Consequences of Exposure to the Thin Ideal in Mass Media Depend onModerators in Young Women: An Experimental Study

Simone Munsch1, Nadine Messerli-Bürgy1, Andrea H. Meyer1, 2, Nadine Humbel1, Kathrin Schopf3,Andrea Wyssen1, Felicitas Forrer1, Esther Biedert1, Julia Lennertz3, Stephan Trier4, Bettina Isenschmid5,

Gabriella Milos6, Malte Claussen6, Katherina Whinyates7, Dirk Adolph3, Jürgen Margraf3,Hans-Jörg Assion8, Tobias Teismann3, Bianca Ueberberg8, Georg Juckel9, Judith Müller10,

Benedikt Klauke10, and Silvia Schneider31 Clinical Psychology and Psychotherapy, Department of Psychology, University of Fribourg

2 Department of Psychology, Division of Clinical Psychology and Epidemiology, University of Basel3 Faculty of Psychology, Mental Health Research and Treatment Center, Ruhr-Universität Bochum

4 Private Clinic Aadorf, Aadorf, Switzerland5 Center for Eating Disorders and Obesity, Clinic Zofingen, Zofingen, Switzerland

6 Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich7 Private Clinic Rheinfelden, Rheinfelden, Switzerland

8 Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, LWL-Clinic Dortmund, Dortmund, Germany9 Department of Psychiatry, Psychotherapy and Preventive Medicine, Ruhr University Bochum, LWL University Hospital, Bochum,

Germany10 Christoph-Dornier-Clinic for Psychotherapy, Münster, Germany

This study examined the consequences of media exposure to thin ideals compared to pictures of land-scapes in healthy young women and women with eating and mixed mental disorders and investigatedwhether appearance-related cognitive factors and cognitive distortions moderate the effects. Two hun-dred seventy-five women in a multisite laboratory trial (174 in- or outpatients and 101 healthy women;M age 22.87 years, SD = 3.94) were exposed to either thin ideals or to landscape pictures and guidedthrough a vivid imagery of these pictures thereafter. Changes in body image dissatisfaction, mood, eat-ing behavior, and physiological markers were assessed. After thin ideal exposure and even more afterguided imagery, women’s body image dissatisfaction increased and mood declined. The effect on moodwas most pronounced in women with eating disorders, less in women with mixed disorders, and small-est in healthy controls. No effects were found on physiological measures. Higher values of appearance-related cognitive factors moderated the effect of thin ideal exposure and guided imagery on all psycho-logical outcomes. Cognitive distortions moderated the effect of thin ideal exposure and guided imageryon mood. Findings indicate an overall susceptibility to viewing thin ideal pictures in magazines inyoung and especially in women with eating disorders. Though exposure in the laboratory resulted inpsychological effects, it did not lead to a physiological stress response. The impact of thin ideal expo-sure on mood is in line with affect-regulation models in eating disorders, with appearance-related cogni-tive factors and cognitive distortions potentially accelerating such effects.

General Scientific SummaryBody image concerns, which are often influenced by thin ideal exposure of mass media are a keyfeature of disturbed eating and eating disorders. This study supports that exposure to mostlyunachievable thin ideals in mass media in the laboratory leads to body image dissatisfaction andimpaired mood not only in young women with eating disorders, but further in those with mixedmental disorders and in healthy ones. In particular, impaired mood after thin ideal exposure

Simone Munsch https://orcid.org/0000-0002-6187-8912

Nadine Messerli-Bürgy https://orcid.org/0000-0001-8619-5950

Andrea Wyssen https://orcid.org/0000-0003-0836-9817

Benedikt Klauke https://orcid.org/0000-0001-6838-7414

This project was funded by the Swiss National Science Foundation, SNSF,lead agency project and the German Research Foundation, the Swiss AnorexiaNervosa Foundation, and the Research Funds of the University of Fribourg.

We thank all of the master’s students in Psychology involved in the project(especially Alexander Ariu, Tom Kirsch, and Phillip Pompetzki). Severalarticles have been published based on preliminary samples but were related toother research questions.

Correspondence concerning this article should be addressed to SimoneMunsch, Clinical Psychology and Psychotherapy, Department of Psychology,University of Fribourg, Rue P.-A. de-Faucigny 2, 1700 Fribourg, Switzerland.Email: simone.munsch@unifr.ch

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Journal of Abnormal Psychology

© 2021 American Psychological Association 2021, Vol. 130, No. 5, 498–511ISSN: 0021-843X https://doi.org/10.1037/abn0000676

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activated disturbed eating behavior in women with eating disorders. Effects in all groups were morepronounced in case of increased cognitive processing relating the thin ideals in mass media withself-ideals and provoking a negative belief that the likelihood of an undesirable event (e.g., weightgain) will occur by the mere thinking about it (thin ideals).

Keywords: eating disorders, mixed mental disorders, media exposure, cognitive factors, psychophysio-logical correlates

Supplemental materials: https://doi.org/10.1037/abn0000676.supp

Body dissatisfaction is the degree to which individuals are con-cerned about or dissatisfied with their appearance, includingrelated thoughts, beliefs, feelings, and behaviors (Cash et al.,2004; Cash & Smolak, 2011). Body image dissatisfaction in ado-lescents and young adults, especially for females, is currently ofsuch high prevalence that it is deemed a “normative” condition(Fiske et al., 2014; Knafo, 2016). A large, multicenter interculturalstudy found that exposure to Western media, which typicallydepicts and promotes an unrealistic female thin ideal, is at leastassociated with, and hypothesized to be partly responsible for, theworldwide increase in body image dissatisfaction in regions withhigh socioeconomic status (Micali et al., 2015; Swami et al.,2010). Repeated exposure to the thin ideal amplifies a felt discrep-ancy between one’s own and the ideal body shape, which fostersnegative affect, and can lead to unhealthy eating and/or unhealthyweight regulation attempts (Dondzilo et al., 2018; Grogan, 2016).Laboratory, cross-sectional, and longitudinal studies in nonclini-

