Look at yourself: can body image therapy affect the cognitive and emotional response to seeing oneself in the mirror in eating disorders?

Mirror Exposure Training for Adolescents With Anorexia Nervosa (MIRADAN): Cognitive Mechanisms of Body Disturbance - A Study Protocol

Background

Anorexia Nervosa (AN) is a severe mental illness, which typically develops in adolescence and, if left untreated, often becomes chronic. Body dissatisfaction is a core characteristic of AN. Mirror exposure (ME) is an effective therapeutic technique to tackle body dissatisfaction in adult patients with eating disorders, but there is limited evidence for the effects of ME in adolescence. One potential mechanism underlying effects of ME on body dissatisfaction is change in body-related attention bias. However, this mechanism remains to be empirically tested. Accordingly, the aim of the current study is twofold: primarily, we aim to test if ME can reduce body dissatisfaction and associated symptoms in adolescent patients with AN. Additionally, we aim to investigate whether change in biased body-related attention due to ME is a possible mechanism of action.

Method

Adolescent patients with AN are randomized to either 12 sessions of ME (3 ME-sessions/week) or wait-list within four weeks. Main outcomes include body dissatisfaction and associated symptoms of AN. Moreover, body-related attention bias is assessed at baseline and post-treatment by means of eye-tracking with two paradigms. Further, process variables are collected weekly. In addition, 12 weeks after end of the study, the acceptability of the ME is assessed.

Discussion

The main aim of the study is to evaluate high-frequency and high-intense ME for treating body dissatisfaction in adolescents with AN. In addition, we would like to clarify whether change in attentional bias for body stimuli is a mechanism underlying change in body dissatisfaction due to ME.

An Attentional Bias Modification Task, through Virtual Reality and Eye-Tracking Technologies, to Enhance the Treatment of Anorexia Nervosa

Mirror exposure therapies (METs) have been shown to be effective in reducing body image disturbances through the habituation process. Virtual reality (VR) combined with eye-tracking techniques can provide innovative solutions to some of METs’ limitations reported with patients with anorexia nervosa (AN), especially the negative influence of body-related attentional bias (AB). This pilot study aimed to assess the preliminary efficacy of a new VR-based AB modification task (ABMT) among healthy women and the procedure’s user experience. AB levels towards weight- and non-weight-related body parts, using complete fixation time (CFT) and number of fixations (NF), were assessed throughout the ABMT procedure (300 trials). The user experience was evaluated at the end of the procedure. The results showed that VR-based ABMT was effective in reducing AB significantly after 150 trials for both CFT- and NF-based measures, although 225 trials were necessary to get the same result for women with an NF initially more oriented towards weight-related body parts. Overall, the software received a “C-rating” on a scale from “A” (most usable) to “F” (least usable). These results provide evidence of the opportunity to use a VR-based ABMT procedure to reduce AB and improve existing treatments for AN.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

Consequences of Repeated Critical Versus Neutral Body Checking in Women With High Shape or Weight Concern

Body checking is a repeated behavior conducted in an attempt to gain information about one's shape, weight, size, or body composition. Body checking is associated with negative behavioral, emotional, and cognitive outcomes and may maintain body dissatisfaction and eating disorders. The precise function and consequences of body checking remain less well understood. Specifically, immediate and delayed impacts of repeated critical body checking (CBC) have not been determined. The current study randomly assigned 142 young women with high shape/weight concern to daily 10-min CBC, neutral body checking (NBC), or a non-body critical checking (NBCC) comparison condition, examining their immediate and delayed (one-week follow-up) effects on body satisfaction, self-esteem, and negative affect. Multilevel modeling and follow-up planned comparisons found that compared to NBCC, CBC participants' body satisfaction and self-esteem immediately decreased, but negative affect improved from baseline to follow-up. Compared to CBC, NBC participants' self-esteem and negative affect improved immediately, and their self-esteem improved over time compared to NBCC. Over time, all participants' state body satisfaction improved, regardless of condition. Our findings suggest a 10-min CBC session may function differently than typical (harmful) in vivo body checking. However, reasons for this difference are unclear. Additional research is needed to distinguish (harmful) in vivo body checking from CBC procedures such as this and other mirror exposure interventions. Research is needed to examine the effects of varying CBC duration and instructions during body exposure to further clarify mechanisms of change during body exposures.

