An Exploration of Emotional Distress in Adults with Acne

152 Pages·2016·1.41 MB·English

by  Susie Clark

An Exploration of Emotional Distress in
Adults with Acne

Susannah Clark

Professional Doctorate in Clinical Psychology
University of East London

May 2016

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ABSTRACT
Rationale: Current empirical yet atheoretical psychodermatological literature
demonstrates the importance of demographic and psychodermatological factors
in the distress experienced in adult acne. Objectification Theory (OT) provides a
promising approach to understand distress, which has not previously been
explored for relevance in this group. OT emphasises the roles of body
surveillance and body shame. The potential relevance of both general and
acne-specific OT constructs to further understanding of distress in adult acne
has been demonstrated. The study’s aim was to explore the relevance of
demographic, psychodermatological and OT factors in predicting distress in this
population.
Method: A cross-sectional design was used to examine relationships between
age, psychodermatological factors (acne severity, visibility, duration), general
OT factors (body surveillance, body shame), acne-specific OT factors (acne
surveillance, acne shame) and emotional distress variables (low self-esteem,
depression, anxiety, appearance-distress). 116 adults receiving acne treatment
completed a series of questionnaires online examining the study variables. Four
hierarchical multiple regression analyses were conducted.
Results: Age and the psychodermatological set of variables contributed a
relatively limited proportion of the variance in predicting distress, and only
significantly predicted appearance-distress. The general OT set of variables
contributed the greatest proportion of the variance, followed by the acne-
specific set. Both sets significantly predicted each distress variable. Acne
shame was the most important individual predictor. Overall, the relationship
patterns between the OT and distress variables provided some tentative
support for the OT framework.
Conclusion: The findings question the relative utility of demographic and
psychodermatological variables in understanding emotional distress in adult
acne, and reveal the importance of OT factors. They demonstrate the relevance
of both general and acne-specific OT constructs in predicting distress and
therefore the potential utility of OT in this area. The findings also demonstrate
the possible promise of applying the OT framework to understand distress in
this population.
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ACKNOWLEDGEMENTS

I would like to thank my research supervisor, Dr Ken Gannon, for all of his
support and feedback.
I also thank those who offered their time to be consulted on the study’s
measures (including Dr Mark Turner and Dr Heidi Williamson).
Finally, I am also extremely thankful to all those who participated in this study.

