آینه، آینه بر روی دیوار، چه کسی زشت از همه است؟ آسیب شناسی نگاه خیره به آینه در اختلال بدریخت انگاری

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.

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 and Neziroglu & Yaryura-Tobias, 1993). BDD is a hidden disorder, as many patients do not tend to seek help from mental health professionals. 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 “dysmorphophobia” (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 schizophrenia, 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.

This is the first experimental study on the psychopathology of mirror gazing in BDD. We have found that BBD patients hold a number of problematic beliefs and behaviours in their mirror use compared to controls. Mirror gazing in BDD does not follow a simple model of a compulsive checking in OCD in terms of a repetitive behaviour for anxiety reduction and is a more complex phenomenon. It is best conceptualised as a series of idiosyncratic and complex safety behaviours, that is designed to prevent a feared outcome and in which the patient is seeking safety (Salkovskis, 1991). The feared outcome may be the internal aversion and disgust about one's appearance (and in many patients social anxiety and beliefs about rejection). This study has demonstrated that BDD patients have a number of different motivations and behaviours in their use of mirrors: (a) BDD patients have an eternal hope that they will look different to their internal body image or feel comfortable with their appearance. This may be intermittently reinforced when a patient feels better about their appearance or not as bad as they thought. However as the gazing becomes more repetitive, the reinforcement schedule may be reduced or depend more on other factors such as mood. However, mirror gazing then becomes counter-productive as it increases distress, self-consciousness, and confirms the negative aesthetic judgement. (b) BDD patients are uncertain about their body image and demand to know exactly how they look. This may be briefly rewarded whilst staring in the mirror, but once a patient is away from the mirror the focus of attention is on the mental representation of their body image and the uncertainty returns. There is some similarity to OCD patients who check their memory for actions in which each check can increase doubts and uncertainty about an event (Salkovskis, personal communication). The act of mirror gazing also creates further confusion for many patients as they report seeing one or more faces at different times or in different mirrors or lights. For example, one patient would sometimes see a “good” face, which was associated with being able to go out and function. However most of the time she would see a “bad” face, which meant total avoidance and being housebound. For others being able to see a “good” image was partly under their control if they were able to tilt a favourite mirror in a particular light. Other patients disbelieved what they saw in the mirror — for example one patient who obsessed about his mouth drooping took a photograph of himself daily in a photo-booth. This briefly reassured him that his mouth was not drooping but there remained a marked discrepancy with his body image and how he felt. (c) BDD patients believe they will feel worse if they resist gazing. However BDD patients subsequently report that mirror gazing increases distress and there is no significant increase in distress after resisting the urge to gaze. Presumably BDD patients do not resist the urge to gaze because other factors such the hope that they look different and knowing exactly how they look are more important in the short-term. (d) BDD patients are driven by a desire to camouflage their appearance or excessively groom to make themselves look their best or to feel “comfortable”. By contrast controls were motivated to use a mirror for more functional reasons such as making themselves look presentable or shaving. In this regard, grooming or putting on make-up in BBD patients accounts for some of the excessive time during the long sessions and the checks in the short sessions. Some BDD patients are also trying to change their internal body image to see something different. This might be regarded as a type of mental cosmetic surgery. For some patients, this may be intermittently reinforced as occasional satisfaction or a memory of a “good” image from the past that they are trying to recreate. Another interesting difference from controls is the way BDD patients are more likely to report using an “internal impression of how they feel” when they look in the mirror. This may be partly dependent on the length of time spent in front of a mirror, as there were no differences in the focus of attention between BDD patients and controls for short sessions. It implies that when BDD patients look in a mirror for a longer period of time, they are more likely to selectively attend to a mental representation of their body image (rather than an external reflection in a mirror). They may then compare this with their external reflection and idealised body image (or a photo of how they used to look like). The confusion as to how they look is further exacerbated by the ambiguous reflection that they obtain from windows, the backs of CDs or cutlery. It suggests that BDD patients selectively attend to an unstable internal body image and that this further drives the need to mirror gaze to know exactly how they look in a vicious circle. The greater internal focus of attention is also a factor in the “emotional reasoning” and the aesthetic judgement about their appearance. If the patient feels ugly or defective, then he or she reasons that it must be a fact and assume that others can also see them as ugly. Further experimental research is now required on “in vivo” mirror gazing so that the beliefs, focus of attention, mood and behaviours may be analysed immediately prior to and after gazing. As a result of this study, we have adapted our therapeutic strategies to help BDD patients to stop mirror gazing. We monitor (a) the time taken for the longest mirror session, (b) the frequency of the short mirror sessions. If a patient can reduce the amount of make-up or grooming, then this will tend to reduce significantly the amount of time in front of a mirror and the frequency of the short sessions (when patients tend to check that their camouflage is adequate). However this is often not possible at an early stage in therapy. It is also worth remembering that when women reduce the amount of excessive camouflage on their face, they may well receive comments from others that they look different. This requires some preparation, as the comments about being different are likely to be distorted to being “ugly” or defective. Some patients try to cover up or take down mirrors (or previous therapists may have encouraged it). However in our experience this can lead to a different set of problems of mirror avoidance. In this scenario, a patient is likely to still maintain his distorted body image and symptoms of BDD. Furthermore, he or she will be overwhelmed by reflections that they accidentally catch when they pass a mirror. We think it is better that patients learn to use mirrors in a healthy way with negotiated timed limits depending on the activity (for example using a limited amount of make-up). Patients (whether they are gazing or avoiding) are encouraged to develop the following goals: 1. To use mirrors at a slight distance or ones that are large enough to incorporate most of their body; 2. To deliberately focus attention on their reflection in the mirror rather than an internal impression of how they feel; 3. To only use a mirror for an agreed function (e.g. shaving, putting on make-up) for a limited period of time; 4. To use a variety of different mirrors and lights rather sticking to one which they “trust”; 5. To focus attention on the whole of their face or body rather than a specific area; 6. To suspend judgement about one's appearance and distance oneself from automatic thoughts about being ugly or defective; 7. Not to use mirrors that magnify their reflection; 8. Not to use ambiguous reflections (for example windows, the backs of CDs or cutlery or mirrors that are dusty or cracked); 9. Not to use a mirror when they feel have the urge but to try and delay the response and do other activities until the urge has diminished.