Clinical Psychology Review 65 (2018) 163–174

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Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

Mirror exposure therapy for body image disturbances and eating disorders: T
A review
⁎
Trevor C. Griffena, , Eva Naumannb, Tom Hildebrandtb
a
Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
b
Eating and Weight Disorders Program, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA

H I GH L IG H T S

• 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.

A R T I C LE I N FO A B S T R A C T

Keywords: Mirror exposure therapy is a clinical trial validated treatment component that improves body image and body
Body image satisfaction. Mirror exposure therapy has been shown to benefit individuals with high body dissatisfaction and
Mirror exposure therapy patients with eating disorders (ED) in clinical trials. Mirror exposure is an optional component of cognitive
Eating disorders behavioral therapy (CBT), an effective treatment for body dysmorphic disorder (BDD). However, most clinical
Body dysmorphic disorder
trials of mirror exposure therapy have been small or uncontrolled and have included few male subjects. Adverse
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 evaluate the evidence in favor
of mirror exposure therapy. We discuss clinical indications and technical considerations for the use of mirror
exposure therapy.

1. Introduction
The self-perception of and emotional valence attached to one's body
affects many important aspects of life. Negative body image is asso-
ciated with low self-esteem, disordered eating, negative sexual experi-
ences, depression and anxiety, and is a risk factor for the development
of ED (Cash & Szymanski, 1995; Davison & McCabe, 2005; Faith &
Schare, 1993; Johnson & Wardle, 2005; Koch, Mansfield, Thurau, &
Carey, 2005; Noles, Cash, & Winstead, 1985; Stice & Shaw, 2002). Body
image influences the emotional responses people have while viewing
themselves in a mirror (Servián-Franco, Moreno-Domínguez, & Reyes
Del Paso, 2015; Svaldi, Zimmermann, & Naumann, 2012). Many in-
dividuals with ED and BDD have a problematic relationship with mir-
rors, often alternating between excessive mirror checking and mirror
avoidance (Beilharz, Castle, Grace, & Rossell, 2017; Grant & Phillips,
2005).
Both ED and BDD include body image disturbance as a core clinical
feature, share common pathological elements and have increased co-
morbidity with obsessive-compulsive disorder (American Psychiatric
Association [APA], 2013; Phillips & Kaye, 2007). Severity of body
image disturbance correlates with ED symptom persistence, suggesting
that specifically targeting body image disturbances could promote re-
covery from ED (Stice & Shaw, 2002). Although several interventions
have been designed to target body image dissatisfaction, a meta-ana-
lysis of randomized controlled trials of body image interventions, in-
cluding fitness training, 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, Tuschen-Caffier, &
Vögele, 2002; Rosen, Reiter, & Orosan, 1995). Exposure therapies have
been found to be broadly effective, including for the treatment of

⁎
Corresponding author at: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029, USA.
E-mail address: trevor.griffen@mountsinai.org (T.C. Griffen).

https://doi.org/10.1016/j.cpr.2018.08.006
Received 8 February 2018; Received in revised form 25 August 2018; Accepted 27 August 2018
Available online 29 August 2018
0272-7358/ © 2018 Elsevier Ltd. All rights reserved.
T.C. Griffen et al.
specific psychiatric illnesses such as obsessive-compulsive disorder (Foa
& McLean, 2016). Thus, mirror exposure therapy targeting body dis-
satisfaction is a rationally designed psychotherapeutic intervention.
Here, we examine where people direct their gaze during mirror
exposures, discuss the acute effects of mirror exposure on both clinical
and non-clinical populations, review both controlled and uncontrolled
trials of mirror exposure as therapy with attention to specific patholo-
gies, explore technical differences in the implementation of mirror ex-
posure, consider potential risks of and contraindications to mirror ex-
posure therapy and attempt to develop a theoretical understanding of
the mechanisms of action of mirror exposure therapy. We also 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 clearly elucidate
the risks, benefits and optimal techniques across different pathological
states.
2. The locus of focus during mirror gazing
2.1. Non-clinical populations
Where does one look when presented with one's reflection in a
mirror? Excessive focus 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 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 of either po-
sitive 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., 2008).
