A study on Body

dysmorphic disorder

Presentation

by E. Kent

Rogers

WHAT IS BODY DYSMORPHIC DISORDER?

• Dysmorphic is a term used to describe a feature of anatomy

that is atypical or deformed.

Specifically, BDD is diagnosed by the presence of the following

criteria (a short list compared to other dx’s)

A. Preoccupation with an imagined defect in appearance. If a

slight physical anomaly is present, the person's concern is

markedly excessive.

B. The preoccupation causes clinically significant distress or

impairment in social, occupational, or other important areas of

functioning.

C. The preoccupation is not better accounted for by another

mental disorder (e.g., dissatisfaction with body shape and size in

Anorexia Nervosa).

WHAT IS IT? CONTINUED

• First documented in 1891 by Enrique Morsell

• Originally classified in the DSM as a Somatoform Disorder.

• Somatoform Disorders are psychological disorders that manifest as

physical problems when there is no medical or physiological cause

(including drugs/substances) and no other psychological/psychiatric

cause.

• For example, catatonia a lack of movement occurs in schizophrenia and so

would not be a somatoform disorder. However, paralysis can be a symptom of

Conversion Disorder which is a somatoform disorder.

• However, in the most recent version DSM 5, it is now classified

within the newly created Obsessive Compulsive Spectrum

Disorders. OCD spectrum disorders are characterized by

obsessions--invasive, repetitive and distressing thoughts which

lead to an extreme sense of need to perform certain actions. A

classic example of OCD is constantly feeling contaminated

resulting in compulsive hand washing. Many such sufferers rub

their hands raw.

• Which do you think is a better classification for BDD? Why?

In BDD, the mind itself does

something similar to what this

funhouse mirror is doing.

Except it is anything but fun.

It always shows a disfigured

image that strikes horror in

the sufferer to the point that

the individual may never leave

their home or room. Many

cloak their image if they do go

out.

• It occurs in about 1% of the population but in the

US, a recent study indicates a prevalence rate of

almost two and a half times that: 2.4% (2.5% for

women, 2.2% for men

• What does the variance in prevalence according to

region/nation suggest to you?

• It has high comorbidity (occurs at the same time as)

depression and anxiety.

• There is an elevated rate of suicide in sufferers over the general

population

• It often goes untreated because many sufferers are reclusive

and isolate themselves

• They are ashamed of how they look

• They are ashamed of their mirror-gazing behaviors and so avoid

treatment.

They likely feel something like this:

OR THIS…

ON TO THE STUDY…

Context and Background

• After a patient reported having looked into a mirror for six hours

Veale and Riley decided some further investigation was

appropriate.

• There were few or no studies on the role of mirror gazing in

BDD.

CONTEXT AND BACKGROUND

• There were a few studies on how healthy samples use mirrors

• It was found that more attractive individuals used mirrors more often, glancing

as they pass by mirrors etc.

• Another study found that when healthy individuals gazed into mirrors

in a dimly lit room, their self-appraisal of attractiveness decreased

with time.

CONTEXT AND BACKGROUND

• Many psychologists believe that all behavior serves some purpose or

function.

So what purpose does mirror-gazing server?

• Is mirror-gazing in BDD similar to OCD compulsions which

reduce the anxiety produced by unpleasant obsessive thoughts

such as, “I forgot to lock the door”?

• Is it similar to addiction behaviors which serve to temporarily

lesson chemical withdrawal induced craving—agitation, loss of

pleasure and joy, tremors, seizures etc.?

• In some addiction recovery programs, they say “self-pity is

arrogance in reverse.” Could mirror-gazing serve as an

unconscious means for the sufferer to focus on him or herself

within the context of a negative self-image paradigm?

Purpose?...

BUT WHAT DOES MIRROR-GAZING ACTUALLY DO?

