The role of psychological flexibility in appearance anxiety in people who have experienced a visible burn injury

Abstract

Background: Individuals with visible differences can experience appearance anxiety that is distressing and disruptive to daily functioning. Understanding psychological factors that maintain appearance anxiety related to scarring is important in developing theoretical understanding of adjustment to injury, and in identifying targets for psychological therapies. This study aimed to investigate whether psychological flexibility, a key element underpinning acceptance and commitment therapy (ACT), was associated with appearance anxiety. It was hypothesised that reduced psychological flexibility (lower acceptance, cognitive defusion, mindfulness, and committed action) would be related to increased appearance anxiety. The role of psychological flexibility in the maintenance of appearance anxiety was investigated using a cross-sectional quantitative questionnaire study. Method: Seventy-eight burns patients (47 female, 31 male; M age = 45.2 years) completed the Derriford Appearance Scale (DAS-24), the Acceptance and Action Questionnaire (AAQ-II), the Cognitive Fusion Questionnaire (CFQ), the Five Facet Mindfulness Questionnaire (FFMQ), and the Committed Action Questionnaire (CAQ-8). Results: As hypothesised, increased appearance anxiety was related to reduced acceptance (rs (76)=0.80, p<0.001, onetailed) and cognitive defusion (rs(76)=0.76, p<0.001). Reduced levels of mindfully describing (r(72)=-0.39, p<0.001), acting with awareness (r(72)=-0.57, p<0.001), non-judging (r(72)=-0.61, p<0.001) and non-reactivity (r(72)=-0.28, p<0.01) as well as reduced committed action (r(72)=-0.57, p<0.001) were also related to increased appearance anxiety. Conclusions: Individuals experiencing appearance anxiety associated with a burn injury may struggle with accepting difficult emotions, stepping back from distressing thoughts, being mindful and engaging in valued action. These findings suggest that ACT may be useful in treating appearance related anxiety and concerns associated with conditions causing a visible difference.

Cancer and changes in facial appearance: A meta‐ethnography of qualitative studies

“…Targeted forms of cognitive behavioural therapy (e.g. Clarke et al, 2013) and approaches such as Acceptance and Commitment Therapy (Feros, Lane, Ciarrochi, & Blackledge, 2013;Shepherd, Reynolds, Turner, O'Boyle, & Thompson, 2019;Zucchelli, Donnelly, Williamson, & Hooper, 2018) and Compassion-Based Therapy (Kirby, Tellegen, & Steindl, 2017;Hudson et al in second review) might be particularly useful to facilitating adjustment for people coming to terms with living with an altered appearance.…”

The development of a self-help intervention to build social confidence in people living with visible skin conditions or scars: a think-aloud study

“…Indeed, a recent study indicates that some of the variables specifically targeted in these variations of CBT are associated with appearance-related anxiety in people with burn-related scarring. 42 This study is the first qualitative examination of the acceptability, usability and need for selfhelp for people with a skin conditions and scars. The study provides support for the utility of a CBT-based self-help booklet focussed on improving social confidence.…”

Acceptance and commitment therapy for appearance anxiety: three case studies

“…This measure is commonly used in appearance research and was used in a previous study exploring the relationship between appearance anxiety and psychological flexibility after burns. 17 The Work and Social Adjustment Scale (WSAS) 28 The Acceptance and Action Questionnaire (AAQ-II) 29 was used to measure acceptance (e.g. 'I'm afraid of my feelings').…”

“…13 However, there is a lack of high-quality studies investigating the effectiveness of CBT, or indeed any other psychological therapy, for appearance anxiety associated with a visible difference. 14,15 More recently, three studies have highlighted the potential importance of other psychological factors such as mindfulness (the ability to be in the present moment), 16,17 acceptance (willingness to experience internal experiences, including distress), 17,18 cognitive defusion (standing back from thoughts) 17 and committed action (doing what matters despite distress) 17 in reduced appearance anxiety. These are all elements of 'psychological flexibility', which underpins a newer form of CBT that incorporates mindfulness and acceptance, called Acceptance and Commitment Therapy (ACT).…”