Autonomic Nervous System Response to Psychosocial Stress in Anorexia Nervosa: A Cross-Sectional and Controlled Study

To foster understanding in the psychopathology of patients with anorexia nervosa (P_AN) at the psychological and physiological level, standardized experimental studies on reliable biomarkers are needed, especially due to the lack of disorder-specific samples. To this end, the autonomic nervous system (ANS) response to a psychosocial stressor was investigated in n = 19 P_AN (BMI: 18.7 ± 3.3 kg/m²), age, and gender-matched to n = 19 healthy controls (HC; BMI: 24.23 ± 3.0 kg/m²). For this purpose, heart rate (HR) and heart rate variability (HRV) parameters were assessed in a cross-sectional study design under two experimental conditions: (1) rest and (2) stress (Trier Social Stress Test). In addition, psychological indicators of stress were assessed. An 2 × 2 × 8 ANOVA demonstrated similar HR and HRV patterns (except LF-HRV) between P_AN and HC at rest. Under stress, P_AN (vs. HC) demonstrated a blunted HR [condition^*time^*group: F_{(2.91, 104.98)} = 9.326, p = 0.000, η² = 0.206] and an attenuated HRV response (reduced SNS/PNS reactivity). Significant effects of stress appraisal (SA) and BMI on HRV-reactivity were revealed. SA on SDNN = Condition^*time^*SA = F_{(4.12, 140.15)} = 2.676, p = 0.033, η² = 0.073. BMI on LF/HF-Ratio = Condition^*time^*BMI = F_{(3.53, 60.16)} = 3.339, p = 0.019, η² = 0.164. Psychological indices suggested higher levels of chronic and appraised stress in P_AN relative to HC. Additional analyses demonstrated that ED-symptoms are highly correlated with the latter constructs, as well as with psychological burden, but not with weight. Further, it was shown that abnormalities in reactivity persisted despite normalized ANS activity. Overall, we suggested that besides weight recovery, improvement in stress appraisal could be beneficial for cardiac health. In this light, a combination of therapy (e.g., development and activation of coping skills, cognitive reappraisal) and biofeedback training may improve treatment outcomes and regulate stress reactivity.

AN-VR-BE. A Randomized Controlled Trial for Reducing Fear of Gaining Weight and Other Eating Disorder Symptoms in Anorexia Nervosa through Virtual Reality-Based Body Exposure

In vivo body exposure therapy is considered an effective and suitable intervention to help patients with anorexia nervosa (AN) reduce their body image disturbances (BIDs). However, these interventions have notable limitations and cannot effectively reproduce certain fears usually found in AN, such as the fear of gaining weight (FGW). The latest developments in virtual reality (VR) technology and embodiment-based procedures could overcome these limitations and allow AN patients to confront their FGW and BIDs. This study aimed to provide further evidence of the efficacy of an enhanced (by means of embodiment) VR-based body exposure therapy for the treatment of AN. Thirty-five AN patients (16 in the experimental group, 19 in the control group) participated in the study. FGW, BIDs, and other body-related and ED measures were assessed before and after the intervention and three months later. The experimental group received treatment as usual (TAU) and five additional sessions of VR-based body exposure therapy, while the control group received only TAU. After the intervention, ED symptoms were clearly reduced in both groups, with most of the changes being more noticeable in the experimental group. Specifically, after the intervention and at follow-up, significant group differences were found in the FGW and BIDs, with the experimental group showing significantly lower values than the control group. The current study provides new insights and encouraging findings in the field of exposure-based therapies in AN. VR technology might improve research and clinical practice in AN by providing new tools to help patients confront their core fears (i.e., food- or weight-related cues) and improve their emotional, cognitive, and behavioral responses to their body image.

Self-focused attention enhances tactile sensitivity in women at risk from eating disorders

We examined whether alterations in body perception in EDs extend to the integration of exteroceptive visual and tactile information. Moreover, we investigated the effect of self-focused attention on the ability to correctly detect tactile stimuli. Twenty-seven women reporting low ED symptoms, versus 26 women reporting high ED symptoms, undertook a modified version of the Somatic Signal Detection Task (SSDT), which involved detecting tactile stimuli on the cheek in the presence or absence of a concomitant light. The SSDT was completed while looking at a photograph of one’s own face, another female face, and a scrambled face. Heart rate and skin conductance were recorded continuously during the SSDT. Although ED symptoms were not associated with an overall increased tendency to misperceive touch in the presence of a light, High ED participants were differentially affected by self-focused attention. For the High ED group, physiological arousal, and tactile sensitivity (d′) were increased when self-focused attention was augmented. For the Low ED group, sensitivity (d′) and physiological arousal were higher in the control conditions. We suggest that in those with High ED symptoms, attention to the bodily self may exacerbate a predisposition to focusing on external rather than internal bodily information.

