Alex Clarke

CBT for appearance anxiety : psychosocial interventions for anxiety due to visible difference

CBT For Appearance Anxiety: Psychosocial Interventions For Anxiety Due To Visible Difference (Softcover) - Libros de Medicina - Psicologia General - 42,00

Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder

Background: Practitioners in a cosmetic setting need a screening questionnaire to identify people with Body Dysmorphic Disorder (BDD). Method: Two groups who desired a cosmetic procedure completed the Cosmetic Procedure Screening Questionnaire (COPS): (a) a group diagnosed with BDD (n =97) and (b) a community control group (n=108). Both groups desired a cosmetic procedure. Item characteristics, reliability and factorial structure were analysed. Convergent validity with selected questionnaires was determined. Sensitivity to change during cognitive behaviour therapy was also determined in a sub-sample of BDD patients. Results: The most sensitive items discriminating between the two groups were used to form the final questionnaire. Receiver Operating Characteristics analysis was used to assess sensitivity and specificity of the COPS to discriminate between the groups and a cut-off score of 40 was chosen. Conclusions: The COPS is a sensitive and specific screening measure for BDD that can be used in cosmetic settings and as a potential research tool to predict dissatisfaction or changes in BDD symptoms after any treatment. Background: Guidelines recommend screening patients for Body Dysmorphic Disorder (BDD) prior to cosmetic surgery to identify those who may require further psychological assessment 1 but there are few validated instruments available. The aim of the current study was therefore to develop a screening questionnaire that (a) was brief, free to download and could identify people with BDD, (b) might predict either dissatisfaction with a cosmetic procedure or no change or deterioration in symptoms of BDD, and (c) may be sensitive to change after an intervention. The new scale was informed by the diagnostic criteria, expert opinion and a previous study that compared patients satisfied with cosmetic rhinoplasty with BDD patients who craved rhinoplasty but had not been able to obtain it . Method: Two groups of participants were recruited: a) Community group We recruited a community group of both genders who were either planning or very motivated to have a cosmetic procedure in the future. The questionnaire was completed by n=108 participants. b) BDD group A psychiatrist conducted an interview based on DSM-IV to diagnose BDD in a clinical setting. Ninety-seven patients with BDD seeking a cosmetic procedure were recruited. All participants completed the following: 1) Cosmetic Procedure Screening (COPS) questionnaire The questionnaire asks for the feature(s) that the person finds unattractive, the nature of the cosmetic procedures they are seeking and diagnostic criteria of BDD. The final version of COPS questionnaire comprises 9 items. Items are scored from 0 (least impaired) to 8 (most impaired). The scale and a full version of this paper is available to download from: http://www.iop.kcl.ac.uk/cadatquestionnaire. The score is achieved by summing Q 2-10. Items 2, 3 and 5 are reversed. The total ranges from 0 to 72 with a higher score reflecting greater impairment. 2) Hospital Anxiety and Depression Scale (HAD) 3) Body Image Quality of Life Inventory (BIQLI) 4) Body Image Disturbance Questionnaire (BIDQ) Results Items on the COPS that showed a significant difference between the two groups, which did not have a significant group x sex interaction and had an effect size (Cohen’s d) of at least 0.80 were retained in the item discriminatory analysis. Nine items met these criteria and were used to form the final questionnaire (see Table 1). Internal Consistency Reliability analysis resulted in an internal consistency of Cronbach’s α = 0.91 with corrected item total ranging from 0.41 to 0.86. Test-retest Reliability 67 participants in the community group repeated the COPS after 1 week. The COPS had good test–retest reliability (r = 0.87, p< 0.01). First administration (M=27.94, SD=13.89), second administration (M=30.71, SD=14.04). Convergent validity Based on the data from both groups the COPS correlated highly with the HAD depression subscale (r = 0.7, p< 0.01) and anxiety subscale (r = 0.66, p< 0.01). COPS also correlated highly with the BIQLI (r = 0.68, p<0.01). Thus higher scores on COPS are associated with lower body image quality of life. Cut-off value and ROC analysis Figure 1 represents the ROC curve for BDD patients compared with community controls. The area under the curve (AUC) for this analysis was .905 (95% CI = .862 .948) indicating that the COPS is an accurate diagnostic test. Based on the discrimination of BDD patients from the community group, a cut-off value of ≥ 40 resulted in a maximal kappa coefficient (k = 0.69, p<0.001). On the basis of this cutoff value, 88.9% of BDD patients and 80.6% of the community group were classified correctly. Sensitivity to change We examined sensitivity to change in a sub-sample of 5 patients with BDD who were undergoing cognitive behaviour therapy . Scores on the COPS were examined at baseline, 6 weeks, and 12 weeks. The mean and SD on the 9-item COPS was 52.40 (SD= 16.70) at baseline and 35.00 (SD= 22.88) at 12 weeks. A one-way repeated measures ANOVA was conducted to compare scores across these 3 treatment points. There was a significant effect across the 3 treatment points [F (1.10, 4.38)= 7.35, p = .047]. Discussion We have developed a brief (nine item) screening questionnaire (COPS) that can be used in a cosmetic procedure setting to screen patients with BDD. The scale has acceptable internal consistency, test-retest reliability, and convergent validity. It has a high sensitivity for the diagnosis of BDD in people who are likely to seek a cosmetic procedure. Individuals who score 40 or more should be referred for further assessment. The COPS was also sensitive to change in patients receiving cognitive behaviour therapy . It may therefore be used an outcome measure after any treatment (including cosmetic procedures) to determine (a) if there is any improvement in symptoms of BDD on a continuous dimension (b) whether it may predict persistence of symptoms or dissatisfaction with a cosmetic procedure (in the absence of any surgical complications). Conflict of interest: None Funding: None Ethical Approval: Brighton and Sussex Ethics Committee Acknowledgements: David Veale and Nell Ellison are supported by the National Institute for Health Research (NIHR) Specialist Biomedical Research Centre for Mental Health award to the South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, Kings College London. References: 1. National Institute of Clinical Excellence (NICE). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical Guideline 31, 2005. 2. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. British Journal of Plastic Surgery 2003; 56: 546-551. 3. Veale, D., & Neziroglu, F. (2010). Body Dysmorphic Disorder: a treatment manual. Chichester: John Wiley & Sons. 4. Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, et al. Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy 1996; 34: 717-729. Figure 1. Receiver operating characteristics plot of COPS scores of BDD patients compared with community controls.

