased selective self-focused attention following any duration of mirror gazing (Windheim, Veale, & Anson, 2011). Such findings may therefore support the idea that selective self-focused attention is a unique process that occurs in BDD (Feusner, Moody et al., 2010;Feusner, Neziroglu et al., 2010). ...
... Other studies suggest the effects of gazing may be common, rather than unique to BDD. For example, selective self-focused attention increases in both BDD and non-clinical populations following 10 min of mirror gazing (Windheim et al., 2011). This may occur because individuals without body image disturbances might be unlikely to naturally engage with the mirror for extended periods of time, meaning the increased time could elicit excessive processing that allows individuals to approach their body image in a more detailed and selective way (Windheim et al., 2011). ...
... For example, selective self-focused attention increases in both BDD and non-clinical populations following 10 min of mirror gazing (Windheim et al., 2011). This may occur because individuals without body image disturbances might be unlikely to naturally engage with the mirror for extended periods of time, meaning the increased time could elicit excessive processing that allows individuals to approach their body image in a more detailed and selective way (Windheim et al., 2011). Further supporting this idea, non-clinical participants who have low body satisfaction experience more dissatisfaction following mirror gazing than those who are satisfied (Mulkens & Jansen, 2009). ...
... However, this visual training research targeted only a single aspect of visual perception, while the literature suggests abnormalities that are more widespread. It has therefore been suggested that a broader and more comprehensive visual training program should be implemented with BDD participants, in an attempt to remediate visual abnormalities and reduce symptom severity [10,43,44]. ...
... The 12 items in this measure are rated on a 5-point Likert scale from 0 = absent to 4 = extreme symptoms. The BDD-YBOCS has been well validated in BDD populations and classifies symptoms as 'mild' (0-15), 'moderate' (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) and 'severe' (31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48) [65,66]. ...
... The Mirror Gazing: Cognition and Affect Rating Scale (MG-CARS) will measure appearance-related distress, mirror use and focus of attention [44]. Six items are rated along visual analogue scales and were developed from the CBT model of BDD. ...
Background:
Body dysmorphic disorder (BDD) is a characterised by perceived defects or flaws in appearance which are associated with distressing thoughts, repetitive or obsessive behaviours, and significant impairment in social and occupational functioning. A core feature of BDD involves abnormalities of visual processing, although this is not typically a focus of psychological and psychiatric treatments. While current treatments generally show moderate effectiveness in the short-term, those with BDD can have high relapse rates, as they still 'see' their flaws or defects. The current research trials a visual training program designed to remediate visual abnormalities and reduce symptom severity of BDD.
Methods:
This is a single-group open-label pilot study assessing the feasibility and potential efficacy of a 10-week visual training program. This pilot trial will be conducted at Swinburne University of Technology, Melbourne, Australia, and will recruit up to 20 participants diagnosed with BDD. These participants will complete pre- and post-assessments and a 10-week visual training program encompassing three phases of basic visual processing, face and emotion recognition, and self-perception. The primary outcomes focus on feasibility and acceptability of the intervention, with secondary outcomes exploring clinical outcomes related to symptom severity, quality of life and eye movements.
Discussion:
This pilot trial will translate the empirical findings of abnormalities in visual processing among those diagnosed with BDD, to an innovative treatment method across a range of visual processing levels. This trial will assess the feasibility and potential efficacy of such a visual training program, paving the way for further research including a future definitive randomised control trial.
Trial registration:
Australian New Zealand Clinical Trial Registry, ACTRN 12618000274279, Registered 22nd February 2018.
... Body dissatisfaction and distress increase in both men and women after they briefly look at themselves in a mirror (Veale et al., 2016;Walker, Murray, Lavender, & Anderson, 2012;Windheim, Veale, & Anson, 2011). However, in mirror exposure tasks lasting longer than 30 min in which women are instructed to view body parts in a top down fashion, negative emotions have been found to remain unchanged from baseline after the task (Shafran, Lee, Payne, & Fairburn, 2007;Vocks, Legenbauer, Wächter, Wucherer, & Kosfelder, 2007) and a transient decrease in feelings of fatness occurs (Shafran et al., 2007). ...
... Approximately 90% of individuals with BDD report spending excessive amounts of time looking at themselves in the mirror (Phillips et al., 1997;Phillips et al., 2005) and nearly 10% report having had a panic attack triggered by looking at themselves in the mirror (Phillips, Menard, & Bjornsson, 2013). After looking in the mirror, individuals with BDD experience more distress and anxiety than healthy controls (Buhlmann, Teachman, Naumann, Fehlinger, & Rief, 2009;Parsons, Straub, Smith, & Clerkin, 2017;Windheim et al., 2011). Additionally, individuals with BDD have higher baseline disgust sensitivity and experience more disgust in response to viewing themselves in a mirror than healthy controls (Neziroglu, Hickey, & McKay, 2010). ...
... Uncontrolled trials that show symptomatic improvement might represent a slowing of normal recovery relative to no treatment and provide no baseline of adverse events for comparison. As looking at oneself in a mirror can lead to significant distress and worsening of negative emotional states (Veale et al., 2016;Walker et al., 2012;Windheim et al., 2011), mirror exposure therapy could be destabilizing and dangerous for certain individuals. ...
Mirror exposure therapy is a clinical trial validated treatment component that improves body image and body satisfaction. Mirror exposure therapy has been shown to benefit individuals with high body dissatisfaction and patients with eating disorders (ED) in clinical trials. Mirror exposure is an optional component of cognitive behavioral therapy (CBT), an effective treatment for body dysmorphic disorder (BDD). However, most clinical trials of mirror exposure therapy have been small or uncontrolled and have included few male subjects. Adverse events have been reported during mirror exposure clinical trials. We discuss how individuals respond when looking in a mirror and how mirrors can be used therapeutically, and we critically evaluate the evidence in favor of mirror exposure therapy. We discuss clinical indications and technical considerations for the use of mirror exposure therapy.
... The whole procedure is taking place in public with at least one security agent overseeing the body scan and usually quite a number of other passengers waiting in line. Recent studies have shown that situations, which afford high attention to one's own appearance, can have a negative impact on one's self-evaluation (Beach, 1993;Hoffmeister, Teige-Mocigemba, Blechert, Klauer, & Tuschen-Caffier, 2010;Moreno-Domínguez, Rodríguez-Ruiz, Fernández-Santaella, Jansen, & Tuschen-Caffier, 2012;Windheim, Veale, & Anson, 2011). Hoffmeister et al. (2010, for example, asked their participants to stand in front of a mirror wearing a tight tank top. ...
... In another study the mirror exposure led to a short-term increase in discomfort (Moreno-Domínguez et al., 2012). In addition, it has been shown that focusing on one's own face through mirror-gazing does not only lead to an increased self-focused attention but also to an increased distress in healthy participants (Windheim, et al., 2011). These findings are in line with one assumption of the control theory of Carver and Scheier (1981) saying that induced self-focus (e.g., by mirror-gazing or the presence of foreign people in the same room) leads to a comparison with assumed standards, which can either turn out satisfactory or unsatisfactory. ...
... The finding that a body scan negatively influences the implicit body image of overweight participants is not only in line with studies demonstrating that associations measured by the IAT are generally capable of being influenced by situational factors (Gawronski & Conrey, 2004), but also with studies showing that situations enforcing high attention to one's own appearance can have a negative impact on one's self-evaluation (Beach, 1993;Hoffmeister et al., 2010;Moreno-Domínguez et al., 2012;Windheim et al., 2011). It can be assumed that the increased self-focus, which is induced by the scanning procedure, leads to a comparison with implicit standards, which -in case of overweight people -turns out unsatisfactory and thereby has a negative impact on the body image of the user (Carver & Scheier, 1981). ...
p>Whereas the introduction of body scanners at airports has been accompanied by critical voices raising concerns that body scanners might have a negative impact on different minority groups, it has not been investigated thus far whether they might also have negative impacts on the average flight passenger and if the provision of adequate information might attenuate such negative impacts. Using a pre/post-design the current study examines the effect of a body scan in a controlled laboratory setting on the explicit and implicit body image of normal-weight and overweight people as assessed by questionnaires and an Implicit Association Test. Half of the sample received an information sheet concerning body scanners before they were scanned. While there was a negative impact of the body scan on the implicit body image of overweight participants, there was a positive impact on their explicit body image. The negative effect of the body scan was unaffected by receiving information. This study demonstrates that body scans do not only have negative effects on certain minority groups but potentially on a large proportion of the general public which suggests a critical reconsideration of the control procedures at airports, the training of the airport staff who is in charge of these procedures and the information flight passengers get about these procedures.
</p
... Intensive and dysfunctional mirror checking occurs frequently in people suffering from BDD and is, among other safety behaviors, considered to be a main maintenance factor (Veale & Riley, 2001;Windheim et al., 2011). The theoretical models for BDD agree on typical mechanisms considered responsible for the maintenance of the disorder which are selective attention, negative evaluation of the own appearance, negative affect related to the evaluation and safety behaviors (Möllmann et al., 2020;Phillips, 2005;Veale & Neziroglu, 2010;Wilhelm et al., 2013). ...
... The results indicate that a negative belief system is activated in people with BDD symptoms. The results complement earlier findings that showed an elevated level of negative body related cognitions in clinical samples (Kollei & Martin, 2014;Windheim et al., 2011). Unfortunately, we did not assess a baseline value for self-hostile cognitions. ...
Background and objectives
The look into the mirror represents a typical trigger situation for people with body dysmorphic concerns. Mirror exposure on the other hand is commonly used in the treatment of Body Dysmorphic Disorder even though little is known about its precise effects. This study aimed to investigate cognitive-affective processes related to mirror gazing.
Methods
A total of 125 individuals (screening for body dysmorphic concerns: NBDD+ = 56, negative NBDD- = 69) participated in a laboratory study using a guided 10-min mirror gazing task. Participants were randomized to one of two experimental conditions, a non-judgmental and judgmental description of the own body during mirror gazing. Distress, self-hostile cognitions and post-event processing were assessed after the task and at follow-up.
Results
Participants with body dysmorphic concerns showed higher values regarding subjective appearance distortion, stress induced by the exposure, distress, self-hostile cognitions and post-event processing compared to the symptom negative group. The two conditions did not yield differential effects.
Limitations
The short duration of the mirror gazing and the only internal description of the body may have contributed to a missing effect for the approach.
