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CBT for Appearance Anxiety: Psychosocial Interventions for Anxiety due to Visible Difference

Borah, Gregory L. M.D., D.M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 579–580
doi: 10.1097/PRS.0000000000000530


In 1987, a fire originated in a wooden escalator in the London Underground at the King’s Cross station when a lit cigarette ignited the oily residue under the treads. The fire burned slowly until it exploded in an overflash phenomenon known as the “trench effect,” which instantly engulfed the ticket hall above, killing 31 people and burning an additional 100 people, 19 of whom were severely injured. Many of the burn patients were brought to University College Hospital, where they were treated by a team led by the plastic surgeon on duty, Michael Brough. The team that he assembled at University College Hospital eventually comprised 21 consultants from 11 different specialties to address the comprehensive ranges of problems with burn patients. Brough’s advocacy for a team approach to treat severe injury would eventually lead to his establishment of the first Department of Plastic Surgery at a British university.

As a function of the casualties from the King’s Cross fire, Dr. Brough was profoundly impressed by the impact of the psychological consequences of the permanent scars and deformities suffered by the fire victims. The experience of treating these patients and observing the long-term effects of their injuries on the survivors and their families moved Dr. Brough to establish two charities to raise funds for research into effective treatment protocols that could help patients with disfiguring conditions better cope and return to meaningful lives. Dr. Brough was named president of the British Association of Plastic Surgeons in 2002 and was also a member of the National Health Service Modernization Agency’s Action on Plastic Surgery that redesigned plastic surgery training in the United Kingdom.

In 2002, Brough established The Healing Foundation, a national charity to address the needs of people living with disfigurement and loss of function that funds research into surgical and psychological healing techniques. The foundation funded a 3-year study into the psychological effects of burn injuries and similar disfigurement, the Appearance Research Collaboration. This clear, comprehensive, and thoughtful text was produced as a result.

CBT for Appearance Anxiety: Psychosocial Interventions for Anxiety due to Visible Difference is written for psychologists and clinicians who are already versed in cognitive behavioral therapy (CBT) and who work with adults disturbed by visible appearance difference that is either congenital or posttraumatic in nature. The authors have thoughtfully built a systemic approach to treatment based on recent studies on the effectiveness of cognitive behavioral therapy intervention to ease anxiety and improve social functioning in those patients who view their appearance as abnormal. The authors support each of the well-structured chapters with current evidence-based articles, supplemented extensively by clinical examples of representative patient scenarios aggregated from numerous patients that illustrate the common threads of each area of concern. These various kinds of clinical examples will be immediately familiar to plastic surgeons who treat patients with appearance problems.

The soft-cover book is organized in a logical fashion, beginning with a summary entitled “Background, Clinical Problems, Common Presentation and Treatment Considerations.” This is one of the clearest and most thorough outlines of the major components of anxiety and psychological impairment is currently available. The authors describe in a succinct but comprehensive narrative the issues, problems, and concerns that patients experience, while acknowledging the importance of culture, age, and gender in each individual’s situation and that patient’s likely response to therapy.

There are successive chapters describing the team’s approach to developing a conceptual structure for management of appearance-related distress, followed by techniques for clinical assessment of the individual and then the implementation of social skills and coping strategies. The middle chapters are focused on a session-by-session guide to real-life treatment planning and progressive interventions for a variety of clinical examples of appearance-related impairments. Each chapter in this group has suggested patient-actuated activities and metrics for documenting progress with rating scales.

The next-to-last chapter is of interest for the clinician treating the adolescent who is transitioning out of the largely protective and supportive world of the pediatric patient into the more challenging world of independent adulthood. Here the attendant issues of self-image development, separation from parental control, normal rebellion, and evolving romantic concerns add to the therapeutic concerns for the health professional’s working with these emerging adults who see themselves as different because of their appearance.

Of special concern for the plastic surgeon is the final chapter on psychological assessment for cosmetic surgery. The authors address this challenge in a typically structured way and offer guidelines from a series of standardized symptom inventories. They offer a number of clinical examples that describe the needs of the surgeon as well as the needs of the patient to understand the psychologist’s assessment. Because the authors are working in the United Kingdom, they approach this issue from the perspective of being asked to evaluate patients for suitability and likely success of appearance-related surgery in a nationalized health care system. There are some unique aspects of the National Health Service that are less applicable to the system in the United States, but in general, the issues and concerns of cosmetic evaluation are universal.

Overall, this is a very informative and highly useful text for any clinician who wants to both better understand and treat the issues and problems of the patient affected by a difference in appearance due to trauma, congenital, or developmental sources. It will find its home with psychologists, psychiatrists, and counselors who seek to help patients learn to adapt and thrive socially and psychologically. The inquisitive plastic surgeon who has an interest in understanding the basic precepts and concerns of abnormal appearance will also find much to learn here.

Regrettably, Dr. Brough did not live to see the full fruits of his initiative to help future generations of disfigured patients live fuller lives. Although a nonsmoker all his life, he died of lung cancer exactly on the 17th anniversary of the King’s Cross fire in 2004.

©2014American Society of Plastic Surgeons