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Facial Disfigurement and Avoidance The University of Hull FACIAL DISFIGUREMENT AND AVOIDANCE: A COGNITIVE BEHAVIOURAL APPROACH being a Thesis submitted for the Degree of DOCTOR OF PHILOSOPHY in the University of Hull by Robert John Newell, BSc (Psychology), Birkbeck College, London March 1998 ACKNOWLEDGEMENTS My thanks to my supervisor, Professor Margaret Clarke, for her continuing support and guidance during the life of this project. To Dr Tim Greene for statistical advice. To Mr N. Hart, Dr K. Keszkes, Mr P. O'Hare, Dr J. Vestey and the nursing, secretarial and clerical staff of local plastic surgery and dermatology clinics, for facilitating access to patients. To Professor I. Marks and colleagues for facilitating access to the database of phobic patients. To Professor W. Cunliffe, Professor I. Marks and Mr Bob Price and facilitators and participants of Let's Face It groups for comments on the original form of the questionnaire. To Dr M. Probst, for permission to use the Body Attitudes Test. To Corinna Petre for formatting and proof reading the final script. To my partner, Caroline Plews, for her unfailing support and interest. Finally, my thanks to those who participated in the study, and who shared so much of their often difficult personal experiences of facial disfigurement. i CONTENTS Page Acknowledgements i Figures v Tables vi Frequently used Abbreviations ix PART 1 INTRODUCTION AND LITERATURE REVIEW Chapter 1 Introduction 2 Section 1.1 Introduction to the study area 2 Section 1.2 Organisation of the literature review 5 Chapter 2 Elements of Body Image 9 Section 2.1 The concept of body image 9 Section 2.2 Models of body image 11 Section 2.3 Approaches to measurement of body image 20 Chapter 3 Studies of Facial Attractiveness 26 Section 3.1 Introduction 26 Section 3.2 Attribution of positive characteristics to attractive people. 26 Section 3.3 Studies of children 29 Section 3.4 Social interactions and dating 30 Section 3.5 Employment suitability 34 Section 3.6 Helping behaviour 36 Section 3.7 Summary discussion of key studies of attractiveness 38 Chapter 4 General Effects of Disfigurement 40 Section 4.1 Introduction 40 Section 4.2 Disfigurement as disability 41 Section 4.3 Disability, disfigurement and stigma 43 Section 4.4 Disfigurement and children 50 Section 4.5 First-hand accounts by disfigured people 60 Section 4.6 Chapter Summary 68 Chapter 5 Disfigurement and Psychosocial Disturbance in Adulthood 70 Section 5.1 Introduction 70 Section 5.2 The nature and extent of psychosocial disturbance 70 Section 5.3 Severity and location of disfigurement as predictors of 78 psychosocial disturbance Section 5.4 Other predictors of psychosocial difficulties following disfigurement 88 Section 5.5 Responses of plastic surgery patients and relevance to studies of 92 disfigurement Section 5.6 Summary discussion of studies of disfigurement 102 Chapter 6 Disfigurement and social interactions 104 Section 6.1 Introduction 104 Section 6.2 Experimental and field studies of social interactions with disfigured 105 people Section 6.3 Helping behaviour 111 11 Section 6.4 Judgements of social competence of disfigured people 118 Section 6.5 Addressing the psychosocial difficulties of facially disfigured people 121 Section 6.6 Chapter summary of studies of disfigurement and social interaction 126 Chapter 7 The Cognitive-Behavioural Approach to Body Image Disturbance 128 and its Treatment Section 7.1 Introduction 128 Section 7.2 Development of behaviour therapy 128 Section 7.3 Behaviour therapy and cognitive therapy 132 Section 7.4 Cognitive-behaviour therapy 136 Section 7.5 Cognitive-behavioural approaches to treatment of disturbed body 140 image and disfigurement Section 7.6 Chapter summary 148 Chapter 8 Towards a Cognitive-Behavioural Approach to Body Image 151 Disturbance In Facial Disfigurement Section 8.1 Introduction 151 Section 8.2 Development of the cognitive-behavioural model of psychosocial 152 disturbance following disfigurement Section 8.3 The fear-avoidance model of psychosocial difficulties following 155 disfigurement Section 8.4 Examination of the fear-avoidance model 162 PART 2 EMPIRICAL STUDIES Chapter 9 General Methodological Issues 168 Section 9.1 Introduction 168 Section 9.2 General methodological considerations 168 Section 9.3 Choice of treatment intervention 172 Section 9.4 Ethical considerations 177 Chapter 10 Method 184 Section 10.1 Introduction 184 Section 10.2 Measures 184 Section 10.3 The self-help leaflet. 