Accepted Manuscript

Mirror exposure therapy for body image disturbances and eating

disorders: A review

Trevor C. Griffen, Eva Naumann, Tom Hildebrandt

PII: S0272-7358(18)30057-6
DOI: doi:10.1016/j.cpr.2018.08.006
Reference: CPR 1715
To appear in: Clinical Psychology Review
Received date: 8 February 2018
Revised date: 25 August 2018
Accepted date: 27 August 2018

Please cite this article as: Trevor C. Griffen, Eva Naumann, Tom Hildebrandt , Mirror
exposure therapy for body image disturbances and eating disorders: A review. Cpr (2018),
doi:10.1016/j.cpr.2018.08.006

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Mirror Exposure Therapy for Body Image Disturbances and Eating Disorders: A Review

Trevor C. Griffena,*, Eva Naumannb, Tom Hildebrandtb

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aDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA

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bEating and Weight Disorders Program, Department of Psychiatry, Icahn School of Medicine at

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Mount Sinai, New York, NY, USA

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*Corresponding author at:

Department of Psychiatry
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Icahn School of Medicine at Mount Sinai

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1 Gustave L Levy Place

New York, NY 10029

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USA
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E-mail: trevor.griffen@mountsinai.org

Phone: (212) 659 – 8734

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Fax: (212) 996 – 8931

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Abstract

Mirror exposure therapy is a clinical trial validated treatment component that improves

body image and body satisfaction. Mirror exposure therapy has been shown to benefit

individuals with high body dissatisfaction and patients with eating disorders (ED) in clinical

trials. Mirror exposure is an optional component of cognitive behavioral therapy (CBT), an

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effective treatment for body dysmorphic disorder (BDD). However, most clinical trials of mirror

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exposure therapy have been small or uncontrolled and have included few male subjects. Adverse

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events have been reported during mirror exposure clinical trials. We discuss how individuals

respond when looking in a mirror and how mirrors can be used therapeutically, and we critically

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evaluate the evidence in favor of mirror exposure therapy. We discuss clinical indications and
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technical considerations for the use of mirror exposure therapy.
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Keywords: body image; mirror exposure therapy; eating disorders; body dysmorphic disorder
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Introduction

The self-perception of and emotional valence attached to one’s body affects many

important aspects of life. Negative body image is associated with low self-esteem, disordered

eating, negative sexual experiences, depression and anxiety, and is a risk factor for the

development of ED (Cash & Szymanski, 1995; Davison & McCabe, 2005; Faith & Schare, 1993;

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Johnson & Wardle, 2005; Noles, Cash & Winstead, 1985; Koch, Mansfield, Thurau & Carey,

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2005; Stice & Shaw, 2002). Body image influences the emotional responses people have while

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viewing themselves in a mirror (Servían-Franco, Moreno-Domínguez & del Paso, 2015; Svaldi,

Zimmermann & Naumann, 2012). Many individuals with ED and BDD have a problematic

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relationship with mirrors, often alternating between excessive mirror checking and mirror
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avoidance (Beilharz, Castle, Grace & Rossell, 2017; Grant & Phillips, 2005).

Both ED and BDD include body image disturbance as a core clinical feature, share
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common pathological elements and have increased comorbidity with obsessive-compulsive

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disorder (American Psychiatric Association [APA], 2013; Phillips & Kaye, 2007). Severity of

body image disturbance correlates with ED symptom persistence, suggesting that specifically
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targeting body image disturbances could promote recovery from ED (Stice & Shaw, 2002).
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Although several interventions have been designed to target body image dissatisfaction, a meta-

analysis of randomized controlled trials of body image interventions, including fitness training,
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self-esteem enhancement, media literacy and psychoeducation, found only a small effect size for

improving body image across these interventions (Alleva, Sheeran, Webb, Martijn & Miles,

2015).

Mirror exposure therapy, the systematic, repetitive viewing of oneself in a mirror with

specific guidance, has been proposed as a treatment for body image dissatisfaction (Hilbert,
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Tuschen-Caffier & Vögele, 2002; Rosen, Reiter & Orosan, 1995). Exposure therapies have been

found to be broadly effective, including for the treatment of specific psychiatric illnesses such as

obsessive-compulsive disorder (Foa & McClean, 2016). Thus, mirror exposure therapy targeting

body dissatisfaction is a rationally designed psychotherapeutic intervention.

Here, we examine where people direct their gaze during mirror exposures, discuss the

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acute effects of mirror exposure on both clinical and non-clinical populations, review both

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controlled and uncontrolled trials of mirror exposure as therapy with attention to specific

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pathologies, explore technical differences in the implementation of mirror exposure, consider

potential risks of and contraindications to mirror exposure therapy and attempt to develop a

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theoretical understanding of the mechanisms of action of mirror exposure therapy. We also
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present novel hypotheses of pathologies that may be amenable to treatment with mirror exposure

therapy and call for large scale, randomized controlled trials of mirror exposure therapy to more
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clearly elucidate the risks, benefits and optimal techniques across different pathological states.
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The locus of focus during mirror gazing

Non-clinical populations
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Where does one look when presented with one’s reflection in a mirror? Excessive focus
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on an area that is perceived as flawed may reinforce negative cognitions while focus on areas

that are perceived positively may serve to improve self-esteem. Women without a history of ED
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have been found to dedicate nearly equivalent amounts of time to looking at body parts that they

identify as their most attractive and as their least attractive when looking in a mirror (Tuschen-

Caffier et al., 2015). The even split between positively and negatively perceived body parts is

unmodified by mood as adolescent females without ED spend nearly the same amount of time

looking at their self-identified most and least attractive body parts in a mirror after the induction
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of either positive or negative mood (Svaldi et al., 2016). Although not directly tested during

mirror gazing, women with body dissatisfaction recruited from non-clinical populations spend

relatively more time looking at the body parts that they feel most dissatisfied with compared to

those they are most satisfied with when looking at pictures of themselves (Glashouwer, Jonker,

Thomassen & de Jong, 2016; Janelle, Hausenblas, Ellis, Coombes & Duley, 2009; Roefs et al.,

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2008).

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Body dysmorphic disorder

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Most individuals with BDD report spending excessive amounts of time examining their

perceived physical defects in the mirror (Phillips et al., 1997; Phillips, Menard, Fay & Weisberg,

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2005). When shown pictures of themselves, those with BDD tend to bias their attention towards
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the areas that they are most dissatisfied with (Greenberg, Reuman, Hartman, Kasarskis &

Wilhelm, 2014; Grocholewski, Kliem & Heinrich, 2012; Kollei, Horndasch, Erim & Martin,
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2017); however, when scanning is analyzed on a case-by-case basis, some individuals show a
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strong avoidance of the features with which they are preoccupied (Toh, Castle & Rossell, 2017).

Thus, individuals with BDD may comprise a heterogeneous population, some with enhanced
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visual attention to their perceived defects and some engaging in repetitive mirror gazing but
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avoiding their perceived defects. These results have not yet been replicated using eye tracking

while individuals with BDD look at themselves in a mirror.

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Eating and weight disorders

Similar to body dissatisfied women without ED, women with anorexia nervosa (AN) and

bulimia nervosa (BN) spend more time looking at the body parts that they identify as their most

ugly compared to those they identify as their most beautiful (Tuschen-Caffier et al., 2015). Mood

may interact with ED to influence where individuals look in the mirror as adolescent females
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with AN spend a significantly greater amount of time looking at their self-reported most

unattractive body parts after induction of negative mood, but are no different from peers without

ED after induction of positive mood (Svaldi et al., 2016). Together, these findings suggest that

individuals with ED spend more time looking at their negative features than healthy individuals

when looking in the mirror. Positive mood may be protective against this bias (Svaldi et al.,

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2016). When those with ED or who are overweight view pictures of themselves, they also tend to

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have bias toward their self-reported more unattractive body parts (Jansen, Nederkoorn &

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Mulkens, 2005; Kollei et al., 2017; Svaldi, Caffier, Tuschen-Caffier, 2011) although this result

has not been consistent across all studies (Warschburger, Calvano, Richter & Engbert, 2015; von

Wietersheim et al., 2012).