Body shape in inpatients with severe anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a severe mental disorder. Body shape disturbances are key in the development and maintenance of AN. Only few data are available on inpatients with life-threatening AN. Therefore, we aimed to investigate if body shape difficulties-with a focus on both body checking and avoidance-could improve during hospitalization in both subtypes of AN and to ascertain eventual associations between body shape concerns upon admission and clinical outcome.

METHODS

Upon hospital admission and end of treatment (EOT), 139 inpatients with AN completed Body Shape Questionnaire (BSQ), Body Checking Questionnaire (BCQ), and Body Image Avoidance Questionnaire (BIAQ) in addition to measures of eating and general psychopathology.

RESULTS

Patients with severe AN reported improved BSQ and BIAQ scores at EOT while BCQ did not significantly change. Diagnostic subtypes differed only in baseline BSQ scores and had an impact on the improvement in BSQ at EOT. Baseline BCQ was associated with patients' clinical improvement at EOT, even after controlling for age, duration of illness, Body Mass Index, depression, and anxiety scores.

CONCLUSIONS

Data on body shape concerns and their trajectory during hospitalization for severe AN are lacking; our findings provide support to the effectiveness of hospitalization in improving body shape concerns and body avoidance, but not body checking. Also, baseline body shape concerns (especially body checking) impacted on clinical improvement. Future research is needed to identify treatments that could further improve the therapeutic approach to severe patients of AN in the acute setting.

Cognitive-Emotional Involvement During Mirror Exposure Is Not Accompanied by Physiological Activation in Binge Eating Disorder

Body image interventions have been shown to reduce self-reported cognitive-emotional facets of body image disturbance in binge eating disorder (BED). However, more objective assessment methods are required to evaluate the effects of these interventions. Therefore, the present study aimed at investigating the usefulness of vocally encoded emotional arousal as physiological correlate of body dissatisfaction during mirror exposure in women with BED. Women with BED (n = 60) and weight-matched controls (CG; n = 60) participated in an experimental thought-sampling procedure including a mirror exposure and a control condition in a repeated-measures design. Fundamental frequency as a vocal correlate of emotional arousal as well as negative, neutral, and positive body-related cognitions during both conditions were analyzed. In line with our hypotheses, the BED group verbalized more negative, and less positive and neutral body-related cognitions during the mirror exposure condition compared to the CG. Contrary to our hypotheses, though, there was a stronger increase in physiological arousal between the control and the mirror exposure condition in the CG relative to the BED group. Furthermore, a significant negative correlation between fundamental frequency and the severity of cognitive-emotional body image disturbances emerged. The findings indicate a cognitive-emotional over-involvement with physical appearance during mirror exposure in women with BED compared to weight-matched controls in the absence of a corresponding physiological pattern. Results are discussed in terms of an impaired ability of women with BED to show adequate physiological responses to body-related stress. In addition, methodological recommendations for future research are presented.

Patients' experiences from basic body awareness therapy in the treatment of binge eating disorder -movement toward health: a phenomenological study

BACKGROUND

Binge Eating Disorder (BED) is the most common eating disorder. Patients with BED are often not diagnosed, nor offered adequate specific treatment. A great number of those who receive recommended treatment do not recover over time. More knowledge about central aspects of BED, and treatments that specifically target such aspects is needed. Previous research has linked body experience to the development and maintenance of eating disorders, as well as influencing treatment results and the risk of relapse. The aim of this study was to explore how patients with BED experience Basic Body Awareness Therapy (BBAT), which is a psychomotor physiotherapy treatment addressing body experience.

METHOD

In this phenomenological study, we interviewed two patients with BED in depth during and after treatment. Video observations of treatment sessions and logs written by the patients were used as supporting data. The analysis was guided by Van Manen's hermeneutic phenomenology.

RESULTS

A meaning structure was identified: "On the way from the body as a problem to the body as a possibility." The two participants that besides BED also had a history of childhood trauma, perceived BBAT as a process of getting to know their own bodies in new ways, and described that the way they related to their own body changed as did aspects of their way of being. These changes were prominent when the participants described emotions, movement, pain, calmness, and self-experience, and interwoven with relational aspects as well as practices in everyday life.