Conclusions
The results indicate the importance of cognitive and affective processes in reaction to mirror exposure. They support the cognitive model of BDD and suggest post-event processing as a relevant factor requiring further investigation in future research.
... Patients with BDD can spend many hours a day mirrorgazing in order to achieve "mental cosmetic surgery" to modify body image (Phillips, 1991). Researchers have theorized (Veale et al., 1996;Windheim et al., 2011) that mirrors trigger symptoms among individuals with BDD by increasing self-focused attention and associated distress. ...
... In BDD patients, self-evaluation of appearance consequent to mirror-gazing is often associated with anxiety and behavioral avoidance (Clerkin & Teachman, 2009;Parsons et al., 2017). Moreover, mirror-gazing increases distress and self-focused attention, whereas, unexpectedly, healthy participants, unlike BDD patients, experience more distress when looking in the mirror for a long period of time as opposed to a short period of time (Windheim et al., 2011). ...
We critically reviewed the protocols, results, and potential implications from empirical studies ( n = 44) on mirror-gazing (including the “psychomanteum”) and eye-to-eye gazing, both in healthy individuals and clinical patients, including studies of hypnotic mirrored self-misidentification, mirror-gazing in body dysmorphic disorder and schizophrenia. We found these methods to be effective for eliciting altered states or anomalous experiences under controlled conditions and in non-clinical samples. Mirror-gazing and eye-to-eye-gazing produced anomalous experiences almost exclusively in the visual, bodily, and self-identity modalities, whereas psychomanteum experiences tended also to involve voices, smells, and bodily touches. The complexity, diversity, and specificity in contents across these anomalous experiences suggest mechanisms beyond perceptual distortions or illusions. We argue that mirror- and eye-gazing anomalous perceptions implicate different mechanisms that induce (i) Derealization (anomalous perceptions of external reality); (ii) Depersonalization (anomalous perceptions of the body), and (iii) Dissociated identity (anomalous perceptions of another identity in place of the self in mirror-gazing or in place of the other in eye-to-eye gazing). These interpretations suggest directions for future researches.
... The postulated increased negative affect before CB and the reduction thereof by CB has so far not been empirically confirmed. In an experimental laboratory study by Windheim et al. (2011), the emotional burden of patients with BDD (but also of healthy control participants) did not decrease over the course of CB, but in fact increased. A more recent study confirmed this finding in young healthy female participants, and revealed that CB in the form of mirror gazing for two minutes led to increased body dissatisfaction, irrespective of whether participants adopted an external or an internal focus of attention (Veale et al., 2016). ...
... individuals with AN and BN in daily life that might be closer to the real CB-experience and not distorted by memory biases compared to the present study. The other studies, both in EDs (Shafran et al., 2007) and BDD (Veale et al., 2016;Windheim et al., 2011) were performed in the laboratory and limited to CB in the mirror, while the range of CB in our sample was considerably wider. ...
Checking behavior (CB) occurs in a variety of disorders such as obsessive-compulsive (OCD), body dysmorphic (BDD), illness anxiety (IA), and panic disorder (PD), as well as anorexia (AN) and bulimia nervosa (BN). Etiological models of these disorders – with the exception of those for PD – postulate that CB mainly occurs in situations characterized by negative affect and serves to regulate it. We aimed to test these assumptions: N = 386 individuals with a self-reported diagnosis of one of the disorders rated their affect at baseline, directly before a remembered CB episode, during, immediately afterwards, and 15 and 60 minutes afterwards, and rated their endorsement of different functions of CB. The results show that transdiagnostically negative affect is significantly higher before CB compared to baseline, and is significantly reduced from before CB to all post-CB assessments. Reduction of negative affect and Attainment of certainty were the sole functions predicting the affective course during CB, and most prominently reported transdiagnostically. Assumptions of the etiological models were confirmed, suggesting that exposure and ritual prevention should be examined across disorders. As attainment of certainty seems to be predictive for the course of CB, this might be targeted in cognitive interventions.
... BDD is a debilitating psychological condition characterized by preoccupations with perceived bodily flaws and physical appearance. Although flaws are often minimal, or nonexistent (Windheim, Veale, & Anson, 2011), adolescents diagnosed with BDD have a genuine, heartfelt belief in their physical ugliness, which provokes overwhelming anxieties about deformity, inadequacy, and judgments by others (Phillips, 2004). The central theme of the disorder is a delusional obsession centered on physical appearance. ...
... Adolescents with this obsession may describe themselves as unattractive and deformed. Although the face is frequently the primary source of concern, they may be worried over every bodily region (Windheim et al., 2011). ...
... These findings are consonant with those of Veale and Riley (31) who, in a retrospective forced-choice questionnaire, found that individuals with BDD, in contrast to controls, were motivated to check mirrors for three primary reasons; they (1) hoped that they may look different, (2) believed that they would feel worse if they did not check, and (3) desired to know exactly how they looked. Further, Windheim et al. (32) found that people with BDD were distressed both before and after mirror-gazing sessions. Baldock, Anson, and Veale (33) suggested that mirror-checking in BDD may persist despite distress, as individuals with BDD are more likely to use internal goals (e.g., needing to feel "right" about their appearance) compared to control participants who tended to have external goals (e.g., having finished applying makeup), and that in BDD these ambiguous internal goals were relied upon to inform their stop-criteria for mirror-use. ...
Body Dysmorphic Disorder (BDD) is characterized by an intense preoccupation with one or more perceived “defects” in physical appearance. Despite the distress and impairment associated with BDD, the disorder remains understudied and poorly understood. In particular, there are limited studies available which give voice to those with firsthand experiences of the disorder. A qualitative approach was employed to study lived experience of BDD. In-depth semi-structured interviews were conducted with 12 participants with BDD, aiming to understand their subjective experiences of the disorder. Data was analyzed using Interpretative Phenomenological Analysis (IPA). The results identified three superordinate themes; (1) consumed by the disorder, (2) the flawed self, and (3) intolerance of uncertainty about appearance. The qualitative findings of this study are discussed in relation to current conceptual understandings of BDD, including the cognitive behavioral model.
... During videoconferencing, however, the image created by your own camera (i.e., self-view) is typically visible on the conferencing screen, effectively placing a mirror within constant gaze. Previous research has reported that heightened appearance concerns can be experienced after just 2.5 min of mirror exposure (Veale et al., 2016), and this finding is supported by other studies with varied exposure times (Kollei & Martin, 2014;Windheim et al., 2011). Given that videoconferencing may occur across much of the work or study day, these negative effects may have been strengthened during the pandemic due to prolonged exposure to self-view. ...
Objective:
The use of videoconferencing has increased during the pandemic, creating prolonged exposure to self-image. This research aimed to investigate whether eating disorder (ED) risk was associated with videoconferencing performance for work or study and to explore whether the use of safety behaviors and self-focused attention mediated the relationship between ED risk and perceived control over performance anxiety, impaired engagement, or avoidance of videoconferencing for work or study.
Method:
In 2020, an online survey was distributed within Australia to those aged over 18 years via academic and social networks, measuring: use of videoconferencing for work/study, demographics, ED risk, safety behaviors for appearance concerns, self-focused attention, perceived control over performance anxiety, perceived engagement impairment, and avoidance of videoconferencing. A total of 640 participants (77.3% female, Mage = 26.2 years) returned complete data and were included in analyses.
Results:
245 participants (38.7%) were considered at-risk for EDs (SCOFF > 2). Those at-risk reported significantly more safety behaviors, self-focused attention, impaired engagement, and avoidance, plus lower perceived control over performance anxiety than those not at-risk. Multiple mediation models found the effects of ED risk on control over performance anxiety, impaired engagement, and avoidance were partially mediated by safety behaviors and self-focused attention.
Discussion:
Our cross-sectional findings suggest videoconferencing for work/study-related purposes is associated with performance anxiety, impaired engagement, and avoidance among individuals at-risk for EDs. Poorer videoconferencing outcomes appear more strongly related to social anxiety variables than ED status. Clinicians and educators may need to provide extra support for those using videoconferencing.
Public significance:
Because videoconferencing often involves seeing your own image (via self-view) we wondered whether the appearance concerns experienced by those with eating disorders (EDs) might interfere with the ability to focus on or to contribute to work/study videoconferencing meetings. We found that although those with EDs experience more impairments in their videoconferencing engagement/contribution, these were linked just as strongly to social anxiety as they were to appearance concerns.
... Disorders are arranged in the DSM taxonomy based on shared phenomenological features (e.g., repetitive, compulsive behaviors) and possible shared etiology. There has been some debate over the classification of OCD with the disorders grouped in the OCRD category (Abramowitz and Jacoby 2015), yet there are substantial similarities between OCD and BDD in phenomenological presentation and treatment response (Phillips et al. 2010;Veale and Riley 2001;Windheim et al. 2011). OCD is the only disorder in the OCRD category that has been extensively studied in a perinatal-specific context. ...
Obsessive–compulsive disorder (OCD) symptoms are more likely to develop or be exacerbated during pregnancy and the postpartum period, which can cause significant distress and impairment. However, the disorders grouped with OCD in the DSM-5, obsessive–compulsive and related disorders (OCRD; e.g., hoarding disorder (HD), body dysmorphic disorder (BDD), trichotillomania (TTM), excoriation disorder (ED)), have rarely been examined in the perinatal period. This study aimed to explore (1) the prevalence of all clinically significant OCRD symptoms in pregnancy and the postpartum period and (2) the correlations between OCRD psychopathology and postpartum functioning. Participants were recruited during their second trimester of pregnancy from a Midwestern medical center. Participants completed an online questionnaire and a semi-structured clinical interview during pregnancy (28–32 weeks’ gestation, N = 276) and the postpartum period (6–8 weeks, N = 221). BDD and OCD symptoms were the most prevalent. In pregnancy, 14.9% (N = 41) of participants endorsed clinically significant BDD symptoms and 6.2% (N = 17) endorsed clinically significant OCD symptoms. In the postpartum period, 11.8% (N = 26) endorsed clinically significant BDD symptoms and 14% (N = 31) endorsed clinically significant OCD symptoms. Poorer postpartum functioning was associated with elevated OCRD symptoms in pregnancy and postpartum. OCRD symptoms occur during pregnancy and the postpartum period at rates similar or higher than other life periods. Elevated OCRD symptoms are associated with poorer postpartum functioning across domains. Future research should explore how all OCRD symptoms may affect functioning in the perinatal period, not only OCD symptoms.