Clinical outcomes of facial transplantation: A review

A total of 18 composite tissue allotransplants of the face have currently been reported. Prior to the start of the face transplant programme, there had been intense debate over the risks and benefits of performing this experimental surgery. This review examines the surgical, functional and aesthetic, immunological and psychological outcomes of facial transplantation thus far, based on the predicted risks outlined in early publications from teams around the world. The initial experience has demonstrated that facial transplantation is surgically feasible. Functional and aesthetic outcomes have been very encouraging with good motor and sensory recovery and improvements to important facial functions observed. Episodes of acute rejection have been common, as predicted, but easily controlled with increases in systemic immunosuppression. Psychological improvements have been remarkable and have resulted in the reintegration of patients into the outside world, social networks and even the workplace. Complications of immunosuppression and patient mortality have been observed in the initial series. These have highlighted rigorous patient selection as the key predictor of success. The overall early outcomes of the face transplant programme have been generally more positive than many predicted. This initial success is testament to the robust approach of teams. Dissemination of outcomes and ongoing refinement of the process may allow facial transplantation to eventually become a first-line reconstructive option for those with extensive facial disfigurements.

Evaluation of the effectiveness of Face IT, a computer-based psychosocial intervention for disfigurement-related distress

Some people who have a visible difference (disfigurement) experience psychosocial adjustment problems that can lead to social anxiety and isolation. The aim of thisstudy was to assess the effectiveness of a new computerised CBT-based intervention (Face IT) in reducing anxiety and appearance-related distress for individuals with visible differences. Face IT was tested against a non-intervention control group and standard CBT-based face-to-face delivery. Eighty-three participants were assessed at four time points using the Hospital Anxiety and Depression Scales, Derriford Appearance Scale-24, Body Image Quality of Life Inventory and Fear of Negative Evaluation (FNE). The findings indicate a significant reduction in anxiety and appearance-related distress in both the Face IT intervention and the face-to-face condition. Similar findings were reported for depressive symptoms and FNE. Results at the three and six months follow-up demonstrate increased improvements in psychological functioning with both interventions. This new online psychosocial intervention has been found to be effective at reducing anxiety, depression and appearance concerns amongst individuals with disfigurements, whilst increasing positive adjustment. A remote-access, computer-based intervention offers the potential to provide psychosocial support more easily and in a cost-effective manner to adults with appearance-related distress.

Informed consent for facial transplantation

Now that partial face transplantation has been performed, attention is focused on likely functional, aesthetic and immunological outcomes, and full facial transplantation is the likely next step. Facial transplantation has been the source of ethical debate, a key part of which focuses on valid informed consent. We review the process of informed consent in health settings, assessing how applicable the current standards are for facial transplantation. The factors which need to be assessed during the screening programme are outlined. We conclude that both individual and process factors are important in obtaining consent for radical new procedures, and outline our own gold standard for ensuring informed consent in facial transplantation.

The psychological management of facial transplantation

Facial transplantation is a major advance in reconstructive surgery, providing enormous potential benefit in terms of improved function and cosmesis. Managing the challenges it brings depends on understanding both technical and psychological issues. Research on the psychological aspects of organ transplantation is a starting point; however, issues of altered appearance and identity, adjustment to change, the management of suboptimal adherence to immunosuppression, and how we present and understand risk, particularly related to immunosuppression and rejection, must all be addressed before the procedure becomes a clinical option. This review addresses the psychological issues highlighted in the Royal College of Surgeons Working Party Report on facial transplantation, describing how these have been addressed in the development of a clinical program.