CONCLUSION

The present results indicate that BBAT stimulated body experience in a way that opened new possibilities for two participants with BED, and hence that BBAT can improve the health status of BED patients also suffering from childhood trauma.

Bulimia Nervosa: A Comprehensive Analysis of Treatment, Policy, and Social Work Ethics

Bulimia nervosa is an often debilitating eating disorder with a biopsychosocial set of risk factors. Those presenting are at an increased mortality rate and often have physical health complications as well as harmful cognitions related to self-esteem and overall self-concept. This article examines treatment, policy, and social work ethics as they relate to bulimia nervosa. A comprehensive cognitive-behavioral approach including psychoeducation, self-monitoring, exposure therapy, interpersonal therapy, body image therapy, energy balance training, and relapse prevention is recommended as evidence-based practice for treating bulimia nervosa. Authors identify health care policy and analyze it as a common barrier to treatment access. They also review ethical principles of competency and social justice as they relate to social work practitioners working with those diagnosed with bulimia nervosa.

Effects of a cognitive-behavioral exposure-based body image therapy for overweight females with binge eating disorder: a pilot study

BACKGROUND

Although not part of the diagnostic criteria of the DSM-5, body image disturbance seems to be a relevant feature of Binge Eating Disorder (BED) as well as of other eating disorders such as Anorexia Nervosa (AN) or Bulimia Nervosa (BN). Hence, the aim of the present pilot study was to assess the changeability of body image disturbance in a sample of overweight females with BED by a cognitive-behavioral treatment, directly addressing body image disturbance.

METHOD

Overweight females (N = 34) with BED were randomized to a manualized body image therapy or a waiting-list control group. The final sample consisted of n = 15 participants in the intervention group and n = 19 in the control group due to two drop-outs in the control condition. Before and after the intervention or the waiting period, respectively, participants filled out a questionnaire battery assessing several body image and eating disorder related features. To quantify the perceptual component of body image disturbance, a digital photo distortion technique based on a picture of each participant taken in a standardized suit was applied.

RESULTS

In a two-way ANOVA, significant Time × Group interactions were found for eating and shape concerns, drive for thinness, body dissatisfaction, depressiveness and low self-esteem. Follow-up t-tests indicated a significant symptom reduction of a generally high magnitude in the intervention group. No significant changes concerning body checking and the estimations of one's own "real", "felt" and "ideal" body dimensions were found.

CONCLUSION

The strong symptom reduction in the cognitive-affective component of body image disturbance indicates that an exposure-based cognitive-behavioral body image intervention is a promising treatment module for overweight females with BED, but future research with a larger sample size is needed to quantify possible changes in all components of body image.

Does habituation really happen? Investigation of psycho-biological responses to body exposure in bulimia nervosa

BACKGROUND

Body exposure is a common and effective treatment for body image disturbance in bulimia nervosa (BN). However, little is known about treatment mechanisms. Based on models of emotional processing and neurovisceral integration, we expected to observe a) initial activation and b) habituation of cognitive-affective and autonomic responding within one and between two standardized body exposure sessions.

METHODS

A group of 13 women with BN and 13 healthy controls (HC) were repeatedly exposed to their bodies. Prior to and after treatment with three individualized mirror exposure sessions participants received a session of standardized exposure to videographic recordings of their body. Subjective ratings of body-related emotions and thoughts were assessed repeatedly throughout the standardized exposure sessions and autonomic responses were recorded continuously.

RESULTS

Subjective and sympathetic responses were activated initially in both groups. Cognitive-affective responses habituated within the standardized sessions in both groups, whereas between the standardized sessions habituation was only found in women with BN. Increasing sympathetic responses were found within the sessions in both groups.

CONCLUSIONS

The results support cognitive-affective habituation during body exposure in BN and to a lesser extent in HC. Autonomic responses however did not show a corresponding pattern and did not distinguish between groups. Implications for body exposure research and practice are discussed.

An interactive training programme to treat body image disturbance

Objectives

Anorexia nervosa (AN) is a life‐threatening mental health condition. A core feature is a disturbance of body image, such that sufferers see themselves as fatter than they actually are.

Design

We tested the effectiveness of a novel training programme to recalibrate our participants’ perception of body size.

