“Mirror, Mirror on the Wall…Who is the Ugliest of Them All?” Unit 12 – Psychological Disorders and Case Studies (Individual Differences)

Introductory Videos  Before we begin our discussions and case study on body dysmorphic disorder, view the following crash course video.  As you watch, be sensitive to those around you.  Become the psychologist and attempt to understand a difficult disorder that, although may be not a big deal to you, can be a world of difficulty to another.  BDD – Crash Course  0 – 45s.  5:35 - 9:00   Dr. Phil!!   Mirror, Mirror: Body Dysmorphic Disorder  

Introduction – BDD  Body dysmorphic disorder – a somatoform disorder in which a person becomes so preoccupied with his or her imagined ugliness that normal life is impossible.  Minor or imagined  Somatoform disorder – disorders in which there is an apparent physical illness for which there is no organic basis.  DSM does not categorize this as an eating disorder  Shares some traits with OCD  Unwanted repetitive thoughts, which become obsessions.  Check yourself over and over again for flaws.  Associated with depression  Constant fixation on a certain body part  Constantly asking for reassurance that the defect is not visible or too obvious

Background: BDD Symptoms  Experiencing problems at work or school, or in relationships due to the inability to stop focusing about the perceived defect  Feeling self-conscious, not wanting to go out in public, feeling anxious when around other people  Repeatedly consulting with medical specialists, such as plastic surgeons or dermatologists, to find ways to improve his or her appearance

BDD – Continued  Causes:  Genetics  Environment and familial factors  Learning from family and peers  Behavioral modeling and learning processes  Treatable and preventable!  Psychotherapy  Medications  Suggested! – Avoid plastic surgery, or the quick fix!!

Background: BDD Treatment  Medications  Antidepressants  Cognitive behavioral therapy - This is a type of therapy with several steps. With the help of a therapist:  The patient enters social situations without covering up the "defect."  The patient stops doing the compulsive behaviors to check the defect or cover it up  The patient changes the false beliefs about their appearance

Case Study “Mirror, Mirror” - Introduction  Case Study – “Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder.” (2001)  Authors – David Veale and Susan Riley  Field of Psychology – Individual Differences  Determining/studying the differences, or abnormalities among people (certain population).  What makes us different!?  Study of abnormalities  Body Dysmorphia in this case study

Background  This study was prompted by a patient with (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.  Questions that arose:  What exactly did the behavior consist of?  What was the function of the behavior?  What maintained this behavior? (especially when he reported feeling worse after gazing in the mirror)

Mirror Gazing  The most common behavior related to BDD  Occurs in about 80% of patients while others tend to avoid mirrors (covering or removing them)  Motivations might be:  Hoping to look different  A desire to know exactly how they look  Reassurance that their efforts at camouflage have worked  Belief that they will feel worse if they resist

Aim/Theories  To better understand the psychopathology of mirror gazing in order to better define BDD & develop new strategies for cognitive behavioral therapies for BDD patients

Psychological Jargon  Body Dysmorphic Disorder  Somatoform Disorder  Mirror Gazing  Self – Reporting Questionnaire  Opportunity Sample  Uses people from a target population available at the time and willing to take part  Based on convenience  Long Session  Short Session  Psychopathology  The scientific study of mental disorders  Matched Pairs

Essential Vocabulary  Body Dysmorphic Disorder  Definition: a somatoform disorder in which a person becomes so preoccupied with his or her imagined ugliness that normal life is impossible.  Application: 52 BDD patients were given the self – report questionnaire to compare mirror gazing to the control group.  Mirror Gazing  Definition: Checking appearance in mirrors.  Application: Subjects were asked a variety of questions about their mirror gazing to hopefully determine the difference in mirror gazing between BDD patients and a control group.  Matched Pairs Design  Definition: the experimenter tries to match as many aspects as possible, on which the participants may differ, that might extraneously affect the dependent variable.  Application: – participants were matched on age and sex  30.1 vs years  40.4% male and 48% male

Essential Vocabulary  Self – Report Questionnaire  Definition: participants read the question and select a response by themselves without researcher interference.  Application: BDD subjects and the control group answered questions in a self – report questionnaire to determine the factors/motives of mirror gazing.  Selectively Avoid  Definition: purposefully keeping away from or doing something.  Application: Some of the BDD patients reported that they avoided some mirrors, using mirrors in better light, private mirrors, and using mirrors that were cracked.  Individual Differences  Definition: the study of the differences that exist between individuals in a society; study of abnormal behavior.  Application: BDD is the ‘abnormality’ that is studied in Veale and Riley’s case study.