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Responses to looking in the mirror

Mirrors are ubiquitous in contemporary society; they are nearly impossible to avoid.
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Those with body image disturbances look at themselves in the mirror differently than those with
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higher body satisfaction (Tuschen-Caffier et al., 2015; Svaldi et al., 2016). Mirrors provide a

source of repeated and possibly distressing exposure to and reminder of one’s self-perceived best
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features and worst flaws.

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Non-clinical populations

Body dissatisfaction and distress increase in both men and women after they briefly look
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at themselves in a mirror (Veale et al., 2016; Walker, Murray, Lavender & Anderson, 2012;

Windheim, Veale & Anson, 2011). However, in mirror exposure tasks lasting longer than 30

minutes in which women are instructed to view body parts in a top down fashion, negative

emotions have been found to remain unchanged from baseline after the task (Shafran, Lee, Payne

& Fairburn, 2007; Vocks, Legenbauer, Wächter, Wucherer & Kosfelder, 2007) and a transient
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decrease in feelings of fatness occurs (Shafran et al., 2007). When women are directed to look at,

touch and describe emotions related to the body parts with which they are most dissatisfied while

looking in a mirror, body dissatisfaction acutely increases but then decreases to below baseline

30 min later (Shafran et al., 2007). Thus, the length of a mirror viewing session and presence of

specific instructions influences the emotional response to viewing oneself in a mirror.

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Baseline body dissatisfaction also affects emotional responses to mirror exposure.

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Females without ED or obesity but with high body dissatisfaction experience more negative

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emotions during brief mirror exposure than those low in body dissatisfaction (Servían-Franco et

al., 2015). Interestingly, females with high body dissatisfaction experience increased body

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dissatisfaction after a negative but not after a positive manipulation of self-esteem prior to the
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mirror exposure session (Svaldi et al., 2012). Mirror exposure does not alter body satisfaction for

those with low baseline body dissatisfaction (Svaldi et al., 2012).

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In summary, in non-clinical populations mirror exposure leads to distress and worsening

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of body dissatisfaction (Walker et al., 2012; Veale et al., 2016). This population effect is likely

driven by reactions from individuals with high baseline body dissatisfaction (Servían-Franco et
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al., 2015; Svaldi et al., 2012). Manipulating the emotional content of a mirror exposure session,
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either through instruction in where to look or prior to exposure, may influence changes in mood

and body satisfaction as well as their persistence (Shafran et al., 2007; Svaldi et al., 2012; Vocks
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et al., 2007).

Body dysmorphic disorder

Approximately 90% of individuals with BDD report spending excessive amounts of time

looking at themselves in the mirror (Phillips et al., 1997; Phillips et al., 2005) and nearly 10%

report having had a panic attack triggered by looking at themselves in the mirror (Phillips,
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Menard & Bjornsson, 2013). After looking in the mirror, individuals with BDD experience more

distress and anxiety than healthy controls (Buhlmann, Teachman, Naumann, Fehlinger & Rief,

2009; Parsons, Straub, Smith & Clerkin, 2017; Windheim et al., 2011). Additionally, individuals

with BDD have higher baseline disgust sensitivity and experience more disgust in response to

viewing themselves in a mirror than healthy controls (Neziroglu, Hickey & McKay, 2010). Thus,

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for individuals with BDD mirror gazing is often a compulsive act that occupies a substantial

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amount of their time. Rather than relieving negative emotions, for individuals with BDD, looking

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in the mirror produces negative emotions.

Eating and weight disorders

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Like individuals with BDD, most women with ED engage in body checking behaviors,
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including examining themselves in a mirror. Those with more severe ED symptoms engage in

body checking behaviors more frequently (Shafran, Fairburn, Robinson & Lask, 2004). Women
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with ED also frequently engage in body avoidance behaviors, such as covering mirrors, and
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many women with ED alternate between checking and avoiding behaviors (Shafran et al., 2004).

In summary, women with ED, like individuals with BDD, spend a significant amount of time
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engaging in body checking and/or avoiding behaviors, often mirror related, that lead to
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considerable distress.

Those with ED tend to experience even more distress and negative emotions than healthy
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individuals soon after being exposed to their reflection in a mirror, although this effect may be

specific to BN and BED and may not apply to those with AN (Cooper & Fairburn, 1992;

Naumann, Trentowska & Svaldi, 2013; Vocks et al., 2007). Additionally, for women with BED a

brief mirror exposure increases both salivation and their desire to binge eat (Naumann et al.,

2013).
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To cope with the negative emotions caused by looking at themselves in the mirror,

individuals with ED report using similar cognitive self-regulation skills to help overcome the

elicited negative emotions as healthy controls; however, those with ED report finding them less

useful (Crino, Touyz & Rieger, 2017). This perceived lack of self-efficacy may be at least partly

unfounded: when undergoing prolonged mirror exposure as 40 min of recording guided self-

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viewing, individuals with ED experience an increase in negative emotions at the start of the

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mirror exposure that declines to near baseline by the end of the session (Vocks et al., 2007).

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Thus, if they tolerate the initial distress of self-viewing and continue for a prolonged period of

time, they are able to regulate their emotions, at least with the help of a recording.

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Body image disturbances in ED often go beyond dissatisfaction with one’s appearance
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and may include profound disturbances in body self-perception. Early studies examining self-

estimation of body size by women with AN had heterogenous results (Farrell, Lee & Shafran,
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2005). Most contemporary studies have found that females with AN and BN overestimate their
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body size more than healthy controls (Gardner & Brown, 2014; Mölbert et al., 2017); however,

Mölbert et al. (2018) recently found the opposite for individuals with AN when 3 dimensional
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avatars were used to make body size estimations. Overestimation of body size by women with
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ED is not limited to situations when sensory feedback is not directly available, as they

overestimate body size more than those without ED even when looking in a mirror while
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estimating (Shafran & Fairburn, 2002). A single mirror exposure session where subjects are

asked to describe themselves and touch their body contours leads most individuals, including

those with AN, BN and no ED, to decrease their body size estimations (Norris, 1984).

Individuals with AN decrease their estimations of body size after mirror exposure significantly

more than those without ED (Norris, 1984).

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These data show that although seeing at oneself in a mirror is a common experience,

looking in a mirror can induce distress and negative emotions, especially in those with negative

body image and eating pathology. They also show that at the end of a single, prolonged and

directed mirror exposure exercise, women with ED report only baseline negative emotions and

women with AN decrease their estimation of their body size even more than those without ED

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(Vocks et al., 2007; Norris, 1984).

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Mirror exposure therapy

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The power of mirrors to elicit an emotional reaction to self-viewing has been used in a

variety of therapeutic modalities to treat psychiatric disorders with symptomatic negative body

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image. Mirror exposure has been incorporated into manualized, disease-focused CBT paradigms,
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some having specific sessions dedicated to mirror exposure, some having optional mirror

exposure modules and some using exposure-response prevention with the means of exposure left
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to the discretion of the therapist (Beilharz et al., 2017; Harrison, Fernández de la Cruz, Enander,
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Radua & Mataix-Cols, 2016). Mirror exposure has also been used as an adjunctive, stand-alone

therapy designed to augment ongoing, disease targeting interventions (Hildebrandt, Loeb,

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Troupe & Delinsky, 2012). Beyond interventions for those with diagnosable psychiatric
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illnesses, mirror exposure therapy has been used to improve body image in non-clinical

populations, including both individuals seeking treatment for body dissatisfaction and healthy
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individuals (those without psychiatric illness or severe body image concerns) recruited to serve

as experimental controls (Delinsky & Wilson, 2006; Moreno-Domínguez, Rodríguez-Ruiz,

Fernández-Santaella, Jansen & Tuschen-Caffier, 2012). We review the literature on controlled

and uncontrolled trials using therapeutic mirror exposure in a variety of conditions.