cal samples of young women have confirmed that repeated massmedia exposure, such as viewing beauty magazines, fosters and isrelated to the development of body image dissatisfaction and eat-ing disorder symptoms (Hausenblas et al., 2013; Levine & Mur-nen, 2009; López-Guimerà et al., 2010). According to the dualpathway model of eating pathology (Stice, 2001; Thompson &Stice, 2001), body image dissatisfaction is often accompanied byunhealthy dieting behavior and/or negative affect, which may pro-gress to disturbed or disordered eating, as shown in longitudinalstudies (Keski-Rahkonen & Mustelin, 2016; Stice et al., 2017;Stice et al., 2011). The pursuit of the thin ideal, body image dissat-isfaction, dieting, and unhealthy weight control behaviors havebeen specifically linked to binge/purge spectrum eating disordersin a large longitudinal study (Stice et al., 2017), whereas inher-ently lean young women who undereat for other reasons than striv-ing for thin ideal achievement were at a specific risk for anorexianervosa (Stice & Desjardins, 2018; Stice et al., 2017).In sum, body image dissatisfaction plays an important role in

the development of unhealthy eating behavior, but also of lowself-worth, anxiety, depressive, and somatoform symptoms (Pax-ton et al., 2006). In addition, sociocultural influences and associ-ated appearance-related cognitive factors, such as constantly beingaware of the thin ideal, the pressure to adhere to it, and the tend-ency to internalize and adopt thin ideals, promoted via mass media(Durkin et al., 2007; Knauss et al., 2007), might moderate theeffect of thin ideal exposure on eating behavior. Several studiesshow that these factors influence the perceived discrepancybetween one’s own and the thin ideal body in healthy females(Mussweiler et al., 2000; Myers & Crowther, 2009). Nevertheless,cognitive distortions (i.e., consistent, false, and skewed patterns of

thinking often related to psychopathology) have hardly been inves-tigated in eating disorders, until the concept of the food-relatedThought Shape Fusion (TSF) gained researchers’ interest (Coelhoet al., 2015; Radomsky et al., 2002; Wyssen et al., 2016; Wyssenet al., 2018). The original TSF concept includes irrational beliefsabout the closeness of the relationship between thoughts aboutfood and the physical world. The TSF concept was adapted fromthe concept of thought action fusion in individuals with obses-sive–compulsive disorders (OCD), which holds that the likelihoodof an undesirable event occurring is increased by a negativethought (likely thought action fusion) and that these negativethoughts are morally equal to the actual performance of the nega-tive behavior (moral thought action fusion; Rachman & Shafran,1999; Shafran et al., 1996). Originally, TSF was experimentallyinduced via the instruction to think about high caloric/fatteningfood, to imagine vividly eating large amounts of this food andthen to write down the sentence “I am eating” (inserting the nameof the food(s) they were imagining; Coelho et al., 2008). There-after, feelings of fatness, perceived weight gain, feelings of guilt,of moral wrong-doing and the pressure to neutralize the effects ofsuch cognitions increased slightly in healthy individuals butincreased significantly more in individuals with eating disorders(Coelho et al., 2015; Coelho et al., 2010; Ouellet-Courtois et al.,2015).

Analogous to thinking about food, the mere vivid imaginationof thin ideals has also been associated with body-related cognitivedistortions in both healthy controls as well as in those with eatingdisorders (TSF Body [TSF-B]; Wyssen et al., 2016; Wyssen et al.,2017). According to a previous study by our group, where theTSF-B questionnaire has been validated, a core belief measured inthe subscale “imagination of thin ideals” is that the mere vividimagination of a thin women increases the likelihood of gainingweight or changing shape, and a typical belief of the subscale“striving for own thin ideal” is that simply thinking about givingup the thin ideal is as morally objectionable as giving it up for real(Wyssen et al., 2017). In a previous pilot study, TSF-B was experi-mentally induced by exposing healthy women in a waiting roomto thin ideals via fashion magazines, who were then asked to imag-ine the images seen in the magazines as vividly as possible (guidedimagery), which resulted in decreased mood and increased bodyimage dissatisfaction, especially in women with subclinical eatingdisorder symptoms (Wyssen et al., 2016). In sum, people who aresusceptible to cognitive distortions, such as TSF-B, experience afusion of thoughts and their perception of their own body similarto the process involved in thought action fusion in OCD. Eventhough they probably realize that merely thinking about certainfoods (Coelho et al., 2015) or a thin body (Wyssen et al., 2017)

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cannot influence their body shape or weight, they neverthelesshave anxiety about this potential outcome. However, there is stilllimited data on a potential moderating role of such body-relatedcognitive distortions in clinical samples exposed to thin ideals.Daily exposure to unachievable thin ideals may have such a det-

rimental impact on mental health that it meets the criteria of anenvironmental stressor such as for example, being in unpleasantcompany or feeling lonely (Jacobs et al., 2007; Kirschbaum &Hellhammer, 1989; Matias et al., 2011). Its effects are enhancedby the inherent ego-involvement of the content and ensuing feel-ings of shame and guilt (Ehlert et al., 1999), especially in youngwomen, for whom body image is particularly salient and mightresult in increased stress levels and activations of the two physio-logical stress systems: the hypothalamic pituitary adrenal (HPA)axis and the autonomic nervous system (ANS). However, previousstudies did not find any consistent HPA activation after body con-frontations (Servián-Franco et al., 2015; Svaldi et al., 2009; Vockset al., 2007) and ANS responses have not been investigated so far.Therefore, it has not yet been examined whether being exposed toa daily challenge such as to thin ideals and guided imagery there-after leads to physiological stress responses of both stress systems,even though physiological correlates of stress have the potential tocontribute to the vicious cycle of body image dissatisfaction, nega-tive mood, and impaired eating and nutritional behavior thereafter,as eating under stress is known to be associated with altered foodchoices (Epel et al., 2001; Oliver et al., 2000). There is furthermixed evidence for the effects of body salience on body-relatedstress and it remains unclear whether thin ideal stressors shouldprovoke physiological stress responses (i.e., an increase in cortisollevel or decrease in heart rate variability [HRV]). Existing studieson the exposure to one’s own body do not find consistentresponses of the HPA axis and the sympathetic branch of the auto-nomic nervous system (anorexia nervosa) in individuals with eat-ing disorders, when compared to healthy women (Vocks et al.,2007). A later study involving mirror exposure revealed greaternegative effects, in terms of higher body image dissatisfaction andmore intense negative cognitions, after viewing one’s own body inyoung women from the general population with high body imagedissatisfaction, as compared to women with low body image dis-satisfaction (Servián-Franco et al., 2015). Interestingly, these self-reported psychological effects were not accompanied by increasedskin conductance or heart rate. In sum, raising body salience canhave detrimental effects on the human psyche in vulnerable indi-viduals. However, evidence on physiological effects remains lim-ited by the generally small sample sizes in prior studies, and bythe typical lack of parallel physiological assessment of the twostress branches, the ANS including heart rate variability (capturingthe parasympathetic nervous system, PNS; Thayer et al., 2012),salivary alpha-amylase release (capturing the sympathetic nervoussystem, SNS; Chatterton et al., 1996), and salivary cortisol (cap-turing HPA activation).Overall, studies in nonclinical samples of young women indi-