2.2. Body dysmorphic disorder
Most individuals with BDD report spending excessive amounts of
time examining their perceived physical defects in the mirror (Phillips,
Hollander, Rasmussen, & Aronowitz, 1997; Phillips, Menard, Fay, &
Weisberg, 2005). When shown pictures of themselves, those with BDD
tend to bias their attention towards the areas that they are most dis-
satisfied with (Greenberg, Reuman, Hartmann, Kasarskis, & Wilhelm,
2014; Grocholewski, Kliem, & Heinrichs, 2012; Kollei, Horndasch,
Erim, & Martin, 2017); however, when scanning is analyzed on a case-
by-case basis, some individuals show a 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 visual attention to their perceived defects and some
engaging in repetitive mirror gazing but avoiding their perceived de-
fects. These results have not yet been replicated using eye tracking
while individuals with BDD look at themselves in a mirror.
2.3. Eating and weight disorders
Similar to body dissatisfied women without ED, women with an-
orexia 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 with AN spend a significantly greater
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Clinical Psychology Review 65 (2018) 163–174
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). To-
gether, 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., 2016). When those with ED or who are overweight view
pictures of themselves, they also tend to have bias towards their self-
reported more unattractive body parts (Jansen, Nederkoorn, &
Mulkens, 2005; Kollei et al., 2017; Svaldi, Caffier, & Tuschen-Caffier,
2011) although this result has not been consistent across all studies
(von Wietersheim et al., 2012; Warschburger, Calvano, Richter, &
Engbert, 2015).
3. Responses to looking in the mirror
Mirrors are ubiquitous in contemporary society; they are nearly
impossible to avoid. Those with body image disturbances look at
themselves in the mirror differently than those with higher body sa-
tisfaction (Svaldi et al., 2016; Tuschen-Caffier et al., 2015). Mirrors
provide a source of repeated and possibly distressing exposure to and
reminder of one's self-perceived best features and worst flaws.
3.1. Non-clinical populations
Body dissatisfaction and distress increase in both men and women
after they briefly look 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 min 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
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.
Baseline body dissatisfaction also affects emotional responses to
mirror exposure. Females without ED or obesity but with high body
dissatisfaction experience more negative emotions during brief mirror
exposure than those low in body dissatisfaction (Servián-Franco et al.,
2015). Interestingly, females with high body dissatisfaction experience
increased body dissatisfaction after a negative but not after a positive
manipulation of self-esteem prior to the 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).
In summary, in non-clinical populations mirror exposure leads to
distress and worsening of body dissatisfaction (Veale et al., 2016;
Walker et al., 2012). This population effect is likely driven by reactions
from individuals with high baseline body dissatisfaction (Servián-
Franco et al., 2015; Svaldi et al., 2012). Manipulating the emotional
content of a mirror exposure session, 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 et al., 2007).
3.2. Body dysmorphic disorder
Approximately 90% of individuals with BDD report spending ex-
cessive 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,
Menard, & Bjornsson, 2013). After looking in the mirror, individuals
T.C. Griffen et al.
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 ex-
perience more disgust in response to viewing themselves in a mirror
than healthy controls (Neziroglu, Hickey, & McKay, 2010). Thus, for
individuals with BDD mirror gazing is often a compulsive act that oc-
cupies a substantial amount of their time. Rather than relieving nega-
tive emotions, for individuals with BDD, looking in the mirror produces
negative emotions.
3.3. Eating and weight disorders
Like individuals with BDD, most women with ED engage in body
checking behaviors, 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
with ED also frequently engage in body avoidance behaviors, such as
covering mirrors, and 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 engaging in body checking and/or avoiding behaviors, often
mirror related, that lead to considerable distress.
Those with ED tend to experience even more distress and negative
emotions than healthy 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). Ad-
ditionally, for women with BED a brief mirror exposure increases both
salivation and their desire to binge eat (Naumann et al., 2013).
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-effi-
cacy may be at least partly unfounded: when undergoing prolonged
mirror exposure as 40 min of recording guided self-viewing, individuals
with ED experience an increase in negative emotions at the start of the
mirror exposure that declines to near baseline by the end of the session
(Vocks et al., 2007). 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.
Body image disturbances in ED often go beyond dissatisfaction with
one's appearance 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,
2005). Most contemporary studies have found that females with AN and
BN overestimate their 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 dimen-
sional avatars were used to make body size estimations. Overestimation
of body size by women with ED is not limited to situations when sen-
sory feedback is not directly available, as they overestimate body size
more than those without ED even when looking in a mirror while es-
timating (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).
These data show that although seeing at oneself in a mirror is a
common experience, looking in a mirror can induce distress and ne-
gative 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
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Clinical Psychology Review 65 (2018) 163–174
estimation of their body size even more than those without ED (Norris,
1984; Vocks et al., 2007).
