Consequences of Repeated Critical Versus Neutral Body Checking in Women With High Shape or Weight Concern (2024)

Associated Data

Supplementary Materials

Abstract

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

Keywords: mirror exposure, body checking, body image, eating disorder

Increased attention in body image and eating disorder (ED) research over the past two decades has focused on body checking behaviors, which are identified as potential etiological and maintenance factors of ED pathology in cognitive behavioral models of EDs (Fairburn et al., 2003; Walker et al., 2018). Body checking includes repeated behaviors aimed at gaining information about one’s shape, weight, size, or body composition (American Psychiatric Association, 2013). It is typically focused on disliked body parts and occurs multiple times throughout the day (). Some typical body checking behaviors among women include pinching one’s waist or other body part (e.g., thigh) to assess body fat, measuring the size of a body part (e.g., wrist), and visual examination in a mirror (e.g., standing sideways to evaluate shape of hips and buttocks). A recent meta-analysis found moderate-to-large correlations of .59 between body checking and ED pathology and .62 between body checking and body dissatisfaction (Walker et al., 2018), supporting the importance of body checking in body dissatisfaction and ED etiology and treatment.

Despite body checking’s proposed role as an expression of the core psychopathology of EDs and as a maintenance factor of extreme body dissatisfaction (Fairburn et al., 2003; Shafran et al., 2004), the precise functions, antecedents, and consequences of body checking behaviors remain less well understood (Walker et al., 2018). Based on the transdiagnostic model of EDs, particular variables of interest that may interact with body dissatisfaction and lead to subsequent risk for ED pathology are core low self-esteem and mood intolerance (Fairburn et al., 2003). Prior research demonstrates moderate negative correlation between body checking and self-esteem (r = .39; Reas et al., 2006), and positive correlation between body checking and mood/affect (ρ = .39; Walker et al., 2018), supporting the relationships between these variables. In particular, when individuals pay particular attention to small discernable changes while body checking, perceived fluctuations may trigger negative mood changes, which may contribute to self-critical cognitions and ED behaviors (Mountford et al., 2006). Thus, not only does preexisting low self-esteem increase ED risk (Fairburn et al., 2003), but self-esteem may also be worsened by body checking (Mountford et al., 2006), which may further drive ED pathology. As such, self-esteem and negative affect may both directly and indirectly influence body dissatisfaction and ED psychopathology following body exposure.¹

Function of Body Checking in Body Dissatisfaction and ED Etiology

Body checking may increase vigilance and selective attention to disliked body parts (Shafran et al., 2004; ). In both clinical treatment-seeking (Jansen et al., 2005) and non-clinical (Roefs et al., 2008) samples, women higher in body dissatisfaction demonstrate greater visual attention to self-described unattractive body parts compared to women with lower body dissatisfaction. Selectively attending to disliked body parts may increase body dissatisfaction by magnifying bodily imperfections (Williamson et al., 2004). Supporting this, single session experimental manipulations that induce attentional bias to disliked body parts increased body dissatisfaction in women with EDs and healthy controls (Smeets, Jansen, et al., 2011). Because body checking increases state body dissatisfaction, urges to restrict intake may be heightened (Mountford et al., 2006). This is supported by ecological momentary assessment (EMA) research, in which women with anorexia nervosa restricted more after days in which they engaged in high-frequency body checking (Lavender et al., 2013).