ACCORDING THE COGNITIVE BEHAVIORAL APPROACH it is very

damaging…

• “Mirror gazing is a crucial factor in maintaining the preoccupation

with one’ s appearance…

• “It increases self-consciousness and

• “selective attention,

• “and may magnify the patient’s perception of their perceived defects.

• “It therefore distorts their aesthetics judgment.”

METHODS

• A PILOT STUDY

• Investigated BDD mirror-gazing behavior and among other things,

found that sufferers had two distinct types of mirror use, i.e. long

and short session

• Veale and Riley used the pilot study to develop a meaningful

questionnaire.

THE QUESTIONNAIRE INVESTIGATED

1. Time spent mirror gazing

2. Frequency & duration of long and short sessions

3. Activities while gazing

4. Feelings before and after gazing

5. Distress level when resisting gazing

6. Internal or external focus while gazing

7. Focus on whole image or feature

8. Type of light used

9. Type of reflective surface

10. Mirror avoiding

11. Gazing motivations

SAMPLE1. Experimental Group:

a) 52 mirror-gazing BDD patients

b) About 40% male

c) Average age about 30

d) “Recruited” (probably from UK therapists with BDD patients)

WHAT KIND OF SAMPLE COLLECTION METHOD IS

THIS?

2. Control Group:

a) 55 healthy individuals

b) 48% male

c) Average age about 34

d) Obtained from personal contacts

WHAT KIND OF SAMPLE COLLECTION METHOD IS

THIS?

In both the experimental and the

control groups, the sampling was

convenience or opportunity

sampling.

DATA COLLECTION

• Self-Report via questionnaire…

• The one (with some minor alterations) you filled out over

the weekend!

What are a few problems with self-report

data collection?

MORE ON METHODS

•IV: presence of BDD

•DV: Answers given on the survey which

represent behaviors, attitudes and

thoughts caused by BDD

TYPE OF STUDY

•Based on the IV mentioned above, what

kind of study is this?

Quantitative Data

DATA TYPE

• Quantitative.

• The questionnaire mostly asked qualitative questions

but answers required numerical answers

• Some involved forced-choice Likert scales

• Some involved length of time data

• Some involved “visual analogue scale” (-4, +4) This is very

similar to a gradient magnitude scale.

• Some involved % answers.

0

1

2

3

4

5

6

Quantitative Data

DATA TYPE• Qualitative: The behaviors section of the questionnaire offered blanks

to list behaviors not listed as options in the questionnaire. These

qualitative answers consisted of:

• “washing rituals”

• “combing my eyebrows”

• “studying my eyes, hair and skin to observe the effect of stress on

the ageing process”

• “pulling my features or squashing my nose to see how I’d look if I

had plastic surgery”;

• “pull ugly faces to prove how disgusting I am” or

• “I try to permanently fix my image mentally”

DATA TYPE

• Why do you think Veale and Riley predominantly opted for

quantitative data?

• What would have been advantageous about more qualitative

data?

RESULTS

1. More BDD’s had daily long sessions (84.6% vs 29.6%)

2. BDD’s had longer long sessions (avg. 72.5 vs 21.3 min.)

3. BDD’s more daily short sessions (avg. 14.6 vs. 3.9)

4. BDD’s had SHORTER short sessions (avg. 4.8 vs. 5.5

min)

RESULTS

1. BDD’s had a stronger tendency towards internal focus

during long sessions (-.49 vs -2.2 on the -4 through +4

visual analogue)

2. BDD’s focused more on specific features and control

focused more on whole image during long sessions

3. Controls mostly looked in mirror to “look presentable”

whereas BDD’s scored higher than controls on all

other (less than healthy!) motives (see questionnaire)

RESULTS

• For long sessions, BDD’s and Controls had similar PROPORTIONS

regarding activities in front of mirror EXCEPT

• Controls spent a higher % of time shaving/hair removal and

• BDD’s spent more time comparing real image to mental “ideal” image

• For short sessions, BDD’s more likely to:

