1 Body Image Treatment Within an Inpatient Program for Anorexia Nervosa: The Role of Mirror Exposure in the Desensitization Process Adrienne Key, 1 C. Louise George, 2 Desley Beattie, 3 Kate Stammers, 3 Hubert Lacey, 1 and Glenn Waller 1 1 Department of General Psychiatry, St. George s Hospital Medical School, University of London, London, United Kingdom 2 Wesley Private Hospital, Carlingford, New South Wales, Australia 3 South West London and St. George s NHS Trust, Springfield Hospital, Tooting, London, United Kingdom Accepted 5 March 2001 Abstract: Objective: This pilot study examined the role of mirror confrontation in the desensitization process of a body image treatment within an inpatient program for anorexia nervosa. Method: A within-subjects design was used. It compared the impact of two modes of group body image treatment on body dissatisfaction, anxiety, and avoidance behaviors. Both treatments followed a set format of exposure exercises and homework, but the modified treatment also included mirror confrontation as an exposure exercise. Results: Standard treatment did not produce any significant changes. Modified treatment produced a significant and sustained improvement in body dissatisfaction and a significant reduction in body anxiety and avoidance behaviors. Discussion: Mirror confrontation is a more effective form of exposure because of the strong emotional response it elicits. Patients pronounced emotional response to this exercise allowed easier identification of the affective and behavioral components of body dissatisfaction and more cogent links into a developmental body image timeline. Ó 2002 by Wiley Periodicals, Inc. Int J Eat Disord 31: , 2002; DOI /eat Key words: anorexia nervosa; body image; cognitive-behavioral therapy INTRODUCTION A core diagnostic feature of anorexia nervosa is the presence of a disorder of body image. The classification in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) defines this as a disturbance in the way in which body weight or shape is experienced, with undue influence of body weight or shape on self evaluation. For the patient, these disturbances produce an Correspondence to: Adrienne Key, Department of Psychiatry, Jenner Wing, St. George s Hospital Medical School, Cranmer Terrace, Tooting, London, SW17 ORE, United Kingdom. Ó 2002 by Wiley Periodicals, Inc.
2 186 Key et al. intense body dissatisfaction that can sometimes persist following an otherwise successful treatment of their eating disorder (Deter & Herzog, 1994; Goldbloom & Olmsted, 1993; Windauer, Lennerts, Talbot, Touyz, & Beaumont, 1993). The persistence of this body dissatisfaction has been found to be a reliable predictor of relapse (Fairburn, Peveler, Jones, Hope, & Doll, 1993; Freeman, Beach, Davis, & Solyom, 1985; Rosen, 1990) and has promoted the development of therapies to target specifically body image concerns (Cash, 1991; Cash & Grant, 1995; Rosen, Reiter, & Orosan, 1995). These treatment programs combine education with cognitive-behavioral techniques to reduce body dissatisfaction, body anxiety, and the use of avoidance behaviors. They have demonstrable efficacy in the treatment of body dysmorphic disorder and body dissatisfaction in average weight non eating-disordered women (Cash & Grant, 1995; Rosen et al., 1995). However, these programs are broad and there is a dearth of controlled treatment studies that determine the effectiveness of specific components of these interventions within eating disorder populations. 2 Cash (1995) described a cognitive-behavioral body image therapy program that involves body image exposure and desensitization through specific homework exercises and full-length mirror confrontation. The mirror exercise is particularly anxiety provoking for patients and other exercises appear to offer adequate opportunity for body exposure without precipitating such alarm. Despite experiencing this anxiety, patients in our treatment program retrospectively reported greatly valuing the mirror exercise when we incorporated it into our body image treatment. We hypothesized that body image therapy with the mirror confrontation exercise would be more effective at reducing body dissatisfaction, body anxiety, and the use of avoidance behaviors when compared with a similar treatment without the mirror exercise. METHODS Design The study compared treatment with (modified) and without (standard) the repeated use of the mirror exposure exercise. We also compared pretreatment and posttreatment measures of body image disturbance of the two therapy groups, which did not otherwise 3 differ in the treatment received. Six-month follow-up data were also collected on patients participating in the modified treatment. Sample All participants were Caucasian women with a diagnosis of anorexia nervosa, binge eating/purging subtype, and were currently inpatients on the eating disorder unit. Participants were eligible for the group once they achieved their target weight (body mass index = ). The standard group consisted of 6 women, with an age range of years (mean 23.5 years) and a duration of illness of 6 10 years (mean 8.2 years). Of the women in this group, 4 had at least one prior admission for treatment of anorexia nervosa and 3 had a history of repeated self-injury. The modified group consisted of 9 women, with an age range of years (mean 27 years) and a duration of illness from 3 to 20 years (mean 8.7 years). Of the women in this group, 6 had at least one prior admission for treatment of anorexia nervosa and 4 had a history of repeated self-injury.