Attitudes to face transplantation: results of a public engagement exercise at the Royal Society Summer Science Exhibition.

Hettiaratchy and Butler (Lancet 2002;360:5–6) framed face transplantation as the next logical step on the reconstructive ladder for severe facial injury, in particular, pan-facial burns. The procedure formed the basis for a Royal College of Surgeons of England working party report. Ethical, surgical, and psychological issues were identified as research priorities before face transplantation is attempted in the United Kingdom. Public engagement is a vital mechanism if people are to be informed about the risks and benefits of the technique and ultimately to be able to consent to either receiving or donating facial tissue. To sample public opinion about the procedure, 304 people attending the Royal Society Summer Science Exhibition were sampled by online questionnaire to determine their attitude toward face transplantation. Although people were more cautious about face transplantation when comparing this with solid-organ transplantation, most of the sample were in favor of the procedure, whether receiving a donor face or donating their own face after their death. Only 10% were against the idea in principle. Concerns about altered identity were not a barrier to face transplantation for 69% of the sample, with most people appropriately identifying the long-term problems of immunosuppression as the issue that most concerned them. There is a substantial population of people who, given the right circumstances, would contemplate face transplantation for themselves and would be willing to donate their own face for transplantation after their death.

The psychological impact of facial changes in scleroderma

The physical disabilities associated with scleroderma are well known but the psychological impact of the condition has received less attention. Few studies have examined appearance related issues, most notably of the face. The aim of this study is to evaluate the psychological impact of facial, aesthetic and functional changes in scleroderma. One hundred seventy-one patients with a clinical diagnosis of scleroderma were recruited into the study. Digital photographs were objectively graded into groups based on severity of disfigurement as judged by an observer. Facial movement was recorded using a modified House–Brackmann Grading Scale. Psychological evaluation comprised the Derriford Appearance Scale short-form (DAS), the Noticeability and Worry score and the Hospital Anxiety and Depression Scale (HADS). Severity of disfigurement predicted decreased mouth opening, the extent to which participants judged their appearance as noticeable to others, and the level of appearance-related concern as measured by the DAS24. There was an inverse relationship with age. Facial changes were ranked as the most worrying aspect of the condition. This study shows facial disfigurement impacts on patient with scleroderma independent of functional changes related to systemic disease. The major difficulty is with the perceived noticeably of the condition to other people and the resulting self-consciousness in social encounters.

Differential judgements about disfigurement: the role of location, age and gender in decisions made by observers

Psychological distress associated with disfiguring facial lesions is common. However, whilst the intrusive behaviour of observers is commonly reported, for example, staring, comments and questions, these factors which may influence the judgements of observers have not been well described. This is important as it may influence a subjects perception of how their appearance is viewed by the external world. This study is the first to investigate age and gender differences when measuring the importance of location in judgements about facial disfigurement. Observers were asked to rank the impact of simulated lesions in different positions on the face of Caucasian subjects. Age and gender varied in both groups. Our results show that lesions on the young and female subjects are ranked as having a greater impact than those on the old and male subjects. Lesions on central facial features have a higher impact than those located more peripherally. Both of these findings were not significantly influenced by observer age or gender. These results are discussed in terms of culturally derived attributions about appearance. It is also suggested that there is a scope to use feedback on how disfigurement is viewed by others as a therapeutic tool in clinical settings.

Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases: a mixed-methods study

Objective Multidisciplinary team (MDT) meetings are assumed to produce better decisions and are extensively used to manage chronic disease in the National Health Service (NHS). However, evidence for their effectiveness is mixed. Our objective was to investigate determinants of MDT effectiveness by examining factors influencing the implementation of MDT treatment plans. This is a proxy measure of effectiveness, because it lies on the pathway to improvements in health, and reflects team decision making which has taken account of clinical and non-clinical information. Additionally, this measure can be compared across MDTs for different conditions. Methods We undertook a prospective mixed-methods study of 12 MDTs in London and North Thames. Data were collected by observation of 370 MDT meetings, interviews with 53 MDT members, and from 2654 patient medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation, whether their preferences and other clinical/health behaviours were mentioned) and MDT features (as measured using the ‘Team Climate Inventory’ and skill mix) on the implementation of MDT treatment plans. Results The adjusted odds (or likelihood) of implementation was reduced by 25% for each additional professional group represented at the MDT meeting. Implementation was more likely in MDTs with clear goals and processes and a good ‘Team Climate’ (adjusted OR 1.96; 95% CI 1.15 to 3.31 for a unit increase in Team Climate Inventory (TCI) score). Implementation varied by disease category, with the lowest adjusted odds of implementation in mental health teams. Implementation was also lower for patients living in more deprived areas (adjusted odds of implementation for patients in the most compared with least deprived areas was 0.60, 95% CI 0.39 to 0.91). Conclusions Greater multidisciplinarity is not necessarily associated with more effective decision making. Explicit goals and procedures are also crucial. Decision implementation should be routinely monitored to ensure the equitable provision of care.