Methods

In a novel adaptation of a cognitive bias training programme, participants judged the body size of a series of female bodies and were given feedback to improve their accuracy over four daily training sessions. In Study 1, we recruited young women with high concerns about their body size for a randomized controlled study. In Study 2, we then applied the training programme to a case series of women with atypical AN.

Results

In Study 1, the training programme significantly improved the body size judgements of women with high body concerns compared to controls. We also found evidence of improved body image and reduced eating concerns in this group. In Study 2, the programme again recalibrated the body size judgements of women with atypical AN. We also saw evidence of a clinically meaningful reduction in their body size and eating‐disordered concerns.

Conclusions

This training has the potential to be a valuable treatment used together with more traditional talking therapies.

Predictors of improved eating behaviour following body image therapy: a pilot study

Cognitive processes seem to play a vital role in eating disorders and body image. The current study, therefore, examines the impact and change of dysfunctional cognitions during a body image group therapy, which included 41 patients with an eating disorder. Dysfunctional cognitions were assessed with the 'Eating Disorder Cognition Questionnaire' both before and after treatment. Eating disorder psychopathology was also assessed. Results indicate a significant reduction of dysfunctional cognitions relating to 'body and self-esteem', 'dietary restraint', 'eating and loss of control', as well as 'internalisation and social comparison'. Furthermore, the changes in dysfunctional cognitions were associated with a reduction in eating disorder psychopathology. Body image therapy is a worthy complementation to standardised eating disorder treatment programmes as it reduces negative eating related thoughts and changes attitudes towards the body.

Alterations in Activity, Volume, and Connectivity of Body-Processing Brain Areas in Anorexia Nervosa

Body image disturbance is one of the main symptoms of eating disorders; however, the neural basis of this phenomenon is not well understood yet. In the present paper, we review studies investigating the neuronal correlates of visual body perception in anorexia nervosa. We first focus on the well-known parietal lobe contribution to body image processing and its malfunction. Additionally, we focus on the contribution and involvement of the extrastriate and fusiform body area in eating disorders, especially anorexia nervosa. The summarized studies provide first evidence for a reduced activity, volume, and connectivity in brain areas involved and specialized in the visual processing of human bodies. In general, the reviewed studies provide evidence for abnormalities in body-processing brain areas in anorexia nervosa, indicating two structures in the brain that are involved: early stages of body processing in the visual extrastriate cortex and later stages in the parietal cortex.

BodyWise: evaluating a pilot body image group for patients with anorexia nervosa

Body image disturbance can be enduring and distressing to individuals with eating disorders and effective treatments remain limited. This pilot study evaluated a group-based treatment-BodyWise-developed for use in full and partial hospitalization with patients with anorexia nervosa at low weight. A partial crossover waitlist design was used. BodyWise (N = 50) versus treatment as usual (N = 40) were compared on standardized measures of body image disturbance. Results demonstrated significant improvement in the group compared to treatment as usual for the primary outcome measure (Eating Disorder Examination-Questionnaire Shape Concern subscale) and other manifestations of body image disturbance including body checking and body image quality of life. BodyWise appeared acceptable to participants, and was easy to deliver within the pragmatics of a busy eating disorder service. There is potential for its wider dissemination as a precursor to more active body image interventions.

Efficacy of body exposure as treatment component for patients with eating disorders

BACKGROUND AND OBJECTIVES

Body exposure and cognitive restructuring are well known interventions in cognitive-behavioral therapies for patients with eating disorders. Though promising, little is known about the impact of body exposure on body dissatisfaction, overvaluation of weight and shape and other aspects of eating disorder psychopathology. Thus, the aim of the two studies presented here is to evaluate the efficacy of mirror exposure and video exposure on body dissatisfaction, weight and shape concerns and other aspects of eating disorder psychopathology. METHOD STUDY 1: Fourteen women diagnosed with Eating Disorders Not Otherwise Specified (EDNOS; DSM-IV-TR) were treated in repeated mirror exposure sessions. Assessments were carried out before (baseline) and after body exposure.

RESULTS STUDY 1

Measures of body dissatisfaction, shape concerns and eating disorder psychopathology were significantly improved at the post treatment assessment. METHOD STUDY 2: Thirteen women with Bulimia Nervosa (BN; DSM-IV-TR) received repeated mirror and video exposure sessions. Measures were assessed before (baseline) and after body exposure. RESULTS STUDY 2: Body image dissatisfaction was significantly improved at post treatment assessment.

LIMITATIONS

These preliminary results are based on subjective data from two small clinical samples. Comparisons between the studies are limited by design variations.