4. Mirror exposure therapy
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 image. Mirror exposure has
been incorporated into manualized, disease-focused CBT paradigms,
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 to the discretion of
the therapist (Beilharz et al., 2017; Harrison, Fernández De La Cruz,
Enander, Radua, & Mataix-Cols, 2016). Mirror exposure has also been
used as an adjunctive, stand-alone therapy designed to augment on-
going, disease targeting interventions (Hildebrandt, Loeb, Troupe, &
Delinsky, 2012). Beyond interventions for those with diagnosable psy-
chiatric 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 individuals
(those without psychiatric illness or severe body image concerns) re-
cruited 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.
4.1. Search strategy
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 dys-
morphic.” This search returned 954 titles, which were screened at the
level of title and abstract, and included if criteria were met after review
of the text. Additionally, the reference lists of included studies as well as
those of review articles identified that focused on treatment of eating,
feeding, body image or weight disorders were screened. Inclusion cri-
teria were: 1) Full length articles written in English 2) Articles indexed
on Pubmed as of April 27, 2018 3) Articles describing prospectively
designed clinical evaluations of mirror exposure therapy, independent
of randomization or control, with at 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 therapeutic intent, even if additional therapeutic ele-
ments were incorporated. Studies identified that included mirror ex-
posure as one required component of multisession therapy but with
ambiguity as to whether at least two separate mirror exposures were
required of all participants were excluded formally (but discussed in the
text) 4) Articles with outcomes related to body 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 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 ad-
ditional studies were identified through the reference lists of those
studies. Five treatment focused review articles were found using the
search query, but no additional studies fitting inclusion criteria were
identified through their reference lists.
4.2. Non-clinical populations
Four uncontrolled studies have examined whether repeated mirror
T.C. Griffen et al.
exposure therapy might benefit healthy adult women without a history
of an ED. In one, healthy control women (n = 19) had very low baseline
negative thoughts, negative emotions and levels of distress, and they
had high baseline positive emotions. These parameters did not change
between mirror exposure 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 improvements in mood (Hilbert et al., 2002; Luethcke,
McDaniel, & Becker, 2011), body satisfaction and ED symptoms fol-
lowing mirror exposure therapy (Luethcke et al., 2011). Another small
(n = 13) study of healthy women found that negative thoughts asso-
ciated with watching a film of one's body were reduced after 3 sessions
of mirror exposure therapy (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 mood and possibly body image satisfaction. How persistent
these changes are and whether the observed improvement in ED
symptoms reduces risk of developing an ED remain unanswered.
Three small, randomized controlled trials have examined whether
mirror exposure is beneficial for women with body dissatisfaction re-
cruited 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
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 measures, including
negative thoughts, feelings of ugliness, body checking and dissatisfac-
tion, ED symptoms and depression (Delinsky & Wilson, 2006;
Glashouwer et al., 2016; Moreno-Domínguez et al., 2012). Mirror ex-
posure therapy did not, however, change the proportion of time that
body dissatisfied women spent looking at their self-reported least at-
tractive compared to most attractive body parts during a picture
viewing assessment (Glashouwer et al., 2016). Two 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 across conditions (n = 22 and
n = 35; Díaz-Ferrer, Rodríguez-Ruiz, Ortega-Roldán, Mata-Martín, &
Carmen Fernández-Santaella, 2017; Jansen et al., 2016).
4.3. Body dysmorphic disorder
BDD is an extreme form of body dissatisfaction that includes ob-
sessions and/or 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 identify any
studies investigating the efficacy of mirror exposure therapy for in-
dividuals with BDD as defined in our methods. BDD specific CBT has
been extensively studied and found to be an effective treatment
(Beilharz et al., 2017; Harrison et al., 2016). 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., 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 et al., 2011; Wilhelm et al., 2014; Wilhelm,
Buhlmann, Hayward, Greenberg, & Dimaite, 2010; Wilhelm, Otto, Lohr,
& Deckersbach, 1999; Wilhelm, Phillips, Fama, Greenberg, & Steketee,
2011), group CBT with at home mirror exposure homework (Rosen
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Clinical Psychology Review 65 (2018) 163–174
et al., 1995), CBT with optional mirror exposure (Mataix-Cols et al.,
2015; Veale et al., 2014), CBT with exposure-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, 1996) and CBT without any explicit
description of mirror exposure (Enander et al., 2016; Veale 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, Kalantari, Molavi, & Bahrami,
2012). Although mirror exposure has been included as a required 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 descriptions of mirror
exposure have both reported clinically significant benefit and no study
has directly compared different paradigms. Whether mirror exposure
provides additive benefit beyond CBT without mirror exposure for in-
dividuals with BDD remains unexplored.
