10/28/2013. Brief discussion of Body Image among Women with Lupus. Adapting a Body Image Intervention. Details of the Intervention

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1 Kristin Flynn Peters, PhD, LCP Assistant Clinical Professor Department of Health Sciences School of Health Professions University of Missouri Health System Brief discussion of Body Image among Women with Lupus Collaborator and Principal Investigator Meenakshi Jolly, MD, MSCP Director, Rush Lupus Clinic Associate Professor of Medicine Rheumatology Section, Dept. of Medicine & Dept. of Behavioral Medicine Adapting a Body Image Intervention Details of the Intervention How to Use This Material in Day-to-Day work with Women with Lupus 82% of those with SLE identified, changes in body appearance as an area of unmet need in their efforts to attain optimal health and quality of life (Moses et al 2005) Mental picture of one s body, an attitude about the physical self, appearance, and state of health, wholeness, functioning and sexuality. Our perceptions, thoughts, and feelings about body size, competence and function Having a presentable skin surface has a strong impact on body image. Body Integrity, Wholeness 1

2 How an individual responds to the physical, mental, and social effects of illness How these responses influence how satisfied one feels with one s life in the context of chronic illness Body Image is poor in SLE as compared to healthy controls and Rheumatoid Arthritis patients. (Cornwell & Schmitt, 1990) Body Image distress correlates lower QOL over time (Jolly et al, 2011) Body Image distress is associated with previous diagnosis of depression, disease flares, and disease damage (Jolly et al, 2010) The inner picture of the body and the judgments and attitudes toward one s body are associated with, but are not completely explained by what other people see on the outside. (Butters & Cash, 1987) Most (but not all) patients with SLE report a negative impact on self-image because of changes in appearance, ability to work, and sexuality (Stein et al, 1986) Cultural Socialization Interpersonal Experiences with Family and Peers Body Image Physical & Functional* Characteristics and Changes - Personality Traits (risk or resilience) In part, body image is learned. The Cognitive Model The way we perceive situations influences the way we feel. Cognitions: We change perceptions. Behaviors: We can change how we interact with our environment. Emotions: We can decrease the intensity of emotions. Activating Events and Situations Beliefs, Assumptions, Judgments, Interpretations, And Other Thoughts Consequences: Body Image Emotions Consequences: Self-Defensive Actions (e.g., avoidance, appearance fixing) 2

3 Cognitive Behavioral Therapy: Shown to improve Body Image (Jarry & Cash, 2011) Behavioral interventions can improve health outcomes (compliance) in chronic disease (Austin 1996,Trask 2003, Antoni 2006, Garley 2006). Effective BI interventions may have to be tailored to the specific needs of different client groups to be maximally effective (Jarry & Berardi, 2004). Is a Cognitive Behavior Therapy Body Image Intervention feasible among women with SLE? Can Cognitive Behavior Therapy modify body image among women with SLE when compared to those not receiving an intervention other than usual care? Does the effect persist when intervention over? Does modifying BI result in changes of other psychosocial and physical health outcomes? 13 Intervention and 10 control (not randomized) Controls received usual care Controls & Intervention Participants were scheduled visits for doing surveys Baseline Post intervention 18 week follow-up after intervention 24 week follow-up after intervention Demographics BMI Disease activity Disease damage Medications Body Image Quality of Life Depression Anxiety Body Image in Lupus Screen (BILS) Multi-dimensional Body-Self Relations Questionnaire (MBSRQ): Appearance Evaluation Appearance Orientation Overweight preoccupation Weight Satisfaction subscales Body Area Satisfaction Scale Situational Inventory of Body-Image Dysphoria Psycho-social: Depression: Center for Epidemiological Studies Depression (CES-D) Anxiety: PANAS (Positive and negative) State Trait Anxiety Scale Self Esteem (SE) Perceived health competence scale COPING: Brief Cope Quality of Life: LupusPRO 3

4 Intervention Group: 13 participants in 2 groups 10 sessions; once weekly, 2 hour sessions Session Content *Health Education (1) *CBT (8) *Appearance Enhancement (1) CBT workbook adapted to better suit women with Lupus. LUPUS (not EATING DISORDER RISK) Examples based on experiences of women with lupus COGNITIVE DISFUNCTION & MULTIPLE ROLES Reduced homework expectations Conducted exercises in session SOCIAL ISOLATION & POWER OF SOCIAL SUPPORT Group intervention WOMEN OF COLOR Recognizing the need for cultural competence Adjusting examples for use with book Relative to Caucasian women, tend to have more positive body image regardless of weight, and even at larger sizes, a thick ideal Impacted less by white images in the media Impact of Media with African American images (Rap videos vs. TV with African American families) Define attractiveness in many ways that go beyond body shape and size The way she puts herself together We can tell how she s doing by whether her nails are done. Well, I always had good hair. Light skin, even skin Flynn & Fitzgibbon (1998).Body images and obesity risk among Black females: A review of the literature. Annals of Behavioral Medicine, 20, Franko & Roehrig (2011). African American Body Images. In Body image: A Handbook of Science, Practice, and Prevention, Ed. TF Cash and L Smolak. The Guilford Press: New York. Step 1: Discovering your personal Body Image Step 2: Understanding the origins of your BI story Step 3: Mindfulness & acceptance of your BI experiences Step 4: Beneath the surface of your private body talk Step 5: Mindfully modifying your mental mistakes Step 6: Facing your BI avoidance Step 7: Erasing your BI rituals Step 8: Treating your body well 4