Search strategy
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To identify clinical trials examining the efficacy of mirror exposure therapy, a systematic

search was performed in Pubmed, last updated on April 27, 2018, using the search query: “mirror

body image OR mirror binge OR mirror nervosa OR mirror obese OR (mirror exposure therapy

NOT stroke) OR mirror body dissatisfaction OR mirror body dysmorphic.” This search returned

954 titles, which were screened at the level of title and abstract, and included if criteria were met

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after review of the text. Additionally, the reference lists of included studies as well as those of

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review articles identified that focused on treatment of eating, feeding, body image or weight

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disorders were screened. Inclusion criteria were: 1) Full length articles written in English 2)

Articles indexed on Pubmed as of April 27, 2018 3) Articles describing prospectively designed

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clinical evaluations of mirror exposure therapy, independent of randomization or control, with at
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least 3 participants. A study was determined to include mirror exposure if all subjects in a group

were required to look at their undistorted reflection in a mirror on separate occasions with
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therapeutic intent, even if additional therapeutic elements were incorporated. Studies identified
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that included mirror exposure as one required component of multisession therapy but with

ambiguity as to whether at least two separate mirror exposures were required of all participants
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were excluded formally (but discussed in the text) 4) Articles with outcomes related to body
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image, psychopathology and/or body size estimation 5) Studies of subjects with eating, feeding,

body image or weight disorders and/or who reported dissatisfaction with their body and/or who
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were not recruited based on the presence of a pathological condition. Studies of subjects with

neurological disorders (i.e. with discrete histopathological intracranial lesions such as tumors or

stroke) were excluded.

15 studies were identified through the primary search and no additional studies were

identified through the reference lists of those studies. Five treatment focused review articles were
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found using the search query, but no additional studies fitting inclusion criteria were identified

through their reference lists.

Non-clinical populations

Four uncontrolled studies have examined whether repeated mirror exposure therapy

might benefit healthy adult women without a history of an ED. In one, healthy control women (n

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= 19) had very low baseline negative thoughts, negative emotions and levels of distress, and they

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had high baseline positive emotions. These parameters did not change between mirror exposure

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sessions (Trentowska, Bender & Tuschen-Caffier, 2013). However, two larger studies with

healthy women (n = 30 and n = 168, divided across 3 types of mirror exposure therapy) found

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improvements in mood (Hilbert et al., 2002; Luethcke, McDaniel & Becker, 2011), body
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satisfaction and ED symptoms following mirror exposure therapy (Luethcke et al., 2011).

Another small (n = 13) study of healthy women found that negative thoughts associated with
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watching a film of one’s body were reduced after 3 sessions of mirror exposure therapy
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(Trentowska, Svaldi, Blechert & Tuschen-Caffier, 2017). Together, these studies suggest that for

unselected, non-clinical women, mirror exposure therapy may provide some benefit in improving
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mood and possibly body image satisfaction. How persistent these changes are and whether the
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observed improvement in ED symptoms reduces risk of developing an ED remain unanswered.

Three small, randomized controlled trials have examined whether mirror exposure is
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beneficial for women with body dissatisfaction recruited from non-clinical populations. Moreno-

Domínguez et al. (2012) compared 2 types of mirror exposure therapy (n = 10 each) to imagery

guided therapy (n = 11), during which subjects describe themselves without a mirror present.

Delinsky and Wilson (2006) compared mirror exposure therapy (n = 24) to supportive

psychotherapy (n = 21). Glashouwer et al. (2016) compared mirror exposure (n = 15) to no

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intervention (n = 13). These studies excluded women with low or high BMI (composite range:

18.5 – 28) and 2 excluded women with a history of ED (Delinsky & Wilson, 2006; Moreno-

Domínguez et al., 2012); however, with the exception of Glashouwer et al. (2016) who excluded

women with depression, other psychiatric illnesses, including BDD, were not screened for or

excluded. Mirror exposure therapy was found to be superior to control interventions on most

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measures, including negative thoughts, feelings of ugliness, body checking and dissatisfaction,

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ED symptoms and depression (Delinsky & Wilson, 2006; Glashouwer et al., 2016; Moreno-

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Domínguez et al., 2012). Mirror exposure therapy did not, however, change the proportion of

time that body dissatisfied women spent looking at their self-reported least attractive compared

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to most attractive body parts during a picture viewing assessment (Glashouwer et al., 2016). Two
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additional studies of women with body dissatisfaction compared 2 mirror exposure paradigms

without control groups and found improvement in thought content, mood and body satisfaction
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across conditions (n = 22 and n = 35; Díaz-Ferrer, Rodríguez-Ruiz, Ortega-Roldán, Mata-Martín

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& Fernández-Santaella, 2017; Jansen et al., 2016).

Body dysmorphic disorder

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BDD is an extreme form of body dissatisfaction that includes obsessions and/or

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compulsions and body image concerns that are grossly disproportionate with respect to how

others perceive a purported flaw (APA, 2013). Through our systematic search, we did not
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identify any studies investigating the efficacy of mirror exposure therapy for individuals with

BDD as defined in our methods. BDD specific CBT has been extensively studied and found to

be an effective treatment (Harrison et al., 2016; Beilharz et al., 2017). Six randomized controlled

trials (and several uncontrolled trials) have found clinically significant benefits of CBT for BDD

and study populations have included male and female adolescents and adults (Harrison et al.,
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2016); however, there are variations of CBT for BDD with different usages of mirror exposure:

CBT with mirror exposure in at least one session (Fang, Schwartz & Wilhelm, 2016; Greenberg

et al., 2010; Greenberg, Mothi & Wilhelm, 2016; Weingarden, Marques, Fang, LeBlanc &

Buhlmann, 2011; Wilhelm et al., 2014; Wilhelm, Buhlmann, Hayward, Greenberg & Dimaite,

2010; Wilhelm, Otto, Lohr & Deckersbach, 1999; Wilhelm, Phillips, Fama, Greenberg &

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Steketee, 2011), group CBT with at home mirror exposure homework (Rosen et al., 1995), CBT

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with optional mirror exposure (Mataix-Cols et al., 2015; Veale et al., 2014), CBT with exposure-

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response prevention strategies with the means of exposure left to the discretion of the therapist

(Krebs, Turner, Heyman & Mataix-Cols, 2012; Neziroglu, McKay, Todaro & Yaryura-Tobias,

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1996) and CBT without any explicit description of mirror exposure (Enander et al., 2016; Veale
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et al., 1996). A single randomized controlled trial also found benefit of non-disease specific

metacognitive therapy for BDD without any description of mirror exposure (Rabiei, Mulkens,
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Kalantari, Molavi & Bahrami, 2012). Although mirror exposure has been included as a required
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or optional component of many CBT for BDD studies, no study has looked explicitly at the value

of mirror exposure for the treatment of BDD. Studies of CBT for BDD with and without explicit
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descriptions of mirror exposure have both reported clinically significant benefit and no study has
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directly compared different paradigms. Whether mirror exposure provides additive benefit

beyond CBT without mirror exposure for individuals with BDD remains unexplored.
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Eating and weight disorders

Mixed eating disordered populations. Individuals with ED have significant

impairments in body image. One small, randomized controlled trial including individuals with all

ED, except for those who were underweight or obese, compared mirror exposure therapy (n =

17) to supportive psychotherapy (n = 16; Hildebrandt et al., 2012). Mirror exposure therapy
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resulted in a significantly greater decrease in body dissatisfaction and ED symptoms compared to

the control body image intervention (Hildebrandt et al., 2012). Two trials of a cognitive

behavioral group therapies for mixed ED that included at least 1 mirror exposure session, one

waitlist controlled and one uncontrolled, found improvements in body image after treatment

(Bhatnagar, Wisniewski, Solomon & Heinberg, 2013; Vocks, Wächter, Wucherer & Kosfelder,

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2008).