cate that the pursuit of the thin ideal is associated with increasedlevels of body image dissatisfaction, which contributes to dieting,maladaptive weight control behaviors and to an increased risk foreating disorders (Stice et al., 2017). Nevertheless, studies on howcognitive processes influence the relationship between thin idealexposure and body image dissatisfaction, mood or eating disorderssymptoms are scarce. In addition, research on the specificity of

such processes, and on potential physiological responses in largergroups, including healthy women and women with mental disor-ders, is lacking.

The present laboratory study addresses these gaps in being thefirst to focus on shared versus specific effects of the exposure tothin ideals via beauty magazines, followed by guided imagery ofthese thin ideals, on state measures of body image dissatisfaction,mood, eating behavior, and on physiological responses in healthyyoung women and in a sample of women with eating disorders aswell as in a sample including anxiety, depressive or somatoformdisorders (mixed mental disorders). To clarify the role of cognitiveprocesses, we assessed the moderating effect of appearance-related cognitive factors such as awareness, thin ideal internaliza-tion, perceived pressure to conform to a thin ideal and the suscepti-bility to body-related cognitive distortions on the relationshipbetween thin ideal exposure, guided imagery and body image dis-satisfaction, mood, eating behavior, and on measures of physiolog-ical stress.

This study employed a laboratory design from prior research(Munsch, 2014; Wyssen et al., 2016) to test three hypotheses.First, compared to exposure and guided imagery of neutral land-scape images, exposure followed by guided imagery of thin idealimages was expected to lead to a decrease in mood, to an increasein body image dissatisfaction and in internal pressure to engage indysfunctional eating behavior in the overall sample (Green et al.,2009; Junne et al., 2016). Second, the aforementioned effects wereexpected to be more pronounced in women with mental disordersthan in healthy women, and within women with mental disordersto be more pronounced in the eating disorder sample than in themixed mental disorder sample (Rawana et al., 2010; Stice et al.,2017). Third, dysfunctional cognitive processes (i.e., appearancerelated cognitive factors and body-related cognitive distortions,were expected to moderate responses to thin ideal exposure andguided imagery in the overall sample. Finally, we explored towhich extent women showed physiological stress responses to thinideal compared to landscape exposure and guided imagery (i.e.,changes of HPA activation and of ANS activation) with respect toall three hypotheses stated.

Method

Participants

Recruitment was conducted over a three-year period from 2014to 2017 in a multisite trial including 10 different treatment facili-ties (in and outpatient clinics) in Switzerland (N = 4) and Germany(N = 6); the study protocol is detailed out in Munsch (2014). Dur-ing this period, all 362 incoming patients were routinely invited bycollaborating staff members to participate in the study. Study eligi-bility criteria for clincal participants included female gender, agebetween 18 and 35 years, meeting diagnostic criteria for an ano-rexia or bulimia nervosa (eating disorders sample), and anxiety,depressive or somatoform disorder (mixed mental disorders sam-ple), based on a structured clinical interview according to theDSM–IV: the DIPS (Diagnostisches Interview für psychischeStörungen; Schneider & Margraf, 2011). Participants providedinformed consent to participate in the study. Exclusion criteria forall participants were current pregnancy, breastfeeding, or intake of

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beta-blockers. Patients with mixed mental disorders were furtherexcluded if they displayed clinically relevant symptoms of eatingdisorders or a clinical diagnosis of eating disorders (Fischer et al.,2012). Exclusion criteria for healthy participants were the presenceof any current mental disorder or past eating disorders assessed bythe DIPS, or a body dysmorphic disorder assessed by the SCID(Structured Clinical Interview for DSM–IV Axis I, Section G,Body Dysmorphic Disorder; Wittchen et al., 1997), or a total scorehigher than 2.5 on the EDE-Q (Eating Disorder ExaminationQuestionnaire; Fairburn & Beglin, 1994) according to Fischeret al. (2012).Altogether, 213 female in- and outpatients were enrolled,

including 130 patients with eating disorders (n = 64 with anorexianervosa, n = 66 with bulimia nervosa) and 83 patients with mixedmental disorders (depressive disorders n = 54, anxiety disordersn = 26, somatoform disorders n = 3; see Figure 1A). Additionally,approximately 1,000 healthy participants from the University ofFribourg and from several vocational schools in the Canton of Fri-bourg, Switzerland, were reached via flyers (see Figure 1B). Fromthis reached sample, a total of 128 healthy controls (HC) enrolledin the study. A total of 66 women (39 patients and 27 healthywomen) did not complete the study due to withdrawal of participa-tion (i.e., declined to participate, discontinued experiment orunavailable; n = 28) or due to having met one or more exclusioncriteria (n = 38). The final sample therefore consisted of 275young women (174 patients and 101 healthy women) with an agerange of 18 to 35 years (M = 22.87, SD = 3.94). All participantsreceived financial compensation (patients) or credit points (stu-dents) and were debriefed about the purpose of the study aftercompletion.In Switzerland, the study was approved by the local Ethics

Research Committee of the canton of Fribourg (reference no. 023/12-CER-FR) and several other cantons. In Germany, the ethicalcommittee of the Faculty of Psychology at the Ruhr UniversityBochum in Germany approved the study (reference no. 142). Thestudy followed the guidelines of the Declaration of Helsinki andthe Good Clinical Practice Directives of Switzerland. Participationwas voluntary and each participant signed the informed writtenconsent. The trial is registered in the German Clinical TrialsRegistry (trial number: DRKS00005709) and the study protocolhas been published (Munsch, 2014).