... A prominent example from Greek mythology is Narcissus, who fell in love with his own image reflected in a pool of water. However, in everyday life, many people find it distressing to look at themselves [1,2]. For example, in a study by Barnier and Collison [3], five minutes of mirror gazing decreased satisfaction with one's appearance, perceived attractiveness, and selfesteem. ...
While some people enjoy looking at their faces in the mirror, others experience emotional distress. Despite these individual differences concerning self-viewing in the mirror, systematic investigations on this topic have not been conducted so far. The present eye-tracking study examined whether personality traits (self-esteem, narcissism propensity, self-disgust) are associated with gaze behavior (gaze duration, fixation count) during free mirror viewing of one’s face. Sixty-eight adults (mean age = 23.5 years; 39 females, 29 males) viewed their faces in the mirror and watched a video of an unknown person matched for gender and age (control condition) for 90 s each. The computed regression analysis showed that higher self-esteem was associated with a shorter gaze duration for both self-face and other-face. This effect may reflect a less critical evaluation of the faces.
... Lastly, a comprehensive evaluation of BE effectiveness should also include the sys tematic assessment of side effects, adverse events, or predictors of non-responders, and a subsequent trade-off between positive effects and negative aspects for single patient groups. As looking at oneself in a mirror can lead to significant distress and a worsening of negative affect (Veale et al., 2016;Walker et al., 2012;Windheim et al., 2011), BE might destabilize some patients. Eventually, extending research to subgroups will help to formulate diagnosis-and patient group-specific treatment guidelines, which will move us closer to establishing individualized evidence-based treatments. ...
Background
Body image disturbance (BID) is a hallmark feature of eating disorders (EDs) and has proven to be involved in their etiology and maintenance. Therefore, the targeting of BID in treatment is crucial, and has been incorporated in various treatment manuals. One of the most common techniques in the treatment of BID is body exposure (BE), the confrontation with one’s own body. BE has been found to be effective in individuals with EDs or high body dissatisfaction. However, BE is applied in a multitude of ways, most of which are based on one or a combination of the hypothesized underlying working mechanisms, with no differential effectiveness known so far.
Method
The aim of this paper is to selectively review the main hypothesized working mechanisms of BE and their translation into therapeutic approaches.
Results and Conclusion
Specifically, we underline that studies are needed to pinpoint the proposed mechanisms and to develop an empirically informed theoretical model of BE. We provide a framework for future studies in order to identify working mechanisms and increase effectiveness of BE.
... This high degree of control may help ameliorate complications that are present in the early phases of treatment, specifically, creating a more graded level of exposure to anxiety-inducing stimuli. It is not possible to have this degree of control over the augmentations and exposure parameters in mirror therapy, which could cause significant distress (Windheim et al., 2011;Walker et al., 2012;Veale et al., 2016), leading to setbacks in treatment (Griffen et al., 2018). ...
Background: Body image (BI) disturbances have been identified in both clinical and non-clinical populations. Virtual reality (VR) has recently been used as a tool for modulating BI disturbances through the use of eliciting a full body illusion (FBI). This meta-analysis is the first to collate evidence on the effectiveness of an FBI to reduce BI disturbances in both clinical and non-clinical populations.
Methods: We performed a literature search in MEDLINE (PubMed), EMBASE, PsychINFO, and Web of Science with the keywords and synonyms for “virtual reality” and “body image” to identify published studies until September 2020. We included studies that (1) created an FBI with a modified body shape or size and (2) reported BI disturbance outcomes both before and directly after the FBI. FBI was defined as a head-mounted display (HMD)-based simulation of embodying a virtual body from an egocentric perspective in an immersive 3D computer-generated environment.
Results: Of the 398 identified unique studies, 13 were included after reading full-texts. Four of these studies were eligible for a meta-analysis on BI distortion inducing a small virtual body FBI in healthy females. Significant post-intervention results were found for estimations of shoulder width, hip width, and abdomen width, with the largest reductions in size being the estimation of shoulder circumference (SMD = −1.3; 95% CI: −2.2 to −0.4; p = 0.004) and hip circumference (SMD = −1.0; 95% CI: −1.6 to −0.4; p = 0.004). Mixed results were found in non-aggregated studies from large virtual body FBIs in terms of both estimated body size and BI dissatisfaction and in small virtual body FBI in terms of BI dissatisfaction.
Conclusions: The findings presented in this paper suggest that the participants' BIs were able to conform to both an increased as well as a reduced virtual body size. However, because of the paucity of research in this field, the extent of the clinical utility of FBIs still remains unclear. In light of these limitations, we provide implications for future research about the clinical utility of FBIs for modulating BI-related outcomes.
... Other uses of MT include the treatment of anxiety disorders, such as anorexia nervosa (Key et al., 2002) or body dysmorphic disorder (Windheim, Veale, & Anson, 2011), and other rarer conditions such as mirror agnosia, mirrored-self misidentification or asomatognosia (Connors & Coltheart, 2011;Fotopoulou et al., 2011;Paysant, Beis, Le Chapelain, & André, 2004). For instance, in Probst, (2015) patients with eating disorders, where the body image is a problem, were evaluated. ...
Virtual and Augmented Reality are technologies widely used in a variety of areas, including the medical sector. On the other hand, regular mirrors have been traditionally used as tools to aid in mental health treatment for a variety of diseases and disorders. Although it is possible to build Virtual and Augmented Reality experiences based on mirror metaphors, there are very few contributions of this kind in the medical sector. In this chapter, the great benefits that regular mirrors have brought for mental health treatment are addressed. In addition, a review on the state of the art in mirror-based Virtual and Augmented Reality applications is given, highlighting the potential benefits that these enhanced mirrors could bring for the mental health treatment.
... For example, Veale et al. (2016) expanded on previous research demonstrating that people experience more body dissatisfaction after staring into a mirror (e.g. Windheim et al. 2011). They manipulated the object of attention (self vs external) and low mood (self with negative mood induction vs without) among a large sample of unselected women. ...
Experimental psychopathology researchers are devoted to understanding the causes and mechanisms of psychological disorders, with the central goal of developing and improving effective interventions. Indeed, cognitive behavioural therapy (CBT) arose from experiments identifying key mechanisms that clinicians can target to reduce their clients' symptoms. Despite the well-documented efficacy of CBT for diverse problems, many people continue to live with psychopathology, even after CBT. In this paper, we reflect on ways in which experimental psychopathology has advanced CBT (i.e. Where have we been?), areas that are fruitful for continued progress (i.e. Where are we now?), and crucial areas for improvement (i.e. Where are we going?). In particular, we contend that improving the science of psychopathology via open and transparent practices, prioritising diverse samples, testing the effects of specific CBT techniques, and focus-ing on problems that our clients identify will enable experimental psychopathology research to serve as the foundation for evidence-based practice. Keywords Cognitive behavioural therapy. CBT. Experimental psychopathology. Psychopathology. Clinical psychology. Psychotherapy In 2019, Aaron T. Beck published a retrospective on his 60 years in the field of cognitive behavioural therapy (CBT), with a specific focus on the scientific method that guided his work developing, implementing, and disseminating an efficacious treatment for diverse psychological disorders. He highlighted what is now CBT International Journal of Cognitive Therapy
... Other uses of MT include the treatment of anxiety disorders, such as anorexia nervosa (Key et al., 2002) or body dysmorphic disorder (Windheim, Veale, & Anson, 2011), and other rarer conditions such as mirror agnosia, mirrored-self misidentification or asomatognosia (Connors & Coltheart, 2011;Fotopoulou et al., 2011;Paysant, Beis, Le Chapelain, & André, 2004). For instance, in Probst, (2015) patients with eating disorders, where the body image is a problem, were evaluated. ...
Virtual and Augmented Reality are technologies widely used in a variety of areas, including the medical sector. On the other hand, regular mirrors have been traditionally used as tools to aid in mental health treatment for a variety of diseases and disorders. Although it is possible to build Virtual and Augmented Reality experiences based on mirror metaphors, there are very few contributions of this kind in the medical sector. In this chapter, the great benefits that regular mirrors have brought for mental health treatment are addressed. In addition, a review on the state of the art in mirror-based Virtual and Augmented Reality applications is given, highlighting the potential benefits that these enhanced mirrors could bring for the mental health treatment.
... Cognitive-behavioral models of BDD include gazing rituals as a relevant component [6][7][8] and a maintaining factor of BDD [3,9,10]. Specifically, BDD models hypothesize that rituals are performed in reaction to distressing feelings, which emerge from beliefs about the unattractiveness of the perceived flaw. ...
Rituals, such as gazing at faces, are common in body dysmorphic disorder (BDD) and appear in cognitive-behavioral models as a maintaining factor. Rituals are also common in obsessive-compulsive disorder (OCD). In contrast to OCD, the proposed associations between rituals and intrusive thoughts/appearance preoccupation have not been empirically investigated for BDD. We examined if the assumed effect of gazing rituals on attractiveness ratings exists and if it is associated with dissociation. In an experiment, we asked N = 65 non-clinical females to focus on the nose of a photographed face at pre- and post-test. In between, participants gazed at the nose of either the same (relevant gazing) or another face (irrelevant gazing). We found increasing dissociation after gazing in both conditions and a differentially stronger decrease of attractiveness ratings in the relevant gazing condition. Our findings support the hypothesized effect of gazing rituals on attractiveness evaluation in cognitive-behavioral models for BDD.
... However, the differences in visual perception of photos in patients with respect to healthy individuals are not so relevant to explain body dysmorphic disorder in front of the mirror. In a study (Windheim et al., 2011) that used mirrorgazing with high lighting illumination, self-evaluation measures of cognitive functions gave no univocal differences between patients and normal individuals. Therefore, from these studies the fact that patients see distorted (dysmorphic) images when looking in the mirror remains unexplained. ...
A relationship between empathy and self-directed behaviour during mirror-gazing has been hypothesized by some authors. Nevertheless, how these concepts may be connected is still an argument of debate. Previous research on mirror self-recognition may not completely account for the fascination produced by mirror-gazing. In fact, gazing at one's own face in the mirror for a few minutes, at a low illumination level, produces the perception of bodily dysmorphic visual illusions of strange-faces. Strange-face illusions may be the 'projection' of the subject's unconscious contents into mirror image on the basis of somatic/motor mimicry and contagion. Motor mimicry and emotional contagion can operate through the feedback produced by the mirror within the observed/observing subject. The 'projection' of unconscious content can characterize empathy, according to early ideas of Einfühlung. Empirical research provides support for correlations between susceptibility to strange-face illusions and both the Fantasy and Empathic-concern subscales of Interpersonal Reactivity Index (IRI).