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CONTENTS

CHAPTER ONE: INTRODUCTION ........................................................................... 1
1.1 What Is Acne Vulgaris? ........................................................................... 1
1.1.1 Biological Model .................................................................................. 1
1.1.2 Psychological Models .......................................................................... 2
1.2 Treatment ................................................................................................. 3
1.3 Epidemiology ........................................................................................... 4
1.4 Contextualising Psychological Research among People with Acne .. 4
1.4.1 Appearance Concern in the General Population ................................. 4
1.4.2 Appearance Concern and Distress among People Living With Visible
Difference ..................................................................................................... 5
1.4.3 The Impact of Skin Disorders and Distress among People Living with
Them ............................................................................................................ 5
1.5 Why Examine Acne In Adulthood? ........................................................ 6
1.6 Distress in Adult Acne ............................................................................ 7
1.6.1 Depression and Anxiety ....................................................................... 8
1.6.2 Social Anxiety and Appearance-Related Concern ............................... 9
1.6.3 Self-Esteem and Body-Image ............................................................ 10
1.6.4 Quality of Life .................................................................................... 11
1.6.5 Summary: Acne and Emotional Distress Correlates .......................... 12
1.7 Explanations for Distress in Visible Difference .................................. 12
1.7.1 Evolutionary Approaches ................................................................... 13
1.7.2 Models of Stigma ............................................................................... 13
1.7.3 Body Shame and Social Anxiety Models ........................................... 14
1.7.4 Summary of Theoretical Approaches and Critical Evaluation ............ 14
1.8 Objectification Theory ........................................................................... 16
1.8.1 OT Empirical Research: Depression and Self-Esteem ...................... 17
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1.8.1.1 OT and Depression ..................................................................... 19
1.8.1.2 OT and Self-Esteem .................................................................... 20
1.8.1.3 Summary: OT, Depression and Self-Esteem .............................. 21
1.8.2 Group-Specific Manifestations of OT ................................................. 21
1.8.2.1 Culturally-Salient Appearance Concerns .................................... 22
1.8.2.2 Health-Related Appearance Concerns ........................................ 23
1.8.2.3 Summary: Group-Specific Manifestations of OT ......................... 23
1.9 Relevance of Applying OT to Understand Distress in Acne .............. 24
1.9.1 Previous Acne Research: Relevance of OT Constructs .................... 25
1.9.1.1 Body Surveillance ....................................................................... 26
1.9.1.2 Body Shame ................................................................................ 26
1.10 Study Rationale .................................................................................... 28
1.10.1 Summary of Study Rationale and how it might add to Current
Understanding of Distress in Acne ............................................................. 28
1.10.2 Factors to be Investigated ............................................................... 29
1.10.3 Appropriate Methodology ................................................................ 30
1.11 Aims ...................................................................................................... 30
1.12 Research Questions and Hypotheses ............................................... 31
1.12.1 Hypothesis One ............................................................................... 31
1.12.2 Hypothesis Two ............................................................................... 31
1.12.3 Hypothesis Three ............................................................................ 32
1.12.4 Hypothesis Four .............................................................................. 32
CHAPTER TWO: METHOD..................................................................................... 33
2.1 Epistemological Position ...................................................................... 33
2.1.1 Background ....................................................................................... 33
2.1.2. Epistemological Positioning of this Study ......................................... 33
2.2 Ethical Approval .................................................................................... 34
2.2.1 Informed Consent .............................................................................. 34
2.2.2 Deception .......................................................................................... 35
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2.2.3 Recruitment of Participants ............................................................... 35
2.3 Design ..................................................................................................... 36
2.4 Materials ................................................................................................. 36
2.4.1 Demographic Questions .................................................................... 36
2.4.2 Standardised Questionnaires ............................................................ 37
2.4.2.1 Anxiety and Depression .............................................................. 37
2.4.2.2 Appearance-Related Distress ..................................................... 38
2.4.2.3 Self-Esteem ................................................................................. 38
2.4.2.4 Dermatological Quality of Life ..................................................... 39
2.4.2.5 Body Surveillance ....................................................................... 39
2.4.2.6 Body Shame ................................................................................ 40
2.4.3 Questionnaires Adapted for this Study .............................................. 41
2.4.3.1 Acne Surveillance ....................................................................... 41
2.4.3.2 Acne Shame ................................................................................ 42
2.4.3.3 Scale Consultation ...................................................................... 43
2.4.4 Psychodermatological Measures ....................................................... 43
2.4.4.1 Acne Duration ............................................................................. 43
2.4.4.2 Subjective Severity and Visibility ................................................. 43
2.5 Participants ............................................................................................ 44
2.6 Procedure ............................................................................................... 44
2.7 Analysis of Data ..................................................................................... 45
2.7.1 Sample Size Calculation .................................................................... 45
2.7.2 Analysis Approach ............................................................................. 46
CHAPTER THREE: RESULTS ................................................................................ 47
3.1 Sample Demographics .......................................................................... 47
3.2 Descriptive Statistics ............................................................................ 47
3.3 Preparatory Analyses ............................................................................ 51
3.3.1 Psychometric Reliability of the Objectification Theory Measures ...... 51
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3.3.2 Influence of Medication and Co-Morbid Health Conditions ................ 51
3.4 Relationships between the Variables ................................................... 51
3.4.1 Emotional Distress Variables ............................................................. 51
3.4.2 Psychodermatological and Objectification Theory Variables ............. 52
3.4.3 Psychodermatological, Objectification Theory and Emotional Distress
Variables .................................................................................................... 52
3.4.4 Relationships between the Demographic and Study Variables ......... 55
3.4.4.1 Age and Emotional Distress Variables ........................................ 55
3.4.4.2 Age and Psychodermatological and Objectification Theory
Variables ................................................................................................. 55
3.5 Predictors of Emotional Distress ......................................................... 56
3.5.1 Self-Esteem ....................................................................................... 56
3.5.1.1 Assumptions ................................................................................ 57
3.5.1.2 Regression Analysis .................................................................... 57
3.5.2 Depression ........................................................................................ 58
3.5.2.1 Assumptions ................................................................................ 59
3.5.2.2 Regression Analysis .................................................................... 59
3.5.3 Generalised Anxiety .......................................................................... 60
3.5.3.1 Assumptions ................................................................................ 60
3.5.3.2 Regression Analysis .................................................................... 61
3.5.4 Appearance-Distress ......................................................................... 62
3.5.4.1 Assumptions ................................................................................ 62
3.5.4.2 Regression Analysis .................................................................... 63
CHAPTER FOUR: DISCUSSION ............................................................................ 65
4.1. Sample Characteristics ........................................................................ 66
4.1.1 Demographics ................................................................................... 66
4.1.2 Overall Scores ................................................................................... 66
4.2 Summary of Findings and General Discussions ................................ 67
4.2.1 Research Question One .................................................................... 67
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4.2.2 Research Question Two .................................................................... 68
4.2.3 Research Questions Three, Four and Five ........................................ 69
4.2.3.1 Age and Psychodermatological Variables ................................... 71
4.2.3.2 General OT Variables ................................................................. 72
4.2.3.3 Acne-Specific OT Variables ........................................................ 73
4.2.4: Exploring the Influence of Individual Predictors ................................ 74
4.2.4.1: Age ............................................................................................. 74
4.2.4.2 Psychodermatological Variables ................................................. 75
4.2.4.3 Body Surveillance ....................................................................... 75
4.2.4.4 Body Shame ................................................................................ 76
4.2.4.5 Acne Surveillance ....................................................................... 78
4.2.4.6 Acne Shame ................................................................................ 79
4.2.5 Summary and Conclusions ................................................................ 80
4.3 Study Strengths ..................................................................................... 81
4.3.1 Building on Previous Research Using Quantitative Methodology ...... 81
4.3.2 New Evidence ................................................................................... 82
4.3.3 Sample Size and Sample Representativeness .................................. 82
4.4 Study Limitations ................................................................................... 83
4.4.1 OT Measures ..................................................................................... 83
4.4.2 Skewness of Some Variables ............................................................ 84
4.4.3 Limitations to the Findings’ Generalisability ....................................... 84
4.4.4 No Control Group or Inclusion of Wider Confounding Variables ........ 85
4.4.5 Extent the Study Reflected the OT Model ......................................... 86
4.5 Future Research .................................................................................... 86
4.5.1 Study Replication .............................................................................. 86
4.5.2 Measures and Extension of Study ..................................................... 86
4.5.3 Mediational and Moderational Analyses ............................................ 87
4.5.4 Longitudinal and Experimental Studies ............................................. 88
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4.5.5 Qualitative Exploration and Research ............................................... 88
4.6 Clinical Implications .............................................................................. 89
4.6.1 Provision of Support .......................................................................... 89
4.6.2 Psychologists/Counsellors ................................................................. 89
4.6.3 Medical Staff ...................................................................................... 90
REFERENCES ........................................................................................................ 92