Procedure

In all treatment facilities, the study protocol was administered asfollows: After signed informed consent, participants in each groupwere randomly assigned to an exposure condition (exposure to afashion magazine depicting thin ideals, followed by guided imageryof the thin ideals; N = 141; 30 in the AN, 29 in the BN, 31 in themixed mental disorders, and 51 in the healthy control group) or neu-tral control condition (exposure to a nature magazine including land-scape pictures, followed by guided imagery of landscapes; N = 134;28 in the AN, 25 in the BN, 31 in the mixed mental disorders, and 50in the healthy control group). Participants were told that the studyexamines psychological well-being and physiological stressresponses related to body image dissatisfaction in young adults butwere not informed about the objectives of the study until completionof their participation.

Diagnostic interviews were conducted either by telephone orface-to-face. Participants were interviewed shortly after participationagreement and within the first week of treatment start in the case ofthe patient sample. In addition, medication and use of oral contra-ceptives were assessed. One week after the interview, self-reportquestionnaires were sent to all participants using an open-sourceonline survey tool. Healthy participants were invited to a testingafternoon the following week at our lab and patients to a testingafternoon at the corresponding clinical institution. Participants weretold not to eat, not to drink anything else but water, not to brush theirteeth or use mouth-rinse, and not to smoke within one hour beforethe start of the testing afternoon due to the assessment of salivarycortisol and salivary alpha amylase (sAA). The testing took placebetween 2 and 4.30 p.m. with respect to circadian rhythm of physio-logical stress branches. Assessment of psychological and physiologi-cal responses followed a fixed time line (see Figure 2).

Psychological measures on body image dissatisfaction, eatingbehavior, and mood, as well as physiological measures (HRV andsaliva sampling) were assessed before and after media exposureand before and after guided imagery. Saliva was sampled usingsalivettes at specific time points to capture the peak release afterexposure to the stressor (thin ideal vs. landscape exposure andguided imagery; Dickerson & Kemeny, 2004) and participantswere asked to wear a Movisens ekgMove ECG chest belt (Movis-ens, GmbH, Karlsruhe, Germany) during the whole testing after-noon whereof time periods for baseline and expected stressresponse of PNS were analyzed.

As a cover story, all participants were told that a baseline mea-surement of physiological parameters would take place. Hereto-fore, participants were seated in a second room and asked toremain as still as possible during the next 10 min. During this“waiting time,” a magazine was given to participants and partici-pants were asked to look at the magazine closely. In the media ex-posure condition, the most recent edition of Vogue Germanymagazine (June 2014 edition) was used. In the control condition,the Geo Special Germany magazine (cover theme: “Islands”, Janu-ary 2010 edition) was presented. Both magazines displayed a simi-lar amount of pictures and text. The same magazines were usedacross all study centers. Exposure started 40 mins after the begin-ning of the experiment based on an adapted waiting room studydesign according to Turner et al. (1997) and Wyssen et al. (2016).Participants were asked to wait for 10 min in a second room, beinginformed that baseline of physiological measures was assessedduring this period and were told to look at the pictures in the mag-azine they were given. Thereafter experimenters applied a standar-dized protocol to instruct participants to the guided imagery ofpictures they viewed in the magazines and found most attractiveaccording to Coelho et al. (2008). This procedure aimed at induc-ing body-related cognitive distortions of the TSF-B type. After-wards, participants watched a nature movie during 8 min to assessthe salivary amylase peak and HRV reactivity. Participants wereasked to close their eyes and to vividly imagine for 5 minutes thethin ideals (Vogue Germany) they found most attractive or themost impressive landscapes (Geo Special Germany) of the maga-zine previously viewed. After the guided imagery, participantswrote down a short description of the thin ideals or the landscapethey just imagined by using the description of “I imagine . . .”increase ego-involvement (Coelho et al., 2010). Afterward, animplicit picture recognition task was carried out, ratings of

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Figure 1CONSORT Flow Diagram of Recruitment and Progress Throughout the Study

Note. Recruitment and progress throughout the study in the clinical (A) and healthy sample (B). nCH = Swisspatients; nG = German patients; nDEP = patients with depressive disorders; nANX = patients with anxiety disor-ders; nSOM = patients with somatoform disorders.

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intensity of imagination vividness as well as anthropometric meas-ures (weight and height) were taken, and participants weredebriefed.

Psychological Measures

Diagnostic Interview to Assess Mental Disorders

The DIPS (Diagnostisches Interview für psychische Störungen;Schneider & Margraf, 2011) is a structured interview based onthe DSM–IV–TR (Diagnostic and Statistical Manual of MentalDisorders, 4th ed.; American Psychiatric Association, 2000) withinterrater reliability values ranging from .57 to .92, and retest-reliability values (Cohen’s Kappa) ranging from .35 to .94 (Mar-graf, Cwik, Pflug, & Schneider, 2017). For the purpose of ourstudy, only the DIPS eating disorders section was adapted to theDSM–5 (American Psychiatric Association, 2013; Margraf, Cwik,Suppiger, & Schneider, 2017). Interviewers were trained and super-vised by the principal investigator. 10% of the interviews werecoded twice by two independent raters based on the audio record-ings of the interviews. Interrater reliability for primary diagnosesincluded the raters’ and the interviewer’s ratings achieved high val-ues (Fleiss K = .850; Fleiss K = .803).

Visual Analogue Scales to Assess Body Image Dissatisfaction,Mood, and Urge to Engage in Dysfunctional Eating

Body image dissatisfaction was assessed using Visual AnalogueScales (VAS; 0–100) at four time points over the whole experi-ment. The measure included 11 items assessing state-dependentbody image dissatisfaction on a scale of 0 (low) to 100 (high).Items 1 to 4 were reverse-coded to identify body image dissatis-faction and hence had to be recoded prior to further processing.Examples for body image dissatisfaction are “Right now, how sat-isfied are you with your body/weight, general appearance?”; “Howmuch do you have problems accepting your body at this verymoment?”; “How much do thoughts about your body bother youat this very moment?” Lower scores on the scale indicated lowerbody image dissatisfaction. Cronbach’s alpha was .95 at baseline.

The modified version of the Brief Mood Scale (Wilhelm &Schoebi, 2007), assessing state levels of valence and calmness wasused for momentary assessment of mood on eight Visual AnalogueScales, ranging from 0 (low) to 100 (high), at four time points overcourse of the experiment. Examples are “Right now, how happy/unhappy, relaxed/nervous, awake/tired, do you feel?” Cronbach’salpha was .90 at baseline.