... Individuals with BDD also exhibited pronounced automatic associations between the concepts "attractive" and "competent" and "self" and "bad" on the Implicit Association Test (IAT; , reflecting maladaptive core beliefs, which predicted symptom severity and distress during mirror exposure. Mirror exposure was further shown to increase sadness and anger, negative body-related cognitions (Kollei & Martin, 2014), distress, and self-focused attention (Windheim, Veale, & Anson, 2011) in BDD. These studies underscore a potential relationship between interpretation bias, emotional distress, perceived attractiveness, appearance dissatisfaction, and self-esteem in BDD. ...
... Camouflaging the body with clothes . 'Skin Picking' (attempting to remove the imperfection by scratching or plucking it) (Windheim et al. 2011;Newton and Cunningham 2013;Anthony and Farella 2014;Jaiswal et al. 2016). ...
Body dysmorphic disorder (BDD) is a psychiatric disorder in which the individual has a disproportionate concern about a particular body part. With the increasing demand for aesthetic treatments, it is likely that individuals with BDD may present for orthodontic or combined orthodontic and orthognathic treatment. In this review, we shall outline the features of BDD and its prevalence, before discussing the best way for clinicians to identify and manage individuals with this disorder.
... In the camoulage, patients waste too much time trying to hide the defect [3,25,26]. It includes the habit of buying compulsively objects like make-up items, scarfs, and so on [19,27]. ...
Body dysmorphic disorder (BDD) is defined by a recurring and persistent concern characterized by psychic suffering caused by a possible physical imperfection in appearance. It is a severe psychiatric condition, duly confirmed by neuroanatomical findings, very peculiar repetitive behaviors, and specific personalities. The prevalence of BDD is increasing around the world and differs between countries, because of cultural differences and different health-care systems. This increase is worrying because BDD is a pathology that presents comorbidity like severe depression, suicidal ideation, and functional and social impairment. However, BDD is an unrecognized and often not diagnosed in our society. Many patients are ashamed of their complaints and do not usually seek psychiatric help with ease, and unfortunately, they seek help in cosmetic and surgical treatments to improve their appearance, and these professionals are not yet prepared to assist in the diagnosis of this disorder. Therefore, this chapter presents not only the psychopathology of BDD but also its associations with other pathologies and their main factors of influence. Finally, we present a clinical experience with a detailed description of a clinical case. The aim is to contribute to the diagnosis and treatment of this pathology and also to future research that may benefit society and these patients.
... MT in rehabilitation includes treatment of patients with cerebral palsy (Feltham, Ledebt, Deconinck, & Savelsbergh, 2010), recovery from hemiparesis (Altschuler et al., 1999;Dohle et al., 2009;Stevens & Stoykov, 2003) and motor rehabilitation after a stroke (Thieme, Mehrholz, Pohl, Behrens, & Dohle, 2012;Yavuzer et al., 2008), to mention just a few. Another use of MT includes the treatment of anxiety disorders, such as anorexia nervosa (Key et al., 2002) or body dysmorphic disorder (Windheim, Veale, & Anson, 2011), and other rarer conditions such as mirror agnosia, mirrored-self misidentification or asomatognosia (Connors & Coltheart, 2011;Fotopoulou et al., 2011;Paysant, Beis, Le Chapelain, & André, 2004). ...
This chapter deals with the topic of Augmented Reality Mirrors (ARMs) - a kind of specular interfaces making use of Augmented Reality technology. The review presented in the chapter first analyses the current setups for the construction of ARMs. Secondly, it presents a study on their potential for inferring in human perception (e.g. behaviour and emotions) and the high interactivity potential and usability they have. In the third place, it shows their use in different areas of knowledge, namely entertainment, edutainment, clothing, arts and medical therapy. Then, the chapter presents a discussion, highlighting the current technological barriers and the need for more research. Finally, future challenges are provided.
... Advances in eye-tracking research in BDD could bestow real-life therapeutic applications, for instance, integration of such technology to supplement conventional cognitive-behavioural therapy (CBT) treatments for mirror-gazing (Baldock, Anson, & Veale, 2012;Windheim, Veale, & Anson, 2011) could be a potential avenue worth pursuing. In fact, a "personalised" treatment approach could be implemented. ...
Introduction: Body dysmorphic disorder (BDD) is characterised by repetitive behaviours and/or mental acts occurring in response to preoccupations with perceived flaws in physical appearance. Based on an eye-tracking paradigm, this study aimed to examine how individuals with BDD processed their own face. Methods: Participants were 21 BDD patients, 19 obsessive– compulsive disorder patients and 21 healthy controls (HC), who were age-, sex-, and IQ-matched. Stimuli were photographs of participants' own faces as well as those from the Pictures of Facial Affect battery. Outcome measures were affect recognition accuracy as well as spatial and temporal scanpath parameters. Results: The BDD group exhibited significantly decreased recognition accuracy for their own face relative to the HC group, and this was most pronounced for those who had a key concern centred on their face. Individual qualitative scanpath analysis revealed restricted and extensive scanning behaviours in BDD participants with a facial preoccupation. Persons with severe BDD also exhibited more marked scanpath deficits. Conclusions: Future research should be directed at extending the current work by incorporating neuroimaging techniques, and investigations of eye-tracking focused on affected body parts in BDD. These could yield fruitful therapeutic applications via incorporation with existing treatment approaches.
... Advances in eye-tracking research in BDD could bestow real-life therapeutic applications, for instance, integration of such technology to supplement conventional cognitive-behavioural therapy (CBT) treatments for mirror-gazing (Baldock, Anson, & Veale, 2012;Windheim, Veale, & Anson, 2011) could be a potential avenue worth pursuing. In fact, a "personalised" treatment approach could be implemented. ...
Introduction: Body dysmorphic disorder (BDD) is characterised by repetitive behaviours and/or mental acts occurring in response to preoccupations with perceived flaws in physical appearance. Based on an eye-tracking paradigm, this study aimed to examine how individuals with BDD processed their own face.
Methods: Participants were 21 BDD patients, 19 obsessive–compulsive disorder patients and 21 healthy controls (HC), who were age-, sex-, and IQ-matched. Stimuli were photographs of participants’ own faces as well as those from the Pictures of Facial Affect battery. Outcome measures were affect recognition accuracy as well as spatial and temporal scanpath parameters.
Results: The BDD group exhibited significantly decreased recognition accuracy for their own face relative to the HC group, and this was most pronounced for those who had a key concern centred on their face. Individual qualitative scanpath analysis revealed restricted and extensive scanning behaviours in BDD participants with a facial preoccupation. Persons with severe BDD also exhibited more marked scanpath deficits.
Conclusions: Future research should be directed at extending the current work by incorporating neuroimaging techniques, and investigations of eye-tracking focused on affected body parts in BDD. These could yield fruitful therapeutic applications via incorporation with existing treatment approaches.
... Comparatively, healthy controls demonstrate a broader approach to viewing faces. Mirror gazing studies have also demonstrated that focusing on negative aspects of one's own face can increase distress, anxiety and disgust within both BDD and healthy control groups (38,39). However, this was complicated by BDD participants actually decreasing in physiological and psychological measures of disgust over time, despite increased self-report feelings of disgust (39). ...
Objective:
Recent advances in body dysmorphic disorder (BDD) have explored abnormal visual processing, yet it is unclear how this relates to treatment. The aim of this study was to summarize our current understanding of visual processing in BDD and review associated treatments.
Method:
The literature was collected through PsycInfo and PubMed. Visual processing articles were included if written in English after 1970, had a specific BDD group compared to healthy controls and were not case studies. Due to the lack of research regarding treatments associated with visual processing, case studies were included.
Results:
A number of visual processing abnormalities are present in BDD, including face recognition, emotion identification, aesthetics, object recognition and gestalt processing. Differences to healthy controls include a dominance of detailed local processing over global processing and associated changes in brain activation in visual regions. Perceptual mirror retraining and some forms of self-exposure have demonstrated improved treatment outcomes, but have not been examined in isolation from broader treatments.
Conclusion:
Despite these abnormalities in perception, particularly concerning face and emotion recognition, few BDD treatments attempt to specifically remediate this. The development of a novel visual training programme which addresses these widespread abnormalities may provide an effective treatment modality.
... In contrast, most patients with major-depression (MD; [33]) do not perceive strange-face illusions, since they perceive their immobile faces without emotions, as death statues in the mirror [34]. Further research may be done in patients with body-dysmorphic-disorder (BDD; [57]) and anorexia nervosa (AN; [58]), who suffer from their bodily imaginary appearance that, in terms of their actual physical body, is strongly dissociated. Notwithstanding the important psychopathology of BDD and AN patients, relevant differences in perceptual processes with respect to healthy individuals have not been found in previous studies. ...
Cognitive behavioral therapy is the first-line psychological treatment for body dysmorphic disorder (BDD), and is directly translated from integrative research findings on the neurobiological, psychological, and environmental contributions to BDD. This book chapter reviews the core principles of the cognitive behavioral model of BDD and provides pragmatic considerations when applying the treatment model. Through a case example, we highlight how primary treatment strategies, such as motivational enhancement, psychoeducation and case conceptualization, cognitive strategies, exposure and response prevention, mindfulness and perceptual retraining, and relapse prevention, target core patterns of psychopathology in BDD. We also discuss the management of associated clinical features (delusionality, suicidality), concurrent physical treatments, ) and highlight the use of modular intervention strategies to tailor treatment needs. Practical guidance is provided through example language and clinician-patient dialogue. Contemporary cross-sectional, prospective, and experimental research continue to support the comprehensive CBT model for BDD as a robust and empirically validated approach to the treatment of BDD.
The coronavirus disease 2019 (COVID‐19) pandemic led to a global surge in videoconferencing use for work/study‐related reasons. Although these platforms heighten exposure to one's image, the implications of videoconferencing use on body image and eating concerns remain scantly examined. This study sought to investigate, in an Australian sample, whether videoconferencing for work/study‐related reasons predicted increases in body dissatisfaction (BD), urge to engage in disordered eating (DE; restrictive eating, exercise, overeating/purging), and negative mood at the state level. Participants ( N = 482, 78.8% women, M age = 20.5 years [ SD = 5.3]) completed baseline demographic measures, accompanied by an ecological momentary assessment (EMA) of videoconferencing for work/study‐related reasons, BD, DE urges, and negative mood six times a day for 7 days via a smartphone application. Most participants ( n = 429; 89.0%) reported state‐based videoconferencing use during the EMA phase. Consistent with expectations, state‐based videoconferencing use was associated with an increase in state‐level urges to engage in exercise. However, contrary to predictions, state‐based videoconferencing use was linked to a decrease in state‐level BD at the next assessment point and failed to predict negative mood and urges to engage in restrictive eating or overeating/purging at the state level. Given the simplified measure of videoconferencing use, the current research is considered preliminary and future replication and extension, using more nuanced measures, is warranted.