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Anorexia nervosa. Mirror exposure therapy has not been trialed for low weight AN out

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of concern for causing habituation to an underweight body (Morgan, Lazarova, Schelhase &

Saeidi, 2014; see below); however, 2 trials have used mirror exposure therapy to treat recently

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weight restored individuals with AN. Key et al. (2002) conducted a non-randomized trial and
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compared group body image therapy with mirror exposure in 8 sessions (n = 9) to group body

image therapy without mirror exposure (n = 6) and found a significant improvement in body
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dissatisfaction only in the mirror exposure therapy group. A larger, uncontrolled trial of group
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body image therapy (n = 55) that included mirror exposure in most sessions found a significant

decrease in shape and weight concerns and ED symptoms compared to baseline (Morgan et al.,
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2014). Additionally, a case series of three individuals with weight restored AN and persistent ED
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symptoms found benefit for acceptance and commitment therapy that included a mirror exposure

component (Berman, Boutelle & Crow, 2009). A larger, randomized controlled trial is needed to
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replicate these preliminary results.

Bulimia nervosa. Several small, uncontrolled trials have evaluated mirror exposure

therapy in women with BN or with ED-NOS whose frequency of binging and compensatory

behaviors was insufficient to merit a diagnosis of BN (and who would be classified at BN of low

frequency and/or limited duration in the DSM – 5; APA, 2013) with positive results (Díaz-
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Ferrer, Ridríguez-Ruiz, Ortega-Roldán, Moreno-Domínguez & Fernández-Santaella, 2015;

Trentowska et al., 2013; Trentowska et al., 2017; Trentowska, Svaldi & Tuschen-Caffier, 2014).

Trentowska et al. (2014) treated subjects with ED-NOS (n = 14) with 5 mirror exposures

sessions and subjects with BN (n = 13) with alternating video-of-self exposure sessions (3) and

mirror exposure sessions (2) and found improvement in body image dissatisfaction in both

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groups; however, improvement in ED symptoms was only observed in the ED-NOS group. The

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difference in ED symptom improvement could be secondary to the baseline illness severity or to

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the difference in treatment protocols. Three other studies of women with BN (n = 29, n = 19 and

n = 13) found that mirror exposure reduces body dissatisfaction, distress and negative thoughts

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(including those associated with watching videos of one’s body) and increases positive thoughts
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(Díaz-Ferrer et al., 2015; Trentowska et al., 2013; Trentowska et al., 2017). A larger

uncontrolled trial (n = 67) found that manualized CBT including an unspecified number of
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mirror exposure sessions is effective at reducing bingeing, body dissatisfaction and depressive
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symptoms in women with BN (Tuschen-Caffier, Pook & Frank, 2001).

Binge eating disorder. One study has examined the effects of mirror exposure therapy in
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binge eating disorder (BED). Hilbert et al. (2002) found improvement in mood and appearance
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related self-esteem during a second mirror exposure session in a group of women (n = 30) with

BED in an uncontrolled trial. Additionally, in a small, randomized, controlled trial of 19 sessions

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of group CBT with 4 body exposure sessions (including an unspecified number of mirror

exposures) or with 4 cognitive restructuring sessions focused on body image for women with

BED or ED-NOS (and who would qualify for BED of low frequency and/or limited duration in

the DSM – 5; APA, 2013; n = 14 per condition), body dissatisfaction, ED symptoms (including

binging) and depression improved over treatment, but not differentially between conditions
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(Hilbert & Tuschen-Caffier, 2004). It is not clear how much of the exposure sessions were

dedicated to mirror exposure in this trial and whether the benefit of mirror exposure may have

been attenuated or enhanced by its occurrence within a therapy group. Additionally, whether

cognitive restructuring and mirror exposure might have additive benefit was not tested.

Obesity. Body dissatisfaction is prevalent among obese individuals (Weinberger,

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Kersting, Riedel-Heller & Luck-Sikorski, 2016); however, most trials of mirror exposure therapy

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have excluded obese individuals. A small randomized, controlled trial for male and female

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adolescents in a residential obesity treatment program compared mirror exposure therapy added

on to treatment as usual (n = 8) to treatment as usual alone (n = 8) and found a non-significant

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improvement in body dissatisfaction and anxiety (Jansen et al., 2008). This trend towards a
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positive result was accompanied by significantly less weight loss in the mirror exposure group

compared to the control group (Jansen et al., 2008). A small case series of adults with obesity (1
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male, 2 female) undergoing a comprehensive weight loss program that included watching oneself
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eat in a mirror when deviating from pre-planned meals reported promising results for weight loss

(Rosen, 1981); this unique exposure strategy, which did not meet our criteria for mirror exposure
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therapy, has not been followed up with further published research. As these studies were
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uncontrolled or underpowered, larger trials are needed to determine whether mirror exposure

therapy or using a mirror during deviation from a planned diet provides benefit for the treatment
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of obesity and associated body image dissatisfaction.

Comparison of evidence across conditions

Studies of mirror exposure therapy have yielded generally positive results for disorders of

body image perception, eating and weight and for non-clinical populations. Enthusiasm for

mirror image therapy, however, must be tempered by the limitations of these studies. Trials of
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mirror image therapy for body dissatisfaction, BN and BED are limited by having only female

subjects, and very few male subjects were included in studies of mixed ED populations and AN.

For BDD, no trial has tested the benefit of mirror exposure alone or as an isolated component of

CBT. Most importantly, only 6 small trials have directly manipulated mirror exposure and

included control groups. Of these, 1 trial was not randomized and included only 15 participants

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in total (Key et al., 2002). One trial included only 16 total participants, reported only a trend

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towards a benefit, and did not include validated outcome measures of body image satisfaction,

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body image related behaviors and/or eating disorder symptoms (Jansen et al., 2008). Four

randomized controlled trials had between 10 and 24 participants per treatment condition (total n

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= 137, 97% female) and all found significant benefit of mirror exposure therapy over control
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treatment (Delinsky & Wilson, 2006; Glashouwer et al., 2016; Hildebrandt et al., 2012; Moreno-

Dominguez et al., 2012). Additionally, one randomized controlled trial found an effect of time in
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treatment for exposure therapy including mirror exposure that was not better than cognitive
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restructuring therapy (Hilbert & Tuschen-Caffier, 2004). The studies that found benefit for

mirror exposure therapy over the control condition all provided individual mirror exposure and
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excluded individuals that were underweight or obese (Delinsky & Wilson, 2006; Glashouwer et
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al., 2016; Hildebrandt et al., 2012; Moreno-Domínguez et al., 2012). In the study by Hilbert and

Tuschen-Caffier (2004), mirror exposure was provided in a group context and the average BMI
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of participants was in the obese range. All subjects were treated with CBT, either with a body

exposure component or with a cognitive restructuring component. The body exposure component

included mirror and video exposure and exposure to “avoided body-related situations” and the

relative amount of each component was not specified (Hilbert & Tuschen-Caffier, 2004).

Therefore, because the experimental manipulation did not explicitly require multiple mirror
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exposure sessions it did not meet the strict definition for inclusion. This study also had a more

robust, evidence-based control therapy condition compared to the other controlled studies

mentioned above, making detecting superiority of the exposure intervention less likely (Hilbert

& Tuschen-Caffier, 2004). The discrepant results of Hilbert and Tuschen-Caffier (2004) may

therefore be secondary to inclusion criteria (e.g. BMI), experimental intervention (group

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exposure therapy not restricted entirely to mirror exposure) or to the presence of a robust control

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intervention.

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Other stand-alone interventions designed to improve body image have only a small effect

(Alleva et al., 2015). We calculated modified Cohen’s d effect sizes as d+ according the method

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proposed by Morris for pretest-posttest experimental designs (2008) for the 4 randomized,
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controlled studies that matched inclusion criteria, directly manipulated individual mirror

exposure sessions and had validated measures of body image satisfaction, body image related
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behaviors and/or eating disorder symptoms as primary outcomes (Delinsky & Wilson, 2006;
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Glashouwer et al., 2016; Hildebrandt et al., 2012; Moreno-Domínguez et al., 2012). Briefly, the

difference between the pre- and posttest mean of the mirror exposure group was subtracted from
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the difference between the pre- and posttest mean of the control group and divided by the pooled
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pretest standard deviation and then multiplied by a sample size correction factor (Morris, 2008).

