CBT for Appearance Anxiety

Psychosocial Interventions for Anxiety due to Visible Difference

Alex Clarke, Andrew R. Thompson, Elizabeth Jenkinson, Nichola Rumsey, Robert Newell

• Editorial: Wiley-Blackwell
• Año: 2013
• ISBN:
  9781118523414
• Edición: 1
• Categoría: Psychology
• Categoría: Cognitive Behavioral Therapy (CBT)

This clinical manual provides a CBT-based psychosocial intervention for use with individuals distressed about their appearance due to a disfigurement from birth, accident or illness, or those coping with another visible difference.

• Contains a wealth of case material with specific relevance to physical health conditions that affect appearance, practical advice on assessment, and session-by-session guidance for addressing common issues
• Written by leading academics and clinicians working in the management of disfigurement and rational appearance anxiety
• Uses a flexible stepped-care model that allows for use by experienced CBT practitioners as well those wishing to deliver a more basic psychological intervention
• Identifies the psychological factors involved in appearance anxiety while also addressing the practical concerns of living with a visible difference, such as managing the reactions of others

1

Background, Clinical Problems, Common Presentation and Treatment Considerations

Chapter Outline

Physical and Treatment-Related Factors

Socio-Cultural Factors

Psychological Factors and Processes

Body Image Disturbance

Clinical Problems and Presentation

Common Features in Referral

Visibility of Condition

Shame

The Meaning of Visible Difference

The Experience of Loss

Physiological Responses

Culture

Gender

Age

Expectations of Treatment

Association of Physical Change with Psychological Outcome

Fix It Solutions

Treatment Considerations

Whether present at birth or acquired later in life, a visible disfigurement can have a profound ­psychological impact on those affected (Rumsey & Harcourt, 2004, 2005; Thompson & Kent, 2001). Difficulties include adverse effects on body image (Newell, 2000), quality of life and self-esteem and shame (Kent & Thompson, 2002; Turner et al., 1997). Macgregor (1990) and others have argued that visible disfigurement comprises a ‘social disability’, since in addition to impacting on the thoughts, feelings and behaviours of those affected, it also affects the reactions of others. Social encounters can present many challenges, including meeting new people, making new friends, unwelcome attention such as staring, audible comments, teasing and unsolicited questions (Robinson, 1997). Research to date has focused predominantly on the difficulties and distress resulting from disfigurement. Rumsey et al. (2002) reported levels of anxiety, depression, social anxiety, social avoidance and quality of life were unfavourable in a third to a half of a sample of 650 consecutive out-patient adults attending hospitals for treatment of a wide range of disfiguring conditions. However, not all are equally affected. A proportion adapts positively to the demands upon them and either relegates their visible difference to a relatively minor role in life (Rumsey, 2002) or uses it to good advantage (Partridge, 1990).

There is a consensus amongst researchers and practitioners in the field that individual adjustment is affected by a complex interplay of physical, cultural and psychosocial factors (Clarke, 1999; Endriga & Kapp-Simon, 1999; Falvey, 2012; Moss, 1997a; Rumsey & Harcourt, 2004, 2005). However, what is very clear is that people affected by a disfigurement do have to contend with a range of reactions from others, many of which may be subtle and automatic (Grandfield et al., 2005). This is centrally important as the processing of information in people with a visible disfigurement is likely to be primed by the threat posed by the automatic reactions of others and such priming will activate normal bodily threat mechanisms. Awareness of this assists in normalizing the responses. That said, there is a high level of individual variation. Some factors clearly contribute to distress, yet others appear to ‘buffer’ a person against the stresses and strains of living with a visible difference. Some researchers have developed models of the processes involved (see for example, Kent & Thompson, 2002; Newell, 2000; White 2000). However, in most cases these have been condition specific, based on evidence drawn from small samples, and problem focused. Whilst models may help to organize collective thinking, they have the greatest clinical value where they focus on the identification and clarification of those factors which have the potential to be amenable to change through psychosocial support and intervention – either as an adjunct, or where appropriate, as an alternative to surgical and medical intervention. The Appearance Research Collaboration (ARC, funded by the Healing Foundation) has derived a cognitive model of adjustment based on previous research (see Figure 3.5, section ‘The ARC Framework of Adjustment to Disfiguring Conditions’, Chapter 3), and further developed it using data from both community and clinical samples (Thompson 2012).

