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The implications of body-image dissatisfaction among kidney-transplant recipients a
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Yaron Yagil , Shulamit Geller , Yael Sidi , Yael Tirosh , Paulina c
Katz & Richard Nakache
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Department of Social Work and Department of Education, TelHai College, Upper Galilee, Israel b
School of Behavioral Sciences, Tel Aviv–Yaffo Academic College, Tel-Aviv, Israel c
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Organ Transplantation Unit, Tel-Aviv Sourasky Medical CenterAffiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Published online: 24 Oct 2014.
To cite this article: Yaron Yagil, Shulamit Geller, Yael Sidi, Yael Tirosh, Paulina Katz & Richard Nakache (2014): The implications of body-image dissatisfaction among kidney-transplant recipients, Psychology, Health & Medicine, DOI: 10.1080/13548506.2014.972417 To link to this article: http://dx.doi.org/10.1080/13548506.2014.972417
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Psychology, Health & Medicine, 2014 http://dx.doi.org/10.1080/13548506.2014.972417
The implications of body-image dissatisfaction among kidneytransplant recipients Yaron Yagila*, Shulamit Gellerb, Yael Sidib, Yael Tiroshc, Paulina Katzc and Richard Nakachec
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a Department of Social Work and Department of Education, Tel-Hai College, Upper Galilee, Israel; bSchool of Behavioral Sciences, Tel Aviv–Yaffo Academic College, Tel-Aviv, Israel; cOrgan Transplantation Unit, Tel-Aviv Sourasky Medical Center-Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
(Received 4 June 2014; accepted 30 September 2014) The role that body image plays in the psychological adjustment of kidney-transplant recipients is an understudied issue. In the current study, the association between three variables – (a) body-image dissatisfaction, (b) quality of life (QOL), and (c) psychological distress – was investigated. The research participants were 45 kidneytransplant recipients who were under follow-up care at the Transplant Unit of the Tel-Aviv Medical Center (Israel). Body image, psychological distress, and QOL were measured using self-report questionnaires [Body-Image Ideals Questionnaire (BIIQ), Brief Symptoms Inventory (BSI), and SF-12]. Medical and background data were collected from medical and administrative records. The findings indicated an association between higher level of body-image dissatisfaction and a decrease in several quality-of-life dimensions (role emotional, physical pain, general health, and social functioning), and with an increase in psychological distress. These findings highlight the importance of body-image dissatisfaction as a factor that is associated with QOL and psychological distress among kidney-transplant recipients. Body image warrants further attention and should be screened and treated among those who demonstrate high levels of dissatisfaction. Keywords: body image; quality of life; psychological distress; kidney transplantation
Introduction Body image refers to one’s own experiences of embodiment: a cumulative set of images, fantasies, and meanings regarding the body and its parts and functions (Cash, 2004). It is an integral component of self-image and the basis of self-representation. It is also a dynamically and developmentally evolving mental representation of the self (Krueger, 2002), and it may be viewed through two complementary approaches: the cross-situational trait approach and the situational state approach (Cash, 2002, 2011). The trait approach refers to the relatively stable overall schema that a person develops during his/her life about his/her physical appearance. It is a stable cognitive structure that does not change radically following specific life events, but rather incrementally incorporates some changes into its existing structure. The state approach, on the other hand, assumes that body image has a situation-dependent facet. It takes into account life events and experiences that may lead to temporal variations of body image. According *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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Table 1. Spearman correlations between body-image dissatisfaction, QOL, and psychological distress (n = 45).
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Actual–ideal body image gap Quality of life (SF-12) Physical functioning Role physical Role emotional Physical pain General health Vitality Social functioning Mental health Psychological distress (BSI) Somatic symptoms Obsession-compulsion Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid symptoms Alienation symptoms GSI PST PSDI
−.01 −.14 −.23 −.14 −.26 −.04 −.21 −.16 .33* .38** .28 .14 .34* .34* .20 .29* .35* .36* .35* .21
Degree of importance attributed to this gap .21 −.17 −.11 −.14 −.16 −.07 −.17 −.14 .32* .13 .42** .35* .27 .33* .35* .33* .41** .42** .39** .30*
Final body image dissatisfaction score .13 −.20 −.33* −.33* −.32* −.15 −.34* −.20 .48** .54** .44** .40** .45** .37* .37* .49** .55** .56** .57** .36*
*p < .05; **p < .01.