• Check makeup

• Practicing facial expressions for public

• Compare external to internal images

RESULTS

BDD’s also reported:

• Washing rituals

• Combing eye-brows

• Studying eyes, hair, skin to see aging

• Manipulating face to see what plastic surgery would look like

• Making ugly faces to prove how disgusting image is

• To permanently fix image in mind

RESULTS

• BDD’s more distressed than controls

before mirror-gazing

• BDD’s distress amplified by 18.5% mirror-gazing

• Resisting mirror-gazing produced a slight but not significant

amplification of distress for BDD’s though they believed stress

would be greatly increased by avoidance of mirror

• No difference between BDD’s and controls for light preference.

RESULTS

• BDD’s used more likely to use

series of mirrors with different

profiles

• BDD’s used all manner of

reflective surfaces—CD’s, cutlery,

TV screens, table tops, taps

• Both BDD’s and Controls used

shop windows

RESULTS• 67% BDD’s avoided specific mirrors (versus 14% of controls)

• Some BBD’s avoided “bad” mirrors--those in which a particularly stressful

“session” occurred.

• Some BDD’s used only mirrors in which the BDD could avoid seeing his/her

perceived deformity. For example, one man used a hand held mirror to comb

hair because he could avoid seeing his nose.

• Some BDD’s used mirrors only at home and avoided mirrors in public places.

• Some BDD’s only used obscured, tarnished, cracked etc. mirrors.

• Some BDD’s used only mirrors that were in the right light or could be tilted.

The word “Trusted” is used.

CONCLUSIONS

• Before going into the conclusions discussed in the study

itself…

What thoughts arise in light of the fact that BDD’s use words

such as “bad,” “trusted,” “good,” and “unsafe” when describing

mirrors?

IMPORTANT CONCLUSIONS

• Unlike other forms of OCD in which the compulsive behavior serves

the function of reducing the anxiety associated with the obsession,

mirror-gazing DOES NOT reduce the stress caused by the obsession

with the imagined or exaggerated defect. In fact it amplifies the

stress and unhappiness.

IMPORTANT CONCLUSIONS

• BDD’s constantly hope that they will look better than they

had thought. Sometimes, a good session will enforce this

hope.

• It has been proven that intermittent reinforcement causes more

persistent, almost addiction-like behavior that is resistant to

extinction even after the reinforcement is removed. This helps

explain why mirror gazing persists and amplifies even when good

sessions occur less and less often or fail to occur altogether.

IMPORTANT CONCLUSIONS

• BDD’s have an obsession with knowing exactly how they

appear.

• Looking in the mirror may initially satiate that obsession, but as

soon as they are away from the mirror, doubts set in.

• However, many BDD’s reported seeing different images in the

mirror at different times which amplified the stress related to the

obsession of needing to know exactly how they look.

IMPORTANT CONCLUSIONS

• BDD’s excessively groom, apply make-up or otherwise

camouflage themselves as a way of making themselves feel

better, i.e. reducing the anxiety of the obsession.

• They also did this by imagining cosmetic surgery.

APPLICATIONS…

• What applications can you think of?

APPLICATION

• Basis for further studies:

• “in vivo” study on emotions, mood, attitudes, beliefs, attention and behaviors before

and after mirror-gazing

• Refined therapeutic strategies:

• It is difficult for BDD’s to follow the advice: “Don’t look in the mirror,” or “Don’t look

as long/as often etc.” Therefore, an alternative is to say, “Spend less time

grooming/makeup/imagining plastic surgery.” If they limit the time of activities in

front of the mirror, the time spent in front of the mirror will decrease.

• Rather than avoiding mirrors altogether as some therapists have encouraged, help

patients to use mirrors in a healthy way.

APPLICATIONS CONTINUED

• Therapy strategies continued. Encourage BDD’s adopt the following goals.

1. To deliberately focus attention on actual, external image (Why?)

2. To disassociate from judgments on appearances and automatic thoughts about

appearance.