4.4. Eating and weight disorders
4.4.1. 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 resulted in a sig-
nificantly 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 con-
trolled and one uncontrolled, found improvements in body image after
treatment (Bhatnagar, Wisniewski, Solomon, & Heinberg, 2013; Vocks,
Wächter, Wucherer, & Kosfelder, 2008).
4.4.2. Anorexia nervosa
Mirror exposure therapy has not been trialed for low weight AN out
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 weight restored in-
dividuals with AN. Key et al. (2002) conducted a non-randomized trial
and 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 dissatisfaction
only in the mirror exposure therapy group. A larger, uncontrolled trial
of group 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., 2014). Ad-
ditionally, a case series of three individuals with weight restored AN
and persistent ED symptoms found benefit for acceptance and com-
mitment therapy that included a mirror exposure component (Berman,
Boutelle, & Crow, 2009). A larger, randomized controlled trial is needed
to replicate these preliminary results.
4.4.3. 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-Ferrer,
Rodríguez-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 groups; however, improvement in
T.C. Griffen et al.
ED symptoms was only observed in the ED-NOS group. The difference
in ED symptom improvement could be secondary to the baseline illness
severity or to the difference in treatment protocols. Three other studies
of women with BN (n = 29, n = 19 and n = 13) found that mirror ex-
posure reduces body dissatisfaction, distress and negative thoughts
(including those associated with watching videos of one's body) and
increases positive thoughts (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 mirror
exposure sessions is effective at reducing binging, body dissatisfaction
and depressive symptoms in women with BN (Tuschen-Caffier, Pook, &
Frank, 2001).
4.4.4. Binge eating disorder
One study has examined the effects of mirror exposure therapy in
binge eating disorder (BED). Hilbert et al. (2002) found improvement in
mood and appearance related self-esteem during a second mirror ex-
posure session in a group of women (n = 30) with BED in an un-
controlled trial. Additionally, in a small, randomized, controlled trial of
19 sessions of group CBT with 4 body exposure sessions (including an
unspecified number of mirror exposures) or with 4 cognitive re-
structuring 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 dis-
satisfaction, ED symptoms (including binging) and depression improved
over treatment, but not differentially between conditions (Hilbert &
Tuschen-Caffier, 2004). It is not clear how much of the exposure ses-
sions 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.
4.4.5. Obesity
Body dissatisfaction is prevalent among obese individuals
(Weinberger, Kersting, Riedel-Heller, & Luck-Sikorski, 2016); however,
most trials of mirror exposure therapy have excluded obese individuals.
A small randomized, controlled trial for male and female 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 improvement in body dis-
satisfaction and anxiety (Jansen et al., 2008). This trend towards a
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 male, 2 female)
undergoing a comprehensive weight loss program that included
watching oneself 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 therapy, has not been followed up with further published
research. As these studies were 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 of obesity and associated body image dissatisfaction.
4.5. 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
mirror image therapy for body dissatisfaction, BN and BED are limited
by having only female subjects, and very few male subjects were in-
cluded 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
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mirror exposure and included control groups. Of these, 1 trial was not
randomized and included only 15 participants in total (Key et al.,
2002). One trial included only 16 total participants, reported only a
trend towards a benefit, and did not include validated outcome mea-
sures of body image satisfaction, 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 = 137, 97% female) and all found significant benefit
of mirror exposure therapy over control treatment (Delinsky & Wilson,
2006; Glashouwer et al., 2016; Hildebrandt et al., 2012; Moreno-
Domínguez et al., 2012). Additionally, one randomized controlled trial
found an effect of time in treatment for exposure therapy including
mirror exposure that was not better than cognitive 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 excluded individuals that
were underweight or obese (Delinsky & Wilson, 2006; Glashouwer
et 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 of participants
was in the obese range. All subjects were treated with CBT, either with
a body exposure component or with a cognitive restructuring compo-
nent. The body exposure component included mirror and video ex-
posure and exposure to “avoided body-related situations” and the re-
lative amount of each component was not specified (Hilbert & Tuschen-
Caffier, 2004). Therefore, because the experimental manipulation did
not explicitly require multiple mirror 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 con-
trolled 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 exposure therapy not restricted entirely to mirror exposure) or
to the presence of a robust control intervention.