to the state approach, specific events may serve as contextual inductions of negative body image (Cash, 2002; Cash, Duel, & Perkins, 2002). In the current study, negative body image was defined as an experience of discrepancy between actual self-perception and idealized self-perception (actual vs. ideal self guides), and it was assumed to lead to body dissatisfaction (Cash & Szymansky, 1995; Higgins, 1987). Researchers have described physical illness as an event that bears the potential to impact body image in a negative manner. It has been studied in relation to skin diseases (Thompson, 2011), burn injuries (Lawrence & Fauerbach, 2011), rheumatic diseases (Jolly et al., 2011), obstetrics and gynecology (Skouteris, 2011), and oncology (White & Hood, 2011). The current article presents an investigation of body image in the case of kidney-transplant patients following end-stage renal disease. These are vulnerable patients; some of the physical changes following organ transplantation may challenge their body-image beliefs, as well as their feelings of self-worth and self-esteem, especially if some disfigurement occurs (Partridge, 2006). For example, the physical side effects of some transplant medications, such as hirsutism, gingival hyperplasia, and potential weight gain, may affect body image (Danovitch, 2009). It has further been suggested that patients’ inability to incorporate the new kidney into their self-image might contribute to actual rejection of their kidney (Severino, 1980), although this claim has no substantial empirical support. In a recent pioneering small-scale study among post-transplant patients, Látos et al. (2012) empirically validated some association of body image, psychological processes, and medical condition. First, they found a positive correlation between anxiety levels and the size of the transplanted kidneys that the
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patients drew in a drawing test. Then, they discovered that post-transplant blood tests on day 10 showed significantly lower creatinine and urea levels in the patients who had drawn smaller kidneys. In addition to these findings, it has been argued that body image may influence long-term QOL (Pruzinsky, 2004) and psychological distress (Altabe & Thompson, 1996), but then again, sufficient empirical support for this argument has not been shown among kidney-transplant recipients. However, such findings are consistent with those obtained in other areas of medicine. In a study conducted among pectus escavatum and pectus carinatum patients, lower body image was associated with reduced mental, but not physical QOL (Steinmann, Krille, Weber, Reinqruber, & Martin, 2011). In an additional study that was conducted among post-gastric bypass surgery patients, significant correlations were obtained between body-image dissatisfaction and several QOL dimensions: physical pain, general health (GH) perception, physical role functioning, vitality, and mental health (MH) (Sarwer et al., 2010). Among women with pelvic organ prolapse, worsening body image correlated with lower QOL, both physical and mental (Jelovsek & Barber, 2006). The same results were found among fibromyalgia patients (Akkaya, Akkaya, Atalay, Balci, & Sahin, 2012). Severity of body-image disturbance was also found to be associated with increased psychological distress among breast cancer survivors (Cohen, Mabjish, & Zidan, 2011; Przezdziecki et al., 2013), patients with pemphigus vulgaris (Mazzotti et al., 2011), and adult dialysis patients (Partridge & Robertson, 2011). Based on these sets of consistent findings in other medical conditions, the two hypotheses of the current study were that among kidney-transplant patients, higher levels of body image dissatisfaction would be associated with (a) lower QOL and (b) higher levels of psychological distress. Methods Study population A consecutive sampling method was employed, resulting in a research sample of 45 kidney-transplant recipients, who were under follow-up care at the Tel-Aviv Medical Center Transplant Unit. Seventeen of the participants (37.8%) were living-related kidney donor recipients and 28 (62.2%) were cadaveric kidney recipients. The period between the transplant operation and the data collection ranged from 12 to 204 months (mean = 64.4; SD = 43.18); 25 (55.6%) had undergone the procedure less than 5 years prior to data collection, 16 (35.5%) between 5 and 10 years earlier, and 4 (8.9%) over 10 years earlier. Ten (22.2%) of the patients were known to be treated for high blood pressure and 12 (26.7%) had been diagnosed as diabetic. Seven (15.5%) of the patients had both high blood pressure and diabetes. Finally, the range of creatinine serum levels at the time of the survey was .77 to 3.11 mg/dl, with a median of 1.33 mg/dl. Twenty-eight (62.2%) of the participants were males and 17 (37.8%) females. Their ages ranged between 22 and 78 (mean = 53.2; SD = 12.84). Thirty (66.7%) were married and 15 (33.3%) were not. Thirty (66.7%) had less than 12 years of education and the others (n = 15; 33.3%) had higher academic or professional education. Procedure and ethics The Tel-Aviv Medical Center institutional review board (IRB) approved the survey, which was conducted in accordance with Good Clinical Practice standards. A research
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assistant administered the self-report questionnaires. Participants completed consent forms. Only one of the patients approached refused to take part in the study. Measures Data collection was conducted using four inventories related to (a) body image, (b) QOL, (c) psychological distress, and (d) sociodemographic data, respectively. Dissatisfaction with the gap between actual and ideal body image, as well as the importance each participant ascribed to this dissatisfaction were measured using the 22item BIIQ (Cash & Szymanski, 1995). This questionnaire examines 10 physical characteristics: height, skin complexion, hair texture and thickness, facial features, muscle tone and definition, body proportions, weight, chest (or breast) size, physical strength, and physical coordination. An additional item, overall physical appearance, was added, as suggested by Szymanski and Cash (1995). For each of these attributes, the respondents are asked to think about how they actually are and then to think about how they wish they were. Then they are instructed to rate the extent to which they resemble or match this personal physical ideal (gap between actual and ideal) on a 4-point scale (from 0 = “exactly as I am” to 3 = “very unlike me”), with a score of 3 signifying greater body-image dissatisfaction. In the second part of the questionnaire, respondents are asked to rate the importance associated with having or attaining those ideals. A total score of the BIIQ is calculated by multiplying the “gap” score by the “importance” score. The internal consistency of the BIIQ in the current study was found to be satisfying (Cronbach’s alpha = .80). QOL was measured using the SF-12 (2nd version), a 12-item self-report inventory originally developed by Ware, Kosinski, and Keller (1996). This instrument provides scores on eight QOL domains: GH, physical functioning, physical ability to assume social roles (RP), emotional ability to assume social roles (RE), social functioning level (SF), MH, physical pain (BP), and vitality (Vt). In the current study, the SF-12 internal consistency was found to be satisfying as well (Cronbach’s alpha = .87). Psychological distress was measured using the BSI, a 53-item self-report inventory that was originally developed by Derogatis and Melisaratos (1983). The BSI relates to nine symptom domains: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The BSI also includes three global indexes: the General Severity Index (GSI); the Positive Symptom Total (PST), which summarizes the number of non-zero symptoms; and the Positive Symptom Distress Index (PSDI), a score reflecting the intensity of distress. Internal consistency scores (Cronbach’s alpha) in the current study ranged from .67 to .85 for the nine symptom domains, and .96 for the entire scale. Sociodemographic data were collected using a short set of questions added to the self-report inventories. The patients’ medical data were collected from the computerized medical files. Analytical plan Statistical computations were conducted using the SPSS computer package (version 16.0, SPSS Inc. Chicago, Illinois). The sociodemographic and medical data were computed using descriptive statistics. The research hypotheses were tested using Spearman’s Rho correlations.