Purpose of review:
The cessation of in-person teaching to reduce the spread of COVID-19 dramatically increased the use of videoconferencing for home learning among adolescents.
Recent findings:
A consistent finding across studies assessing the relationship between videoconferencing and appearance concerns was that time spent focused on self-view was related to greater appearance concerns. Videoconferencing was associated with an increase in desire for cosmetic surgery and other nonsurgical treatments. Among those at risk of eating disorders, videoconferencing was associated with more appearance-management behaviours and less engagement in the video call. Research to date has been correlational and predominantly involved White, adult women in the USA and in Australia, leaving important gaps in our knowledge, especially around impacts on adolescents.
Summary:
Given their vulnerability to appearance concerns, we encourage practitioners to speak to adolescents about their use of videoconferencing and how they can migitate the potential negative impacts on body image.
Body dysmorphic disorder is a type of psychiatric disorder with the major indicator of overt preoccupation with the imagined minor role in the appearance. The disorder starts in adolescence and has a high prevalence among adolescent girls. This study aimed to extend the research literature through investigating the predicting role of variables of obsessive symptoms, obsessive beliefs and metacognitive beliefs regarding body dysmorphic disorder and presenting a BDD model in adolescent girls based on the aforementioned variables. Research sampling included (n = 263) 14- to 18-year-old adolescent girls who were selected through cluster sampling and filled out the modified version of Yale-Brown Obsessive–Compulsive Scale (Body Dysmorphic Disorder) (YBOCS-BDD), the Maudsley Obsessive–Compulsive Inventory, Obsessive Beliefs Questionnaire-44 (OBQ-44) and Metacognitive Questionnaire-30 (MCQ-30). To investigate the descriptive statistics, the indices of mean and standard deviation were analyzed, and to answer the proposed hypotheses, modeling of structural equations based on covariance was implemented. The findings indicated that in the whole population, all paths’ coefficients were statistically significant and in the order of presenting, obsessive symptoms, obsessive beliefs and metacognitive beliefs have significant positive effects on body dysmorphic disorder. Among the subscales of obsessive symptoms, the subscales of “checking” and among the subscales of obsessive and metacognitive beliefs, the subscales of “importance of thoughts” and “negative beliefs about uncontrollability and danger,” respectively, attained the highest predictive coefficients. The results of the study can be helpful in identifying new scientific ways to treat body dysmorphic disorder.
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
Background and Objectives: Body Dysmorphic Disorder (BDD) is characterized by an abnormal preoccupation with alleged misshapen body parts. There is often poor insight and effort is made to hide the imagined defects, and consultation may be sought seeking unnecessary cosmetic surgery or procedures. It is underdiagnosed and established treatment protocols are lacking. The disease has a chronic and undulating course and is seriously compromises quality of life. Despite the fact that the prime age of onset of BDD is during adolescence relatively little has been written about it during this phase of life. This review aims to comprehensively cover the present understanding of BDD, including clinical features, epidemiology, psychopathology, nomenclature, comorbidity and management. Methods: A literature search was undertaken using suitable key words on Google Scholar, MEDLINE & PsychoINFO up to June 2018 limited to articles in English. Results: The prevalence of BDD is variable in the general and psychiatric population with equal gender distribution. Both sexes are equally affected. It is associated with poor functioning and a chronic course. There is considerable comorbidity and diagnostic overlap between BDD and obsessive-compulsive disorder, major depressive disorder, social anxiety disorder, anorexia nervosa, schizophrenia spectrum disorders and personality disorders. Psychiatric consultation is often late. Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavior Therapy (CBT) are currently the first line modalities for treatment. Internet based CBT, Acceptance and commitment therapy, and repetitive Transcranial Magnetic Stimulation (rTMS) are emerging treatment options. Conclusions: BDD is a complex disorder with still lot of uncertainty about its diagnostic placement, treatment approaches, especially for refractory patients, and prognosis. Further study is needed to clarify its prevalence, especially in adolescents; to fully understand its neurobiological aspects, to determine its exact relation to obsessive compulsive related disorders, and to develop better treatment approaches. An 18-year-old student was brought to our clinic for psychiatric treatment by his father, who was concerned about continuing to pay for costly treatment for hirsutism for his son. The son had developed the symptoms when he was in his first year of college after somebody remarked about the hair on his legs while he was at a beach. He became extremely disturbed and whatever physical problems he suffered from that day on he blamed on his hair growth. He blamed his parents for giving him this "disease" and was convinced that faulty genes were responsible for this disgrace to him. He covered most of his body but believed people still noticed the hair. He had had multiple visits to various dermatologists for his concern. Before coming for psychiatric treatment, he had already undergone repeated laser removal of the hair on his legs. Though the procedure was painful, he felt an immediate sense of relief afterwards, but his worry would recur after a few weeks, and was not relieved by reassurance by the dermatologist that the growth of his hair was within the normal range. He was not able to concentrate on anything and kept searching the internet looking for what else could be done. His father was unable to say no to his only son for the costly treatment. Moreover, his anxieties were shifting to hair on other parts of his body. He had stopped looking for a job, as he felt that he might be rejected because of his hair growth. His social contacts were minimal and did not venture out of his house much. He had earlier been diagnosed with anxiety disorder and was receiving treatment for that from another professional. On mental status examination, he described his mood as depressed, and he had feelings of low self-esteem, worthless-ness and passive suicidal ideation. He had excessive anxiety and appeared extremely disturbed. He attended the clinic for 5 months once a week receiving cognitive behavioral therapy (CBT) for around 20 sessions and a great reduction in his symptoms was seen, to the point where he began wearing short sleeved shirts. No drug treatment was required as this patient responded well to psychological treatment.
The present study aimed to compare the impact of acne on self-esteem and the risk of body dysmorphic disorder symptoms. A descriptive comparative design was utilized. The present study was conducted at the Family medicine outpatient clinic and the Dermatology department in El-Manial Teaching Hospital. A systematic random sample consisted of 300 adolescents divided into two groups in a 1:1 ratio. The group (1) included adolescents diagnosed with acne attending the Dermatology Outpatient Clinics, and group (2) included adolescents free from acne selected from the Family Medicine Clinic. Four tools were used to collect the data for the current study which were socio-demographic data sheet, Body Dysmorphic Disorder Diagnostic Module-for Adolescents, the BDD-YBOCS questionnaire, and Rosenberg Self-Esteem Scale. The results revealed that there was no significant [SYLWAN., 163(6)]. ISI Indexed 205 difference in the severity of BDD between both groups. BDD is a common psychiatric problem among adolescents as (10.3%) was positive for BDD. Prevalence of BDD among the group (1) was higher than group (2) as 14.7% of the adolescents in the group (1) were positive for BDD compared to only 6% in the group (2). Among group (2), there were different foci of concern; obesity and hair were prominent among the different foci, representing 44.4% and 33.3%, respectively. The study concluded that adolescents with acne had lower self-esteem compared to their counterpart who were free of acne. It is recommended that early referral of this particularly vulnerable population might be a crucial step in the prevention and treatment of this distressing disease.
هدف البحث الحالي التعرف على مستوى كل من خبرات الاساءة النفسية في مرحلة الطفولة واضطراب التشوه الوهمي للجسد لدى طلبة الجامعة، وكذلك الكشف عن طبيعة العلاقة بين خبرات الاساءة في مرحلة الطفولة واضطراب التشوه الوهمي للجسد، وما اذا كانت توجد فروق دالة احصائياً في كل من خبرات الاساءة النفسية في مرحلة الطفولة واضطراب التشوه الوهمي للجسد تعزى إلى الجنس، وكذلك الكشف عن إمكانية التنبؤ باضطراب التشوه الوهمي للجسد من خلال درجات خبرات الإساءة النفسية في مرحلة الطفولة. تكونت عينة البحث من 237 (84 ذكور،153 إناث) طالب وطالبة بجامعة الملك خالد بالمملكة العربية السعودية، ممن تراوحت أعمارهم بين (19 – 25) عام. وقد أعد الباحثان مقياس خبرات الاساءة النفسية في مرحلة الطفولة، ومقياس اضطراب التشوه الوهمي للجسد وتم تطبيقهما على عينة البحث بعد التحقق من الثبات والصدق. وأسفرت نتائج التحليل الاحصائي عن وجود مستوى منخفض من خبرات الاساءة النفسية في مرحلة الطفولة في حين وجد مستوى متوسط من اضطراب التشوه الوهمي للجسد لدى طلبة الجامعة. كذلك توصلت نتائج البحث إلى وجود علاقة ارتباطية موجبة دالة احصائياً(عند مستوى دلالة 0.01) بين درجات أفراد عينة البحث على مقياس خبرات الاساءة النفسية في الطفولة ودرجاتهم على مقياس التشوه الوهمي للجسد، كما توصلت النتائج إلى عدم وجود فروق دالة احصائياً تعزى إلى الجنس في كل من خبرات الاساءة النفسية في الطفولة واضطراب التشوه الوهمي للجسد. وأشارت نتائج تحليل الانحدار البسيط إلى أن خبرات الاساءة النفسية في الطفولة منبئ دال احصائياً لاضطراب التشوه الوهمي للجسد لدى طلبة الجامعة. وقد تم تفسير هذه النتائج ووضع الباحثان توصيات في ضوئها.
A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena - edited by Leonardo F. Fontenelle January 2019
A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena - edited by Leonardo F. Fontenelle January 2019
Background and Objectives
Body Dysmorphic Disorder (BDD) is characterized by an abnormal preoccupation with alleged misshapen body parts. There is often poor insight and effort is made to hide the imagined defects, and consultation may be sought seeking unnecessary cosmetic surgery or procedures. It is underdiagnosed and established treatment protocols are lacking. The disease has a chronic and undulating course and is seriously compromises quality of life. Despite the fact that the prime age of onset of BDD is during adolescence relatively little has been written about it during this phase of life. This review aims to comprehensively cover the present understanding of BDD, including clinical features, epidemiology, psychopathology, nomenclature, comorbidity and management.