We then calculated the mean effect size (d) as the mean effect size of all body image and eating
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related validated primary outcome measures weighted by sample size. Baseline and last available

follow-up data were used for effect size calculations.

In the study by Delinksy and Wilson (2006), we found a medium effect of mirror

exposure on shape and weight concerns (Eating Disorder Examination-Questionnaire (EDE-Q),

Shape and Weight Concerns, d+ = 0.50) and small effects on body image avoidance (Body Image
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Avoidance Questionnaire, d+ = 0.33) and body checking (Body Checking Questionnaire (BCQ),

d+ = 0.48). There was no significant treatment effect on dissatisfaction with body parts

(Satisfaction with Body Parts Scale, d+ = -0.05) or dieting (Dutch Restrained Eating Scale, d+ =

0.03). In the study by Moreno-Domínguez et al. (2012), we found a large effect of “pure mirror

exposure” and a medium effect of “guided mirror exposure” on body shape concerns (Body

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Shape Questionnaire (BSQ), d+ = 1.67, 0.57). In the study by Glashouwer et al. (2016), we found

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a medium effect on eating disorder symptoms (EDE-Q, d+ = 0.70). Finally, in the study by

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Hildebrandt et al. (2012), we found medium effects of mirror exposure on body checking (BCQ,

d+ = 0.68), eating-related obsessions (Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS),

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obsessions subscale, d+ = 0.77) and eating-related rituals (YBC-EDS, rituals subscale, d+ =
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0.72), and a small effect of mirror exposure on body shape concerns (BSQ, d+ = 0.21). After

weighting the validated ED and body image symptom primary outcomes from these four studies
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for sample size, we found an overall medium effect of mirror exposure compared to control
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conditions, d = 0.67.

Technical considerations for mirror exposure therapy

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Many variations of mirror exposure therapy have been reported. Most studies of mirror
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exposure therapy utilize a cognitive restructuring approach: the subject is instructed to describe

their reflection using non-judgmental language, typically starting with their head and progressing
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down to their toes, followed by a whole-body description, while a therapist is present and

ensures that the subject adheres to the instructions (Delinsky & Wilson, 2006; Harrison et al.,

2016; Phillips & Rogers, 2011). This approach is known as “guided non-judgmental mirror

exposure therapy.” Another approach, “pure mirror exposure therapy,” involves the subject

looking at their whole body and observing and commenting on evoked emotions as they arise
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(Moreno-Domínguez et al., 2012). Mirror exposure has also been used within group therapy and

as homework to be completed outside of the direct supervision of a therapist (Key et al., 2002;

Rosen et al., 1995).

A small number of randomized trials have compared different technical approaches to

individual mirror exposure therapy, discussed below. Except for a single study of women with

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BN (Díaz-Ferrer et al., 2015), all trials comparing mirror exposure modalities used body

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dissatisfied women as subjects (Díaz-Ferrer et al., 2017; Jansen et al., 2016; Luethcke et al.,

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2011; Moreno-Domínguez et al., 2012). No trial has compared mirror exposure therapy

performed under the guidance of a therapist to mirror exposure therapy performed alone or in the

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context of a therapy group, and no trial has empirically determined the ideal length of mirror
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exposure sessions or the ideal length or frequency of mirror exposure treatment. A recent study

found that after a single mirror exposure session, body dissatisfied women whose posture was
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manipulated to be more upright experienced more positive emotions than those whose posture
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was manipulated to be contracted (Miragall et al., 2018). Whether manipulations that increase

positive emotions after mirror exposure sessions early in therapy lead to larger and more
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sustained improvements is unknown.

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Pure mirror exposure versus guided non-judgmental mirror exposure

The technique applied during a mirror exposure session as well as the length of the
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session can alter the emotional response during and after the exposure session (Díaz-Ferrer et al.,

2015, 2017; Jansen et al., 2016; Luethcke et al., 2011; Moreno-Domínguez et al., 2012; Shafran

et al., 2007; Vocks et al., 2007). Guided non-judgmental mirror exposure therapy has been

compared to pure mirror exposure therapy in 3 randomized trials. For women with body

dissatisfaction, both therapeutic techniques achieve similar improvement over baseline in

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positive and negative thoughts and feelings of ugliness (Díaz-Ferrer et al., 2017; Moreno-

Domínguez et al., 2012), but pure mirror exposure therapy is superior for reducing distress both

within and between sessions (Moreno-Domínguez et al., 2012). Similarly, for women with BN

both pure and guided non-judgmental mirror exposure paradigms lead to equal improvements in

positive and negative thoughts, but pure mirror exposure therapy is superior for reducing body

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dissatisfaction (Díaz-Ferrer et al., 2015). Together, these findings suggest that pure mirror

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exposure therapy may have some benefit over the guided non-judgmental technique. These

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therapies differ in two important ways: where the individual is instructed to look (whole body

versus sequential body parts) and the language that the individual is instructed to use (describing

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emotions that arise versus non-judgmental descriptions of appearance). Either or both of those
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parameters could account for the benefit seen with the pure mirror exposure technique.

Adding an emotional focus to mirror exposure

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Jansen et al. (2016) modulated where subjects with body dissatisfaction directed their
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attention during mirror exposure therapy to determine whether focusing on either subject-defined

attractive or unattractive body parts alters the efficacy of mirror exposure therapy. They
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instructed participants to focus on viewing their self-defined most attractive body parts and use
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language with positive valence exclusively (positive focus group) or to focus on viewing their

self-defined least attractive body parts and attend to their thoughts and feelings as they arise
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(negative focus group; Jansen et al., 2016). Both styles of mirror exposure led to similar

improvements in body satisfaction, body avoidance behaviors and mood; however, body

avoidance continued to improve after completion of the intervention only in the negative focus

group. The negative focus group also had a greater improvement in perceived attractiveness of

their least attractive body part (Jansen et al., 2016). These benefits did not come without cost.
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The negative focus group experienced more negative thoughts during early therapy sessions than

the positive focus group; however, this difference disappeared in later sessions (Jansen et al.,

2016).

To isolate the effect of language valence on mirror exposure, Luethcke et al. (2011)

compared instructing participants to describe their body parts using language with positive

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valence to using non-judgmental language. They found that for both treatment styles, ED

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symptoms and mood improved similarly, but body satisfaction improved only in the positive

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valence condition (Luethcke et al., 2011). This study has two important limitations: only 2 mirror

exposure sessions were used, compared to 3 – 6 sessions in other studies (Delinsky & Wilson,

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2006; Díaz-Ferrer et al., 2015, 2017; Hildebrandt et al., 2012; Jansen et al., 2016; Moreno-
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Domínguez et al., 2012), and the sessions were guided by a list of body parts to describe, not a

trained therapist. Given the results of Jansen et al. (2016) described above, it is possible that had
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Luethcke et al. (2011) extended their treatment to include more mirror exposure sessions, they
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would have found a positive effect of using non-judgmental language on body image.

Risks of and relative contraindications to mirror exposure therapy

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Adverse events in clinical trials of mirror exposure therapy

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Psychotherapies can have harmful side effects and well controlled clinical trials with

adequate monitoring and reporting of adverse events are critical to quantifying the risk of harm
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(Barlow, 2010; Bystedt, Rozental, Andersson, Boettcher & Carlbring, 2014; Crown, 1983).

Uncontrolled trials that show symptomatic improvement might represent a slowing of normal

recovery relative to no treatment and provide no baseline of adverse events for comparison. As

looking at oneself in a mirror can lead to significant distress and worsening of negative

emotional states (Walker et al., 2012; Veale et al., 2016; Windheim et al., 2011), mirror exposure
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therapy could be destabilizing and dangerous for certain individuals.

Many of the uncontrolled trials of mirror exposure therapy or CBT that may or may not

have included mirror exposure reported that at least one participant dropped out or missed

enough treatment sessions to mandate exclusion after starting therapy (Díaz-Ferrer et al., 2015;

Greenberg et al., 2016; Trentowska et al., 2014; Tuschen-Caffier et al., 2001; Vocks et al., 2008;

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Wilhelm et al., 1999). Greenberg et al. (2016) reported that 2 subjects in their trial of CBT with

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mirror exposure for BDD dropped out due to needing a higher level of care. If some participants

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dropped out due to clinical deterioration secondary to therapy, this may have led to

overestimation of benefit.