Another VAS scale on disturbed eating behavior includingseven items was used to assess the tendency toward the urge toengage in binge eating, dieting, excessive exercising, use of laxa-tives, or medication, and so forth. It assessed urges on a scaleranging from 0 (low) to 100 (high). The scale was administeredfour times over the whole experiment. Examples are “Right now,how much urge to diet, exercise, vomit, eat, and so forth do youfeel?” Cronbach’s alpha was .79 at baseline.

Physiological Measures

HRV

HRV was assessed continuously during the experimental pro-cedure by Movisens ekgMove chest belts (ambulatory monitor-ing system; Movisens GmbH, Karlsruhe, Germany) with asampling frequency of 1,024 Hz throughout the testing after-noon. Raw data were visually inspected and divided into differ-ent segments according to the registered time stamps. Interbeatinterval (R-R) data were analyzed using Kubios software (Uni-versity of Eastern Finland, Kuopio, Finland) for the baseline,media exposure, and guided imagery (see Figure 2 and Munsch,2014), considering a smooth priors detrending method (k = 500)and correction for artifacts. Spectral values based on the autoregres-sive method were used to assess PNS activation (high frequencyband HF-HRV). Because of severe artifacts in some cases, onlydata from a total of 271 participants could be included in theanalyses.

Figure 2Timeline of Experimental Procedure

Note. A = amylase; C = cortisol; HFHR = high frequency heart rate segments during media and GI; media = exposure to thin ideal or landscape pic-tures; GI = guided imagery of either thin ideal or landscape pictures; Q = filling in online questionnaires. Visual Analogue Scale (VAS) body image dis-satisfaction, mood and urge to engage in dysfunctional eating. See the online article for the color version of this figure.

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sAA

Salivary cortisol and sAA were collected repeatedly duringthe experimental procedure (see Figure 2 and study protocolfrom Munsch, 2014), before and after media exposure, andbefore and after guided imagery, using Salivettes (Sarstedt,Nümbrecht, Germany). Samples were stored and frozen at –20°Cat the study sites in Switzerland and Germany, prior to analysisat the Laboratory of University of Zürich (Swiss samples) andthe Laboratory of the Department of Genetic Psychology atRuhr-University Bochum (German samples). Salivary cortisollevels were analyzed on a Synergy2 plate reader (Biotek,Winooski, VT), using commercial enzyme-linked immunosor-bent assays (ELISAs; free cortisol in saliva; Demeditec, Ger-many), according to the manufacturer's instructions. Intraassayand interassay coefficients of variation were ,9%. Sensitivity ofthe assay was .019 ng/ml. To measure salivary alpha amylase, acolorimetric test using 2-chloro-4-nitrophenyl-a-maltrotriosoide(CNP-G3) as a substrate reagent was applied (Lorentz et al.,1999). Intraassay and interassay coefficients of variation were,10%. Sensitivity was at .65 U/ml.

Moderators

Appearance Related Cognitive Factors

The Sociocultural Attitudes Toward Appearance Questionnaire(German version; Knauss et al., 2009) includes 19 items. Weselected the mean score which summarizes the item values of threesubscales: pressure (to achieve thin ideals), awareness (of thinideals promoted by media), and internalization (of the promotedthin ideal as a self-reference for an ideal body). Scores range from1 (not at all) to 5 (absolutely true). Cronbach’s alpha across allinvolved items was .93.

Body-Related Cognitive Distortions

We used the previously validated German version of the TSF-Bto assess cognitive distortions related to the imagination of thinideals (Wyssen et al., 2017). The TSF-B Questionnaire includes12 items representing the concept section with two subscales:“imagination of thin ideals” (e.g., “the mere thought of thinwomen makes me want to exercise”; “if I think about thin women,I want to check that my clothes aren’t fitting more tightly”), and“striving for thin ideals” (e.g., “thinking about giving up my thinideal is almost as immoral to me as actually giving it up”; “think-ing about giving up my thin ideal can make me gain weight”), andseven additional items to assess frequency, impact, suppression,and uncontrollability of TSF-B related thoughts (Clinical impactscale). Cronbach’s alpha for the scale across the 19 items was .96at baseline.

Covariates

Use of Medication and Hormonal Contraceptives

Participants were asked about their intake of hormonal contra-ceptives and medication intake 1 week (numerals should be usedwith units) prior to the experiment, by assessing the exact nameand use of the medical product. Current medication was then clas-sified into one of two categories, according to its potential effect

on the cardiovascular system and/or HPA axis (specified informa-tion is available by the authors).

Vividness of Imagery Check

At the end of the guided imagery, all participants rated the per-ceived vividness of imagination during the task using a scale from0 (little vivid) to 10 (very vivid).

Implicit Memory Check

According to our experimental protocol, overall, 98% reportedhaving viewed the magazines as instructed (99% in the landscapecondition and 97% in the thin ideal condition). During the implicitpicture recognition task, 10 images taken from the magazine ofthe corresponding condition, and 10 pictures from another issueof the magazine were presented, and participants were asked toselect the pictures previously seen in the magazine. To define thelevel of implicit memory, we calculated a kappa value for eachparticipant, which was based on the four proportions: image cor-rectly identified as previously presented, image correctly identifiedas previously not presented, image incorrectly identified as previ-ously presented, and image incorrectly identified as previously notpresented.

Statistical Data Analysis

We performed an a priori power analysis (see study protocolfrom Munsch, 2014). The power analysis referred to comparisonsbetween clinical and control groups but did not include compari-sons within clinical subsamples.