Methods  Matched pairs design – participants were matched on age and sex  30.1 vs years  40.4% male and 48% male  Self – report questionnaire  Participants answered a set of questions without the psychologists present.

Method/Procedure  Self-report mirror gazing questionnaire.  Instructions informed them that the researchers were interested in the feelings that they had in front of a mirror during the past month  The subjects were asked if they had a long session in front of a mirror on most days of the past month  Longest amount of time a person spends in front of the mirror  Example: Getting ready for the day  If yes, then they were asked a series of questions about a typical long session in front of a mirror  The same questions were asked about a typical short session in front of a mirror  Example: Checking their appearance

Procedure  Setup of Procedure  Ps were given self-report mirror gazing questionnaire  Ps were to report the feelings they had while in front of a mirror during the past month  Ps were first asked if they had a ‘long session’ in front of the mirror (like shaving or putting on makeup)  If so, they were asked a series of questions about their actions and/or thoughts during a typical long session  Ps then repeated same questioning about ‘short sessions’  Example= checking appearance

Procedure  Question #1: “Length of time mirror gazing”  Ps were asked about: a.1. The average duration of a “long” session in minutes. b.2. The estimated maximum amount of time on any one occasion that he or she had spent in front of a mirror in hours/minutes c.3. The average duration (in minutes) and the frequency of a short session in front of a mirror during the last month

Procedure  Question #2: “Motivation before looking in a mirror” (Statements shown in Table 2)  Subjects were given statements in which they had to rate how much they agree with that statement on a scale of 1-5 (strongly disagree to strongly agree) a.There was also space where they could fill in any additional reasons for looking in the mirror b.Questions were repeated for short session as well

Procedure  Question #3: “Focus of Attention” 1.Subjects were asked what they focus on (physical and/or emotional) during both long and short sessions 2.Subjects rated their experiences on a 9 point scale a.-4 meaning ‘I am entirely focused on my reflection’ b.+4 meaning ‘I am entirely focused on an impression or feeling that I get about myself’

Procedure  Question #4: “Distress before & after looking in front of mirror” 1.Asked to rate degree of distress on 10 point scale 2.Asked at 3 different times to rate their distress a.before they looked in the mirror for a long session b.immediately after looking in the mirror c.after resisting the urge to look in a mirror 3.Same questions then applied to short sessions a.Ps only responded to 2 different times (before & immediately after)

Procedure  Question #5: “Behavior in front of a mirror” 1.Subjects were asked what activities they did in front of the mirror for both long and short session 2.Asked to rate the percentage of time spent on 9 activities and it had to add up to 100% a.Such as “combing/styling hair” and “feeling the skin” 3.At the end, there was also a blank area for other behaviors to be written in

Procedure  Question #6: “Type of light preferred” 1.Ps asked if the type of light was important a.Ranged from ‘natural day light’ to ‘artificial light’  Question #7: “Types of reflective surfaces” 1.Inquired into what Ps used to mirror gaze a.Such as just mirrors or what else  Question #8: “Mirror avoidance” 1.Asked if they avoided certain types of mirrors & in which situations they did so

Participants  52 patients with BDD who reported mirror gazing to be a feature of their problem were recruited to complete a “Mirror gazing questionnaire”  A group of 55 controls were recruited from personal contacts

Ethical Guidelines  Overall, it can be concluded that this study is ethical. 1.Subjects gave informed consent to participate in the study. 2.No deception occurred. 3.The identities of the subjects were kept private. 4.No emotional or physical harm was inflicted.

Data Collection  Data was gathered both quantitatively and qualitatively  Qualitatively  For question #2, space was provided were participants write any additional reasons for looking in the mirror  Question #2 = motivation for looking in a mirror  For question #5, there was a blank area for other behaviors to be written  Question #5 = behavior in front of a mirror  For question #7, space was provided for participants to write the surface that was used to mirror gaze.  Question #7: Types of reflective surfaces”  For question #8, an open ended question asking about avoidance of mirrors and the situations when these occurred  Question #8: Mirror avoidance  Quantitative  Questions 1, 2, 3, 4, 5, and six all provide quantitative data.  Rich data is collected, which will allow psychologists to develop ways to help patients manage their mirror gazing.