Cognitive behavioral models of EDs suggest that body checking may serve as a safety behavior, reducing anxiety and negative affect in the short-term, but worsening body image, negative affect, and eating-related cognitions and behaviors over time (). For example, if a woman desires weight loss and is anxious that she gained weight, stepping on the scale and finding that her weight was the same or lower than the last time she weighed herself would immediately² decrease her anxiety, negatively reinforcing that body checking behavior (). Although weighing oneself may immediately reduce anxiety on a majority of weigh-ins, when weight stays the same or is lower (assuming random weight fluctuation), regular body checking would maintain or increase self-focus on weight, which is associated with body dissatisfaction and ED pathology (Fairburn et al., 2003). Supporting this, Bailey and Waller (2016) found that women randomly assigned to engage in body checking eight times in a day reported greater fear of uncontrollable weight gain on the body checking day compared to a day on which they were asked not to engage in body checking. Across anxiety-related pathology, safety behaviors provide immediate relief, but create paradoxical increases in anxiety and avoidance tendencies over time (). Were body checking serving as a safety behavior, it would be expected to immediately reduce anxiety, at least on a proportion of discrete body checking events (Kraus et al., 2015). However, naturalistic examinations of body checking using EMA and experimental body exposure paradigms indicate that body checking has immediate negative consequences on self-esteem, negative affect, and body dissatisfaction (Kraus et al., 2015; Tanck et al., 2019). Thus, current data do not seem to support body checking’s role as a safety behavior, as it does not appear to immediately decrease anxiety or negative affect.

Additionally, prior experimental research found that although women’s body dissatisfaction increased immediately following a critical body checking (CBC) manipulation, their body dissatisfaction returned to baseline levels following a 30-minute delay (Shafran et al., 2007). Jansen et al. (2016) randomly assigned body dissatisfied women to five 30-minute negative or positive body exposure sessions over 3 weeks: participants were asked to focus on their most unattractive or attractive body parts, respectively, describing their thoughts and feelings aloud. Although negative body exposure participants experienced immediate increases in body dissatisfaction within the first three exposure sessions, body dissatisfaction decreased within the fourth and fifth sessions. Negative body exposure led to similar decreases in body dissatisfaction, body checking, body avoidance, shape concern, and depression as positive body exposure at post-intervention and 1-month follow-up. Thus, repeated sustained (i.e., 30-min) critical body exposure has positive delayed and long-term effects on body dissatisfaction and depression. Questions remain as to what makes in vivo body checking deleterious, whereas sustained negative in-laboratory body exposure appears to confer delayed and long-term benefits. It is possible that the type (e.g., critical vs. nonjudgmental or positive) or duration of body checking partially explains these results.

Clinical Implications

Because of its role in the etiology and maintenance of EDs, CBC and body avoidance are targeted in ED and body dysmorphic disorder treatments. Interventions targeting CBC and avoidance include scheduled weekly weighing, education, assessment, and addressing motivations for, and consequences of, checking and avoidance via behavioral experimentation and Socratic questioning (Fairburn, 2008). Other research suggests potential utility for habit reversal, given body checking appears to reflect cue-behavior associations (Steinglass et al., 2018). Although more theoretically linked to reducing body avoidance, mirror exposure interventions have also demonstrated utility at decreasing CBC (see Griffen et al., 2018, for a review of mirror exposure’s purported mechanisms of action). Improved understanding of the immediate and delayed consequences of body checking behaviors may be leveraged to improve current and novel interventions.

Mirror Exposure

Mirror exposure involves systematic exposure to the body, and has consistently demonstrated efficacy in improving body dissatisfaction and decreasing body checking and avoidance in clinical and nonclinical samples (Griffen et al., 2018). Mirror exposure has been combined with cognitive techniques to reframe how individuals think about their body, such as mindfulness () and cognitive dissonance (). Mirror exposure has also been assigned without instructions regarding one’s visual or cognitive attention, or “pure” mirror exposure (Díaz-Ferrer et al., 2015). Given the many negative outcomes associated with self-reported body checking (Walker et al., 2018), understanding the immediate and delayed sequelae of repeated CBC sessions of varied durations is crucial to best target interventions, such as mirror exposure, to reduce harmful body checking.

Current Study

Experimental body checking examinations have typically manipulated body checking in a single session of mirror exposure (e.g., Shafran et al., 2007; Smeets, Tiggemann, et al., 2011; Svaldi et al., 2012; Tanck et al., 2019; Vocks et al., 2008a). However, single-session body checking manipulations do not provide information on body checking’s impacts over time. They also lack ecological validity, given that body checking behaviors are typically repeated frequently over time (Shafran et al., 2004; ). Thus, to be clinically relevant, research must examine repeated experimental manipulations of body checking (Shafran et al., 2007). Further, although EMA studies provide ecological validity, they lack the ability to test causal hypotheses. Thus, the incremental and cumulative effects of repeated body checking behaviors must be assessed using experimental paradigms (Walker et al., 2018).