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Results The associations among body-image dissatisfaction, QOL, and psychological distress are presented in Table 1 The findings demonstrate no significant associations between the actual–ideal body image gap and any of the QOL (sf-12) dimensions. Nor was there any association between the importance attributed to this gap and the QOL dimensions. However, significant correlations were found between the total BIIQ score and the four QOL dimensions (physical pain, GH perception, role emotional, and SF). These findings partially corroborate the research hypothesis that higher levels of body image dissatisfaction would be associated with lower QOL. With regard to the second research hypothesis, the findings demonstrate significant associations between the actual–ideal body image gap and most of the psychological distress symptoms (BSI). Associations were also found between the importance attributed to this gap and almost all psychological distress symptoms (BSI). Finally, significant correlations were found between the total BIIQ score and all of the psychological distress symptoms. These findings strongly corroborate the second research hypothesis, according to which, higher levels of body image dissatisfaction would be associated with higher levels of psychological distress. Discussion and practical implications The main purpose of the current study was to conduct a pioneering investigation of the role of body image and its association with QOL and psychological distress among kidney-transplant recipients. Two research hypotheses were tested. The first one asserted that body-image dissatisfaction would be associated with lower QOL, and the second one that body-image dissatisfaction would be correlated with higher levels of psychological distress. The first hypothesis was partially confirmed. The final body-image dissatisfaction score significantly correlated with four of the SF-12 dimensions: role emotional, physical pain, GH perception, and SF. Similar findings were reported in a previous study that had been conducted among post-gastric bypass surgery patients (Sarwer et al., 2010). In both studies, the associations between body-image dissatisfaction and QOL were not universal, and varied across different measures and subscales. These results differ from the findings of most previously conducted studies, in which full and consistent associations between these two variables were reported (Akkaya et al., 2012; Jelovsek & Barber, 2006; Steinmann et al., 2011). This difference could be explained by methodological factors, such as the small sample size or the selection of a less-sensitive QOL measure (SF-12 vs. SF-36). However, these findings might also indicate that the association between body image and QOL may comprise additional variables (mediators or moderators) that were not investigated in the current study (e.g. medical condition and/ or premorbid body image). The second hypothesis was confirmed; higher levels of body-image dissatisfaction were found to be associated with higher levels of psychological distress. This is consistent with previous studies that were conducted among patients with other types of illnesses (Cohen, Mabjish, & Zidan, 2011; Mazzotti et al., 2011; Partridge & Robertson, 2011; Przezdziecki et al., 2013). These findings stress the importance of body image as a factor that is either affected or affects psychological distress, and needs to be addressed by clinicians.
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The common theoretical model that was assumed in previous studies is that body-image dissatisfaction aggravates psychological distress (e.g. Friedman, Reichmann, Costanzo, & Musante, 2002; Monaghan et al., 2007; Picardi, Abeni, Melchi, Puddu, & Pasquini, 2000). Although the current study’s design does not allow the conclusion of a causal relationship between the studied variables, we still assume this approach could be useful as a tentative practical perspective, which relates to body-image dissatisfaction as an impacting variable that needs to be addressed by clinicians. Cash, Santos, and Williams (2005) offered three coping strategies for managing body-image dissatisfaction: (a) avoidance actions (e.g. not looking at the mirror), interactions (e.g. decreasing interaction with others), and tuning out thoughts and feelings; (b) appearance fixing (e.g. doing things to look more attractive); and (c) rational acceptance (e.g. acknowledging one’s appearance has changed, but recognizing that there are other facets of personality). Most people tend to spontaneously and successfully adopt one or more of these strategies, even though each of them has its limitations and might not fully compensate for the negative implications of body-image dissatisfaction. Therefore, professional intervention may be beneficial when body-image dysfunctions and deficient coping strategies evoke distress. According to Jarry and Cash (2011), body-image cognitive behavioral therapy (BI-CBT) is one of the most-accepted intervention approaches for changing negative body image. As it has been implemented in a wide range of settings, it is presented as a program that can be applied to a variety of medical conditions, rather than being a “disease-specific intervention” (p. 420). The BI-CBT includes several components, such as a psycho-educational transmission of knowledge, mindfulness, self-regulation, change of irrational automatic thoughts, self-talk, and behavioral components like exposure and relaxation. To conclude, the current study provides some additional evidence of the importance of being attentive and addressing body-image dissatisfaction among kidney-transplant recipients. The effort to advance towards higher levels of body-image satisfaction may result in improvement of QOL and alleviate psychological distress. This, in turn, may enhance adherence and recovery. White and Hood (2011) proposed the idea that body-image dissatisfaction merits attention in a variety of medical conditions, in which negative impact on appearance and function is apparent. The findings of the current study provide some support to this principle. Therefore, we suggest that as a routine, body-image satisfaction should be screened and aimed whenever assessed as affecting QOL and psychological distress, in the context of all medical conditions which pose a threat to body image. References Akkaya, N., Akkaya, S., Atalay, N.S., Balci, C.S., & Sahin, F. (2012). Relationship between the body image and level of pain, functional status, severity of depression, and quality of life in patients with fibromyalgia syndrome. Clinical Rheumatology, 31, 983–988. doi:10.1007/ s10067-012-1965-9 Altabe, M., & Thompson, J.K. (1996). Body-image: A cognitive self-schema construct? Cognitive Therapy and Research, 20, 171–193. doi:10.1007/BF02228033 Cash, T.F. (2002). Beyond traits: Assessing body-image states. In: T.F. Cash & Y. Pruzinsky (Eds.), Body-images: A handbook of theory, research, and clinical practice (pp. 163–170). New York, NY: Guilford Press. Cash, T.F. (2004). Body image: Past, present, and future. Body Image, 1(1), 1–5. doi:10.1016/ S1740-1445(03)00011-1