In addition to emphasis on appearance-specific cognitive processes highlighted in the current research programme, previous research has indicated that a range of physical, treatment-related, socio-cultural and some other psychological factors are implicated in adjustment. Readers are referred to Moss (1997a), Clarke (1999), Newell (2000), Kent & Thompson (2002), Rumsey and Harcourt (2004), Moss (2005), Ong et al. (2007), and Thompson (2012). However, a brief resumé of the factors identified in previous research as the ‘likely suspects’ affecting adjustment is offered below. The findings of the ARC research programme are expanded in Chapter 3 of this guide.

Physical and Treatment-Related Factors

These include aetiology, the extent, type and severity of the disfiguring condition, and the treatment history of each individual. Contrary to the expectations of the lay public and many health care providers, the bulk of the research, clinical experience and personal accounts written by those affected, demonstrates that the extent, type and severity of a disfigurement are not ­consistent predictors of adjustment, although the visibility of the condition has been shown in some studies to exacerbate distress (Moss, 2005; Ong et al., 2007; Rumsey & Harcourt, 2004; Thompson & Kent, 2001).

Socio-Cultural Factors

Socio-cultural factors are particularly important as there is a fundamental human motivation to be connected with one another and the nuances of how these connections operate are dictated by social and cultural conventions. Cultural factors influence the core beliefs that people share about the meaning and consequences of disfiguring conditions. Social and cultural factors therefore provide a context in which adjustment takes place and are often influenced by demographic factors such as age, developmental stage, gender, race, and social class as well as the broader cultural milieu, religion, and parental and peer group influences. Research has also established that the media can play a role in creating and exacerbating the pressures on those distressed by their appearance although the impact of media and other socio-cultural factors varies between individuals (see Halliwell & Diedrichs, 2012; Prichard & Tiggemann, 2012 for review). Early experiences of attachment and of being accepted are likely to be particularly important in sensitizing individuals to the perceived threat posed by a disfigurement (Kent & Thompson, 2002), and this should be fully explored as part of the history and formulation ­building during therapy.

Psychological Factors and Processes

Factors included in this category include the structure of a person’s self-esteem and self-image (e.g. the weight given to the opinions of others and to broader societal standards), a person’s personality/disposition, characteristic attributional style, coping repertoire, perceptions of social support, levels of psychological well-being (e.g. anxiety, depression) and social anxiety, feelings of shame and the perceived noticeability of their visible difference to others (see Moss & Rosser, 2012a, 2012b for review). Again, it is important to consider that such factors are intimately associated with, and shaped by, socio-cultural factors. They can be broadly categorized as affective (relating to feelings), cognitive (relating to thoughts) or behavioural (relating to behaviour), and are, on the whole, more amenable to change than physical, treatment-related or socio-cultural factors.

Body Image Disturbance

In addition to those people with a disfiguring condition visible to others, there is a second group for whom their concern is related to self-perception, or a perceived problem or deficit in their appearance. Body Dysmorphic Disorder (BDD) is described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR, 2000) under somatoform disorders, and is defined as a preoccupation with an imagined or slight defect in appearance, which cannot be better explained in terms of an eating disorder (such as Anorexia Nervosa) or a disfiguring condition.

Many commentators have expressed concern about a diagnostic category which is dependent on the observation and judgment of an observer rather than the experience of the individual. An experienced plastic surgeon is likely to use a different normative scale from someone who is influenced primarily by the norms of their peer group. The definition also suggests that someone with a very obvious disfiguring condition should be excluded from this diagnosis; yet there are some people in this group for whom the high levels of preoccupation and concern are very ­characteristic of BDD.

For all these reasons, in our opinion, and contrary to the categorical DSM-IV-TR definition, BDD represents the extreme end of a continuum which can arguably be anchored at the opposite pole by a ‘normal’ preoccupation with appearance, dress and dissatisfaction with appearance. In clinical settings, body image disturbance is often present in disfiguration independent of cause or severity, and may be most evident in the more objectively ‘minor’ disfiguration group. The perceived mismatch between actual and ideal (how they ought, should or used to look) can result in considerable preoccupation, checking behaviour and anxiety in the absence of actual negative social reactions from other people. (See Price (1990) for discussion of this mismatch in mediating challenge to the integrity of body image.) Indeed, reassurance seeking from others that ‘they look okay’ serves to maintain anxiety, probably by maintaining focus on the perceived threat (Veale et al., 2009).