192 Section 10.4 Pilot study 197 Section 10.5 Survey of plastic surgery ex-patients 200 Section 10.6 Media recruited questionnaire study 204 Section 10.7 Treatment leaflet pilot study 207 Section 10.8 Comparison of facially disfigured people with phobic patients 208 Section 10.9 Data analysis 210 Chapter 11 Results 218 Section 11.1 Introduction 218 Section 11.2 Characteristics of the FAAC 219 Section 11.3 Pilot study (dermatology outpatients) 227 Section 11.4 Survey of plastic surgery ex-patients 238 Section 11.5 Media recruited questionnaire study 248 Section 11.6 Treatment leaflet pilot study 265 Section 11.7 Comparison of facially disfigured people with phobic patients 270 Chapter 12 Discussion 275 Section 12.1 Introduction 275 Section 12.2 Questionnaire characteristics 275 Section 12.3 Characteristics of the study group 281 111 Section 12.4 Treatment leaflet study 294 Section 12.5 Comparison of facially disfigured people with phobic patients 296 Section 12.6 Summary of support provided by the study for a fear-avoidance 297 model of psychological difficulty in disfigurement Section 12.7 Limitations of the study 300 Section 12.8 Future research 305 Section 12.9 Concluding remarks 308 References 312 Appendices 335 Appendix 1 Example brief explanatory letter. Media study 336 Appendix 2 Questionnaire front sheet study details. Media study 337 Appendix 3 Example initial contact letter. Plastic surgery ex-patients study 338 Appendix 4 Letter granting ethical approval 340 Appendix 5 Face and body attitudes and behaviours questionnaire 341 (monochrome facsimile) Appendix 6 Letter granting permission to use the BAT 350 Appendix 7 Self-help leaflet (monochrome facsimile of A5 doublesided original) 351 Appendix 8 Pilot study consent form 361 Appendix 9 Follow-up letter. Plastic surgery ex-patients study 362 Appendix 10 Text of contact articles published in papers for media study 363 Appendix 11 Anonymised reply to under 17 year old respondent to media study 364 request for participants Appendix 12 Letter sent to treatment group with treatment leaflet 365 Appendix 13 Letter sent to control group 366 Appendix 14 Media sample correlation matrix prior to factor analysis 367 Appendix 15 Pilot study: non-significant correlations with FAAC subscales 368 (Kendal's Tau) Appendix 16 Treatment study participants: correlations between time since 369 disfigurement and outcome measures (Pearson's Product Moment coefficient) Appendix 17 ANCOVA table for comparisons between agoraphobics and facially 370 disfigured people Appendix 18 ANCOVA table for comparisons between social phobics and 371 facially disfigured people Appendix 19 Fear Questionnaire subscale scores of agoraphobic and social 372 phobic samples iv FIGURES Page Figure 2.2.1 Price's model of body image 12 Figure 2.2.2 Slade's model of body image disturbance 19 Figure 6.5.1 The Scared Syndrome 123 Figure 8.2.1 Lethem et al's model of exaggerated pain perception 154 Figure 8.3.1: A model of disturbed body image (From Newell, 1991) 156 Figure 8.3.2 A model of successful adaptation following change of body image 158 Figure 8.3.3 A fear-avoidance model of psychosocial difficulties following 159 disfigurement Figure 10.3.1 Anxiety and changes in facial appearance: Readability figures 194 Figure 10.3.2 Readability statistics following removal of clinical descriptors 194 Figure 11.2.1 Scattergram of test/retest correlations - FAAC total score 225 Figure 11.2.2 Scattergram of test/retest correlations - FAAC face/others 225 subscale Figure 11.2.3 Scattergram of test/retest correlations - FAAC face/self subscale 226 Figure 11.2.4 Scattergram of test/retest correlations - FAAC rest subscale 226 V TABLES Page Table 4.2.1 Impairment of performance by disfigurement according to age 42 Table 10.9.1 Sample sizes likely to be necessary to detect differences between 215 treated and untreated groups where such differences are present. Table 10.9.2 Minimum numbers necessary to detect differences between facially 217 disfigured people and agoraphobics or social phobics where such differences are present. Table 11.2.1 Variance by Rotated Factor (n = 199) 220 Table 11.2.2 Item loading on the three FAAC factors 221 Table 11.2.3 Cronbach's Alpha coefficient: plastic surgery ex-patients 222 Table 11.2.4 Cronbach's Alpha coefficient: media-recruited sample 222 Table 11.2.5 Causes of disfigurement: retest respondents and non-respondents 224 Table 11.2.6 Sex of respondents and non-respondents 224 Table 11.2.7 FAAC:test-retest reliability: correlations between time 1 and time 2 224 administration Table 11.3.1 Pilot study FAAC responses 229 Table 11.3.2 Pilot study Fear Questionnaire responses 230 Table 11.3.3 Pilot study Social Adjustment Questionnaire (SAQ) scores 231 Table 11.3.4 Pilot study General Health Questionnaire Scores 231 Table 11.3.5 Pilot study Hospital Anxiety & Depression Scale Scores 231 Table 11.3.6 Pilot study Maudsley Obsessions Checklist Scores 232 Table 11.3.7 Pilot study male/female differences 1: FAAC scores. 233 Table 11.3.8 Pilot study male/female differences 2: Other measures 234 Table 11.3.9 Pilot study Correlations with FAAC subscales (Kendal's Tau) 236 Table 11.3.10 Pilot study Correlations between FAAC and BAT items 237 Table 11.3.11 Pilot study avoidance tactics 238 Table 11.4.1 Plastic surgery ex-patients: causes of disfigurement 239 Table 11.4.2 Plastic surgery ex-patients: Comparison of questionnaire 239 respondents and non-respondents according to diagnosis.
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