Downloaded by [University of Otago] at 09:38 17 July 2015
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Cash, T.F. (2011). Crucial considerations in the assessment of body-image. In: T.F. Cash & L. Smolak (Eds.), Body-Image: A handbook of science, practice, and prevention (pp. 129–137). New York, NY: Guilford Press. Cash, T.F., Duel, L.A., & Perkins, L.L. (2002). Women’s psychosocial outcomes of breast augmentation with silicone gel-filled implants: A 2-year prospective study. Plastic & Reconstructive Surgery, 109, 2112–2121. Cash, T.F., Santos, M.T., & Williams, E.F. (2005). Coping with body-image threats and challenges: Validation of the body image coping strategies inventory. Journal of Psychosomatic Research, 58, 191–199. doi:10.1016/j.jpsychores.2004.07.008 Cash, T.F., & Szymanski, M.L. (1995). The development and validation of the body-image ideals questionnaire. Journal of Personality Assessment, 64, 466–477. doi:10.1207/s15327752jpa6403_6 Cohen, M., Mabjish, A.A., & Zidan, J. (2011). Comparison of Arab breast cancer survivors and healthy controls for spousal relationship, body image, and emotional distress. Quality of Life Research, 20, 191–198. doi:10.1007/s11136-010-9747-9 Danovitch, G.M. (2009). Handbook of kidney transplantation. Philadelphia, PA: Lippincott Williams & Wilkins. Derogatis, L.R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological Medicine, 13, 595–605. doi:10.1017/S0033291700048017 Friedman, K.E., Reichmann, S.K., Costanzo, P.R., & Musante, G.Z. (2002). Body image partially mediates the relationship between obesity and psychological distress. Obesity Research, 10, 33–41. doi:10.1038/oby.2002.5 Higgins, E.T. (1987). Self-discrepancy: A theory relating to self and affect. Psychological Review, 94, 319–340. doi:10.1037/0033295X.94.3.319 Jarry, J.L., & Cash, T.F. (2011). Cognitive-behavioral approaches to body image change. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 415–423). New York, NY: Guilford Press. Jelovsek, J.E., & Barber, M.D. (2006). Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. American Journal of Obstetrics and Gynecology, 194, 1455–1461. doi:10.1016/j.ajog.2006.01.060 Jolly, M., Pickard, A.S., Mikolaitis, R.A., Cornejo, J., Sequeira, W., Cash, T.F., Block, J.A. (2011). Body image in patients with systemic lupus erythematosus. International Journal of Behavioral Medicine, 19, 157–164. doi:10.1007/s12529-011-9154-9 Krueger, D.W. (2002). Integrating body self and psychological self: Creating a new story in psychoanalysis and psychotherapy. New York, NY: Brunner-Routledge. Látos, M., Barabás, K., Lázár, G., Marofka, F., Szederkényi, E., Szenohradszky, P., & Csabai, M. (2012). Psychological factors of successful kidney transplantations. The effects of anxiety and intrapsychic integration of the organ on recovery. OrvosiHetilap, 153, 592–597. doi:10.1556/ OH.2012.29327 [Article in Hungarian]. Lawrence, J.W., & Fauerbach, J.A. (2011). Body image issues associated with burn injuries. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 358–368). New York, NY: Guilford Press. Mazzotti, E., Mozzetta, A., Antinone, V., Alfani, S., Cianchini, G., & Abeni, D. (2011). Psychological distress and investment in one’s appearance in patients with pemphigus. Journal of the European Academy of Dermatology and Venereology, 25, 285–289. doi:10.1111/j.1468-3083. 2010.03780.x Monaghan, S.M., Sharpe, L., Denton, F., Levy, J., Schrieber, L., & Sensky, T. (2007). Relationship between appearance and psychological distress in rheumatic diseases. Arthritis & Rheumatism, 57, 303–309. doi:10.1002/art.22553 Partridge, J. (2006). From burns unit to boardroom. British Medical Journal, 332, 956–959. doi:10.1136/bmj.332.7547.956 Partridge, K.A., & Robertson, N. (2011). Body-image disturbance in adult dialysis patients. Disability and Rehabilitation, 33, 504–510. doi:10.3109/09638288.2010.498556 Picardi, A., Abeni, D., Melchi, C.F., Puddu, P., & Pasquini, P. (2000). Psychiatric morbidity in dermatological outpatients: An issue to be recognized. The British Journal of Dermatology, 143, 983–991. doi:10.1046/j.1365-2133.2000.03831.x Pruzinsky, T. (2004). Enhancing quality of life in medical populations: A vision for body image assessment and rehabilitation as standards of care. Body Image, 1, 71–81. doi:10.1016/S17401445(03)00010-X
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Y. Yagil et al.
Przezdziecki, A., Sherman, K.A., Baillie, A., Taylor, A., Foley, E., & Stalgis-Bilinski, K. (2013). My changed body: Breast cancer, body image, distress and self-compassion. Psycho-Oncology, 22, 1872–1879. doi:10.1002/pon.3230 Sarwer, D.B., Wadden, T.A., Moore, R.H., Eisenberg, M.H., Raper, S.E., & Williams, N.N. (2010). Changes in quality of life and body image after gastric bypass surgery. Surgery for Obesity and Related Diseases, 6, 608–614. doi:10.1016/j.soard.2010.07.015 Severino, S.K. (1980). Body-image changes in hemodialysis and renal transplant. Psychosomatics, 21, 509–512. Skouteris, H. (2011). Body image issues in obstetrics and gynecology. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 342–349). New York, NY: Guilford Press. Steinmann, C., Krille, S., Mueller, A., Weber, P., Reinqruber, B., & Martin, A. (2011). Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: A control group comparison of psychological characteristics prior to surgical correction. European Journal of Cardio-Thoracic Surgery, 40, 1138–1145. doi:10.1016/ j.ejcts.2011.02.019 Szymanski, M.L., & Cash, T.F. (1995). Body-image disturbances and self-discrepancy theory: Expansion of the body-image ideals questionnaire. Journal of Social and Clinical Psychology, 14, 134–146. doi:10.1521/jscp.1995.14.2.134 Thompson, A.R. (2011). Body image issues in dermatology. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 323–332). New York, NY: Guilford Press. Ware, J.E., Kosinski, M., & Keller, S.D. (1996). A 12 item short form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220–233. White, C.A., & Hood, C. (2011). Body image issues in oncology. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 333–341). New York, NY: Guilford Press.
Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
The implications of body-image dissatisfaction among kidney-transplant recipients a
b
b
c
Yaron Yagil , Shulamit Geller , Yael Sidi , Yael Tirosh , Paulina c
Katz & Richard Nakache
c
a
Department of Social Work and Department of Education, TelHai College, Upper Galilee, Israel b
School of Behavioral Sciences, Tel Aviv–Yaffo Academic College, Tel-Aviv, Israel c
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Organ Transplantation Unit, Tel-Aviv Sourasky Medical CenterAffiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Published online: 24 Oct 2014.
To cite this article: Yaron Yagil, Shulamit Geller, Yael Sidi, Yael Tirosh, Paulina Katz & Richard Nakache (2014): The implications of body-image dissatisfaction among kidney-transplant recipients, Psychology, Health & Medicine, DOI: 10.1080/13548506.2014.972417 To link to this article: http://dx.doi.org/10.1080/13548506.2014.972417
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Psychology, Health & Medicine, 2014 http://dx.doi.org/10.1080/13548506.2014.972417
The implications of body-image dissatisfaction among kidneytransplant recipients Yaron Yagila*, Shulamit Gellerb, Yael Sidib, Yael Tiroshc, Paulina Katzc and Richard Nakachec
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a Department of Social Work and Department of Education, Tel-Hai College, Upper Galilee, Israel; bSchool of Behavioral Sciences, Tel Aviv–Yaffo Academic College, Tel-Aviv, Israel; cOrgan Transplantation Unit, Tel-Aviv Sourasky Medical Center-Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
(Received 4 June 2014; accepted 30 September 2014) The role that body image plays in the psychological adjustment of kidney-transplant recipients is an understudied issue. In the current study, the association between three variables – (a) body-image dissatisfaction, (b) quality of life (QOL), and (c) psychological distress – was investigated. The research participants were 45 kidneytransplant recipients who were under follow-up care at the Transplant Unit of the Tel-Aviv Medical Center (Israel). Body image, psychological distress, and QOL were measured using self-report questionnaires [Body-Image Ideals Questionnaire (BIIQ), Brief Symptoms Inventory (BSI), and SF-12]. Medical and background data were collected from medical and administrative records. The findings indicated an association between higher level of body-image dissatisfaction and a decrease in several quality-of-life dimensions (role emotional, physical pain, general health, and social functioning), and with an increase in psychological distress. These findings highlight the importance of body-image dissatisfaction as a factor that is associated with QOL and psychological distress among kidney-transplant recipients. Body image warrants further attention and should be screened and treated among those who demonstrate high levels of dissatisfaction. Keywords: body image; quality of life; psychological distress; kidney transplantation
Introduction Body image refers to one’s own experiences of embodiment: a cumulative set of images, fantasies, and meanings regarding the body and its parts and functions (Cash, 2004). It is an integral component of self-image and the basis of self-representation. It is also a dynamically and developmentally evolving mental representation of the self (Krueger, 2002), and it may be viewed through two complementary approaches: the cross-situational trait approach and the situational state approach (Cash, 2002, 2011). The trait approach refers to the relatively stable overall schema that a person develops during his/her life about his/her physical appearance. It is a stable cognitive structure that does not change radically following specific life events, but rather incrementally incorporates some changes into its existing structure. The state approach, on the other hand, assumes that body image has a situation-dependent facet. It takes into account life events and experiences that may lead to temporal variations of body image. According *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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Table 1. Spearman correlations between body-image dissatisfaction, QOL, and psychological distress (n = 45).
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Actual–ideal body image gap Quality of life (SF-12) Physical functioning Role physical Role emotional Physical pain General health Vitality Social functioning Mental health Psychological distress (BSI) Somatic symptoms Obsession-compulsion Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid symptoms Alienation symptoms GSI PST PSDI
−.01 −.14 −.23 −.14 −.26 −.04 −.21 −.16 .33* .38** .28 .14 .34* .34* .20 .29* .35* .36* .35* .21
Degree of importance attributed to this gap .21 −.17 −.11 −.14 −.16 −.07 −.17 −.14 .32* .13 .42** .35* .27 .33* .35* .33* .41** .42** .39** .30*
Final body image dissatisfaction score .13 −.20 −.33* −.33* −.32* −.15 −.34* −.20 .48** .54** .44** .40** .45** .37* .37* .49** .55** .56** .57** .36*
*p < .05; **p < .01.