CONCLUSIONS

The studies provide evidence that body exposure is a promising technique for treatment of body dissatisfaction in EDNOS and BN. Moreover, in EDNOS shape concern and aspects of eating disorder psychopathology were improved after body exposure. Reasons for the lack of change in shape and weight concern as well as in eating disorder psychopathology in BN are discussed.

Standardized mirror confrontation: Body-related emotions, cognitions and level of dissociation in patients with Posttraumatic Stress Disorder after childhood sexual abuse

BACKGROUND

A criterion for Posttraumatic Stress Disorder (PTSD) is the avoidance of trauma-associated stimuli that trigger emotional suffering. First studies on body image of patients with PTSD after childhood sexual abuse (CSA) support the hypothesis that awareness of the own body triggers emotional suffering.

METHODS

Body-related emotions, cognitions and level of dissociation of n = 17 patients meeting DSM-IV criteria for PTSD and n = 29 healthy controls (HCs) during a standardized mirror confrontation while wearing a standard bikini were assessed.

RESULTS

It was shown that expecting to be and while being confronted with one's own body, patients with PTSD showed significantly stronger negative emotionality and cognitions as well as higher dissociative states as compared to HCs.

CONCLUSIONS

Findings suggest that in patients with PTSD after CSA, one's own body might function as a stimulus that leads to aversive emotional responses, negative cognitions and dissociative states. The elaboration of treatment for PTSD should consider these body-related aspects, e.g., by investigating the effects of body exposure.

Ten session body image therapy: efficacy of a manualised body image therapy

OBJECTIVE

To determine the efficacy of 10 session body image therapy (BAT-10) in the treatment of anorexia nervosa with adherence to the methodological guidance for complex interventions.

METHOD

Fifty-five adult inpatients with anorexia nervosa at two national centres received the group-based manualised body-image therapy (BAT-10). BAT-10 was refined, developed and manualised over two decades, by using the mindfulness-based cognitive behavioural therapy, including mirror exposure. Outcomes were evaluated using Body Checking Questionnaire, Body Image Avoidance Questionnaire, Physical Appearance State and Trait Anxiety Scale, Eating Disorders Examination Questionnaire and Quality of Life in Eating Disorders. Participant experience was evaluated qualitatively by an interpretative phenomenological analysis.

RESULTS

Ten session body image therapy achieved highly statistically significant changes in body checking, body avoidance and anxiety, as well as shape-concern and weight-concern, without the between-therapist effects. The quality of life improved globally but not in relation to the psychological subcategory.

DISCUSSION

Ten session body image therapy delivers behavioural and cognitive improvements in body image in the short-term, suggesting an effective, feasible and acceptable manual-based therapy.

Low baseline startle in anorexia nervosa patients

This study examined baseline startle magnitude, using eye blink response and skin conductance response in anorexia nervosa patients. Twenty female in-patients with anorexia nervosa and an equal number of female healthy controls were tested. Baseline startle response was assessed during blank screens while four startling loud sounds (a 116 dB, 1s, 250 Hz tone) were delivered with a time interval ranging from 35 to 55 s. It was investigated if BMI and state anxiety correlated with physiological responses. The clinical sample showed a lower baseline startle reflex measured with both indices, than healthy controls. Across the whole sample, a single regression model partially explained the relationship between BMI and baseline skin conductance response.

The direct effects of manipulating body checking in men

The purpose of the current study was to examine how body checking affects men's state body image and state muscle dissatisfaction using an experimental design. Male undergraduates (N=234) were randomly assigned to a high body checking group, in which they were asked to focus their attention on typically disliked body parts, and a low body checking group, in which they were asked to focus on their bodies as a whole and describe themselves using neutral, nonjudgmental terms. Contrary to initial hypotheses, regardless of condition, participants' body image satisfaction decreased significantly following the body checking procedure and did not change significantly after a 10-min delay. Additionally, in both conditions, participants' muscle dissatisfaction did not immediately change, but muscle dissatisfaction increased significantly following the 10-min delay. One mirror exposure session had similar effects on men's body image and muscle dissatisfaction regardless of how they were asked to examine their bodies.