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 proposed by Morris
for pretest-posttest experimental designs (Morris, 2008) for the 4 ran-
domized, controlled studies that matched inclusion criteria, directly
manipulated individual mirror exposure sessions and had validated
measures of body image satisfaction, body image related behaviors
and/or eating disorder symptoms as primary outcomes (Delinsky &
Wilson, 2006; 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 the difference between the pre- and posttest mean of the control
group and divided by the pooled 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 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 Delinsky and Wilson (2006), we found a medium
effect of mirror exposure on shape and weight concerns (Eating Dis-
order Examination-Questionnaire (EDE-Q), Shape and Weight Con-
cerns, d+ = 0.50) and small effects on body image avoidance (Body
Image 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 Shape Ques-
tionnaire (BSQ), d+ = 1.67, 0.57). In the study by Glashouwer et al.
(2016), we found a medium effect on eating disorder symptoms (EDE-
T.C. Griffen et al.
Q, d+ = 0.70). Finally, in the study by 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 Dis-
order Scale (YBC-EDS), obsessions subscale, d+ = 0.77) and eating-re-
lated rituals (YBC-EDS, rituals subscale, d+ = 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 out-
comes from these four studies for sample size, we found an overall
medium effect of mirror exposure compared to control conditions,
d = 0.67.
5. Technical considerations for mirror exposure therapy
Many variations of mirror exposure therapy have been reported.
Most studies of mirror 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 pro-
gressing 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 obser-
ving and commenting on evoked emotions as they arise (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 BN (Díaz-Ferrer et al.,
2015), all trials comparing mirror exposure modalities used body dis-
satisfied women as subjects (Díaz-Ferrer et al., 2017; Jansen et al.,
2016; Luethcke et al., 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
context of a therapy group, and no trial has empirically determined the
ideal length of mirror 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
manipulated to be more upright experienced more positive emotions
than those whose posture 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
sustained improvements is unknown.
5.1. Pure mirror exposure versus guided non-judgmental mirror exposure
The technique applied during a mirror exposure session as well as
the length of the session can alter the emotional response during and
after the exposure session (Díaz-Ferrer et al., 2015; Díaz-Ferrer et al.,
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 dis-
satisfaction, both therapeutic techniques achieve similar improvement
over baseline in 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 dissatisfaction (Díaz-Ferrer et al., 2015). Together, these findings
suggest that pure mirror exposure therapy may have some benefit over
the guided non-judgmental technique. These therapies differ in two
important ways: where the individual is instructed to look (whole body
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versus sequential body parts) and the language that the individual is
instructed to use (describing emotions that arise versus non-judgmental
descriptions of appearance). Either or both of those parameters could
account for the benefit seen with the pure mirror exposure technique.
5.2. Adding an emotional focus to mirror exposure
Jansen et al. (2016) modulated where subjects with body dis-
satisfaction directed their 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 instructed participants to focus on viewing their self-defined most
attractive body parts and use 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 (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. The negative focus
group experienced more negative thoughts during early therapy ses-
sions than the positive focus group; however, this difference dis-
appeared 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 valence to using non-
judgmental language. They found that for both treatment styles, ED
symptoms and mood improved similarly, but body satisfaction im-
proved only in the positive valence condition (Luethcke et al., 2011).
This study has two important limitations: only 2 mirror exposure ses-
sions were used, compared to 3–6 sessions in other studies (Delinsky &
Wilson, 2006; Díaz-Ferrer et al., 2015, 2017; Hildebrandt et al., 2012;
Jansen et al., 2016; Moreno-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 Luethcke et al. (2011) extended their treatment to include
more mirror exposure sessions, they would have found a positive effect
of using non-judgmental language on body image.
6. Risks of and relative contraindications to mirror exposure
therapy
6.1. Adverse events in clinical trials of mirror exposure therapy
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 (Barlow, 2010; Bystedt,
Rozental, Andersson, Boettcher, & Carlbring, 2014; Crown, 1983).
Uncontrolled trials that show symptomatic improvement might re-
present 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 (Veale et al., 2016; Walker et al., 2012;
Windheim et al., 2011), mirror exposure 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; Wilhelm et al., 1999). Greenberg et al. (2016)
reported that 2 subjects in their trial of CBT with mirror exposure for
BDD dropped out due to needing a higher level of care. If some parti-
cipants dropped out due to clinical deterioration secondary to therapy,
T.C. Griffen et al.
this may have led to overestimation of benefit.