Results  Question #1: Ps experiencing a “long session” each day  1. 44/52 BDD Ps (84.6%) vs. 16/54 control Ps (29.6%)  a. Average Time: BDD= 72.5mins vs. Control= 21.3mins  b. BDD longest time=173.8mins vs. control longest time= 35.5mins  Question #2: Ps experiencing a “short session” each day  1. 45/52 BDD Ps (86.5%) vs. 43/54 control Ps (79.6%)  a. Average Time: BDD= 4.8mins vs. Control= 5.5mins  b. Average Instances per day: BDD= 14.6 vs. Control= 3.9 *No significant differences were found for age and gender among Ps

Results  Question #2: “Motivation for looking in a mirror” 1.BDD Ps were more likely to endorse all the beliefs listed a.Also more likely to gaze when feeling depressed 2.Control Ps were more interested in making themselves look presentable  Question #3: “Focus of attention in mirror” 1.For a long session: a.BDD more likely to focus on an internal impression/feeling b.BDD more likely to focus on specific parts of their appearance  Question #4: “Distress before, after, or resisting a check” 1.BDD significantly more distressed than controls in LS & SS 2.BDD more distressed after gazing & greater distress if they resisted the urge to gaze 3.BDD reported more handicaps from mirror gazing a.Such as ‘being late to appointments’ or ‘causing traffic accidents’

Results  Question #5: “Behavior in front of mirror” 1.Long sessions: a.Same for BOTH groups in the activities of:  applying makeup, styling hair, picking their spots, feeling skin with their fingers b.Controls more likely to: “removing hairs or shaving” c.BDD more likely to: “compare their image to one they had in their head” and “try to see something different 2.Short sessions: a.Controls more likely to: “shaving” b.BDD more likely to: “Checking make up, practicing best face, comparisons with image”

Results  Question #6: “Type of Light”  1. No sig. diff. for among BDD & controls for light preference (either natural day-light or artificial)  Question #7: “Types of Reflective Surfaces”  1. For a long sessions:  a. 22/42 BDD used a series of mirrors with different profiles compared to 1/15 Controls  BDD patients reported using a variety of reflective surfaces such as car mirrors, cutlery, TV screens, table tops, and the backs of CDs.  b. both BDD & controls used shop windows  c. BDD used different reflective surfaces

Results  Question #8: “Mirror Avoidance”

Overall Conclusions 1.Mirror gazing is complex, being viewed as a series of idiosyncratic (personal) and varied safety behaviors designed to prevent a future outcome. 2.BDD patients always hope that they will look different than their internal body image. 3.BDD patients demand to know exactly how they look. 4.BDD patients believe they will feel worse if they resist mirror gazing 5.BDD patients have the need to camouflage by excessive grooming – what could be called mental cosmetic surgery.

Overall Conclusions 6.BDD patients can be helped to manage their mirror – gazing strategies by: Use mirrors so they show most of the body, or the whole face, rather than a specific part. Focus attention on reflection rather than internal impression of feelings, and do not make an automatic “ugly” judgment. Use a mirror for a function, such as shaving or to do make – up. Use different mirrors rather than the “trusted” one and do not use magnifying mirrors or mirrors that give ambiguous reflections. Do not use a mirror when they have the urge but to delay and do other tasks instead.

Methodological Issues  Validity  This case study is valid as the experiment measures the hypothesis.  Ecological validity is high as it is a questionnaire that is conducted away from a laboratory and asks questions that can be asked in everyday life.  Reliability  Due to the self – report questionnaire, the reliability can be high.  Sample size is quite large.  Matched – Pairs Design  However, reliability can be questioned as the sex and age are not as close as needed.

Strengths of the Study  Strengths  High level of control – both groups were matched by age and sex, hopefully reducing individual differences that could potentially affect results.  Matched pairs design.  Standardized structure of the questionnaire – more reliable results  Qualitative and qualitative data – through study and straightforward statistics.  Replicable due to standardized questions and matched pairs design.  Application to real life – results can be used to treat patients with BDD.

Weaknesses of the Study  Weaknesses  Demand characteristics – BDD patients could have altered the information on the questionnaire because they wanted to seem socially desirable or “normal”.  Cannot generalize results - the study is restricted in terms of age and sex.  Results could be different if a different sample was tested.  Sample is not representative of the world population.