Changes in body image during inpatient treatment for eating disorders predict outcome

This study investigated changes and predictors during inpatient treatment of 55 adult in a transdiagnostic sample of patients with eating disorders. Patients were assessed at admission and discharge with the Body Attitude Test (BAT), Symptom Check List 90 Revised, Circumplex of Interpersonal Problems, Body Mass Index (BMI) and Eating Disorder Inventory 2 (EDI-2). Significant changes were found in all measures. Regression analyses showed that BAT changes during treatment were the strongest predictor of EDI-2 changes. No predictors of changes in BMI were found. Improvement of body image is important for the efficacy of inpatient treatment.

Changes in neuronal correlates of body image processing by means of cognitive-behavioural body image therapy for eating disorders: a randomized controlled fMRI study

BACKGROUND

Previous neuroimaging studies have demonstrated abnormalities in visual body image processing in anorexia and bulimia nervosa, possibly underlying body image disturbance in these disorders. Although cognitive behavioural interventions have been shown to be successful in improving body image disturbance in eating disorders, no randomized controlled study has yet analysed treatment-induced changes in neuronal correlates of visual body image processing.

METHOD

Altogether, 32 females with eating disorders were randomly assigned either to a manualized cognitive behavioural body image therapy consisting of 10 group sessions, or to a waiting list control condition. Using functional magnetic resonance imaging, brain responses to viewing photographs of one's own and another female's body taken from 16 standardized perspectives while participants were wearing a uniform bikini were acquired before and after the intervention and the waiting time, respectively.

RESULTS

Data indicate a general blood oxygen level dependent signal enhancement in response to looking at photographs of one's own body from pre- to post-treatment, whereas exclusively in the control group activation decreases from pre- to post-waiting time were observed. Focused activation increases from pre- to post-treatment were found in the left middle temporal gyrus covering the coordinates of the extrastriate body area and in bilateral frontal structures including the middle frontal gyrus.

CONCLUSIONS

Results point to a more intense neuronal processing of one's own body after the cognitive behavioural body image therapy in cortical regions that are responsible for the visual processing of the human body and for self-awareness.

Effects of body image therapy on the activation of the extrastriate body area in anorexia nervosa: an fMRI study

To test effects of body image therapy in anorexia nervosa, functional magnetic resonance imaging was used to assess neuronal responses to viewing photographs of one's own body before and after treatment. Activation decreases emerged in a distributed network and increases were observed in the extrastriate body area, possibly reflecting more intense body image processing.

Neural correlates of viewing photographs of one's own body and another woman's body in anorexia and bulimia nervosa: an fMRI study

BACKGROUND

In spite of many similarities in the psychopathology of anorexia nervosa (AN) and bulimia nervosa (BN), the 2 groups seem to differ in terms of body image disturbances. Therefore, the aim of the present study was to compare neuronal correlates of viewing photographs of one's own body and another woman's body in patients with these forms of eating disorders as well as controls.

METHODS

We performed functional magnetic resonance imaging while women with AN (n = 13), BN (n = 15) and healthy controls (n = 27) viewed 16 standardized pictures of their own body and another woman's body, taken while the participants were wearing a bikini.

RESULTS

When viewing their own body, participants with AN and BN showed reduced activity in the inferior parietal lobule compared with healthy women. In response to looking at another woman's body, participants with AN had higher amygdala activity than did those in the BN and control groups.

LIMITATIONS

The generalizability of the results is limited by the small sample size.

CONCLUSION

Our data suggest decreased attentional processes in AN and BN toward one's own body, possibly reflecting body-related avoidance behaviour. Enhanced limbic activity elicited by looking at another woman's body in participants with AN might be a neural correlate of stronger emotional activation and enhanced vigilance, possibly resulting from social comparison processes. Our study reveals hints about body image-associated alterations in brain activity, which seem to be more pronounced among women with AN than among those with BN.

Therapeutic mirror interventions: an integrated review of the literature

The mirror is an object that shows one a reflected image of body areas. There appears to be limited nursing literature about the role of a nurse in the use of a mirror. There is, however, literature of the therapeutic use of mirrors in medicine, neurology, psychiatry, psychology, physical medicine and rehabilitation, and rheumatology. The objective of this article is to review the basic elements and the underlying theoretical framework of mirror interventions. In 2007 to 2008, a keyword, abstract, and title search was conducted for therapeutic mirror studies between the years 1998 and 2008. A multidisciplinary, integrated review approach was used when it became apparent that there were limited nursing studies. Qualitative and quantitative strategies for reviewing evidence were used, and a narrative synthesis approach was used to guide the comprehensive synthesis. Underlying theoretical models were identified, and five elements of mirror interventions were synthesized from the literature.