The list of outcomes included the three self-reported variablesbody image dissatisfaction, mood, and urge to engage in dysfunc-tional eating behavior. In addition, we explored changes in thethree physiological measures cortisol, sAA, and HF-HRV. A ran-dom-intercept model was used to analyze all hypotheses,1 with the10 treatment facilities as Level 3, subjects within study sites asLevel 2, and time within subjects as Level 1 variables. The basemodel contained the two predictors “prepost” and “thin ideal expo-sure versus landscape exposure,” as well as “guided imagery ofthin ideal versus landscape pictures,” and the interaction betweenthe two, plus the covariate’s country of recruitment (Switzerland/Germany), vividness of imagery and the reliability measure kappawhich indicates how well a participant recognized pictures previ-ously seen (implicit memory test). To facilitate the reading, wereport the combined results for the two factors “thin ideal exposureversus landscape exposure” and “guided imagery of thin ideal ver-sus landscape pictures” (henceforth named “thin ideal exposureplus guided imagery versus landscape exposure plus guided im-agery”), as they can be seen to represent a combined purpose ofexposure to thin ideals in mass media, while the results of the twoindividual manipulations are reported in case they differ from eachother (i.e., if there was an interaction between these two factors,which was, however, rarely the case). For the exploratory analysesof the three physiological characteristics (cortisol, sAA, and HF-

1 The analyses of all hypothesis were according to as planned in thestudy design (Munsch, 2014), with the following exceptions: We addedappearance related cognitive factors (Sociocultural Attitudes TowardsAppearance Questionnaire) to the moderator analysis included thosecovariates as reported in this section.

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HRV), the two covariates use of hormonal contraceptives andmedication were used in the base model. For Hypothesis 1, thebase model was used, while focusing on the interaction effectbetween prepost and thin ideal exposure plus guided imagery ver-sus landscape exposure plus guided imagery. Effect sizes were cal-culated according to Feingold (2009), whereby estimates of thestandard deviation were based on the baseline measurements ofthe entire sample.For Hypotheses 2, the study sample was added as a factor with

the levels “eating disorders,” “mixed mental disorders,” and“healthy controls.” An omnibus test, testing the unspecific hypoth-esis of differences between the three levels was not performed, aswe did not consider it of scientific importance. Rather, weexpected healthy subjects and eating disorder patient to lie at op-posite ends of the spectrum with respect to their effect on theinvestigated outcomes and the mixed disorder patients lying inbetween. Therefore, the factor study sample was tested as a linearcontrast (i.e., largest effects were expected in the eating disordersample, intermediate effects in the mixed mental disorder sample,and smallest effects in the healthy controls). Thus, a significantresult for this contrast means that indeed the effect of the factorstudy sample referred to such a pattern.In statistical terms, the three-way interaction effect Prepost 3

Thin Ideal Exposure Plus Guided Imagery vs. Landscape Expo-sure Plus Guided Imagery 3 Linear [Sample] was of interest. ForHypothesis 3, each of the moderator variables was added sepa-rately to the base model: The Sociocultural Attitudes TowardsAppearance Questionnaire (SATAQ-G; appearance related cogni-tive factors) and TSF-B (body-related cognitive distortions). Thethree-way interaction effects between prepost, thin ideal exposureplus guided imagery versus landscape exposure plus guided im-agery, and the respective moderator variable was of main interest.To deal with the multiple testing problem, familywise error rateswere controlled for, and all p-values are hence adjusted accord-ingly using Hochberg’s method (Hochberg, 1988). Each family oftests thereby included the three outcomes examined. For Hypothe-sis 3, each family contained the three outcomes times the twomoderators, resulting in six tests per family. The outcomes urge toengage in dysfunctional eating behavior, sAA, and cortisol wereall square-root transformed, and HF-HRV was ln-transformedprior to the analyses to meet model assumptions, whereas baselinecharacteristics shown in Table S1 (see online supplementary mate-rials) are all based on untransformed variables.

Results

Descriptive statistics for the sample are displayed in Table S1(see online supplementary materials). The clinical sample differedfrom healthy young women with respect to psychopathologicaland physiological features. Differences in socioeconomical factors(e.g., higher educational status in the control condition) werelikely to be due to the strategy to recruit young female students toparticipate in the healthy controls. With respect to medication, atotal of 61.9% (n = 169) were taking hormonal contraceptives, and32.6% of the participants (83 patients and six HCs) took one ormore medications with potential effect on the cardiovascular sys-tem and/or HPA axis.The manipulation check showed that after media exposure, the

majority (76%) of the pictures were correctly recognized or

rejected (see implicit memory test in Table S1 in the online sup-plementary materials). Vividness of imagery was comparable toother studies (Coelho et al., 2012; Ouellet-Courtois et al., 2015)and group differences in relation to physiological measures atbaseline too (Lelli et al., 2019; Luz Neto et al., 2019).

Hypotheses H1 and H2: Impact of Thin Ideal ExposurePlus Guided Imagery Versus Landscape Exposure PlusGuided Imagery Overall and by Study Sample

Body image dissatisfaction increased after thin ideal exposurefollowed by guided imagery but decreased after exposure to land-scape pictures followed by guided imagery (H1: Pre_Post3 Expo-sure: b = –4.49, SE = .89, p , .001, d = .17; see Figure S1 inonline supplementary materials). This effect was lower after mediaexposure (b = –2.34, SE = 1.05, p = .027, d = .1) than after guidedimagery (b = –6.65, SE = 1.09, p , .001, d = .25; differencebetween these two effects: p = .014) but did not vary between sam-ples (H2: Pre_Post 3 Exposure 3 Linear [Sample]: b = –1.30,SE = 1.42, p = .360).

Mood declined after thin ideal exposure followed by guided im-agery but increased after landscape exposure pictures followed byguided imagery (H1: Pre_Post 3 Exposure: b = –7.56, SE = 1.14,p , .001, d = .39). This effect was much lower after media expo-sure (b = –3.18, SE = 1.35, p = .019, d = .17) than after guided im-agery (b = –11.95, SE = 1.47, p , .001, d = .62; differencebetween these two effects: p , .001). Also, this effect was mostpronounced in the eating disorder sample, somewhat less in themixed mental disorder sample, and least so in healthy controls(see Figure 3; H2: Pre_Post 3 Exposure 3 Linear [Sample]: b =–5.66, SE = 1.88, p = .006).

The urge to engage in dysfunctional eating behavior slightlyincreased after thin ideal exposure and remained on the same levelafter landscape exposure (H1: Pre_Post 3 Exposure: b = .15, SE =.08, p = .054, d = .07; see Figure S2 in online supplementary mate-rials). This effect was virtually absent after media exposure (b =–.01, SE = .10, p = .943, d , .01) but considerable after guidedimagery (b = .32, SE = .09, p , .001, d = .15; difference betweenthese two effects: p = .020). As for body image dissatisfaction,this effect did not vary between samples (H2: Pre_Post 3 Expo-sure3 Linear [Sample]: b = .12, SE = .12, p = .330).