In randomized controlled trials of CBT with either optional or no
explicit mention of 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
CBT and 1 sleep disturbance in and 1 suicide attempt by control sub-
jects (Enander et al., 2016; Mataix-Cols et al., 2015). In those rando-
mized controlled trials where mirror exposure was included in CBT for
all subjects, 5 receiving CBT compared to 6 controls dropped out
(Hilbert & Tuschen-Caffier, 2004; Wilhelm et al., 2014). Thus, in ran-
domized controlled trials of CBT with or without mirror exposure, drop-
out and adverse event rates are similar in study and control interven-
tions. One cannot determine the specific impact of mirror exposure in
these trials given that mirror exposure was not manipulated in isola-
tion.
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 be-
haviors; both had prior histories of these behaviors (Hildebrandt et al.,
2012). No 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 sig-
nificantly 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 intervention and to extend our understanding of whether there may
be gender differences in treatment risk. Given that the total number of
adverse events that has been reported in mirror 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.
6.2. Underweight and obese populations
Mirror exposure therapy for individuals at weight extremes is con-
troversial (Morgan et al., 2014) and most randomized controlled trials
of mirror exposure therapy have excluded underweight and obese in-
dividuals (Delinsky & Wilson, 2006; Glashouwer et al., 2016;
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 decrease in motivation
to change weight. During a small randomized controlled trial of mirror
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 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 in-
vestigated in a future larger and longer clinical trial.
Vocks et al. (2008) included 3 subjects with AN who were pre-
sumably underweight by 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 re-
storation; however, a single ME in this group does result in a reduction
of body size estimation (Norris, 1984). Whether the reduction in body
dissatisfaction and negative emotions seen after mirror exposure
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
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underweight body.
A controlled trial of a psychoeducational group therapy focused on
body image compared to waitlist was well tolerated and led to im-
provement in shape and weight concerns for underweight individuals
with AN (Mountford et al., 2015). If mirror exposure can be tolerated
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 lose weight at the core of
AN pathology. This hypothesis remains to be tested and should be done
so with caution given concerns of experienced clinicians (Morgan et al.,
2014).
7. Mechanism of action of mirror exposure therapy
How mirror exposure therapy confers therapeutic benefit is un-
known. 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 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 me-
chanism and it is unknown whether mirror exposure therapy is effective
or safe in underweight individuals with AN (see above). Beyond un-
derweight AN, there is insufficient empirical evidence to assign possible
mechanisms of action to specific underlying pathological states.
Appearance related cognitive biases, both attentional and inter-
pretive, have been described in ED (Bauer et al., 2017; Cardi et al.,
2017; Cooper, 1997; Glashouwer et al., 2016; Smeets, Jansen, & Roefs,
2011) and BDD (Greenberg et al., 2014). Individuals with ED tend to
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 interpret negative
social cues as relating to their appearance (Buhlmann et al., 2002).
Interventions targeting negative interpretation biases have had some
success in BDD and AN (Summers & Cougle, 2016; Turton, Cardi,
Treasure, & Hirsch, 2018). Mirror exposure therapy may normalize
interpretive biases by training individuals to interpret their bodies in an
objective, affectively neutral or affectively positive manner (Delinsky &
Wilson, 2006; Luethcke et al., 2011).
Individuals with body dissatisfaction also have attentional biases
that likely play both etiological and maintaining roles in their pa-
thology. These attentional biases take the form of both own-body spe-
cific and generalized visual processing deficits. Individuals with AN, BN
and BDD spend more time visually attending to fine details at the ex-
pense of global features relative to healthy controls, resulting in defi-
cient performance on the Rey-Osterrieth Complex Figure Task
(Deckersbach et al., 2000; Lang et al., 2016). The biases of body dis-
satisfied 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; Windheim et al., 2011;
Zucker et al., 2015). Interestingly, underweight individuals with AN
report less self-focused attention than healthy controls (Zucker et al.,
2015). In BDD, it has been 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-
representation within sensory cortex dedicated to processing perceived
defect-related stimuli.
Acute mirror exposure increases self-focused attention, both in
T.C. Griffen et al.
individuals with BDD and healthy controls (Wilhelm et al., 2011. Ad-
ditionally, experimentally increasing self-focused attention prior to
mirror exposure worsened body satisfaction in a non-clinical sample of
women (Veale et al., 2016). These findings appear paradoxical given
the association between elevated self-focused attention and psycho-
pathology and the efficacy of mirror exposure therapy; however, they
may explain the clinical worsening that a small number of vulnerable
individuals 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 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 fo-
cusing on fine details. Individuals who dedicate excessive attention to a
particular area and engage in excessive 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 dissatisfaction (Smeets et al., 2011). Un-
fortunately, both training paradigms decreased mood acutely and the
persistence of efficacy was not tested (Smeets et al., 2011). Glashouwer
et al. (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 pictures of
themselves even though the therapy improved body satisfaction. Fur-
ther research is required to determine whether other styles or longer
durations of mirror exposure therapy act via redirecting gaze pre-
ference, reducing self-focused attention or modifying other attentional
biases.