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In randomized controlled trials of CBT with either optional or no explicit mention of
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mirror exposure therapy, 2 subjects receiving CBT compared to 5 control subjects dropped out

(Veale et al., 2014) and 3 adverse events were reported: 1 suicide attempt by a subject receiving
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CBT and 1 sleep disturbance in and 1 suicide attempt by control subjects (Enander et al., 2016;
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Mataix-Cols et al., 2015). In those randomized controlled trials where mirror exposure was

included in CBT for all subjects, 5 receiving CBT compared to 6 controls dropped out (Wilhelm
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et al., 2014; Hilbert & Tuschen-Caffier, 2004). Thus, in randomized controlled trials of CBT
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with or without mirror exposure, drop-out and adverse event rates are similar in study and

control interventions. One cannot determine the specific impact of mirror exposure in these trials
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given that mirror exposure was not manipulated in isolation.

In randomized controlled trials examining mirror exposure therapy as an isolated

manipulation adverse events were also reported. In one study of an ED population, 2 subjects

receiving mirror exposure therapy were withdrawn after acute increases in non-suicidal self-

injurious behaviors; both had prior histories of these behaviors (Hildebrandt et al., 2012). No
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adverse events were reported in the control condition (Hildebrandt et al., 2012). In a study of

females with body images disturbance, 3 subjects in the mirror exposure condition and none in

the control condition dropped out of the study; the dropouts had significantly higher baseline

depression scores than other participants (Delinsky & Wilson, 2006). Larger, more inclusive

trials isolating mirror exposure therapy are warranted to more fully characterize the safety of this

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intervention and to extend our understanding of whether there may be gender differences in

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treatment risk. Given that the total number of adverse events that has been reported in mirror

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exposure conditions is numerically greater than for control interventions, caution is warranted

when treating individuals with a history of self-injurious behavior or current clinical depression.

Underweight and obese populations

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AN
Mirror exposure therapy for individuals at weight extremes is controversial (Morgan et

al., 2014) and most randomized controlled trials of mirror exposure therapy have excluded
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underweight and obese individuals (Delinsky & Wilson, 2006; Glashouwer et al., 2016;
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Hildebrandt et al., 2012; Moreno-Domínguez et al., 2012). Fostering body acceptance in

individuals for whom weight loss or gain would confer medical benefit could in theory lead to a
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decrease in motivation to change weight. During a small randomized controlled trial of mirror
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exposure for adolescents in an obesity treatment program, those in the mirror exposure group lost

significantly less weight than those in the control condition (Jansen et al., 2008). However, if
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mirror exposure for obese individuals were to be shown to lead to more gradual weight loss and

a reduction in psychiatric symptoms, it could possibly lead to more sustained weight loss and

well-being (Pasanisi, Contaldo, de Simone & Mancini, 2001). This is an enticing hypothesis that

could be investigated in a future larger and longer clinical trial.

Vocks et al. (2008) included 3 subjects with AN who were presumably underweight by
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diagnosis in their uncontrolled trial of group CBT in which 3 sessions included mirror exposure.

Four subjects were excluded from this trial after missing 2 or more treatment sessions. Neither

the ED of nor the sessions missed by the excluded subjects were reported (Vocks et al., 2008);

therefore, it is not clear how well the treatment was tolerated by the individuals in the study with

AN. No trial has explicitly tested mirror exposure for AN before weight restoration; however, a

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single ME in this group does result in a reduction of body size estimation (Norris, 1984).

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Whether the reduction in body dissatisfaction and negative emotions seen after mirror exposure

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therapy in other ED would occur in AN is not known. Similarly, it is not known whether mirror

exposure therapy would change the patient’s resistance to changing weight or a lead to

habituation to an underweight body.

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AN
A controlled trial of a psychoeducational group therapy focused on body image compared

to waitlist was well tolerated and led to improvement in shape and weight concerns for
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underweight individuals with AN (Mountford et al., 2015). If mirror exposure can be tolerated
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by underweight individuals with AN and decreases self-perceived body size overestimation

(Noris, 1984) and body dissatisfaction (as seen in with other ED), it could reduce the desire to
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lose weight at the core of AN pathology. This hypothesis remains to be tested and should be
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done so with caution given concerns of experienced clinicians (Morgan et al., 2014).

Mechanism of action of mirror exposure therapy

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How mirror exposure therapy confers therapeutic benefit is unknown. Those high in body

image concerns and with ED spend more time looking at their less attractive body parts when

they look in the mirror and experience more distress after looking in the mirror (Buhlmann et al.,

2009; Svaldi et al., 2016; Tuschen-Caffier et al., 2015; Veale et al., 2016; Vocks et al., 2007;

Walker et al., 2012; Windheim et al., 2011) with no clear disease specific responses thus far
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identified that might differentiate distinct mechanisms of action in distinct pathologies. The one

exception is that mirror exposure reduces body size overestimation in underweight AN more

than in other groups (Norris, 1984). A more realistic evaluation of self-body size could lead to

reduced drive to lose weight; however, this is a speculative mechanism and it is unknown

whether mirror exposure therapy is effective or safe in underweight individuals with AN (see

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above). Beyond underweight AN, there is insufficient empirical evidence to assign possible

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mechanisms of action to specific underlying pathological states.

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Appearance related cognitive biases, both attentional and interpretive, have been

described in ED (Bauer et al., 2017; Cardi et al., 2017; Cooper, 1997; Glashouwer et al., 2016;

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Smeets, Jansen & Roefs, 2011) and BDD (Greenberg et al., 2014). Individuals with ED tend to
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interpret ambiguous negative situations as being related to their shape or weight (Bauer et al.,

2017; Cooper, 1997; Cooper, Cohen-Tovée, Todd, Wells & Tovée, 1997) and those with BDD
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interpret negative social cues as relating to their appearance (Buhlmann et al., 2002).
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Interventions targeting negative interpretation biases have had some success in BDD and AN

(Summers & Cougle, 2016; Turton, Cardi, Treasure & Hirsch, 2018). Mirror exposure therapy
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may normalize interpretive biases by training individuals to interpret their bodies in an objective,
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affectively neutral or affectively positive manner (Delinsky & Wilson, 2006; Luethcke et al.,

2011).
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Individuals with body dissatisfaction also have attentional biases that likely play both

etiological and maintaining roles in their pathology. These attentional biases take the form of

both own-body specific and generalized visual processing deficits. Individuals with AN, BN and

BDD spend more time visually attending to fine details at the expense of global features relative

to healthy controls, resulting in deficient performance on the Rey-Osterrieth Complex Figure

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Task (Deckersbach et al., 2000; Lang et al., 2016). The biases of body dissatisfied for processing

of own-body are characterized by an increase in general self-focused attention with a specific

focus on their self-defined least attractive body parts. Increased self-focused attention has been

observed in many psychiatric disorders (Ingram, 1990), including BDD, BED and weight-

restored individuals with history of AN (Sawaoka, Barnes, Blomquist, Masheb & Grilo, 2012;

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Windheim et al., 2011; Zucker et al., 2015). Interestingly, underweight individuals with AN

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report less self-focused attention than healthy controls (Zucker et al., 2015). In BDD, it has been

CR
suggested that repeated mirror gazing may lead to cognitive distortions and over representation

of the perceived defect (Veale & Riley, 2001). Hypothetically, this could lead to an over-

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representation within sensory cortex dedicated to processing perceived defect-related stimuli.
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Acute mirror exposure increases self-focused attention, both in individuals with BDD and

healthy controls (Winheim et al., 2011). Additionally, experimentally increasing self-focused

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attention prior to mirror exposure worsened body satisfaction in a non-clinical sample of women
ED

(Veale et al., 2016). These findings appear paradoxical given the association between elevated

self-focused attention and psychopathology and the efficacy of mirror exposure therapy;
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however, they may explain the clinical worsening that a small number of vulnerable individuals
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have experienced early in treatment with mirror exposure therapy. Mirror exposure therapy may

act in part by redirecting the focus of attention away from negative body parts to the more
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balanced focus of those low in body image concerns (Glashouwer et al., 2016; Smeets et al.,

2011), thereby globally reducing self-focused attention after completion of a full course of

treatment. Mirror exposure might also act in part through a cognitive retraining mechanism,

whereby the individual is trained to view their body more globally rather than focusing on fine

details. Individuals who dedicate excessive attention to a particular area and engage in excessive
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mirror gazing may benefit from learning to spread their attention across their body.