List of Figures and Tables

Figure One: Objectification Theory Framework................................................. 17
Table One: Participant Demographics ............................................................. 47
Table Two: Descriptive Statistics ..................................................................... 50
Table Three: Spearman’s Correlation Coefficients and Significance Values for
the Study Variables .......................................................................................... 54
Table Four: Spearman’s Correlation Coefficients and Significance Values for
Relationships between Age and the Study Variables ....................................... 55
Table Five: Individual Predictor Coefficients for the Self-Esteem Model .......... 58
Table Six: Individual Predictor Coefficients for the Depression Model ............. 60
Table Seven: Individual Predictor Coefficients for the Generalised Anxiety
Model ............................................................................................................... 62
Table Eight: Individual Predictor Coefficients for the Appearance-Distress
Model ........................................................................................................................................ 64

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APPENDICES ........................................................................................................ 104
Appendix 1: Initial Ethical Approval Letter Received on 3rd May 2015 .... 104
Appendix 2: Methodological Amendment Request Approval Letter Received
on 7th June 2015 ...................................................................................... 107
Appendix 3: Methodological Amendment Request Approval Letter Received
on 13TH November 2015 ........................................................................... 110
Appendix 4: Participant Information Sheet ............................................... 113
Appendix 5: Debrief Letter ........................................................................ 116
Appendix 6: Study Leaflets ....................................................................... 118
Appendix 7: Study Poster ......................................................................... 119
Appendix 8 - The Hospital Anxiety and Depression Scale (Zigmond and
Snaith, 1983) ............................................................................................ 120
Appendix 9 - Rosenberg's Global Self-Esteem Scale (1965). .................. 122
Appendix 10: Dermatology Life Quality Index (Finlay & Khan, 1994). ...... 123
Appendix 11: McKinley and Hyde's Body Surveillance Subscale (1996) .. 125
Appendix 12: McKinley and Hyde's Body Shame Subscale (1996) .......... 126
Appendix 13: Acne Surveillance Scale (modelled on Buchanan et al.'s skin-
tone surveillance scale (2007) .................................................................. 127
Appendix 14: Acne Shame Subscale (modelled on McKinley and Hyde's
body shame subscale (1996) ................................................................... 128
Appendix 15: Order of Questionnaires/Questions .................................... 129
Appendix 16: Hierarchical Multiple Regression Analyses Predicting Self-
Esteem ..................................................................................................... 130
Appendix 17: Self-Esteem Histogram and Normality Plot......................... 131
Appendix 18: Self-Esteem Scatterplot for the Standardised Residuals and
Predicted Values ...................................................................................... 132
Appendix 19: Hierarchical Multiple Regression Analyses Predicting
Depression ............................................................................................... 133
Appendix 20: Depression Histogram and Normality Plot .......................... 134
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