The aims of this research were twofold. First, the study attempted to replicate prior research demonstrating the immediate deleterious effects of repeated CBC on body satisfaction, self-esteem, and negative affect compared to both a neutral body checking (NBC) and a non-body critical checking (NBCC) control condition. The CBC procedure was modeled after the high body checking condition described in Shafran et al. (2007), in which participants’ selective attention and vigilance to typically disliked body parts were experimentally induced. Similarly, the NBC condition was modeled after Shafran et al. (2007) low body-checking condition, in which participants were asked to describe themselves objectively using neutral language. Hypothesis 1: similar to previous research (e.g., Shafran et al., 2007; Smeets, Jansen, et al., 2011; Tanck et al., 2019), it was hypothesized that CBC would lead to immediate decreases in state body satisfaction and self-esteem and increases in negative affect compared to NBC and NBCC. The second aim was to examine the delayed impact of repeated CBC and NBC manipulations on state body satisfaction, self-esteem, and negative affect, compared to a NBCC control condition. Hypothesis 2: in line with prior research (Jansen et al., 2016), we hypothesized that both repeated CBC and NBC would result in increased state body satisfaction, self-esteem, and decreased negative affect over time compared to NBCC. In line with Jansen et al.’s (2016) findings among participants receiving negative and positive body exposure manipulations, we expected similar delayed impacts of CBC and NBC at a 1-week follow-up, relative to NBCC. We expected improvement in both CBC and NBC conditions over time due to the sustained (i.e., 10-min) duration of the CBC and NBC procedures in the current study.

Method

Results

Discussion

This study was the first to directly compare immediate and delayed impacts of CBC and NBC to a non-body control condition that involved critical checking behavior. The additional NBCC condition suggests that the impacts of CBC may have been a result of body checking in particular, rather than a result of critical checking behaviors more generally. Overall, the CBC condition produced the expected negative consequences compared to NBCC immediately following the manipulation, with a significant medium effect on body satisfaction, a small nonsignificant effect on self-esteem, and a medium nonsignificant effect on negative affect. CBC also produced the expected negative consequences compared to NBC immediately following the manipulation, with a medium significant effect on body satisfaction, a small nonsignificant effect on self-esteem, and a small significant effect on negative affect.

From baseline to follow-up, NBC led to significant improvements in self-esteem, relative to NBCC. After correcting for multiple comparisons, the baseline to follow-up increase in self-esteem for those in the CBC group was not statistically different from NBCC. Relatedly, CBC and NBC both led to decreased negative affect from baseline to follow-up compared to NBCC. This finding aligns with research indicating that the negative impacts of CBC dissipate following a 10–30 minute delay (Shafran et al., 2007; ). Similarly, in treatment-seeking samples, pure unguided mirror exposures typically demonstrate within-session improvement in body satisfaction and negative affect (Vocks et al., 2008b), comparable to gains seen in mindfulness-based mirror exposure interventions with demonstrated efficacy (Díaz-Ferrer et al., 2015). At minimum, critical body exposures, even of relatively brief 10-minute durations compared to longer mirror exposure protocols, do not appear to cause delayed worsening of body satisfaction, negative affect, or self-esteem, even in samples of women with high shape or weight concern. It is possible that the absence of delayed negative impacts from CBC in the current study resulted from a ceiling effect, as individuals with high shape and weight concern typically engage in regular in vivo body checking. It is important to examine this question further in future study, by comparing the effects of repeated CBC among participants who are low versus high in shape/weight concern at baseline to determine whether preexisting shape/weight concern decreases additional delayed impacts of CBC due to ceiling effects. When paired with prior research demonstrating improvement in body image following pure mirror exposures, the trend towards greater self-esteem and significantly lower negative affect at follow-up in the current study suggest that habituation or inhibitory learning may explain benefits of sustained (>10 min) body exposure (Griffen et al., 2018), even when that exposure involves CBC. This is an important question for future research.