In support of the hypothesis that cognitive biases towards negatively perceived body parts

may perpetuate body dissatisfaction, a single computer training session that focused attention on

self-defined most attractive body parts, but not a training session that focused attention evenly

across the body, was found to increase body satisfaction for subjects with high body

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dissatisfaction (Smeets et al., 2011). Unfortunately, both training paradigms decreased mood

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acutely and the persistence of efficacy was not tested (Smeets et al., 2011). Glashouwer et al.

CR
(2016) found that 4 sessions of mirror exposure therapy in which subjects were asked to focus on

their self-defined most attractive body parts had no effect on where they looked when viewing

US
pictures of themselves even though the therapy improved body satisfaction. Further research is
AN
required to determine whether other styles or longer durations of mirror exposure therapy act via

redirecting gaze preference, reducing self-focused attention or modifying other attentional biases.
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In addition to benefits for anxiety, obsessive-compulsive and post-traumatic stress

ED

disorders, exposure response prevention therapy has been shown to have some benefit in both

AN and BN and is explicitly incorporated into CBT for BDD (Bulik, Sullivan, Carter, McIntosh
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& Joyce, 1998; Foa & McLean, 2016; Leitenberg, Rosen, Gross, Nudelman & Vara, 1988;
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Harrison et al., 2016; Levinson et al., 2015; McKay et al., 2015; Steinglass et al., 2014; Wilson,

Eldredge, Smith & Niles, 1991). During mirror exposure, one’s own body image in the mirror
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serves as a conditioned stimulus (CS), which may elicit a conditioned response (CR) of anxiety

(Klimek, Grotzinger & Hildebrandt, 2016). Mirror exposure therapy may act via mechanisms

similar to other exposure therapies by enhancing extinction learning, through formation of a new

safety memory that attenuates the negative response and/or through habituation (Craske et al.,

2008; Foa & McLean, 2016). Several studies on mirror exposure therapy suggest that habituation
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to the discomfort and negative affect associated with visual exposure to one’s own body occurs

within and between sessions (Díaz-Ferrer et al., 2017; Trentowska et al., 2013; Trentowska et al.,

2017). Thus, the total negative valence of the CR, anxiety, diminishes over the course of the

mirror exposure therapy (Key et al., 2002; Jansen et al., 2008). While some degree of anxiety

response attenuation often occurs within sessions, the precise learning mechanism (habituation,

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extinction learning and/or new safety memory) is unclear. Further, within session attenuation of

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negative affect does not necessarily correlate with treatment outcomes in other exposure

CR
paradigms (Caske et al., 2008), and Díaz-Ferrer et al. (2017) found that although within session

attenuation of negative emotion occurs during pure mirror exposure therapy but not during

US
guided non-judgmental mirror exposure therapy, both types of mirror exposure are therapy
AN
effective.

Alternatively, it has been proposed that disgust towards one’s own body may contribute
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to body image disturbances by serving as the primary CR, not anxiety (Klimek et al., 2016).
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Differently from conditioned anxiety, conditioned disgust is more effectively modified by

counterconditioning (e.g. novel pairing of the CS (body image) with positive or neutral emotions
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via classical conditioning) than by manipulation of the original CS (body image)  CR (disgust)
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association (i.e. operant conditioning; Engelhard, Leer, Lange & Olatunji, 2014). In this model,

mirror exposure may improve body image dissatisfaction through counterconditioning rather
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than weakening the net negative valence of the CR (Klimek et al., 2016). Evaluative

conditioning (EC), the basis for counterconditioning, transfers valence between a CS and an

unconditioned stimulus (US) without utilizing a contingency (CS-US). The neurocircuitry of EC,

particularly in the context of disgust, involves greater insula processing of a CS-US association

and less robust activation in the dorsal anterior cingulate cortex and nucleus accumbens
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compared to reward learning (Schweckendiek et al., 2013). Therefore, body image disturbances

may be resistant to change through traditional exposure therapies because they originate from the

acquisition of a disgust response to one’s body. Classic exposure models rely on the creation of

a new, less threatening contingency and consolidation of this new memory (Craske, Hermans &

Vervliet, 2018), a memory that would not form if the exposure led consistently to an aversive

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(i.e. disgust) response. Counterconditioning does not rely on the conscious formation of a new

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memory (Sweldens, Corneille & Yzerbyt, 2014) and may change valence independent of

CR
awareness of the perceived causal relationship between body exposure and negative

consequences. For example, during guided non-judgmental mirror exposure therapy, the repeated

US
pairing of a negatively valanced CS (body image) with a neutrally valanced US (the descriptive
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procedure) may act by transferring valence from the US to the CS over time and reducing its

negativity.
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Mirror exposure therapy may also act through the creation of cognitive dissonance,
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discomfort arising through a conflict between belief and behavior (Festinger, 1957; Jansen et al.,

2016; Klimek et al., 2016; Luthcke et al., 2011). The creation of discomfort is thought to drive
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behavioral modification to align belief and behavior and decrease discomfort (Festinger, 1957;
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Jansen et al., 2016; Klimek et al., 2016; Luthcke et al., 2011). Although cognitive dissonance is

most clearly created when a subject is asked to describe body parts exclusively using language
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with positive valence (Jansen et al., 2016; Luthcke et al., 2011), even the use of neutral language

could create dissonance for an individual with strongly negative body image related beliefs

sufficient to drive a behavioral change.

In addition to change induced while an individual confronts their body in a mirror, mirror

exposure therapy paradigms may effect change outside of the therapist’s office. Most
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interventions implicitly or explicitly ask patients to reduce body-checking and avoidance outside

of sessions (Delinsky & Wilson, 2006; Glashouwer et al., 2016; Harrison et al., 2016;

Hildebrandt et al., 2012). These behavioral changes may play a role in driving improvements in

body image during mirror exposure therapy; however, they are likely not the only mechanism of

change in mirror exposure therapy as Delinsky and Wilson (2006) included similar homework

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assignments in their mirror exposure and control conditions and still found a benefit to mirror

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exposure therapy. Mirror exposure in the therapeutic context, however, may act to drive

CR
behavioral changes outside of sessions beyond instructive interventions. By training one to look

at themselves in the mirror differently than they had been, mirror exposure therapy might

US
provide benefit both to individuals who engage in excessive body checking and to those who
AN
avoid mirrors. No study has examined whether individuals who engage in a particular mirror

related pathological behavior, either avoidance or excessive use, might be more or less likely to
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benefit from mirror exposure therapy. Importantly, the proposed mechanisms of action discussed
ED

here are not mutually exclusive and some or all may contribute to therapeutic benefit in any

given patient (Klimek et al., 2016).

PT

Mirror exposure therapy beyond eating, weight and body image disorders
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Body image disturbances occur in pathologies beyond eating, weight and body

dysmorphic disorders and exposure to mirrors occurs frequently in every-day life. Responses to
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single mirror exposure sessions have been examined in women with post-traumatic stress

disorder (PTSD) and impairments in sexual arousal (Borgmann, Kleindienst, Vocks & Dyer,

2014; Seal & Meston, 2007). As we hypothesize that mirror exposure therapy for eating, weight

and body dysmorphic disorders likely acts via generalized mechanisms, we will review these

experiments and propose the testable hypotheses that mirror exposure therapy could provide
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benefit for individuals with these pathologies.