Methods
A literature search was undertaken using suitable key words on Google Scholar, MEDLINE & PsychoINFO up to June 2018 limited to articles in English.
Results
he prevalence of BDD is variable in the general and psychiatric population with equal gender distribution. Both sexes are equally affected. It is associated with poor functioning and a chronic course. There is considerable comorbidity and diagnostic overlap between BDD and obsessive-compulsive disorder, major depressive disorder, social anxiety disorder, anorexia nervosa, schizophrenia spectrum disorders and personality disorders. Psychiatric consultation is often late. Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavior Therapy (CBT) are currently the first line modalities for treatment. Internet based CBT, Acceptance and commitment therapy, and repetitive Transcranial Magnetic Stimulation (rTMS) are emerging treatment options.
Conclusions
BDD is a complex disorder with still lot of uncertainty about its diagnostic placement, treatment approaches, especially for refractory patients, and prognosis. Further study is needed to clarify its prevalence, especially in adolescents; to fully understand its neurobiological aspects, to determine its exact relation to obsessive compulsive related disorders, and to develop better treatment approaches.
Recent psychophysical and neurocognitive findings implicate abnormal visual processing for a range of stimuli in body dysmorphic disorder (BDD); such abnormalities differentiate BDD from other mental health disorders. Current treatments most commonly involve cognitive behavior therapy with or without accompanying antidepressant medications. These are moderately successful yet appear to overlook the core phenomenological aspect of abnormal perception in BDD. The following text summarizes the current literature of perceptual abnormalities within BDD and how these findings may be applied and incorporated into treatment options. Possible modifications of cognitive behavioral therapy (CBT) based on the widespread visual abnormalities within BDD include making perceptual mirror retraining a compulsory component of therapy and implementing self-exposure tasks within exposure and response prevention. Alternative options such as a visual training program to remediate visual abnormalities across a range of visual stimuli are also explored, which may be included as an adjunctive treatment alongside CBT.
The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders includes a new class of obsessive-compulsive and related disorders (OCRDs) that includes obsessive-compulsive disorder (OCD) and a handful of other putatively related conditions. Although this new category promises to raise awareness of under-recognized and understudied problems, the empirical validity and practical utility of this new Diagnostic and Statistical Manual (DSM) category is questionable. This article critically examines the arguments underlying the new OCRD class, illuminates a number of problems with this class, and then discusses implications for clinicians and researchers.
Body Dysmorphic Disorder: An under- diagnosed problem. Although body dysmorphic disorder (BDD) has been
known for centuries, only recently its study has been intensifi ed. In recent years, important advances have been made in the understanding of BDD in the different aspects of this still underdiagnosed disorder. The purpose of this article was to present an actualization of the status of BDD. Among other aspects, the etiopathogenesis, epidemiology, associated complications and the cognitive-behavioral explanation of the disorder were examined. Recent changes in its classifi cation and the related implications are also analyzed. From this perspective, we provide data from our research on the phenomenology of dysmorphic concerns and their consequences, which could be involved in the development and/or the maintenance of BDD. Finally, we present a new instrument, the Appearance Intrusions Questionnaire (AIQ), designed for the early detection of BDD prodromal symptoms in a non-clinical general population.
BDD appears to commence during adolescence, is not gender specific, and is often comorbid with OCD, social phobia, depression, and personality disorders. Its prevalence rate is not yet firmly established, with studies indicating anywhere from 0.7% to 13% of the various populations studied. Most patients with have high overvalued ideas and are difficult to treat. Treatment has consisted of cognitive-behavior therapy and selective serotonin reuptake inhibitors. A behavioral model of a patient's acquisition and maintenance of BDD is provided, with emphasis on classical followed by operant conditioning.
Thirteen cases of Body Dysmorphic Disorder (BDD) were described. There were eight males (61.5%) and five females (38.5%) with ages ranging from 16 to 37 (mean=24.7). All patients were also diagnosed as obsessive compulsive disorder (OCD), according to DSM-III-R, with the exception of one. Patients were administered the Yale Brown Obsessive Compulsive Scale, Beck Depression Inventory, Wechsler Intelligence Scale, Over-valued Ideation Scale and MMPI. The Phenomenology of BDD, its relationship to OCD, and the patients' responses to the above tests were reported. Due to the bizarreness of the symptoms and the secretiveness of the patients, it was suggested that clinicians be thoroughly aware of the disorder and inquire as to its presence during the initial consultation. Otherwise, these patients go unnoticed and they resort to treatment from dermatologists and plastic surgeons.
Body dysmorphic disorder (BDD) consists of a preoccupation with an 'imagined' defect in appearance which causes significant distress or impairment in functioning. There has been little previous research into BDD. This study replicates a survey from the USA in a UK population and evaluates specific measures of BDD.
Cross-sectional interview survey of 50 patients who satisfied DSM-IV criteria for BDD as their primary disorder.
The average age at onset was late adolescence and a large proportion of patients were either single or divorced. Three-quarters of the sample were female. There was a high degree of comorbidity with the most common additional Axis l diagnosis being either a mood disorder (26%), social phobia (16%) or obsessive-compulsive disorder (6%). Twenty-four per cent had made a suicide attempt in the past. Personality disorders were present in 72% of patients, the most common being paranoid, avoidant and obsessive-compulsive.
BDD patients had a high associated comorbidity and previous suicide attempts. BDD is a chronic handicapping disorder and patients are not being adequately identified or treated by health professionals.
A semi-structured interview assessing the presence and characteristics of spontaneous appearance-related images was designed and administered. A total of 18 patients with body dysmorphic disorder (BDD) and 18 normal controls took part. The BDD patients were found to have spontaneously occurring appearance-related images that were significantly more negative, recurrent, and viewed from an observer perspective than control participants. These images were more vivid and detailed and typically involved visual and organic (internal body) sensations. The study also found that BDD images were linked to early stressful memories, and that images were more likely than verbal thoughts to be linked to these memories. Implications for theory and clinical practice are discussed.
Body dysmorphic disorder (BDD) is a relatively common and impairing disorder. However, little is known about non-BDD symptoms and well-being in patients with this disorder. Seventy-five outpatients with DSM-IV BDD completed the Symptom Questionnaire, a validated self-report measure with four scales: depression, anxiety, somatic/somatization, and anger-hostility. Scores were compared to published norms for normal subjects and psychiatric outpatients. Participants in an open-label fluvoxamine trial completed the Symptom Questionnaire at baseline and endpoint. Compared to normal controls, BDD subjects had markedly elevated scores on all four scales, indicating severe distress and psychopathology. Compared to psychiatric patients, BDD subjects had higher scores on the depression, anxiety, and anger/hostility scales but not on the somatic/somatization scale. Scores on all scales significantly decreased with fluvoxamine. In conclusion, patients with BDD have markedly high levels of distress, are highly symptomatic, and have poor well-being in the domains of depression, anxiety, somatic symptoms, and anger-hostility. All of these symptoms significantly improved with fluvoxamine.
Body dysmorphic disorder (BDD) is a highly distressing and impairing disorder characterized by a preoccupation with imagined or slight physical defects in appearance. Well designed studies on its prevalence and on base rates for diagnostic criteria are rare. Therefore this study aimed to reveal prevalence rates of BDD in the general population and to examine clinical features associated with BDD.
Of 4152 selected participants 2552, aged 14-99 years, participated in this German nationwide survey. Participants were carefully selected to ensure that the sample was representative; they were visited by a study assistant who provided instructions and help if needed. Participation rate was 62.3%. DSM-IV criteria for BDD, as well as subthreshold features (e.g. individuals who consider some part(s) of their body as ugly or disfigured, but do not fulfill all BDD criteria) were examined. We also assessed suicidal ideation associated with the belief of having an ugly body part, as well as the desire for cosmetic surgery. Furthermore, somatization symptoms were assessed.
The prevalence of current BDD was 1.7% (CI 1.2-2.1%). Individuals with BDD reported higher rates of suicidal ideation (19% v. 3%) and suicide attempts due to appearance concerns (7% v. 1%) than individuals who did not meet criteria for BDD. Somatization scores were also increased in individuals with BDD, relative to those without. BDD was associated with lower financial income, lower rates of living with a partner, and higher rates of unemployment.
Our study shows that self-reported BDD is relatively common and associated with significant morbidity.
Cross-sectional/retrospective data have indicated that individuals with body dysmorphic disorder (BDD) have high rates of suicidal ideation and attempts. However, no study, to the authors' knowledge, has prospectively examined suicidality in BDD.
In the first prospective study of BDD's course, the authors examined suicidality in 185 subjects for up to 4 years.
Suicidal ideation was reported by a mean of 57.8% of the subjects per year, and a mean of 2.6% attempted suicide per year. Two subjects (0.3% per year) completed suicide.
Individuals with BDD have high rates of suicidal ideation and attempts. The completed suicide rate is preliminary but suggests that the rate of completed suicide in BDD is markedly high.
Cognitive-behavioral therapy (CBT) is an effective treatment for body dysmorphic disorder (BDD). This article reviews the research support for CBT in BDD, describes in detail some of the important considerations when administering CBT in this challenging patient group, and reviews some of the behavioral and cognitive techniques that can be used. In addition, this article identifies three basic principles for clinicians to keep in mind when providing medical treatments for BDD patients. While patients should ordinarily be referred to experienced therapists for CBT, knowledge of the basic principles and techniques can enable medical providers who are not trained in CBT to both make better referrals for treatment and work most effectively with the therapist and BDD patient.
BDD may be related to obsessive-compulsive disorder (OCD) on several dimensions, including symptom profile, patterns of comorbidity, family history, and a possible preferential response to serotonin reuptake inhibitors.
Body dysmorphic disorder (BDD) is characterized by an excessive preoccupation with an imagined or slight defect in one's appearance. BDD is a severe and common disorder associated with high levels of functional impairment and high rates of suicidality. Interventions, including cognitive-behavioral therapy and pharmacotherapy, are effective for BDD. This chapter outlines the cognitive-behavioral model and therapy of BDD. The chapter reviews pharmacotherapy of BDD, and discusses the role of combination therapy. The chapter also addresses ineffective approaches for the treatment of BDD, including the role of cosmetic procedures. Early recognition and intervention are critical, and limit its chronicity and subsequent morbidity.