In addition to benefits for anxiety, obsessive-compulsive and post-
traumatic stress 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, &
Joyce, 1998; Foa & McLean, 2016; Harrison et al., 2016; Leitenberg,
Rosen, Gross, Nudelman, & Vara, 1988; 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
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 ex-
posure 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 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 ne-
gative valence of the CR, anxiety, diminishes over the course of the
mirror exposure therapy (Jansen et al., 2008; Key et al., 2002). While
some degree of anxiety response attenuation often occurs within ses-
sions, the precise learning mechanism (habituation, extinction learning
and/or new safety memory) is unclear. Further, within session at-
tenuation of negative affect does not necessarily correlate with treat-
ment outcomes in other exposure paradigms (Craske 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 guided non-judgmental mirror exposure therapy, both types of
mirror exposure are therapy effective.
Alternatively, it has been proposed that disgust towards one's own
body may contribute to body image disturbances by serving as the
primary CR, not anxiety (Klimek et al., 2016). Differently from
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Clinical Psychology Review 65 (2018) 163–174
conditioned anxiety, conditioned disgust is more effectively modified
by counterconditioning (e.g. novel pairing of the CS (body image) with
positive or neutral emotions via classical conditioning) than by ma-
nipulation of the original CS (body image) ➔ CR (disgust) association
(i.e. operant conditioning; Engelhard, Leer, Lange, & Olatunji, 2014). In
this model, mirror exposure may improve body image dissatisfaction
through counterconditioning rather 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 ac-
cumbens 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 acqui-
sition of a disgust response to one's body. Classic exposure models rely
on the creation of a new, less threatening contingency and consolida-
tion of this new memory (Craske, Hermans, & Vervliet, 2018), a
memory that would not form if the exposure led consistently to an
aversive (i.e. disgust) response. Counterconditioning does not rely on
the conscious formation of a new memory (Sweldens, Corneille, &
Yzerbyt, 2014) and may change valence independent of awareness of
the perceived causal relationship between body exposure and negative
consequences. For example, during guided non-judgmental mirror ex-
posure therapy, the repeated pairing of a negatively valanced CS (body
image) with a neutrally valanced US (the descriptive procedure) may
act by transferring valence from the US to the CS over time and redu-
cing its negativity.
Mirror exposure therapy may also act through the creation of cog-
nitive dissonance, discomfort arising through a conflict between belief
and behavior (Festinger, 1957; Jansen et al., 2016; Klimek et al., 2016;
Luethcke et al., 2011). The creation of discomfort is thought to drive
behavioral modification to align belief and behavior and decrease dis-
comfort (Festinger, 1957; Jansen et al., 2016; Klimek et al., 2016;
Luethcke et al., 2011). Although cognitive dissonance is most clearly
created when a subject is asked to describe body parts exclusively using
language with positive valence (Jansen et al., 2016; Luethcke 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 interventions implicitly or ex-
plicitly 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 ex-
posure therapy; however, they are likely not the only mechanism of
change in mirror exposure therapy as Delinsky and Wilson (2006) in-
cluded similar homework assignments in their mirror exposure and
control conditions and still found a benefit to mirror exposure therapy.
Mirror exposure in the therapeutic context, however, may act to drive
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 provide benefit both to in-
dividuals who engage in excessive body checking and to those who
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 benefit from mirror ex-
posure therapy. Importantly, the proposed mechanisms of action dis-
cussed here are not mutually exclusive and some or all may contribute
to therapeutic benefit in any given patient (Klimek et al., 2016).
T.C. Griffen et al.
8. Mirror exposure therapy beyond eating, weight and body image
disorders
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 single mirror exposure ses-
sions 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 dis-
orders likely acts via generalized mechanisms, we will review these
experiments and propose the testable hypotheses that mirror exposure
therapy could provide benefit for individuals with these pathologies.