to the state approach, specific events may serve as contextual inductions of negative body image (Cash, 2002; Cash, Duel, & Perkins, 2002). In the current study, negative body image was defined as an experience of discrepancy between actual self-perception and idealized self-perception (actual vs. ideal self guides), and it was assumed to lead to body dissatisfaction (Cash & Szymansky, 1995; Higgins, 1987). Researchers have described physical illness as an event that bears the potential to impact body image in a negative manner. It has been studied in relation to skin diseases (Thompson, 2011), burn injuries (Lawrence & Fauerbach, 2011), rheumatic diseases (Jolly et al., 2011), obstetrics and gynecology (Skouteris, 2011), and oncology (White & Hood, 2011). The current article presents an investigation of body image in the case of kidney-transplant patients following end-stage renal disease. These are vulnerable patients; some of the physical changes following organ transplantation may challenge their body-image beliefs, as well as their feelings of self-worth and self-esteem, especially if some disfigurement occurs (Partridge, 2006). For example, the physical side effects of some transplant medications, such as hirsutism, gingival hyperplasia, and potential weight gain, may affect body image (Danovitch, 2009). It has further been suggested that patients’ inability to incorporate the new kidney into their self-image might contribute to actual rejection of their kidney (Severino, 1980), although this claim has no substantial empirical support. In a recent pioneering small-scale study among post-transplant patients, Látos et al. (2012) empirically validated some association of body image, psychological processes, and medical condition. First, they found a positive correlation between anxiety levels and the size of the transplanted kidneys that the
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patients drew in a drawing test. Then, they discovered that post-transplant blood tests on day 10 showed significantly lower creatinine and urea levels in the patients who had drawn smaller kidneys. In addition to these findings, it has been argued that body image may influence long-term QOL (Pruzinsky, 2004) and psychological distress (Altabe & Thompson, 1996), but then again, sufficient empirical support for this argument has not been shown among kidney-transplant recipients. However, such findings are consistent with those obtained in other areas of medicine. In a study conducted among pectus escavatum and pectus carinatum patients, lower body image was associated with reduced mental, but not physical QOL (Steinmann, Krille, Weber, Reinqruber, & Martin, 2011). In an additional study that was conducted among post-gastric bypass surgery patients, significant correlations were obtained between body-image dissatisfaction and several QOL dimensions: physical pain, general health (GH) perception, physical role functioning, vitality, and mental health (MH) (Sarwer et al., 2010). Among women with pelvic organ prolapse, worsening body image correlated with lower QOL, both physical and mental (Jelovsek & Barber, 2006). The same results were found among fibromyalgia patients (Akkaya, Akkaya, Atalay, Balci, & Sahin, 2012). Severity of body-image disturbance was also found to be associated with increased psychological distress among breast cancer survivors (Cohen, Mabjish, & Zidan, 2011; Przezdziecki et al., 2013), patients with pemphigus vulgaris (Mazzotti et al., 2011), and adult dialysis patients (Partridge & Robertson, 2011). Based on these sets of consistent findings in other medical conditions, the two hypotheses of the current study were that among kidney-transplant patients, higher levels of body image dissatisfaction would be associated with (a) lower QOL and (b) higher levels of psychological distress. Methods Study population A consecutive sampling method was employed, resulting in a research sample of 45 kidney-transplant recipients, who were under follow-up care at the Tel-Aviv Medical Center Transplant Unit. Seventeen of the participants (37.8%) were living-related kidney donor recipients and 28 (62.2%) were cadaveric kidney recipients. The period between the transplant operation and the data collection ranged from 12 to 204 months (mean = 64.4; SD = 43.18); 25 (55.6%) had undergone the procedure less than 5 years prior to data collection, 16 (35.5%) between 5 and 10 years earlier, and 4 (8.9%) over 10 years earlier. Ten (22.2%) of the patients were known to be treated for high blood pressure and 12 (26.7%) had been diagnosed as diabetic. Seven (15.5%) of the patients had both high blood pressure and diabetes. Finally, the range of creatinine serum levels at the time of the survey was .77 to 3.11 mg/dl, with a median of 1.33 mg/dl. Twenty-eight (62.2%) of the participants were males and 17 (37.8%) females. Their ages ranged between 22 and 78 (mean = 53.2; SD = 12.84). Thirty (66.7%) were married and 15 (33.3%) were not. Thirty (66.7%) had less than 12 years of education and the others (n = 15; 33.3%) had higher academic or professional education. Procedure and ethics The Tel-Aviv Medical Center institutional review board (IRB) approved the survey, which was conducted in accordance with Good Clinical Practice standards. A research
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assistant administered the self-report questionnaires. Participants completed consent forms. Only one of the patients approached refused to take part in the study. Measures Data collection was conducted using four inventories related to (a) body image, (b) QOL, (c) psychological distress, and (d) sociodemographic data, respectively. Dissatisfaction with the gap between actual and ideal body image, as well as the importance each participant ascribed to this dissatisfaction were measured using the 22item BIIQ (Cash & Szymanski, 1995). This questionnaire examines 10 physical characteristics: height, skin complexion, hair texture and thickness, facial features, muscle tone and definition, body proportions, weight, chest (or breast) size, physical strength, and physical coordination. An additional item, overall physical appearance, was added, as suggested by Szymanski and Cash (1995). For each of these attributes, the respondents are asked to think about how they actually are and then to think about how they wish they were. Then they are instructed to rate the extent to which they resemble or match this personal physical ideal (gap between actual and ideal) on a 4-point scale (from 0 = “exactly as I am” to 3 = “very unlike me”), with a score of 3 signifying greater body-image dissatisfaction. In the second part of the questionnaire, respondents are asked to rate the importance associated with having or attaining those ideals. A total score of the BIIQ is calculated by multiplying the “gap” score by the “importance” score. The internal consistency of the BIIQ in the current study was found to be satisfying (Cronbach’s alpha = .80). QOL was measured using the SF-12 (2nd version), a 12-item self-report inventory originally developed by Ware, Kosinski, and Keller (1996). This instrument provides scores on eight QOL domains: GH, physical functioning, physical ability to assume social roles (RP), emotional ability to assume social roles (RE), social functioning level (SF), MH, physical pain (BP), and vitality (Vt). In the current study, the SF-12 internal consistency was found to be satisfying as well (Cronbach’s alpha = .87). Psychological distress was measured using the BSI, a 53-item self-report inventory that was originally developed by Derogatis and Melisaratos (1983). The BSI relates to nine symptom domains: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The BSI also includes three global indexes: the General Severity Index (GSI); the Positive Symptom Total (PST), which summarizes the number of non-zero symptoms; and the Positive Symptom Distress Index (PSDI), a score reflecting the intensity of distress. Internal consistency scores (Cronbach’s alpha) in the current study ranged from .67 to .85 for the nine symptom domains, and .96 for the entire scale. Sociodemographic data were collected using a short set of questions added to the self-report inventories. The patients’ medical data were collected from the computerized medical files. Analytical plan Statistical computations were conducted using the SPSS computer package (version 16.0, SPSS Inc. Chicago, Illinois). The sociodemographic and medical data were computed using descriptive statistics. The research hypotheses were tested using Spearman’s Rho correlations.