Dysmorphophobia (body dysmorphic disorder), defined as a preoccupation with an imaginary or minimal defect in appearance, has been known for more than a century but has received relatively little empirical study. The authors investigated the demographics, phenomenology, course, associated psychopathology and family history in a series of 58 patients (34 men and 24 women) with the disorder. The patients were assessed with the Hopkins Symptom Checklist and two specially constructed instruments developed by the authors. The mean age at onset of body dysmorphic disorder was 17 (sd = 3.8) years and the average duration was 9 (sd = 5.3) years. The most common preoccupations were defects of the face, nose, genitals and legs. Seventy-nine percent of the patients reported excessive mirror checking and 53% reported attempts to camouflage their ‘deformities’. As a result of their symptoms, 89.6% avoided the usual social activities, 51.7% showed an impairment of their academic or job performance, 45% experienced suicidal ideation and 36% showed aggressive behaviour. Seventy-two percent of the patients had an associated lifetime diagnosis of a major mood disorder and 74% of an anxiety disorder. Body dysmorphic disorder has a generally chronic course, causes considerable distress and a serious impairment in many areas, and shows strong links with mood and obsessive-compulsive disorders.
Reports 2 errors in the original article by J. C. Rosen et al ( Journal of Consulting and Counseling Psychology , 1995[Apr], 63[2], 263–269). On page 263, the correct prevalence of body dysmorphic disorder is 1.5% among women. On page 265, NHANES II stands for National Health and Nutrition Examination Surveys, Study 2. (The following abstract of this article originally appeared in record 1995-26170-001 ). Body dysmorphic disorder (BDD) is a distressing body image disorder that involves excessive preoccupation with physical appearance in a normal appearing person. Prior case reports of behavior therapy were encouraging, but no controlled evaluation of behavior therapy or any other type of treatment had been conducted. In the present study, 54 BDD subjects were randomly assigned to cognitive behavior therapy or no treatment. Patients were treated in small groups for eight 2-hour sessions. Therapy involved modification of intrusive thoughts of body dissatisfaction and overvalued beliefs about physical appearance, exposure to avoided body image situations, and elimination of body checking. Body dysmorphic disorder symptoms were significantly decreased in therapy subjects and the disorder was eliminated in 82% of cases at posttreatment and 77% at follow-up. … (PsycINFO Database Record (c) 2016 APA, all rights reserved)
The present study aimed to test the hypothesis that women with high shape concern would differ in their use of mirrors from women with low levels of shape concern. The “Mirror Questionnaire” was completed by 150 women, half of whom had high levels of shape concern. The findings support the notion that women with high shape concern differ from those with low concern in their use of mirrors, and argue for further investigation of the role of mirror cognitions and behaviours in the maintenance of body image disturbance.
The theoretical and empirical basis of commonly accepted propositions concerning the role of behaviour in the practice of behavioural psychotherapy for anxiety problems is considered. A number of problems are identified, and an alternative, more explicitly cognitive hypothesis is described. According to this cognitive account, there is both a close relationship and specific interactions between “threat cognitions” and “safety seeking behaviour”. For any individual, safety seeking behaviour arises out of, and is logically linked to, the perception of serious threat. Such behaviour may be anticipatory (avoidant) or consequent (escape). Because safety seeking behaviour is perceived to be preventative, and focused on especially negative consequences (e.g. death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety seeking behaviours. By preventing disconfirmation of threat-related cognitions, safety seeking behaviour may be a crucial factor in the maintenance of anxiety disorders. The implications of this view for the understanding and treatment of anxiety disorders are discussed.
Body dysmorphic disorder (BDD) is defined as a preoccupation with an imagined or a very slight defect in physical appearance
that causes significant distress to the individual. The disorder is manifested in people who dislike some aspect of how they
look to such an extent that they cannot stop thinking and worrying about it. To other people these reactions may seem excessive
as the supposed problem may not even be noticeable or is related to a very minor blemish such as a mole, or mild acne scarring
that anyone else may not even notice. To sufferers of the syndrome the “defects” are very real, very obvious, and very severe.
BDD is described with possible methods of treatment. The surgeon should avoid performing surgery on patient with this problem
until medical treatment has been completed.
Two information processing biases that could maintain social anxiety were investigated. High and low socially anxious individuals encoded positive and negative trait words in one of three ways: public self-referent, private self-referent, and other-referent. Half were then told they would soon have to give a speech. As predicted, compared to low socially anxious individuals, high socially anxious individuals recalled less positive public self-referent words, but only when both groups were anticipating giving a speech. No memory biases were observed for private self-referent or other-referent words. Next all participants gave a speech. Correlational analyses suggested that high socially anxious individuals may use the somatic concomitants of anxiety to overestimate how anxious they appear and underestimate how well they come across.
Increased interest in body dysmorphic disorder (BDD) has generated a wealth of recent research. This paper reviews the current literature regarding conceptualizations of the disorder, the development of assessment tools, and treatment outcome. Although BDD has been viewed as a variant of an eating disorder, obsessive compulsive disorder, or a somatoform disorder, it appears best conceptualized as a body image disorder with social, psychological, and possibly biological influences. Assessment instruments with acceptable psychometric properties have been developed to specifically assess BDD (e.g., the Body Dysmorphic Disorder Examination and the Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder). Examination and the initial results from uncontrolled and controlled treatment research suggest that cognitive behavioral treatments for BDD may be as effective as those for possibly related disorders such as obsessive compulsive disorder and bulimia nervosa.
Unlabelled:
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.
Body dysmorphic disorder (BDD) is characterised by a preoccupation with perceived defects in one's appearance, which leads to significant distress and/or impairment. Although several studies have investigated the prevalence of BDD, many studies have methodological limitations (e.g., small sample sizes and student populations), and studies on the prevalence of BDD in the general population are limited. In the current study, 2510 individuals participated in a representative German nationwide survey. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for BDD and associated characteristics such as suicidality and the prevalence of plastic surgeries were examined using self-report questionnaires. The prevalence of current BDD was 1.8% (N=45). Further, individuals with BDD, relative to individuals without BDD, reported significantly more often a history of cosmetic surgery (15.6% vs. 3.0%), higher rates of suicidal ideation (31.0% vs. 3.5%) and suicide attempts due to appearance concerns (22.2% vs. 2.1%). The current findings are consistent with previous findings, indicating that self-reported BDD is a common disorder associated with significant morbidity.
Body dysmorphic disorder is a severe disturbance in which the person is preoccupied with an imagined defect in appearance. It is unclear what causes and what maintains BDD, although it is assumed that patients are characterized by an increased self-focused attention. Since patients spend a lot of time examining their 'defect' in reflecting surfaces, it might well be that mirror gazing itself is an important maintaining factor for BDD, as it may lead to a loss of sense of proportions. If so, normal individuals' body evaluations are expected to decrease likewise after mirror exposure. In the present study, 50 female students watched both their own face in the mirror and a photograph of a neutral female face for 3.5 min. Before and after gazing, they rated the attractiveness of the faces. Results indicate that mirror exposure did not lead to decreased attractiveness in normal participants. However, when participants were divided into high and low satisfaction about appearance, highly satisfied individuals' evaluations of their own face improved, whereas low satisfied individuals' evaluations tended to decrease. For the other face, only the low satisfied individuals showed increased attractiveness scores at post-test. The results are explained by selective visual attention and are in line with recent findings in eating disordered women.
Good correlation has been shown between pain scores derived from 4 different rating scales. The correlation was maintained when presentation of the scales was separated by a series of questions and by physical examination. There is good evidence that the 4 scales are measuring the same underlying pain variable as they calibrate well. There is also evidence that an 11-point (0-10) numerical rating scale performs better than both a 4-point simple descriptive scale or a continuous (visual analogue) scale.
Body dysmorphic disorder, a preoccupation with an imagined defect in physical appearance, has a rich tradition in European psychiatry but has been largely neglected in the United States. Because this little-known disorder is probably more common than is generally realized and can have profound consequences, the author reviews its history, clinical features, and possible relationship to other psychiatric disorders.
Data sources consisted of the MEDLINE database and relevant references in articles obtained from this search. Of 145 articles and books obtained, 100 were selected for inclusion in this review on the basis of how closely they conformed to the concept of body dysmorphic disorder as defined in DSM-III-R and how substantially they contributed to an understanding of the disorder's history, clinical features, or nosologic status.
Body dysmorphic disorder has been colorfully described in the European literature for more than a century. Although its concerns might sound trivial, this disorder can lead to social isolation (including being housebound), occupational dysfunction, unnecessary cosmetic surgery, and suicide. The most commonly associated psychiatric disorder appears to be depression. Although a definitive treatment does not exist, preliminary evidence suggests that serotonergic antidepressant medications may be useful. Whether body dysmorphic disorder is related to other psychiatric disorders, such as psychosis, mood disorder, social phobia, or obsessive-compulsive disorder, is unclear at this time.
More research on the nosology, clinical features, and treatment response of body dysmorphic disorder is important, given the distress and impairment this often secret disorder can cause.
In Experiment I normal subjects performed the classical clinical line-bisection task, and demonstrated a left-side underestimation. In Experiment II subjects maintained fixation upon a central position and adjusted a rod passing through this fixation point so that both extremities were judged equal. The left-side underestimation was very much greater under these conditions, but was considerably reduced when retinal and gravitational coordinates were dissociated by making the subjects lie horizontally on one or other side. Subjects then demonstrated greater left-side and top-half underestimation when lying on the left than on the right side. Gravitational coordinates and the apparent locus of events in extrapersonal space are determinants of perceptual asymmetries at least as important as anatomical connectivities.
We compared the sensitivity of different types of visual analog scales and of descriptive pain terms in healthy volunteers and in postoperative patients. One hundred and seven volunteers marked visual analog scales according to their perception of the descriptive pain terms--little, mild, some, moderate, severe, agonizing. Individual variation in values and preferences between the five following five different visual analog scales were analyzed: 10-cm linear horizontal and vertical scales, a curvilinear scale, and graded horizontal and curvilinear scales. Significantly more volunteers preferred the horizontal scale with gradations. Scores for the vertical linear scale had the greatest coefficient of variation and were least normally distributed. The majority of volunteers considered the phrase "agonizing pain" the best term defining the extreme limit of pain (X2(12) = 41.8, P less than 0.001). There were significant changes in the values of pain intensity measured on visual analog scales by patients using the same descriptive pain term on successive observations. However, the patients' values for pain terms in the preoperative pain-free state were not significantly different from those during postoperative pain. We conclude that graded linear horizontal scales are both more reliable and preferred by participants and that visual analog scales give a more sensitive and accurate representation of pain intensity than do descriptive pain scales.
