PATIENTS WITH BODY DYSMORPHIC DISORDER (BDD)MAY SPEND MANY HOURS IN FRONT OF A MIRROR BUTLITTLE IS KNOWN ABOUT THE PSYCHOPATHOLOGY OR THEFACTORS THAT MAINTAIN THE BEHAVIOURDavid Veale & Susan Riley, 2001
BACK GROUND AND CONTEXT Patients with Body Dysmorphic Disorder (BDD) may spend many hours in frontof a mirror but little is known about the psychopathology or the factors thatmaintain the behaviour This study was prompted by a patient with Body Dysmorphic Disorder (BDD)who reported to one of the authors that he had just spent 6 hours staring athimself in front of a series of mirrors. Mirror gazing occurs in about 80% of patients with BDD while the remaindertend to avoid mirrors sometimes by covering them or removing them to avoidthe distress of seeing their own image and the time wasted mirror gazing BDD is a hidden disorder, as many patients do not tend to seek help frommental health professionals. When BDD patients do seek help, they maypresent with symptoms of depression or social phobia and not reveal theirmain problem unless they are specifically questioned. Patients are secretiveabout mirror gazing probably because they think they will be viewed as vain ornarcissistic. We need a better understanding of the psychopathology of mirror gazing thatwe can use in our formulations with patients and new strategies for therapy.
KEY CONCEPTS Mirror Gazing – Practice of looking into the mirror and appraise self Psychopathology-The scientific study of mental disorders Body Dysmorphic Disorder - Body dysmorphic disorder (BDD, also bodydysmorphia, dysmorphic syndrome; originally dysmorphophobia) is a type of mentalillness, a somatoform disorder, wherein the affected person is concerned with bodyimage, manifested as excessive concern about and preoccupation with a perceiveddefect of their physical features Body Image- Body image is a term which may refer to a persons perception of hisor her own physical appearance for aesthetics or sexual attractiveness Narcissism -Excessive or erotic interest in oneself and ones physical appearance. Obsessive Compulsive Disorder -Obsessive–compulsive disorder (OCD) is ananxiety disorder characterized by intrusive thoughts that produce uneasiness,apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associatedanxiety Visual Analogue scale- is a psychometric response scale wherein respondentsspecify their level of agreement to a statement by indicating a position along acontinuous line between two end-point Mental Cosmetic Surgery- Some patients try to change their internal body image tosee something different of their appearance in the mirror, which is regarded asmental cosmetic surgery
AIM To have a better understanding of thepsychopathology of mirror gazing that can beused in formulations with patients and developnew strategies for therapy. To generate hypotheses for future experimentalstudies in order to develop a cognitivebehavioural model of BDD.
METHODS- DESIGN Sample-52 patients with BDD who reported mirror gazing tobe a feature of their problem were recruited. (Age-30, Sex-40% males); A group of 55 controls were recruited frompersonal contacts to provide a comparison. (Age-33, Sex-48%); Technique-Opportunity sampling. Design- Quasi Experimental Design Independent Variable-BDD or not; Dependent Variable-Length of time mirror gazing, Motivation before looking in amirror , Focus of attention , Distress before and after lookingin front of mirror , Behaviour in front of a mirror , Type of lightpreferred , Types of reflective surfaces , Mirror avoidance Data: Quantitative –rating scales, frequency, percentage,visual analogue; Qualitative-Open ended; Data collectiontechnique-Self report questionnaire
PROCEDURES 52 patients with BDD who reported mirror gazing to be a feature of theirproblem were recruited to complete a “Mirror gazing questionnaire”described below. All patients fulfilled DSMIV diagnostic criteria for BDD(American Psychiatric Association, 1994). A group of 55 controls wererecruited from personal contacts to provide a comparison. The groupswere age and sex matched. Subjects were given a self-report mirror gazing questionnaire. Theinstructions informed them that we were interested in the feelings thatthey had in front of a mirror during the past month. The subject was firstasked if he or she had a long session in front of a mirror on most days ofthe past month. A long session was defined as the longest time duringthe day that the person spends in front of a mirror. An example was givenof getting ready for the day. If the respondent said they had at least onelong session in front of a mirror, then they were asked a series ofquestions about a typical long session in front of a mirror. We thenrepeated the same questions for a typical short session in front of amirror and gave an example of checking their appearance
FINDINGS No significant differences were found in age and sex between BDD patients andcontrols. 44 out of the 52 (84.6%) BDD patients and 16 out 54 (29.6%) control subjectsreported that they had a “long session” in front of the mirror each day. Of those subjects that reported using a mirror for a long session, BDD patientsused a mirror for far longer than controls 45 BDD patients (86.5%) and 43 controls (79.6%) reported that they had one ormore “short sessions” in front of a mirror. BDD patients checked mirrors morefrequently than controls for the short sessions. However there was no differencebetween BDD patients and controls for the average duration of each short session BDD patients were more likely to endorse all the beliefs except that the controlswere more interested in making themselves look presentable. In short sessions, BDDpatients also spontaneously reported that they were more likely to use the mirror ifthey were feeling depressed. For long mirror checking sessions, BDD patients did the same proportion ofactivities (in percentage terms) as controls in front of mirrors for: (a) using make up,(b) combing or styling their hair (c) picking their spots and (d) feeling their skin withtheir fingers. The controls were more likely to use a mirror for removing hairs orshaving. BDD patients were more likely: (a) to compare what they see in front of amirror with an image in their mind of how they think they should ideally look or (b) tryto see something different in the mirror.