Exploratory analyses revealed no significant results for the threeoutcomes of physiological stress responses (cortisol, sAA, andHF-HRV) for all hypotheses (H1 and H2: p . .05 for all effectstested). That is, the changes between before and after thin ideal ex-posure plus guided imagery did not differ from those in the land-scape exposure plus guided imagery group (cortisol: b = .01, SE =.03, p = .762; sAA: b = .08, SE = .19, p = .679; HF-HRV: b =–.05, SE = .06, p = .415), nor was this effect influenced by thestudy samples (cortisol: b = .03, SE = .05, p = .581; sAA: b = –.13,SE = .30, p = .650; HF-HRV: b = .05, SE = .10, p = .603). Notably,baseline values (before media exposure) were 7.86 (SD = 5.37) forcortisol, 106.61 (SD = 108.51) for sAA, and 886.23 (SD =1386.21) for parasympathetic activation, and they all significantlydiffered among the four groups: cortisol: F(3, 270) = 7.43, p ,.001; sAA: F(3, 271) = 4.38, p = .005; parasympathetic activation:F(3, 240) = 3.65, p = .013). Values for cortisol and sAA decreasedafter exposure (independent of exposure type; b = –.181, SE =.016, p , .001 for cortisol; b = –.508, SE = .092, p , .001 for

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Amylase), whereas values for HF-HRV remained constant (b =.038, SE = .031, p = .221).

Hypothesis 3: Moderating Influence of CognitiveFactors (Awareness, Experienced Pressure, andInternalization) as Well as of Cognitive Distortions onthe Impact of Exposure

The correlation between the two moderators tested was .67. Themean score of SATAQ-G moderated the effect of thin ideal expo-sure plus guided imagery versus landscape exposure plus guidedimagery on all three outcomes examined (body image dissatisfac-tion; b = –.45, SE = .18, p = .033; mood: b = –.69, SE = .22, p =.010; urge to engage in dysfunctional eating behavior: b = .043,SE = .015, p = .020), with higher values of SATAQ-G relating tostronger linear increases in body dissatisfaction, and strongerdeclines in mood when exposed to thin ideal followed by guidedimagery rather than landscape pictures followed by guided im-agery (see Figure 4A).Body-related cognitive distortions, measured with the TSF-B,

moderated the effect of thin ideal exposure plus guided imageryversus landscape exposure plus guided imagery on mood (b =–.30, SE = .09, p = .001; see Figure 4B), with higher values ofTSF-B relating to a stronger linear decline of mood when exposedto thin ideal followed by guided imagery rather than landscapepictures followed by guided imagery. The corresponding effectson body image dissatisfaction (b = –.09, SE = .07, p = .196) andon the urge to engage in dysfunctional of eating behavior (b =.012, SE = .006, p = .051) were, in contrast, not significant.

Discussion

Building on preliminary research (Loeber et al., 2016; Wyssenet al., 2016), the current study applied a rigorous approach toexamining the impact of exposure to thin ideals via beauty maga-zines, plus guided imagery, on body image, mood and eatingbehavior, thereby investigating cognitive processes contributing toa higher susceptibility toward such effects in young healthy andwomen with mental illness. The presence or absence of an eatingdisorder or of mixed disorders was verified using structured diag-nostic interviews. Efforts to validate the effect of the experimentalmanipulation included an implicit memory test and the assessmentof the vividness of the imagination of thin ideal versus landscapepictures thereafter. Findings of both measures revealed thatwomen recognized more than two third of the pictures they hadseen before correctly, independent of the sample they were in.Vividness of imagery was comparable to other studies (Coelho etal., 2012; Ouellet-Courtois et al., 2015).

As hypothesized (Hypothesis 1), after exposure to thin idealsand even more pronounced after guided imagery, state-depend-ent measures of body image dissatisfaction and mood deterio-rated in women across all samples. In contrast, the urge toengage in dysfunctional eating behavior was only affected afterguided imagery but not in response to the mere exposure to thinideal pictures. Overall, effect sizes were moderate for mood,small for body image dissatisfaction, and very small for urge toengage in dysfunctional eating behavior. Also, media exposureeffects were smaller throughout the paradigm compared toeffects provoked by guided imagery. Interestingly, mood

Figure 3Effects of Exposure Plus Guided Imagery and Group on Mood

Note. Changes in mood following exposure type and guided imagery, in women with eating disorder, mixed mental disorderother than eating disorder, or healthy controls. Values denote predicted values from a multilevel model. exp = exposure; GI =guided imagery.

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increased after exposure to and imagery of landscape pictures,consistent with the findings of Blackwell and colleagues indepressive patients (Blackwell et al., 2015). The decline ofmood after thin ideal exposure and guided imagery was alsofound in prior research (Turner et al., 1997). According to nega-tive affect models of disturbed eating behavior, the deteriorationof mood after viewing thin ideals in a magazine and processingthem during guided imagery could contribute to an increased

reward of high-calorie food and to overconsumption, dieting orpurging behavior to alleviate aversive mood in daily life. Afteroverconsumption, for example, negative mood might increaseagain and perpetuate the vicious circle (Aldao, 2016; Haedt-Matt et al., 2014; Stice et al., 2017).

The fact that body image dissatisfaction was less affected thanmood in the current laboratory study corroborates findings that theeffect of laboratory exposure to thin ideals promoted via media on

Figure 4Effects of Moderators on Mood

Note. Moderating effect of appearance related cognitive factors (Sociocultural Attitudes Toward Appearance Questionnaire[SATA-Q]; A) and eating and body-related cognitive distortions (Thought-Shape Fusion [TSF]/Thought-Shape Fusion Body[TSF_B] trait; B) on changes in mood following either thin ideal exposure plus guided imagery or landscape exposure plusguided imagery. Values denote predicted values from a multilevel model.