Recent developments in the field of psychophysical scaling offer great promise of providing verbal scales which measure dimensions common to all pain syndromes and would permit comparisons among acute, chronic and experimental pain responses. Moreover, there are promising studies that indicate that sensory and affective verbal pain descriptors may be used as valid and sensitive tools, both for the diagnostic evaluation of pain and for assessing different methods of controlling pain. Lastly, it seems reasonable to assume that the magnitude measures for pain follow laws well-established for magnitude estimation of other psychophysical phenomena.
Body dysmorphic disorder (BDD) is a distressing body image disorder that involves excessive preoccupation with physical appearance in a normal appearing person. Prior case reports of behavior therapy were encouraging, but no controlled evaluation of behavior therapy or any other type of treatment had been conducted. In the present study, 54 BDD subjects were randomly assigned to cognitive behavior therapy or no treatment. Patients were treated in small groups for eight 2-hour sessions. Therapy involved modification of intrusive thoughts of body dissatisfaction and overvalued beliefs about physical appearance, exposure to avoided body image situations, and elimination of body checking. Body dysmorphic disorder symptoms were significantly decreased in therapy subjects and the disorder was eliminated in 82% of cases at posttreatment and 77% at follow-up. Overall psychological symptoms and self-esteem also improved in therapy subjects.
A controversial issue that was debated for DSM-IV is whether body dysmorphic disorder (BDD)--a preoccupation with an imagined defect in appearance--can be psychotic. BDD is classified separately from its delusional counterpart (delusional disorder, somatic type) in DSM-IV, but does it have a psychotic variant that overlaps with, and may even be the same diagnostic entity as, its delusional disorder variant? One hundred consecutive patients with DSM-III-R-defined BDD or its delusional variant were assessed with a semistructured interview, the Structured Clinical Inverview for DSM-III-R, and a modified version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The 48 patients with nondelusional BDD were compared with the 52 patients with delusional BDD (i.e., delusional disorder, somatic type). The two groups did not differ significantly in terms of most variables examined, including demographics, phenomenology, course, associated features, comorbidity, and treatment response. Thus, BDD may have a psychotic subtype that significantly overlaps with, and may even be the same disorder as, its delusional disorder variant. However, delusional subjects had higher total scores on the modified Y-BOCS, suggesting that the delusional variant of BDD may be a more severe form of the disorder. Although preliminary, these findings have implications for BDD's treatment and classification, suggesting that inclusion of a delusional (psychotic) subtype of BDD should be considered for future editions of DSM.
Body dysmorphic disorder, preoccupation with an imagined defect in appearance, is included in DSM-III-R but has received little empirical study. The authors investigated the demographics, phenomenology, course, associated psychopathology, family history, and response to treatment in a series of 30 patients with the disorder.
The patients (including 12 whose preoccupation was of probable delusional intensity) were assessed with a semistructured interview and the Structural Clinical Interview for DSM-III-R, and their family histories were obtained.
The 17 men and 13 women reported a lifetime average of four bodily preoccupations, most commonly "defects" of the hair, nose, and skin. The average age at onset of body dysmorphic disorder was 15 years, and the average duration was 18 years. Seventy-three percent of the patients reported associated ideas or delusions of reference; 73%, excessive mirror checking; and 63%, attempts to camouflage their "deformities." As a result of their symptoms, 97% avoided usual social and occupational activities, 30% had been housebound, and 17% had made suicide attempts. Ninety-three percent of the patients had an associated lifetime diagnosis of a major mood disorder; 33%, a psychotic disorder; and 73%, an anxiety disorder. The patients generally responded poorly to surgical, dermatologic, and dental treatments and to adequate trials of most psychotropic medications, with the exception of fluoxetine and clomipramine (to which more than half had a complete or partial response).
This often secret, chronic disorder can cause considerable distress and impairment, may be related to obsessive-compulsive disorder or mood disorder, and may respond to serotonin reuptake-blocking antidepressants.
A cognitive behavioural model of body image is presented with specific reference to body dysmorphic disorder (BDD). We make specific hypotheses from the model for testing BDD patients in comparison with: (i) patients with "real" disfigurements who seek cosmetic surgery; (ii) subjects with "real" disfigurements who are emotionally well adjusted; and (iii) healthy controls without any defect. There have been no randomised controlled trials of treatment for BDD and therefore the model has clear implications for the development of cognitive behavioural therapy. This was evaluated in a pilot controlled trial. Nineteen patients were randomly allocated to either cognitive behaviour therapy or a waiting list control group over 12 weeks. There were no significant pre-post differences on any of the measures in the waiting list group. There were significant changes in the treated group on specific measures of BDD and depressed mood. Cognitive behaviour therapy should be further evaluated in a larger controlled trial in comparison with another psychological treatment such as interpersonal therapy and pharmacotherapy.
The authors developed the Yale Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), a 12-item semistructured clinician-rated instrument designed to rate severity of body dysmorphic disorder (BDD). The scale was administered to 125 subjects with BDD, and interviews with 15 subjects were rated by 3 other raters. Test-retest reliability was assessed in 30 subjects. Other scales were administered to assess convergent and discriminant validity, and sensitivity to change was evaluated in a study of fluvoxamine. Each item was frequently endorsed across a range of severity. Good interrater reliability, test-retest reliability, and internal consistency were obtained. BDD-YBOCS scores correlated with global severity scores but not with a measure of general psychopathology; they were modestly positively correlated with depression severity scores. Three factors accounted for 59.6 percent of the variance. The scale was sensitive to change in BDD severity. The BDD-YBOCS appears to be a reliable and valid measure of BDD severity and is a suitable outcome measure in treatment studies of BDD.
Body Dysmorphic Disorder (BDD), which consists of pathological preoccupations with defects in different body parts, has been systematically studied only in the last decade. We hypothesized that gender would differentially influence the localization of the preoccupations as well as the extent and type of comorbidity with other psychiatric disorders. With the use of a specially constructed semistructured interview, we evaluated 58 consecutive outpatients with DSM-III-R BDD (women = 41.4%, men = 58.6%). Women had significantly more preoccupations with breast and legs, checking in the mirror and camouflaging, as well as lifetime comorbidity with panic, generalized anxiety, and bulimia. Men had significantly higher preoccupations with genitals, height, excessive body hair, as well as higher lifetime comorbidity with bipolar disorder. Although BDD is almost never found without comorbidity, it does appear to be an autonomous syndrome, and gender tends to influence the nature and extent of this comorbidity.
Gender differences in body dysmorphic disorder (BDD) have received little investigation. This study assessed gender differences in 188 subjects with BDD who were evaluated with instruments to assess demographic characteristics, clinical features of BDD, treatment history, and comorbid Axis I disorders. Ninety-three (49%) subjects were women, and 95 (51%) were men. Men and women did not significantly differ in terms of most variables examined, including rates of major depression, although women were more likely to be preoccupied with their hips and their weight, pick their skin and camouflage with makeup, and have comorbid bulimia nervosa. Men were more likely to be preoccupied with body build, genitals, and hair thinning, use a hat for camouflage, be unmarried, and have alcohol abuse or dependence. Although men were as likely as women to seek nonpsychiatric medical and surgical treatment, women were more likely to receive such care. Men, however, were as likely as women to have cosmetic surgery. Although the clinical features of BDD appear remarkably similar in women and men, there are some differences, some of which reflect those found in the general population, suggesting that cultural norms and values may influence the content of BDD symptoms.
Dermatologic surgeons frequently see patients with body dysmorphic disorder, a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Recognition of this disorder is essential to avoid unnecessary and generally unsatisfying surgical outcomes, but no screening tools are available for use in a dermatology setting.
To develop and validate a brief self-report questionnaire to screen for body dysmorphic disorder in dermatology settings.
A questionnaire was developed and its sensitivity and specificity determined in 46 subjects, using a reliable clinician-administered diagnostic interview for body dysmorphic disorder. The interrater reliability of a defect severity scale was also determined (n = 50).
The self-report questionnaire had a sensitivity of 100% and a specificity of 93%. The interrater reliability (ICC) of the defect rating scale was.88.
This brief questionnaire was a highly effective screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Use of this questionnaire may help identify patients with this syndrome.
The rate of body dysmorphic disorder (BDD) in inpatient psychiatric settings and the nature of the presenting complaints are unknown. Because of the shame and humiliation that BDD patients suffer, we hypothesized that, unless specifically screened for at the time of admission, BDD would be underdiagnosed in psychiatric inpatients.
101 consecutive adult patients and 21 consecutive adolescent patients presenting for psychiatric inpatient admission to a university teaching hospital participated in the study. Subjects completed the Body Dysmorphic Disorder Questionnaire, a brief self-report measure that screens for BDD, and a follow-up interview was conducted using a reliable clinician-administered semistructured diagnostic instrument for DSM-IV BDD. Data concerning current diagnoses, number of hospitalizations, number of suicide attempts, and current level of functioning were also obtained.
Sixteen (13.1%) of the 122 subjects were diagnosed with BDD. None of the subjects with BDD had been diagnosed with BDD by their treating physician during hospitalization. All 16 subjects reported that they would not raise the issue with their physician unless specifically asked due to feelings of shame.
These preliminary results suggest that BDD, an underrecognized and often severe psychiatric disorder, may be relatively common in the psychiatric inpatient setting. It is important that clinicians specifically inquire about BDD because patients will not voluntarily raise these concerns. The comorbidity of this disorder with other psychiatric illnesses may have treatment implications.
One expression of the core psychopathology of eating disorders is the repeated checking and avoidance of shape or weight. Two studies are reported. The primary purpose of the first was to describe the phenomenology of such body checking and avoidance. The aim of the second was to compare body checking and avoidance in women with and without a clinical eating disorder.
In Study 1, 64 female patients with clinical eating disorders participated in a semistructured interview assessing the features of body checking and avoidance. In the second study, a self-report questionnaire was used to compare body checking and avoidance in women with and without a clinical eating disorder (n = 110).
The majority (92%) of the patients in Study 1 checked their bodies to assess their shape or weight and this was associated significantly with eating disorder symptoms. In Study 2, the clinical group had significantly more body checking and avoidance than the comparison group, and there was a strong association between eating disorder psychopathology and body checking and avoidance.
These findings support the view that body checking and avoidance are direct expressions of the overevaluation of shape and weight. Further work is needed to determine whether these expressions contribute to the maintenance of eating disorders.