FINDINGS For short checks BDD patients were more likely than controls to use the mirror: (a)for checking their make-up (b) practising the best position or face to pull or show inpublic and (c) compare what they see in front of a mirror with an image in their mindof how they think they would ideally look. Controls were more likely to use a mirror in ashort session for shaving. BDD patients listed a range of other behaviours that they engaged in whilst in frontof the mirror. These included “washing rituals”; “combing my eyebrows”; “studying myeyes, hair and skin to observe the effect of stress on the ageing process”; “pulling myfeatures or squashing my nose to see how I‟d look if I had plastic surgery”; “pull uglyfaces to prove how disgusting I am” or “I try to permanently fix my image mentally” For both short and long mirror sessions, BDD patients rated themselvesretrospectively as significantly more distressed than controls before any gazing. Forlong mirror sessions, the BDD patients continued to be more distressed thancontrols after mirror gazing. Lastly they experienced a greater degree of distress ifthey resisted gazing in the mirror compared to controls. After a long session in frontof the mirror, BDD subjects overall experienced a significant increase in distress of1.19 (18.5% increase). The overall difference in distress before and after resistingan urge to gaze for a long session was also calculated from the visual analoguescales of the BDD patients. After resisting an urge to gaze, patients reported only aslight but non-significant increase in distress of 0.38 (5.9%).
FINDINGS No significant difference was found between the BDD patients and controlsin their slight preference for natural day-light compared to artificial light on avisual analogue scale. For a long session, BDD patients were more likely to use a series of mirrorswith different profiles (22/42, 52.4%) compared to controls (1/15, 6.7%). Forshort checks, both BDD patients and controls admitted to using shop windows.However, BDD patients spontaneously reported using a wide variety of reflectivesurfaces including car mirrors, windows or bumpers on vehicles, cutlery, fishknifes, TV screens, reflective table tops, glass watch faces, washroom taps orthe back of CDs. 67% of our BDD patients reported that they selectively avoided only certainmirrors compared to 14% of controls
CONCLUSION Mirror gazing in BDD consists of a series ofcomplex safety behaviours. It does not follow asimple model of anxiety reduction that occurs inthe compulsive checking of obsessive–compulsivedisorder.
EVALUATION Usefulness – Mirror gazing in BDD was thought to be compulsivechecking of OCD, and therefore BDD was conceptualized on thespectrum of OCD. The study has brought focus to mirror gazing inBDD as a more complex picture of safety and neutralizing behaviours.It has brought out to attention that BDD patients has mirror gazingsymptom and is distressing than the compulsive checking as in OCD(+) Experimental validity - Use of controls and matching the age and sex,increases the internal validity of the study. This is the firstexperimental study on the psychopathology of mirror gazing in BDD(+). Although BDD has been discussed in the light of mirror gazing asa symptom but the DSM or ICD has not specifically mentioned aboutthis. (-) Since this study is conducted in a lab setting, it may be arguedthat ecological validity is low. (-) Response bias – The BDD patients are secretive about mirror gazingfor the fear of being viewed as vain or narcissistic. The study used selfreport method, one may speculate if there was any under reporting orbias.(-)
EVALUATION Ethnocentrism – There is a fallacy that scrying (looking in the mirror tohave a vision) is prevalent in certain cultures. Mirror gazing may not beseen as psychopathology in these cults.(-) Nomothetic Vs Idiographic – Psychopathology, usually interventionfocused are usually case studies. This study has used nometheticapproach to study a group of BDD patients and normal controls. Ethics- The instructions informed them that we were interested in thefeelings that they had in front of a mirror during the past month(Deception?). (-). The study does not mention about debriefing (-) thecontrol group (-) and one may also fear that normal people may developproblem identification just because they went through this intensivereflection of their thoughts & feelings over their mirror gazing behaviour(harm?) (-). Application – The study has recommended useful strategies todecrease mirror gazing behaviour (response prevention, cost benefitanalysis, response cost). Patients (whether they are gazing or avoiding)has been encouraged to use mirrors in effective ways. The study has alsobeen helpful to engage the BDD patients in a model of “What You See Is