Eating and body image disturbances in male-to-female and female-to-male transsexuals

The aim of the study was to discover whether persons with Gender Identity Disorder (GID) differed from controls of both sexes and from persons with eating disorders in terms of the degree of eating and body image disturbance, self-esteem, and depression. A total of 88 self-identified male-to-female transsexuals (MtF), 43 female-to-male transsexuals (FtM), 62 females with an eating disorder, 56 male controls, and 116 female controls completed the Eating Disorder Examination Questionnaire, Eating Disorder Inventory, Body Checking Questionnaire, Drive for Muscularity Scale, Rosenberg Self-Esteem Scale, and Beck Depression Inventory. MtF showed higher scores on restrained eating, eating concerns, weight concerns, shape concerns, drive for thinness, bulimia, body dissatisfaction, and body checking compared to male controls, and concerning some variables also compared to female controls. FtM displayed a higher degree of restrained eating, weight concerns, shape concerns, body dissatisfaction, and body checking compared to male controls. Furthermore, participants with GID showed higher depression scores than did controls, whereas no differences concerning drive for muscularity and self-esteem were found. Between MtF and FtM, the only significant difference emerged for body checking, with MtF displaying higher scores. Although it was shown that on these variables the values for persons with GID were lower than for those with eating disorders, these data lead us to speculate that persons with GID might be at a higher risk of eating disturbances. Therefore, the implementation of prevention programs might help persons with GID to avoid developing a clinically relevant eating disorder.

International reflections on knowledge and use of the mirror in nursing practice

TOPIC

There are no guidelines on the use of the mirror with patients in nursing practice. Nurses have used their experiences, personal preferences, and best-guess practice models when to offer a mirror.

PURPOSE

This international study provides insight into the current knowledge and uses of the mirror in nursing practice and, as such, provides a small foothold toward understanding the mirror as a multidimensional nursing tool.

SOURCE OF INFORMATION

Ten healthcare providers from eight countries (South Africa, Egypt, Japan, the Netherlands, Panama, Russia, Singapore, and the United Kingdom) took part in semistructured questionnaire conversations via email. Thematic analysis was performed on the data.

CONCLUSIONS

The results suggest the use of the mirror has a place in shaping nursing practice and is currently being used in nursing practice. Mirrors appear to be lacking in hospital environments. There is no known research to guide the nurse in the appropriate type of mirror to have in a hospital or any other healthcare environment.

Overview of treatment modalities in adolescent anorexia nervosa

The aim of this article is to scrutinize and compare the benefits of distinct treatment settings for anorexia nervosa (AN) and to review the different treatment modalities that have proven helpful in the management of young patients with AN. Evidence-based findings on the effect of different treatment methods for AN are limited. Besides different treatment settings, a multimodal treatment approach comprising nutritional rehabilitation, nutritional counseling, individual psychotherapy and family-based interventions emphazising a group psychoeducation program for parents is presented.

Identifikation von erfolgsrelevanten Veränderungen im Prozess einer Körperbildtherapie

Zusammenfassung. Theoretischer Hintergrund: Mehrere Studien belegen gute Ergebnisse für Interventionen zur Verbesserung des Körperbildes bei Patientinnen mit Essstörungen; jedoch fehlen Prozessanalysen der relevanten Wirkfaktoren. Fragestellung: Erfolgsrelevante Veränderungen von Klärungs- und Bewältigungserfahrungen sowie symptomspezifische Intrasession-Veränderungen werden im Verlauf einer standardisierten Körperbildtherapie untersucht. Methode: 54 Patientinnen mit Essstörungen füllten vor und nach jeder Gruppensitzung die Body Image States Scale zur Erfassung der State-Körperunzufriedenheit und am Sitzungsende den Stundenbeurteilungsbogen mit den Wirkfaktoren „Einsicht/Klärung” und „Problembewältigung” aus. Ergebnisse: Bei gleichen Eingangswerten zeigten sich erfolgsabhängige Verläufe für die Körperunzufriedenheit nach Sitzungsende und die erlebte Problembewältigung. Sowohl Klärungs- als auch Problembewältigungsprozesse sind mit der Intrasession-Verbesserung der Körperunzufriedenheit assoziiert. Schlussfolgerungen: Während beide Erfolgsgruppen profitieren, bedarf der differenziell günstigere Verlauf der erfolgreicheren Patienten weiterer und erweiterter Forschung.