In contrast to sustained CBC, a recent meta-analysis found large correlations between body checking and body dissatisfaction (ρ = 0.63) and body checking and ED pathology (ρ = 0.59), and moderate correlations between body checking and negative affect/mood (ρ = 0.39; Walker et al., 2018). Given that theoretical accounts of ED maintenance highlight the role of CBC (Fairburn et al., 2003; Shafran et al., 2004), and EMA studies also suggest that CBC maintains ED pathology (Fitzsimmons-Craft et al., 2015; Lavender et al., 2013), a question remains as to what factors distinguish between pure mirror exposures, CBC as it was performed in the current study, and CBC as it is typically performed in vivo. The duration of CBC, and whether it alternates with immediate avoidance, may, in part, determine whether CBC is harmful (Walker et al., 2018). In the current study, participants engaged in body exposure for 10 minutes, a point at which negative emotions and body-related cognitions have been found to begin to decrease during body exposure (Vocks et al., 2008b). Future research should examine whether varying the duration of repeated CBC differentially impacts body satisfaction, negative affect, and self-esteem, both immediately and over time. For example, research could test the cumulative impacts of one 20-minute session of CBC compared to the impact of 10 two-minute CBC sessions that are intermittently performed throughout the day. Experimental methodology similar to that used in the current study and EMA methodology that specifically assesses duration of CBC may also be particularly useful in examining this question.

Results indicated that NBC also led to significantly increased self-esteem and decreased negative affect directly following the procedure, with small and small-to-medium effect sizes, respectively. Interestingly, neither NBC nor CBC led to delayed improvements in body satisfaction compared to NBCC. Despite the absence of significant Condition × Time interactions demonstrating support for CBC or NBC over the NBCC comparison condition on state body satisfaction, there was a main effect of time across conditions, suggesting improvements in body satisfaction over time did not differ by group. Significant main effects without significant interaction effects may suggest that measurement reactivity was present, despite our attempts to limit their effects by averaging multiple pre-intervention baseline scores; it is also possible that these effects may have resulted from regression to the mean. Our sample size in each condition also precluded the ability to identify any effects with small effect sizes, so we would not have been able to detect any small interaction effects.

The NBC procedure was modeled after Shafran et al. (2007), who, in turn, modeled their low body checking procedure after mindfulness-based mirror exposure procedures (). Mindfulness and acceptance-based interventions such as mindfulness-based mirror exposure may not directly decrease CBC, but may serve to reduce selective attention to disliked body parts and may provide individuals with means of decreasing and reframing critical self-talk, although decreased CBC has been reported following mindful mirror exposure (e.g., ). Given that low self-esteem, negative affect, and body dissatisfaction may worsen ED pathology (Mountford et al., 2006), and also given current study evidence that CBC immediately lowered body satisfaction and self-esteem and increased negative affect, it would be expected that, at least in the moment, motivation to engage in ED behaviors may increase. As a result, addressing CBC and body avoidance via mirror exposure and other intervention techniques may diminish the impact of this possible moment-to-moment relationship between CBC, negative affect, body dissatisfaction, self-esteem, and ED behaviors.

Findings of the current study should be interpreted in light of certain limitations. First, participants were a sample that predominantly consisted of undergraduate and graduate students. This sample reported elevated shape or weight concern, but results may not generalize across individuals with other demographic characteristics, or to clinical ED samples. Nonetheless, research supports heightened importance of body image and elevated risk of eating and body image disturbances among young adult samples (Tiggemann, 2004). Together, this evidence suggests that college students, particularly those with elevated weight or shape concern, represent a particularly relevant population for assessing the impact of immediate and delayed CBC on body satisfaction and an important population in which to test body image interventions.