3 Body Image Treatment for Anorexia Nervosa 187 Measures and Procedure The body image group program consisted of eight weekly sessions of 90 min. No specific body image follow-up or post program relapse prevention was offered. Therapists followed a written session by session manual, consisting of a set format of exposure exercises, relaxation, information giving, group discussions, and homework. Main Themes of Standard Treatment Understanding the Formation of Body Self, Image, and Dissatisfaction Body image was conceptualized as developing over time through individual experiences and consisting of affective, cognitive, and behavioral components. Each woman wrote a brief essay on how she believed her own negative body image developed. Modification of Intrusive Thoughts and Exploration of Underlying Assumptions Negative thoughts and underlying assumptions experienced during homework, discussions, and exposure exercises were identified and challenged. The links between physical appearance and repetitive negative self-statements were particularly highlighted. Exposure Exercises To Reduce Body Anxiety and the Use of Avoidance Behavior A variety of exposure exercises within the group and as homework helped each woman to monitor body dissatisfaction, anxiety, and avoidance behaviors. Homework tasks included goal setting with items of clothing and previously avoided social situations. Development of a Sexual Self and the Relationship to Body Image The women were encouraged to discuss their own understanding of sexuality. These discussions included exploration of individual factors relating to their development, other external or societal influences, their own expectations, ideals, and dissatisfactions, and the relationship of sexuality to body image. We emphasized that discussing sexual issues frequently raised difficult feelings of shame and embarrassment within the group. Main Themes of Modified Treatment These included all the treatment components described above, but with increasing time on the mirror exercise for each person each week. This exercise involved asking each woman to stand in front of a full-length mirror and look at her whole body (clothed) for increasing periods of time each week. In later sessions, participants were encouraged to wear more figure hugging clothes. A set time period for exposure was decided between patient and therapist before exposure and may initially only have involved walking past the mirror. Goals were small enough to be achievable in keeping with the principles of systematic desensitization. The standard program used the mirror exercise only during the first session, although the mirror remained in the room for the duration of the program in both treatment conditions.
4 188 Key et al. Instruments Body image dissatisfaction, body anxiety, and body avoidance behaviors were measured by self-report questionnaires: the 64-item Eating Disorder Inventory (EDI; Garner & Olmsted, 1984); the weight-related trait anxiety items of The Physical Appearance State and Trait Anxiety Scale (PASTAS; Reed, Thompson, Brannick, & Sacco, 1991); and the social activities and clothing subscales of the Body Image Avoidance Questionnaire (BIAQ; Rosen, Srebnik, Saltzberg, & Wendt, 1991). Data Analysis Nonparametric tests were used throughout the study. The Wilcoxon test was used to test for significant improvement in body image and eating variables between the start and end of each group, between the start and 6-month follow-up, and between the end of the group and 6-month follow-up. The Freidman test was applied to compare the mean ranks of the data from the modified treatment group at the three time points, the start and the end of the group and at 6-month follow-up. Statistical significance was set at the 5% level. RESULTS Statistical tests performed on values of Body Dissatisfaction and other EDI subscales, body anxiety, and body avoidance behavior demonstrated no significant differences between the two groups at baseline. None of the subjects dropped out of treatment and all subjects attended the eight sessions. The standard treatment group (N = 6) did not demonstrate statistically significant changes on any measures (Table 1). The modified treatment group (N = 9) was associated with a significant and sustained reduction in Body Dissatisfaction and Maturity Fears at 6-month follow-up and a significant improvement in Interoceptive Awareness and body avoidance social activities over the group period (Table 2). Table 1. Standard treatment (no mirror) Pregroup Postgroup Wilcoxon M (SD) M (SD) Z p Eating Disorder Inventory subscales Drive for Thinness 8 (7.6) 10.5 (7.58).368 NS Bulimia 6.5 (8.59) 0.6 (0.550) NS Body Dissatisfaction (8.57) (10.17).135 NS Perfectionism 10.2 (6.34) (3.86).368 NS Interoceptive Awareness 18.2 (3.12) (6.55) 1.6 NS Maturity Fears 7.8 (8.44) 0.75 (1.50) 1.6 NS Interpersonal Distrust 7.0 (5.57) 4.00 (2.16).368 NS Ineffectiveness 16.0 (7.01) 7.20 (4.15) 1.75 NS Physical Appearance State and Trait Anxiety Scale Weight-related trait items (5.75) (12.63).944 NS Body Image Avoidance Questionnaire subscales Clothing (7.66) (6.36) NS Social activities (6.38) 7.33 (2.88) 1.51 NS 5 *p <.05.