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Results The associations among body-image dissatisfaction, QOL, and psychological distress are presented in Table 1 The findings demonstrate no significant associations between the actual–ideal body image gap and any of the QOL (sf-12) dimensions. Nor was there any association between the importance attributed to this gap and the QOL dimensions. However, significant correlations were found between the total BIIQ score and the four QOL dimensions (physical pain, GH perception, role emotional, and SF). These findings partially corroborate the research hypothesis that higher levels of body image dissatisfaction would be associated with lower QOL. With regard to the second research hypothesis, the findings demonstrate significant associations between the actual–ideal body image gap and most of the psychological distress symptoms (BSI). Associations were also found between the importance attributed to this gap and almost all psychological distress symptoms (BSI). Finally, significant correlations were found between the total BIIQ score and all of the psychological distress symptoms. These findings strongly corroborate the second research hypothesis, according to which, higher levels of body image dissatisfaction would be associated with higher levels of psychological distress. Discussion and practical implications The main purpose of the current study was to conduct a pioneering investigation of the role of body image and its association with QOL and psychological distress among kidney-transplant recipients. Two research hypotheses were tested. The first one asserted that body-image dissatisfaction would be associated with lower QOL, and the second one that body-image dissatisfaction would be correlated with higher levels of psychological distress. The first hypothesis was partially confirmed. The final body-image dissatisfaction score significantly correlated with four of the SF-12 dimensions: role emotional, physical pain, GH perception, and SF. Similar findings were reported in a previous study that had been conducted among post-gastric bypass surgery patients (Sarwer et al., 2010). In both studies, the associations between body-image dissatisfaction and QOL were not universal, and varied across different measures and subscales. These results differ from the findings of most previously conducted studies, in which full and consistent associations between these two variables were reported (Akkaya et al., 2012; Jelovsek & Barber, 2006; Steinmann et al., 2011). This difference could be explained by methodological factors, such as the small sample size or the selection of a less-sensitive QOL measure (SF-12 vs. SF-36). However, these findings might also indicate that the association between body image and QOL may comprise additional variables (mediators or moderators) that were not investigated in the current study (e.g. medical condition and/ or premorbid body image). The second hypothesis was confirmed; higher levels of body-image dissatisfaction were found to be associated with higher levels of psychological distress. This is consistent with previous studies that were conducted among patients with other types of illnesses (Cohen, Mabjish, & Zidan, 2011; Mazzotti et al., 2011; Partridge & Robertson, 2011; Przezdziecki et al., 2013). These findings stress the importance of body image as a factor that is either affected or affects psychological distress, and needs to be addressed by clinicians.
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The common theoretical model that was assumed in previous studies is that body-image dissatisfaction aggravates psychological distress (e.g. Friedman, Reichmann, Costanzo, & Musante, 2002; Monaghan et al., 2007; Picardi, Abeni, Melchi, Puddu, & Pasquini, 2000). Although the current study’s design does not allow the conclusion of a causal relationship between the studied variables, we still assume this approach could be useful as a tentative practical perspective, which relates to body-image dissatisfaction as an impacting variable that needs to be addressed by clinicians. Cash, Santos, and Williams (2005) offered three coping strategies for managing body-image dissatisfaction: (a) avoidance actions (e.g. not looking at the mirror), interactions (e.g. decreasing interaction with others), and tuning out thoughts and feelings; (b) appearance fixing (e.g. doing things to look more attractive); and (c) rational acceptance (e.g. acknowledging one’s appearance has changed, but recognizing that there are other facets of personality). Most people tend to spontaneously and successfully adopt one or more of these strategies, even though each of them has its limitations and might not fully compensate for the negative implications of body-image dissatisfaction. Therefore, professional intervention may be beneficial when body-image dysfunctions and deficient coping strategies evoke distress. According to Jarry and Cash (2011), body-image cognitive behavioral therapy (BI-CBT) is one of the most-accepted intervention approaches for changing negative body image. As it has been implemented in a wide range of settings, it is presented as a program that can be applied to a variety of medical conditions, rather than being a “disease-specific intervention” (p. 420). The BI-CBT includes several components, such as a psycho-educational transmission of knowledge, mindfulness, self-regulation, change of irrational automatic thoughts, self-talk, and behavioral components like exposure and relaxation. To conclude, the current study provides some additional evidence of the importance of being attentive and addressing body-image dissatisfaction among kidney-transplant recipients. The effort to advance towards higher levels of body-image satisfaction may result in improvement of QOL and alleviate psychological distress. This, in turn, may enhance adherence and recovery. White and Hood (2011) proposed the idea that body-image dissatisfaction merits attention in a variety of medical conditions, in which negative impact on appearance and function is apparent. The findings of the current study provide some support to this principle. Therefore, we suggest that as a routine, body-image satisfaction should be screened and aimed whenever assessed as affecting QOL and psychological distress, in the context of all medical conditions which pose a threat to body image. References Akkaya, N., Akkaya, S., Atalay, N.S., Balci, C.S., & Sahin, F. (2012). Relationship between the body image and level of pain, functional status, severity of depression, and quality of life in patients with fibromyalgia syndrome. Clinical Rheumatology, 31, 983–988. doi:10.1007/ s10067-012-1965-9 Altabe, M., & Thompson, J.K. (1996). Body-image: A cognitive self-schema construct? Cognitive Therapy and Research, 20, 171–193. doi:10.1007/BF02228033 Cash, T.F. (2002). Beyond traits: Assessing body-image states. In: T.F. Cash & Y. Pruzinsky (Eds.), Body-images: A handbook of theory, research, and clinical practice (pp. 163–170). New York, NY: Guilford Press. Cash, T.F. (2004). Body image: Past, present, and future. Body Image, 1(1), 1–5. doi:10.1016/ S1740-1445(03)00011-1