The results of the ARC research programme have reinforced the clinical observation that people also present with multiple concerns, or with a specific ‘highlighted’ problem in the context of other concerns about appearance. For example, excess skin following weight reduction is often described as ‘ageing’ and it is important to recognize that the ‘normative’ concern with appearance that is evident in the general population means that there is often a multiplicity of issues underlying appearance cognitions. Further, the ARC study demonstrated that people with a disfigurement might be more concerned about other unaffected areas of their bodies (such as the size of their stomach or buttocks), so it would be inaccurate to assume that the simple anatomical location of the ­disfigurement may be the prime source of concern.

Clinical Problems and Presentation

All examples are based on real clinical examples referred to people working in psychological ­therapies, attached to general hospital services, including plastic surgery. Names and identifying details have been altered. In the brief vignettes in the box below, the range and complexity of appearance concerns are illustrated. This is to provide an overview for those new to this area of work and briefly indicate both the similarities of concerns (e.g. the worries about the reactions of others and the impact of unusual appearance on self-esteem), and also the importance of individual differences (e.g. the meaning of the disfigurement for that person). More in-depth examples are provided through the book to demonstrate treatment approaches, with the major treatment focus in Chapter 7.

---

Example 1

Geraldine has a small skin graft on her nose following treatment for facial cancer. An artist, she finds the change in her appearance devastating although she accepts that it is relatively minor. She is puzzled by her own response to what she can see is a relatively minor change but is seeking revision of surgery to try to achieve symmetry.

Example 2

Jack has a congenital condition which includes an absence of an ear on one side. Although he has undergone ear reconstruction with a good result, he is still anxious about the appearance of his ear and has avoided cutting his hair or going swimming. He continues to wear a hat pulled low over his head.

Example 3

Eve has had surgery to remove facial cancer which has left her with a visible disfigurement, including loss of her nose. She is overcome by this and cannot envisage ever leaving the house again. She confines herself to her bedroom. Her husband seeks help from the doctor and is told that there is nothing that can be done; ‘she just has to learn to live with it’.

Example 4

James has an industrial injury and loses his dominant thumb. He hates the appearance of his hand and is fearful of others seeing it. He has very marked episodes of dissociation, flashbacks of the injury and his mood is low. His doctor lectures him about people who learn to use their feet to write and use cutlery. He tells him he is making too much fuss and should get back to work immediately.

Note that James presents with symptoms characteristic of post-traumatic stress disorder (PTSD) as well as appearance concerns. Managing the impact of trauma is the priority at this point. Hand injuries may also cause pain and this can impact on mood and ability to manage the treatment regimen. Again we would recommend pain intervention as a priority.

Example 5

Pauline has small breasts. She feels that these single her out from her peer group and describes herself as a freak. She has identified breast augmentation as a means of improving her self-confidence and allowing her to undertake her hoped for training as a beautician.

Pauline has breasts which objectively fall within the normal range, but which she perceives to be abnormal. Her own experience of her appearance is very similar therefore to someone who is worried by a disfiguring condition, and for whom this perception results in appearance anxiety. Unfortunately she is likely to be perceived as vain and her concerns dismissed as ‘purely cosmetic’. She is heavily invested in appearance choosing a career in this field.

Example 6

Mark is a builder who has lost a finger in an accident with a Stanley knife at work. He is very distressed by the appearance of his hand, keeping it in his pocket. He anticipates that he will never get a girlfriend because his hand is off-putting and disgusting. He is very angry both with himself and his employer.

Example 7

John has had surgery for a facial palsy. He had a good result but still has a noticeable palsy when he smiles. He presents with a very low mood, finding it hard to cope at University and feeling that his peers treat him differently and that he is unable to fit in.

Example 8

Peter lost an eye as a child, and the resection means that he is unable to wear an eye patch. He is now at University where he feels that his obvious facial disfigurement limits his opportunity to socialize and in particular to meet girls. He describes himself as ‘always the one going home on his own’. He has low self-esteem and self-confidence and perceives his appearance to be limiting his opportunities for the future both socially and for employment. He is becoming increasingly socially avoidant.

Example 9

Lucy has a breast asymmetry. She presents requesting surgery and becoming very upset in the consultation. She feels like a freak, having been for a bra fitting where the assistant has told her: ‘you need to see a doctor my dear, you are deformed’.

Example 10

Jenny has burn scarring affecting 80% of her body. In the past, most people with the severity of her injuries would have died, but advances in burn care mean that she and other people like her now survive. She presents with a chaotic lifestyle, drinking and smoking heavily with a low mood a...