8.1. Post-traumatic stress disorder
PTSD and childhood trauma are both associated with low body sa-
tisfaction (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
and history of childhood sexual abuse cannot be fully accounted for by
the comorbid ED (Dyer et al., 2013). Unsurprisingly, women with
trauma histories associate negative emotions with body areas related to
the traumas they have experienced (Dyer, Feldmann, & Borgmann,
2015). During a standardized mirror exposure paradigm lasting
~10 min, women with PTSD and a history of childhood sexual trauma
experience a significantly greater worsening of negative emotions and
cognition compared to healthy controls (Borgmann et al., 2014), similar
to what has been observed for women with BDD (Buhlmann et al.,
2009; Windheim et al., 2011) and ED (Crino et al., 2017). Given the
high prevalence of body dissatisfaction in women with sexual trauma
and their similar response to a single mirror exposure as women for
whom mirror exposure therapy is an effective treatment, mirror ex-
posure therapy could be empirically tested as a novel therapeutic in-
tervention for individuals with PTSD and a history of sexual trauma
(Borgmann et al., 2014).
8.2. Sexual arousal impairment
Negative body image is correlated with poor sexual functioning
(Davison & McCabe, 2005; Faith & Schare, 1993; Koch et al., 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 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 testing whether mirror exposure therapy has a beneficial and
persistent effect on sexual arousal and performance with a partner.
9. Clinical indications and pearls
Based on the available evidence reviewed here, we recommend
mirror exposure therapy for treatment of body image disturbances, both
in the presence and absence of ED, and as an optional component of
CBT for BDD. Mirror exposure therapy should be carried out under the
supervision of an experienced clinician who can screen for contra-
indications and monitor for adverse events. Particular caution should
be exercised if mirror exposure therapy is used to treat individuals with
a history of self-harm, suicidality or with current clinical depression
based on adverse events observed in clinical trials (Delinsky & Wilson,
171
Clinical Psychology Review 65 (2018) 163–174
2006; Hildebrandt et al., 2012; Mataix-Cols et al., 2015). We re-
commend screening prior to initiation and monitoring during treatment
for: suicidal ideation, self-harm behaviors and depressive symptoms.
Significant worsening in any of these domains should prompt termi-
nation of mirror exposure therapy and 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 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 patient with poor distress tolerance or when only a few
mirror exposure sessions are feasible. Pure mirror exposure therapy and
mirror exposure focusing exclusively on the body parts that a patient is
most dissatisfied with may be the most effective forms of mirror ex-
posure therapy tested (Díaz-Ferrer et al., 2017; Jansen et al., 2016;
Moreno-Domínguez et al., 2012). Focusing on negatively perceived
body parts exclusively has not been trialed in a clinical population.
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 therapy should be
conducted by the same therapist providing the patient with other psy-
chotherapies. During mirror exposure therapy, patients are challenged
to wear revealing clothing, often undergarments. Thus, care should be
taken to ensure that local practice is considered when deciding whether
to undertake therapy with a non-gender matched patient. Our clinical
practices differ in this regard based on experiences with local popula-
tions.
Mirror exposure has been successfully incorporated into manualized
CBT with the same 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-re-
search settings, indications for mirror exposure are often revealed
during ongoing psychotherapy. In this common scenario, we re-
commend that the therapist consider the possible complications of
unwanted transference-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 col-
league for the mirror exposure component of treatment with whom
they can collaborate. We typically provide mirror exposure therapy as
an adjunct to ongoing psychotherapy by the treating therapist when
indicated. A typical course of treatment involves approximately 6 one-
hour sessions, including preparation, exposure and debriefing in each
session.
10. Conclusions
Mirror exposure therapy is a transdiagnostic treatment for in-
dividuals with body image disturbances and ED; however, larger, ran-
domized controlled trials are needed to further validate the efficacy of
and more completely characterize the side effects of mirror exposure
therapy. The 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 mirror
exposure in underweight and overweight populations with attention
paid to weight gain/loss during the trial; and trials in specific ED groups
T.C. Griffen et al.
(AN, BN and BED). Additionally, every clinical trial explicitly including
a mirror exposure component that we have referenced was 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 ex-
posure therapy as an effective and generally well tolerated treatment of
body image dissatisfaction to be administered by an experienced clin-
ician.
Role of funding sources
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.
Conflict of interest
All authors declare they have no conflicts of interest.
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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.
Tom Hildebrandt, PsyD, FAED is the Chief of the Division of Eating and Weight
Disorders (Center of Excellence) at Mount Sinai and an Associate Professor of Psychiatry
at the Icahn 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 clinician and currently oversees the development and ex-
ecution of both the clinical and research programs.
Eva Naumann, PhD is a Visiting Research Fellow at the Eating and Weight Disorders
Program 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 Psychology from the University of Tuebingen and her license as a
psychotherapist from FAVT in Freiburg, Germany.