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body image dissatisfaction are mostly small (Hausenblas et al.,2013; López-Guimerà et al., 2010). Women’s attitudes towardtheir own body tends to be remarkably stable during life span,while the importance of body shape and weight seems to decreaseuntil they are elderly (Tiggemann, 2004). It might be assumed thatthe mere exposure to thin ideals in magazines does not lead tolarger effects unless it is accelerated by a daily repeated exposureor a more personalized comparison process via social media suchas Instagram, for example (Hogue & Mills, 2019). Only such mul-tiply-determined processes might funnel into more pronouncednegative feelings about one’s own body (Haedt-Matt et al., 2012;Wyssen et al., 2020).Mood was the only outcome where the observed effects varied

among samples, with women with eating disorders being mostimpaired, followed by women with mixed mental disorders, andhealthy women. This finding partly supports our assumption regard-ing the specificity of the effects of thin ideal exposure for womenwith eating disorders (Hypothesis 2). Future studies should investi-gate whether women with bulimia nervosa would exhibit more pro-nounced effects in response to thin ideal exposure than women withanorexia nervosa, as recently pointed out by Stice and colleagues(Stice & Desjardins, 2018; Stice et al., 2017).The present study also explored whether thin ideal exposure via

magazines followed by guided imagery would provoke physiolog-ical stress responses (Kudielka & Wüst, 2010) but did not find anyevidence for such an effect. Instead, we found a general decline ofsalivary cortisol and sAA, and no change in HF-HRV during theexperimental paradigm, indicating that if the expectations relatedto an unknown forthcoming condition provoke physiological stressresponses at all, then independent of the content of exposure.Therefore, our findings are in line with other studies where bodyconfrontation led to self-reported impairments, but repeatedlyfailed to result in consistent HPA axis activation (Servián-Francoet al., 2015; Svaldi et al., 2009; Vocks et al., 2007). The high lev-els of HF-HRV in the clinical samples with ED patients at baselinecan be explained by the impact of a limited caloric intake as foundin previous studies (Martin et al., 2007; Peschel et al., 2016). Fur-ther low HF-HRV levels are expected in depressed samples, whichcorresponds with the results showing lower HF-HRV levels in themixed groups than in other groups. In addition, similar group dif-ferences in cortisol levels have been reported previously in otherstudies which had been discussed to be influenced by the currentmalnutrition status, and potentially by preexisting trauma (Lelli etal., 2019; Luz Neto et al., 2019).The mismatch of mood change and physiological responses to

the tasks has previously been reported in many other studies (seereview in Campbell & Ehlert, 2012) and might be related to the in-dependently varying components of the stress response structureand to moderating factors (e.g., assessment features, psychologicaland physiological dispositions of the individuals; Campbell &Ehlert, 2012). The mismatch in this study could be related to thetime differences in peak assessment that the different physiologi-cal stress responses demand and which might not overlap with thefast changes of mood states in individuals during and after a task.Further, other aspects such as physiological and psychological dis-positions (i.e., psychological traits and physiological precondi-tions) might have influenced these results (Campbell & Ehlert,2012).

More pronounced appearance related cognitions (SATAQ-G)were related with an increased effect of exposure and guided im-agery of thin ideals on body image dissatisfaction, mood and onthe urge to engage in dysfunctional eating behavior, while morepronounced body-related distortions (TSF-B) accelerated mooddecline (Hypothesis 3). An increase in body-related distortionsand appearances related cognitive factors by 1 SD was associatedto a mood decline after thin ideal exposure and guided imagery by3.83 and 3.47 points, respectively. Although cognitive distortionsseem to propel negative mood induction (Coelho et al., 2015),appearance related cognitive factors foster the repetitive compari-son of one’s own body to an internalized unrealistic ideal, leadingto an increased self-ideal discrepancy, decreased mood, andincreased body image dissatisfaction (Hausenblas et al., 2013;Stice et al., 2017). Our findings add to the understanding of therole of cognitive factors in the dual pathway and the negativeaffect model of disturbed eating behavior. Future studies shouldspecify, whether certain individuals are more vulnerable to theinfluence of cognitive processes which relate daily thin ideal expo-sure to a negative body image and to negative mood.

The findings of the present study have to be interpreted against thebackground of several limitations. We applied an adapted version(Wyssen et al., 2016) of the waiting room paradigm according toTurner et al. (1997), favoring ecological validity of the laboratorymedia exposure and guided imagery. Although the majority of thewomen actually viewed the pictures during the laboratory paradigm,and the majority of pictures were correctly recognized or rejectedthereafter, we did not control for gaze behavior, which would haveallowed to refer to attentional processes during exposure. For futurestudies, it would be interesting to investigate which of the picture orpictures the participants imagined during guided imagery, and whetherspecific features of a picture, such as color palette, influenced the effectof exposure and guided imagery. As mentioned, we did not find mereexposure to have an influence on mood, body image dissatisfaction,and urge to engage in dysfunctional eating behavior. These parameterswere only impaired after the induction of guided imagery. Neverthe-less, future studies should include an additional mere exposure condi-tion, to detail out the effect of a longer time span of engagementversus the specific effect of guided mental processing during guidedimagery. It should further be examined, whether viewing thin idealpictures in social media elicits qualitatively and quantitatively differentprocesses (Twenge & Campbell, 2019). Finally, it would be interestingto know whether similar processes apply in male participants, wherebody ideals are known to include both the thin but also the muscularideal (Murray et al., 2017). We recruited a large sample of 275 youngfemale patients, which allowed us to detect clinically meaningfuleffects between clinical and control groups, while effects among clini-cal subsamples or higher order-effects such as the moderating influ-ence of cognitive factors would probably require even larger samplesizes (Heo & Leon, 2010). In addition, women in the healthy controlsample were recruited at one study site only and were primarily uni-versity students. Our findings cannot be generalized to women outsidethe age range of 18–35 years, nor to women suffering from binge eat-ing disorder, or to males.

Conclusion

Given the effect of a single laboratory-based exposure to thinideals followed by guided imagery of the most attractive bodies on

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self-reported mood and body image dissatisfaction, it can beassumed that such effects are multiplied and influence psychologi-cal wellbeing of a majority of young women (especially in womenwith eating disorders) on a daily basis. After mere exposure, nega-tive affect was accelerated as soon as women imagined the mostattractive bodies. These findings highlight the importance of theprocessing of thin ideal stimuli. Previously neglected appearancerelated cognitive mechanism and cognitive distortions (Culbert etal., 2015) might propel the vicious circle between dysfunctionalattitudes toward the own body and the self and negative mood.

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Accepted January 12, 2021 n

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