3. To do something else when the urge to use a mirror occurs and wait until the

urge has diminished. (Which specific result explains the value of this?)

4. Don’t use warped or flawed reflective surfaces

(CD’s, cutlery, damaged mirrors). (Why)

1. Do not use magnifying mirrors. (Why?)

APPLICATIONS

6. Use large mirrors at a distance so whole image can be seen. (Why do

you think this is valuable?)

7. Use mirrors only for set purposes such as shaving (Why?)

8. Use a variety of mirrors rather than a “good” or “trusted” mirror.

(Why?)

9. Focus on whole face/body. (Why?)

EVALUATIONS…

• What evaluations can you come up with?

EVALUATIONS: CONS• Forced choice questionnaire means that BDD’s may have other attitudes, feelings and

activities that were not obtained from the study. May weaken…

VALIDITY

• The study was self-report and participants may have given…

• Inaccurate answers due to faulty perceptions (sense of time etc.)

• Falsified answers due to shame

• Responded to demand characteristics

THESE FACTORS JEOPARDIZE…

VALIDITY

EVALUATIONS: CONS

• Sample: Since BDD does seem to be influenced by culture, the all British sample

may not be:

GENERALIZABLE to BDD in other cultures.

• The study did not investigate a range of important factors such as personal and

family history; onset of disorder, duration of the disorder. So the questionnaire may

have lacked…

CONTENT VALIDITY AND CONSTRUCT VALIDITY

• Construct Validity refers to the ability of a measurement tool (e.g., a

survey, test, etc) to actually measure the psychological concept being

studied. In other words, does it properly measure what it's supposed

to measure?

• In psychometrics, content validity (also known as logical validity)

refers to the extent to which a measure represents all facets of a given

social construct.

EVALUATIONS: CONS

• Because the questionnaire was administered only once we do not

know if it is…

RELIABLE

• Because there was no observations or data collection conducted in vivo

during actual mirror-gazing, we may question that…

ECOLOGICAL VALIDITY

EVALUATIONS: PRO• Pilot study helped establish a foundation for the questionnaire’s content validity and

construct validity.

• Forced choice, percentage and scale questions etc. allowed for quantitative data. This is

easier to analyze and is able to be presented in succinct graphics.

• Control and experimental group were well matched improving validity.

• Study did not violate any ethical issues.

• Study had concrete and important therapeutic applications

• Study was groundbreaking investigation into BDD’s and set a foundation for further

research.

• Questionnaire can be repeatedly given to establish reliability.

• Sample size was adequate if not large which improves generalizability and validity.

TERMINOLOGY • Visual Analogue Scale: A gradient scale used on questionnaires to

discern the magnitude of attitudes, feelings and other qualities

that are not directly, physically measurable such as happiness. An

example might be: use the following scale to express how much

you agree with the following statement: Life is inherently good.

(draw a scale on the board).

• Body Dysmorphic Disorder: A mental disorder in which the

sufferer has excessive concern about and preoccupation with a

perceived defect of their physical appearance.

• In vivo: describes a study or therapy that is conducted in real life

situations

TERMINOLOGY CONTINUED

• Obsession: an excessive mental preoccupation with some topic, often

manifesting as repetitive, intrusive thoughts.

• Compulsion: a behavior that arises from an obsession. Sometimes defined

as the mental force that causes the behavior. An obsessive thought about

having left the door unlocked or being contaminated may lead to the

compulsion of checking the door ten times before leaving for work, or

washing one’s hands until they bleed.

• CBT or Cognitive-behavioral therapy: A form of psychotherapy in which

the goal is to have the patient alter thoughts and behaviors to be relieved

of negative emotions and stress. It is very successful in treating BDD.

• http://www.overcomingbdd.com/grief-and-fear-the-backbone-of-bdd-change-and-the-

malleable-brain/http://www.overcomingbdd.com/grief-and-fear-the-backbone-of-bdd-

change-and-the-malleable-brain/