The lack of ED assessment may be interpreted as a second limitation of the current findings. However, direct assessment of EDs was omitted based on ethical concerns raised by the institutional review board regarding assigning individuals with a known ED to the CBC procedure. Although no ED diagnostic measures were given, participants’ EDE-Q shape and weight concern scores were comparable to those reported in clinical samples (e.g., Welch et al., 2011). It is expected that findings in this community sample with high shape or weight concern would apply to clinical groups, but impacts may be expected to be stronger among those with EDs (Shafran et al., 2007). Third, the current study did not assess immediate or delayed dieting motivations or behaviors. Thus, the current study cannot speak to whether manipulating body checking directly increases motivations to diet or actual caloric restriction, as EMA research has suggested (Lavender et al., 2013).

Fourth, the NBCC control condition may have been less appropriate than a comparison condition that had greater personal salience than editing non-body related newspaper articles. Additionally, the NBCC format did not follow an identical format, in that it was not guided step-by-step by an audio recording, as the CBC and NBC conditions were. Instead, participants received initial oral instructions from the researcher and then completed the NBCC procedure without subsequent oral guidance. Future research should devise more self-relevant audio-guided comparison conditions, such as having participants bring in graded exams or written assignments, and asked to review each mistake they had made, with audio guidance on how to critically review their feedback.

Fifth, the current study did not assess body avoidance during the CBC and NBC tasks. Future research might employ eye-tracking methodology to both ensure that participants are not engaged in active avoidance during CBC and NBC procedures, and to better clarify the mechanisms of action of CBC and NBC on the variables of interest. For example, eye tracking could be used to demonstrate whether avoidance of disliked body parts decreases over the course of repeated CBC, or whether NBC prompts participants to examine the body more holistically, reducing selective attention to disliked body parts. Additionally, the current study did not assess social comparisons or variables associated with sociocultural theory, an important known risk factor for body dissatisfaction and ED psychopathology (Ridolfi et al., 2011). Prior research has found that undergraduate women who engaged in upward social comparisons with media images or their peers reported greater body checking and body dissatisfaction (Ridolfi et al., 2011). Future research may include questions at baseline that assess women’s internalization of sociocultural body ideals and comparison to bodies of women in the media and peers immediately following body exposure tasks. Last, the current study used only a female sample, and cannot speak to the impacts of CBC and NBC across genders. Given a lack of research on the impacts of CBC (Tanck et al., 2019; ) and mirror exposure (Griffen et al., 2018) in men, understanding men’s immediate and delayed response to CBC and NBC manipulations is a pressing research question. Such experimental manipulations should induce both leanness and muscularity-oriented CBC behaviors (Tanck et al., 2019; ).

Despite the noted limitations, this research contributes meaningfully to very limited existing research on an understudied and clinically meaningful topic within body image and ED literature. Our results support previous findings (Jansen et al., 2016) suggesting few if any delayed negative effects of repeated sustained (10–30 min) CBC on body satisfaction over time. The study design was innovative in that it allowed for both immediate and cumulative effects of the body exposure sessions to be examined, an ecologically valid method that is essential in determining the function of CBC. The results of the current study contribute to growing literature on body checking and highlight key questions for future research. In particular, additional research is needed in order to understand how, and in what way, in vivo body checking is harmful and differs from the current repeated CBC procedure and other pure mirror exposure procedures that demonstrated improvements in body satisfaction and decreased negative affect (e.g., Díaz-Ferrer et al., 2015; Tanck et al., 2019). Understanding the function of in vivo CBC and how it differs from mechanisms of change in pure mirror exposure interventions is necessary in order to develop and improve interventions aimed at reducing body checking in those with body image and ED pathology.

Supplementary Material

Acknowledgments

This research was supported by internal research grants from the University at Albany, State University of New York; Dr. Gorrell is supported by the National Institutes of Mental Health [T32 grant MH0118261–33].

Footnotes

Contributor Information

D. Catherine Walker, Union College.

Sasha Gorrell, University of California, San Francisco.

Tom Hildebrandt, Icahn School of Medicine at Mount Sinai.

Drew A. Anderson, University at Albany, State University of New York.

References