Behaviour Research and Therapy 39 (2001) 1381–1393 www.elsevier.com/locate/brat Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder David Veale a,*, Susan Riley b a Department of Psychiatry and Behavioural Sciences, Royal Free Campus, Royal Free and University College School of Medicine, University College, University of London, London, UK b The Priory Hospital North London, Grovelands House, The Bourne, Southgate, London N14 6RA, UK Accepted 12 October 2000 Abstract 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. 2001 Elsevier Science Ltd. All rights reserved. Keywords: Body image; Body Dysmorphic Disorder; Psychopathology; Mirror gazing * Corresponding author. The Priory Hospital North London, Grovelands House, The Bourne, Southgate, London N14 6RA, UK. Tel.: +44-20-8882-8191; fax: +44-20-8447-8138. E-mail address: [email protected] (D. Veale). 0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved. PII: S0005-7967(00)00102-9 1382 D. Veale, S. Riley / Behaviour Research and Therapy 39 (2001) 1381–1393 1. Background This study was prompted by a patient with Body Dysmorphic Disorder (BDD) who reported to one of the authors that he had just spent 6 hours staring at himself in front of a series of mirrors. The obvious questions were what exactly did the behaviour consist of, what was the function of the behaviour and what maintained his behaviour especially when he reported feeling worse after gazing in the mirror? Mirror gazing occurs in about 80% of patients with BDD while the remainder tend to avoid mirrors sometimes by covering them or removing them to avoid the distress of seeing their own image and the time wasted mirror gazing (Veale, Boocock, Gournay, Dryden, Shah, Willson et al., 1996; Phillips, McElroy, Keck, Pope & Hudson, 1993; Neziroglu & Yaryura-Tobias, 1993). BDD is a hidden disorder, as many patients do not tend to seek help from mental health pro- fessionals. When BDD patients do seek help, they may present with symptoms of depression or social phobia and not reveal their main problem unless they are specifically questioned (Veale et al., 1996). Patients are secretive about mirror gazing probably because they think they will be viewed as vain or narcissistic. Patients report however shame about their behaviour and disgust about their appearance. This may account for why mirror gazing is not described in standard textbooks of psychopathology or psychiatry since Morselli first described the condition of “dys- morphophobia” (Jerome, 2001, personal communication). There is some literature on the effects of mirror confrontation in normal controls and psychiatric patients. For example Schwarz & Fjeld (1968) found that subjects who were asked to focus on mirror images for a period of time in a darkened room often experienced gross distortions in their apparent appearance or unusual somatic sensations. Fisher (1970) and Duval & Wicklund (1972) have found that increased self-awareness by the presence of a mirror led healthy individuals to become more self-critical by highlighting their own defects and deviations from the ideal. Lipson & Przybyla (1983) observed students as they walked past a long mirror. For both male and female students, time spent mirror gazing was positively correlated with physical attractiveness. Mirror gazing is sometimes seen in schizo- phrenia, especially when a patient makes drastic changes in their appearance (for example shaving off one’s hair or the use of striking make-up) (Campo, Frederikx, Nijman & Merckelbach, 1998). Such dramatic changes in appearance are usually part of a command hallucination or a paranoid delusion and may involve significant periods of mirror gazing. Mirror gazing in BDD has been compared to the compulsive checking of Obsessive Compulsive Disorder (OCD) and BDD has been conceptualised as on the spectrum of obsessive–compulsive disorders (Phillips, McElroy, Hudson & Pope, 1995; Hollander, 1993; Yaryura-Tobias & Neziro- glu, 1997). Early experimental analysis on compulsions such as washing and checking found that they were maintained because they “work” by reducing anxiety in the short-term (Hodgson & Rachman, 1972; Roper, Rachman & Hodgson, 1973; Roper & Rachman, 1976). But does mirror gazing in BDD follow the same model as compulsions in OCD? In the authors’ opinion, mirror gazing appears to be much harder for patients to resist than the checking compulsions of OCD. More recent analyses of compulsions reveal a more complex picture of safety or neutralising behaviours, which are distinct from compulsions (Rachman, 1998) and the recognition that com- pulsions do not always “work” or reduce anxiety. OCD patients also typically use problematic criteria for terminating a compulsion, namely feeling “comfortable” or “absolutely sure” (Richards & Salkovskis, 1995) or the “right feeling” (Yaryura-Tobias & Neziroglu, 1997). It is D. Veale, S. Riley / Behaviour Research and Therapy 39 (2001) 1381–1393 1383 not known whether BDD patients use similar criteria. BDD patients might attempt to use such criteria (similar to patients with obsessional slowness) but rarely achieve it and only terminate mirror gazing because they become too frustrated or angry or they have to finish because of an appointment. Mirror gazing might also occur in obsessional slowness, in which patients perform complex rituals and safety behaviours such as grooming or bathing in a specific order and meticulously. However in such patients, it usually fails to achieve any reduction in anxiety (Rachman, 1974; Veale, 1993). Some patients with obsessional slowness associated with meticulous grooming and shaving described in earlier reports may in retrospect have fitted an additional diagnosis of BDD and have spent some of the time mirror gazing. In a cognitive behavioural model of BDD, mirror gazing is a crucial factor in maintaining the preoccupation with one’s appearance (Veale, Gournay, Dryden, Boocock, Shah, Willson et al., 1996). It increases self-consciousness and selective attention, and may magnify the patient’s per- ception of their perceived defects. It therefore distorts their aesthetic judgement. It is of course vital that patients resist the urge to use mirrors (“response prevention”) but it is very difficult for patients to follow such instructions. We need a better understanding of the psychopathology of mirror gazing that we can use in our formulations with patients and new strategies for therapy. These were the aims of this pilot study as well as generating hypotheses for future experimental studies in order to develop a cognitive behavioural model of BDD. 2. Method 52 patients with BDD who reported mirror gazing to be a feature of their problem were recruited to complete a “Mirror gazing questionnaire” described below. All patients fulfilled DSMIV diag- nostic criteria for BDD (American Psychiatric Association, 1994). A group of 55 controls were recruited from personal contacts to provide a comparison. The groups were age and sex matched (Table 1). A pilot study revealed that there were two types of mirror gazing — many patients and controls tended to have one session a day which tended to be longer (for example putting on make up or shaving at the beginning of the day). The remainder of the mirror sessions consisted of shorter sessions during the day. Controls were however less likely to report a long session. 2.1. Procedure Subjects were given a self-report mirror gazing questionnaire. The instructions informed them that we were interested in the feelings that they had in front of a mirror during the past month. The subject was first asked if he or she had a long session in front of a mirror on most days of the past month. A long session was defined as the longest time during the day that the person spends in front of a mirror. An example was given of getting ready for the day. If the respondent said they had at least one long session in front of a mirror, then they were asked a series of questions about a typical long session in front of a mirror. We then repeated the same questions for a typical short session in front of a mirror and gave an example of checking their appearance. 1384 D. Veale, S. Riley / Behaviour Research and