Post-traumatic stress disorder

PTSD and childhood trauma are both associated with low body satisfaction (Dyer et al.,

2013; Scheffers et al., 2017). Although there is a very high comorbidity between ED and PTSD

with history of childhood sexual abuse, the body image disturbance seen in women with PTSD

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and history of childhood sexual abuse cannot be fully accounted for by the comorbid ED (Dyer

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et al., 2013). Unsurprisingly, women with trauma histories associate negative emotions with

CR
body areas related to the traumas they have experienced (Dyer, Feldman & Borgmann, 2015).

During a standardized mirror exposure paradigm lasting ~10 minutes, women with PTSD and a

US
history of childhood sexual trauma experience a significantly greater worsening of negative
AN
emotions and cognition compared to healthy controls (Borgmann et al., 2014), similar to what

has been observed for women with BDD (Windheim et al., 2011; Buhlmann et al., 2009) and ED
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(Crino et al., 2017). Given the high prevalence of body dissatisfaction in women with sexual
ED

trauma and their similar response to a single mirror exposure as women for whom mirror

exposure therapy is an effective treatment, mirror exposure therapy could be empirically tested
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as a novel therapeutic intervention for individuals with PTSD and a history of sexual trauma
CE

(Borgmann et al., 2014).

Sexual arousal impairment

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Negative body image is correlated with poor sexual functioning (Davison & McCabe,

2005; Faith & Schare, 1993; Koch, Mansfield, Thurau & Carey, 2005), although the relationship

between body image and sexual functioning may be moderated through self-esteem (Davison &

McCabe, 2005). Interestingly, Seal and Meston (2007) found that after a body awareness

exercise using mirror exposure, women with sexual dysfunction report an increase in subjective
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arousal while listening to audiotapes of erotic stories compared to those receiving a control

intervention without mirror exposure. In this mirror exposure paradigm, women were asked to

use a mirror to place electrocardiogram electrodes on their bodies and the mirror remained

present while they subsequently listened to erotica (Seal & Meston, 2007). Future studies could

investigate mirror exposure therapy for sexual arousal impairments and would benefit from

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testing whether mirror exposure therapy has a beneficial and persistent effect on sexual arousal

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and performance with a partner.

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Clinical indications and pearls

Based on the available evidence reviewed here, we recommend mirror exposure therapy

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for treatment of body image disturbances, both in the presence and absence of ED, and as an
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optional component of CBT for BDD. Mirror exposure therapy should be carried out under the

supervision of an experienced clinician who can screen for contraindications and monitor for
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adverse events. Particular caution should be exercised if mirror exposure therapy is used to treat
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individuals with a history of self-harm, suicidality or with current clinical depression based on

adverse events observed in clinical trials (Delinsky & Wilson, 2006; Hildebrandt et al., 2012;
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Mataix-Cols et al, 2015). We recommend screening prior to initiation and monitoring during
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treatment for: suicidal ideation, self-harm behaviors and depressive symptoms. Significant

worsening in any of these domains should prompt termination of mirror exposure therapy and
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referral to a higher level of care if indicated.

Over and underweight individuals comprise special populations for mirror exposure

therapy. Due to their exclusion from most clinical trials, we believe that mirror exposure therapy

for over or underweight individuals should be restricted to expert clinicians whose practices are

focused on these populations and to randomized, controlled clinical trials to assess efficacy
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within these populations.

Several variations of mirror exposure therapy have been reported to have benefit, and

clinicians may wish to tailor therapy to the individual patient. Focusing on a patient’s most

positively perceived body parts and encouraging the use of language with positive valence may

be more tolerable (Jansen et al., 2016; Luethcke et al., 2011) and thus could be selected for a

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patient with poor distress tolerance or when only a few mirror exposure sessions are feasible.

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Pure mirror exposure therapy and mirror exposure focusing exclusively on the body parts that a

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patient is most dissatisfied with may be the most effective forms of mirror exposure therapy

tested (Díaz-Ferrer et al., 2017; Jansen at al., 2016; Moreno-Domínguez et al., 2012). Focusing

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on negatively perceived body parts exclusively has not been trialed in a clinical population.
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Two important considerations should be given attention prior to selection of the mirror

exposure therapist: gender matching between patient and therapist and whether mirror exposure
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therapy should be conducted by the same therapist providing the patient with other
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psychotherapies. During mirror exposure therapy, patients are challenged to wear revealing

clothing, often undergarments. Thus, care should be taken to ensure that local practice is
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considered when deciding whether to undertake therapy with a non-gender matched patient. Our
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clinical practices differ in this regard based on experiences with local populations.

Mirror exposure has been successfully incorporated into manualized CBT with the same
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therapist conducting all components of therapy (Beilharz et al., 2017; Harrison et al., 2016;

Tuschen-Caffier et al., 2001). We support the use of comprehensive, manualized therapy with a

single therapist; however, our clinical experience is that in non-research settings, indications for

mirror exposure are often revealed during ongoing psychotherapy. In this common scenario, we

recommend that the therapist consider the possible complications of unwanted transference-
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countertransference development and/or the appearance of impropriety. A clinician with little

experience in mirror exposure therapy, who is in a private office without other staff, who is

gender mismatched with their patient or who has any other concern that mirror exposure therapy

could disrupt their therapeutic alliance with the patient should feel comfortable referring the

patient to a colleague for the mirror exposure component of treatment with whom they can

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collaborate. We typically provide mirror exposure therapy as an adjunct to ongoing

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psychotherapy by the treating therapist when indicated. A typical course of treatment involves

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approximately 6 one-hour sessions, including preparation, exposure and debriefing in each

session.

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Conclusions
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Mirror exposure therapy is a transdiagnostic treatment for individuals with body image

disturbances and ED; however, larger, randomized controlled trials are needed to further validate
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the efficacy of and more completely characterize the side effects of mirror exposure therapy. The
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greatest areas of need for further clinical trials are: trials with equal gender distributions or

entirely male populations; trials testing the specific value of mirror exposure in BDD; trials of
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mirror exposure in underweight and overweight populations with attention paid to weight
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gain/loss during the trial; and trials in specific ED groups (AN, BN and BED). Additionally,

every clinical trial explicitly including a mirror exposure component that we have referenced was
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conducted in Europe or the United States of America. Whether mirror exposure therapy has the

same benefits and risks in other countries and cultures is unknown. With these caveats in mind,

we recommend mirror exposure therapy as an effective and generally well tolerated treatment of

body image dissatisfaction to be administered by an experienced clinician.

Role of Funding Sources

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The research did not receive any specific grant from funding agencies in the public,

commercial, or not-for profit sectors.

Contributors

TCG wrote the first draft of the manuscript. All authors contributed to revising the

manuscript and all authors have approved the final manuscript.

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Conflict of Interest

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All authors declare they have no conflicts of interest.

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Author Biography

Trevor C. Griffen, MD, PhD is a Resident Psychiatrist at the Mount Sinai Hospital, where he

divides his time between practicing medicine and clinically oriented research. He completed both

medical and graduate school at Stony Brook University.

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Tom Hildebrandt, PsyD, FAED is the Chief of the Division of Eating and Weight Disorders

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(Center of Excellence) at Mount Sinai and an Associate Professor of Psychiatry at the Icahn

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School of Medicine at Mount Sinai. He completed his graduate training at Rutgers University

and his post-doctoral fellowship at the Icahn School of Medicine at Mount Sinai. He is an active

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clinician and currently oversees the development and execution of both the clinical and research
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programs.
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Eva Naumann, PhD is a Visiting Research Fellow at the Eating and Weight Disorders Program
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at Mount Sinai. She completed her graduate training at the University of Marburg and worked as

a research assistant at the University of Freiburg. She received her doctorate in Clinical
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Psychology from the University of Tuebingen and her license as a psychotherapist from FAVT
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in Freiburg, Germany.
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Highlights

 Body dissatisfaction is common and difficult to treat

 Mirror exposure therapy is an effective treatment for body dissatisfaction

 Mirror exposure has been used in eating disorders, BDD and non-clinical populations

 Several styles of mirror exposure therapy are effective

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