5 Body Image Treatment for Anorexia Nervosa 189 Table 2. Modified treatment (with mirror) Pregroup (S) Postgroup (E) At 6 Months Friedman M (SD) M (SD) M (SD) X 2 Wilcoxon Eating Disorder Inventory subscales Drive for Thinness 11.1 (5.09) (6.76) (7.45) 1.6 NS Bulimia 4.00 (3.38) 1.67 (1.94) 2.29 (2.36) 2.8 NS Body Dissatisfaction (5.5) 17.6 (9.16) (9.16) 5.04 S>E=F* Perfectionism 8.33 (4.95) 7.60 (4.45) 6.14 (4.63) 2.67 NS Interoceptive Awareness (6.21) (8.29) (6.78) 4.85 S>E>F* Maturity Fears 6.89 (6.62) 4.22 (5.56) 5.15 (2.97) 6.0 S>E=F* Interpersonal Distrust 9.22 (4.68) (5.64) 6.17 (6.08) 2.11 NS Ineffectiveness (7.38) (11.33) (9.48) 3.19 NS Physical Appearance State and Trait Anxiety Scale Weight trait items (11.77) (10.21) (14.53) 2.33 NS Body Image Avoidance Questionnaire subscales Clothing (5.51) 26.2 (7.80) (8.41) 1.46 NS Social activities 10.3 (5.42) 6.75 (6.39) 5.86 (5.08) 6.87 S>E>F* 6 * p <.05 DISCUSSION Body image treatment involving sustained mirror confrontation produced a significant and sustained reduction in body dissatisfaction. There were also significant improvements on the EDI scales of Maturity Fears and Interoceptive Awareness and the body avoidance scale of social activities over the period of the group although these benefits were not reliably maintained. The treatment group without this mirror confrontation did not produce any significant changes over an equivalent time period. Because all other aspects of the two treatments were held constant, it can be concluded that the mirror confrontation was the active element in producing these changes. The mirror exercise used whole body image confrontation with verbal interaction and challenge by the therapist. This produced a powerful and immediate emotional experience in most subjects when compared with other exposure exercises and prevented escape from that affect. Such strong reactions allowed easier identification of affective and behavioral (avoidance) components of body dissatisfaction and more cogent links into a developmental body image timeline. We suggest that the mirror exercise may be a more effective form of exposure because of this emotional response. In addition, increasing the time in front of the mirror each week meant that the women experienced a feeling of success. The EDI subscales of Maturity Fears and Interoceptive Awareness and the social activities scale of the BIAQ improved during the modified but not during the standard 4 treatment. Such changes may be due to a relationship among body image, maturity fears, and interoceptive awareness and that relationship requires further exploration. The inpatient program provided psychological support for the body image work. In particular, the women had already developed a therapeutic alliance with staff and used the other therapies to express negative feelings aroused by such provocative work. Both these factors enabled the groups to progress with the specific goal of tackling body dissatisfaction. However, the mirror exercise can create intolerable anxiety for some people, and how it is implemented is particularly important. Patients must feel that they are working in alliance with the therapist and that they retain control. Two patients with a history of repeated sexual abuse (one in the standard and one in the modified treat-
6 190 Key et al. ment) found the mirror and other exposure exercises very difficult. This was expressed as overwhelming emotions or blankness at the suggestion of the exercises. We would strongly suggest caution in patients who have a history of sexual abuse and vigilance for either reaction in any patient. These reactions may contraindicate the use of the mirror exercise or its use within the group setting. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Cash, T.F. (1991). Body image therapy: A program for self directed change. New York: The Guildford Press. Cash, T. F., & Grant, J.R. (1995). The cognitive-behavioural treatment of body image disturbances. In V. Van 1 Hasselt & M. Hersen (Eds.), Sourcebook of psychological treatment manuals for adults (pp. xx:xx xx). New York: Plenum Press. Deter, H.C., & Herzog, W. (1994). Anorexia nervosa in a long term perspective: Results of the Heidelberg- Mannheim study. Psychosomatic Medicine, 56, Fairburn, C.G., Peveler, R.C., Jones, R., Hope, R.A., & Doll, H.A. (1993). Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to shape and weight. Journal of Consulting and Clinical Psychology, 61, Freeman, R.J., Beach, B., Davis, R., & Solyom, L. (1985). The prediction of relapse in bulimia nervosa. Journal of Psychiatric Research, 19, Garner, D.M., & Olmsted, M.P. (1984). Eating Disorder Inventory. Odessa, FL: Psychological Assessment Resources. Goldbloom, D.S., & Olmsted, M.P. (1993). Pharmacotherapy of bulimia nervosa with fluoxetine: Assessment of clinically significant attitudinal change. American Journal of Psychiatry, 150, Reed, D.L., Thompson, J., Brannick, M.T., & Sacco, W.P. (1991). Development and validation of the Physical Appearance State and Trait Anxiety Scale (PASTAS). Journal of Anxiety Disorders, 5, Rosen, J.C. (1990). Body Image and eating disorders. In T.F. Cash & T. Pruzinsky (Eds.), Body images: Development, deviance, and change (pp ). New York: The Guildford Press. Rosen, J.C., Reiter, J., & Orosan, P. (1995). Cognitive behavioural body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63, Rosen, J.C., Srebnik, D., Saltzberg, E., & Wendt, S. (1991). Development of a Body Image Avoidance Questionnaire. Journal of Consulting and Clinical Psychology, 3 (1), Windauer, U., Lennerts, W., Talbot, P., Touyz, S.W., & Beaumont, P.J.V. (1993). How well are cured anorexia nervosa patients? An investigation of 16 weight-recovered anorexic patients. British Journal of Psychiatry, 163,