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Cash, T.F. (2011). Crucial considerations in the assessment of body-image. In: T.F. Cash & L. Smolak (Eds.), Body-Image: A handbook of science, practice, and prevention (pp. 129–137). New York, NY: Guilford Press. Cash, T.F., Duel, L.A., & Perkins, L.L. (2002). Women’s psychosocial outcomes of breast augmentation with silicone gel-filled implants: A 2-year prospective study. Plastic & Reconstructive Surgery, 109, 2112–2121. Cash, T.F., Santos, M.T., & Williams, E.F. (2005). Coping with body-image threats and challenges: Validation of the body image coping strategies inventory. Journal of Psychosomatic Research, 58, 191–199. doi:10.1016/j.jpsychores.2004.07.008 Cash, T.F., & Szymanski, M.L. (1995). The development and validation of the body-image ideals questionnaire. Journal of Personality Assessment, 64, 466–477. doi:10.1207/s15327752jpa6403_6 Cohen, M., Mabjish, A.A., & Zidan, J. (2011). Comparison of Arab breast cancer survivors and healthy controls for spousal relationship, body image, and emotional distress. Quality of Life Research, 20, 191–198. doi:10.1007/s11136-010-9747-9 Danovitch, G.M. (2009). Handbook of kidney transplantation. Philadelphia, PA: Lippincott Williams & Wilkins. Derogatis, L.R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological Medicine, 13, 595–605. doi:10.1017/S0033291700048017 Friedman, K.E., Reichmann, S.K., Costanzo, P.R., & Musante, G.Z. (2002). Body image partially mediates the relationship between obesity and psychological distress. Obesity Research, 10, 33–41. doi:10.1038/oby.2002.5 Higgins, E.T. (1987). Self-discrepancy: A theory relating to self and affect. Psychological Review, 94, 319–340. doi:10.1037/0033295X.94.3.319 Jarry, J.L., & Cash, T.F. (2011). Cognitive-behavioral approaches to body image change. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 415–423). New York, NY: Guilford Press. Jelovsek, J.E., & Barber, M.D. (2006). Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. American Journal of Obstetrics and Gynecology, 194, 1455–1461. doi:10.1016/j.ajog.2006.01.060 Jolly, M., Pickard, A.S., Mikolaitis, R.A., Cornejo, J., Sequeira, W., Cash, T.F., Block, J.A. (2011). Body image in patients with systemic lupus erythematosus. International Journal of Behavioral Medicine, 19, 157–164. doi:10.1007/s12529-011-9154-9 Krueger, D.W. (2002). Integrating body self and psychological self: Creating a new story in psychoanalysis and psychotherapy. New York, NY: Brunner-Routledge. Látos, M., Barabás, K., Lázár, G., Marofka, F., Szederkényi, E., Szenohradszky, P., & Csabai, M. (2012). Psychological factors of successful kidney transplantations. The effects of anxiety and intrapsychic integration of the organ on recovery. OrvosiHetilap, 153, 592–597. doi:10.1556/ OH.2012.29327 [Article in Hungarian]. Lawrence, J.W., & Fauerbach, J.A. (2011). Body image issues associated with burn injuries. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 358–368). New York, NY: Guilford Press. Mazzotti, E., Mozzetta, A., Antinone, V., Alfani, S., Cianchini, G., & Abeni, D. (2011). Psychological distress and investment in one’s appearance in patients with pemphigus. Journal of the European Academy of Dermatology and Venereology, 25, 285–289. doi:10.1111/j.1468-3083. 2010.03780.x Monaghan, S.M., Sharpe, L., Denton, F., Levy, J., Schrieber, L., & Sensky, T. (2007). Relationship between appearance and psychological distress in rheumatic diseases. Arthritis & Rheumatism, 57, 303–309. doi:10.1002/art.22553 Partridge, J. (2006). From burns unit to boardroom. British Medical Journal, 332, 956–959. doi:10.1136/bmj.332.7547.956 Partridge, K.A., & Robertson, N. (2011). Body-image disturbance in adult dialysis patients. Disability and Rehabilitation, 33, 504–510. doi:10.3109/09638288.2010.498556 Picardi, A., Abeni, D., Melchi, C.F., Puddu, P., & Pasquini, P. (2000). Psychiatric morbidity in dermatological outpatients: An issue to be recognized. The British Journal of Dermatology, 143, 983–991. doi:10.1046/j.1365-2133.2000.03831.x Pruzinsky, T. (2004). Enhancing quality of life in medical populations: A vision for body image assessment and rehabilitation as standards of care. Body Image, 1, 71–81. doi:10.1016/S17401445(03)00010-X
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Przezdziecki, A., Sherman, K.A., Baillie, A., Taylor, A., Foley, E., & Stalgis-Bilinski, K. (2013). My changed body: Breast cancer, body image, distress and self-compassion. Psycho-Oncology, 22, 1872–1879. doi:10.1002/pon.3230 Sarwer, D.B., Wadden, T.A., Moore, R.H., Eisenberg, M.H., Raper, S.E., & Williams, N.N. (2010). Changes in quality of life and body image after gastric bypass surgery. Surgery for Obesity and Related Diseases, 6, 608–614. doi:10.1016/j.soard.2010.07.015 Severino, S.K. (1980). Body-image changes in hemodialysis and renal transplant. Psychosomatics, 21, 509–512. Skouteris, H. (2011). Body image issues in obstetrics and gynecology. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 342–349). New York, NY: Guilford Press. Steinmann, C., Krille, S., Mueller, A., Weber, P., Reinqruber, B., & Martin, A. (2011). Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: A control group comparison of psychological characteristics prior to surgical correction. European Journal of Cardio-Thoracic Surgery, 40, 1138–1145. doi:10.1016/ j.ejcts.2011.02.019 Szymanski, M.L., & Cash, T.F. (1995). Body-image disturbances and self-discrepancy theory: Expansion of the body-image ideals questionnaire. Journal of Social and Clinical Psychology, 14, 134–146. doi:10.1521/jscp.1995.14.2.134 Thompson, A.R. (2011). Body image issues in dermatology. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 323–332). New York, NY: Guilford Press. Ware, J.E., Kosinski, M., & Keller, S.D. (1996). A 12 item short form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220–233. White, C.A., & Hood, C. (2011). Body image issues in oncology. In: T.F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 333–341). New York, NY: Guilford Press.
