Title: Predicting the development of appearance anxiety following burn injuries and initial evaluation of an early intervention
Funder: Health Education England

Abstract: Research questions Does low psychological flexibility following a burn predict subsequent appearance anxiety? What are burns patients' early experiences of appearance anxiety? Is an early intervention for appearance anxiety acceptable and effective?Background Burns patients experience high rates of mental health problems, and scars can lead to appearance anxiety. Minimal research has explored early psychological processes that predict the development of appearance anxiety, limiting screening potential. Evidence-based interventions are limited. There has been no focus on early intervention. Aims and objectives Investigate whether low psychological flexibility whilst in hospital following a burn predicts subsequent appearance anxiety Identify patients' early emotions and thoughts about their appearance, responses to these and their support needs Develop an early intervention for appearance anxiety and initially evaluate it for effectiveness and acceptabilityMethods Three studies involving adult burns patients from two regional burns services. Study 1 (Years 1-3): A prospective cohort study will investigate early psychological flexibility in the development of appearance anxiety. Burns inpatients (n=153) will complete four questionnaires: Satisfaction with Appearance Scale; Impact of Events Scale - Revised; Acceptance and Action Questionnaire; and Cognitive Fusion Questionnaire. These measure appearance anxiety, post-traumatic stress and psychological flexibility (acceptance and cognitive fusion). Patients will repeat the questionnaires two months and six months after discharge, plus the Work and Social Adjustment Scale, to measure functioning. Linear regression analysis will explore the hypothesis that low psychological flexibility predicts subsequent appearance anxiety. Study 2 (Years 2-3): A qualitative study will explore burns patients' early emotions and thoughts about their changed appearance and future scarring, their responses to and the impact of these, and their support needs. Patients (n=15) showing early signs of appearance anxiety will be interviewed when their wounds are still healing. Interviews will be guided by the theory of psychological flexibility and analysed using content analysis. Patients will complete the Satisfaction with Appearance Scale. Study 3 (Years 4-5): An early intervention for appearance anxiety, likely involving six sessions of acceptance and commitment therapy (ACT), will be developed following interviews with burns psychologists, discussions with patients and charities, and results from Studies 1 and 2. Patients (n=10) with unhealed wounds and showing early signs of appearance anxiety will complete the intervention, completing daily diaries. Five questionnaires will be completed at baseline, pre- and post-intervention, and three months later: Satisfaction with Appearance Scale; Impact of Events Scale - Revised; Acceptance and Action Questionnaire; Cognitive Fusion Questionnaire; and Work and Social Adjustment Scale. The Helpful Aspects of Therapy Form will be completed after every session. Exit interviews will be completed. Visual inspection of the data, descriptive statistics and content analysis will determine the acceptability and effectiveness of the intervention. Anticipated impact and dissemination This research will improve the ability to identify hospitalised burns patients who may later develop appearance anxiety, enhancing screening. Early interventions will become standard practice, reducing appearance anxiety sooner. Results will be disseminated by journals articles, conference presentations, presentations to patient advisors, burns clinicians and researchers, and via websites, social media and newsletters of burns/disfigurement charities.

Lay abstract: Aim(s) of the researchTo increase the ability to predict the development of appearance anxiety following burn injuries and develop an early intervention by: Investigating whether early ways of managing emotions and thoughts predict which patients later develop appearance anxiety Exploring patients' early emotions and thoughts about their appearance and future scars, how they react to these and early support needs Developing and testing a psychological intervention for early signs of appearance anxietyBackground to the researchBurns patients often have mental health problems. One problem is 'appearance anxiety' due to scars. It is important to predict which patients will develop appearance anxiety so they can be identified early and helped. However, what is known already is limited. This research will help burns services improve inpatient screening, and help identify patients who will later develop appearance anxiety. Early identification allows early intervention. This is vital for reducing distress caused by appearance anxiety and the impact of it sooner. During the research, an early intervention will be developed and tested for the first time. The intervention will then be tested further in future research and, if found to be effective, early interventions will be offered following burns. Design and methods usedThree studies will be completed, involving adult burns patients. Study 1: Burns patients (n=153) will complete four questionnaires when in hospital. These will measure appearance anxiety, post-traumatic stress and ways of managing emotions and thoughts. The same questionnaires will be repeated two months and six months after discharge. Another questionnaire will also be completed at these times, measuring functioning. Questionnaires may be completed over the telephone, online or by post. Results will improve understanding about how appearance anxiety develops and the ability to identify patients who will later struggle soon after injury. Study 2: Fifteen burns patients will be interviewed shortly after discharge from hospital. Patients showing early signs of appearance anxiety will be asked about their emotions and thoughts about their appearance and future scarring, how they are managing these, how they are affecting their behaviour, and what support they need. Their answers will be looked at in detail to learn how appearance anxiety develops. Study 3: An early intervention for appearance anxiety will be developed. Interviews with burns psychologists, discussions with patients and charities, and results from Studies 1 and 2, will inform the intervention. The intervention will likely involve six sessions of acceptance and commitment therapy (ACT). This teaches patients ways to manage distressing emotions and thoughts so they can live meaningful lives. The intervention will be tested on 10 burns patients recently discharged from hospital and showing early signs of appearance anxiety. Patients will keep daily diaries and complete five questionnaires at the beginning and end of the intervention, and three months later. Patients will rate every session and be interviewed at the end to test whether the intervention is useful and acceptable. Patient and public involvement Patients, a lay member of a regional burns network, and charities have been involved in the research design. Patients have been vital in considering the timing of an intervention and recruitment barriers. I will continue to involve patients and public organisations at all stages, including data collection. A burns survivor, who is a trustee of a charity supporting people with disfigurements, will collaborate throughout the research, external to the patient advisory group. Dissemination Results will be presented to the patient advisory group, at meetings and conferences related to burn care and appearance changes, through social media platforms and newsletters of charities, and journal articles. Patients will help prepare presentations and attend meetings and a conference.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL;7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH;INJURIES AND ACCIDENTS