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

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=45.2years) 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 (r_s(76)=0.80, p<0.001, one-tailed) and cognitive defusion (r_s(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.