5 Physical characteristics I need to accept more: I need to Negative body image thoughts that I need to reduce or eliminate: Situations I really need to feel more comfortable with: Interpersonal Experiences with Family and Peers Physical Characteristics and Changes Beliefs and behaviors I need to change to be less invested in my appearance for my self-worth: Ways that I cope with my body image difficulties that I need to change: The consequences (effects) of my body image difficulties I want (need) to change: Cultural Socialization Body Image Personality Traits (risk or resilience) At each period of your life listed below, what did you look like? What were your major influences on how you felt about your looks? Be sure to mention significant cultural and interpersonal influences. Gave examples of Lupus Narrative Early Childhood (In session) My Body: Influential Events and Experiences Later Childhood (Day 1) Earlier Adolescence (Day 2) Later Adolescence (Day 3) Adulthood to Now (Day 4) Since Lupus Diagnosis (Day 5) Objectives: Increase awareness of current body image. Understand messages that might have contributed to current image. Understand (not blame) the past. Begin to take control of your personal, here and now judgments and interpretations. Getting tools to answer back negative messages, leading to more acceptance. Mindfulness paying attention to thoughts, feelings and experiences, in the hear and now Acceptance taking the judgment language out of your observations Notice, observe but, don t act or judge 5

6 Raisin Your Awareness Mindful of Minutiae Activating Events and Situations Beliefs, Assumptions, Judgments, Interpretations, And Other Thoughts Body Scan* Mirror Reflections* Consequences: Body Image Emotions Consequences: Self-Defensive Actions (e.g., avoidance, appearance fixing) Activator: was invited to a BBQ, it was hot Belief: my legs look ugly Consequences: Type of Emotion: Dread Before & Nervous During Intensity: 8 / 10 Duration: Until the event was over Effects: Wore pants and sweat, Felt distracted, people asked why I was wearing pants Observing The Thoughts, Emotions and Behaviors without Judgment Observe you reaction but don t judge yourself for that reaction. Homework: Journal ABC:TIDE over next week Activating Event: Distorted Body Talk Belief says: Where is this message coming from? Use material from narratives. Replace the old Consequence with New Dialogue: My new inner voice says What would you tell a friend? What is the New Emotion? 6

7 Activating Event: Invited to High School Reunion Belief: People will stare at me and be afraid to talk to me. I won t be able to focus because I ll be so selfconscious. Consequence: Don t want to go to reunion. Feel sad. Activating Events Appearance Assumptions Distorted Body Talk New Dialogue: I look different than I used to and people may ask about it, but I feel good about myself, my family, and my friendships. I am proud of myself. Positive Emotions: Calm, Looking forward to it. Improved Body Image; Attends Reunion Negative Body Image Emotions Self-Defensive Actions Evasive Actions: Appearance-Preoccupied Running & Hiding Rituals: Checking and Fixing REHEARSE & PRACTICE FOR STABILITY of CHANGE What are my evasive actions, my fixing and checking rituals? Learning mind/body relaxation* Ladder of change PACE yourself Prepare (what will I do, think through ACE) Act (when, where, how long) Cope (accept and cope discomfort) - Reflect Enjoy (reward self) Image used with participant s permission Dear Body of Mine (Relapse Prevention) Positive Behaviors Health And Fitness Appearance Oriented Sensate Self-Assessment & Goal Setting The Narrative Approach was more effective than the quantitative approach Mindfulness Skills Observation and Acceptance Cognitive Behavioral Skills Challenging Unhelpful Beliefs New Inner Voice Changing Thoughts Decreasing Emotional Intensity Relaxation Changing Behaviors Challenging Old Perceptions Relapse Prevention 7

8 Permission obtained Daily care (e.g., sunscreen) Cosmetic Balancing of Features Pigmentation / tone, contouring, focus (Balancing) Wardrobe (body shape) Hair (eyebrows, scalp) Specialists did one-on-one consultation BEFORE AFTER BEFORE AFTER BEFORE AFTER Body Image Intervention Control Mean ± SD P-Value Mean ± SD P-Value Body Image Intervention Control Mean ± SD P-Value Mean ± SD P-Value Lupus PRO BI PRE 40.00± ±25.84 Lupus PRO BI POST 72.00±37.36 PRE vs POST p= ±22.80 PRE vs POST p=0.875 Lupus PRO BI 18wk 66.00±38.00 PRE vs 18wk p= ±20.74 PRE vs 18wk p=0.463 Lupus PRO BI 24wk 79.38±27.18 PRE vs 24wk p= ±21.39 PRE vs 24wk p=0.918 SIBID PRE 1.92± ±0.79 SIBID POST 1.53±0.32 PRE vs POST p= ±0.92 PRE vs POST p=0.545 SIBID 18wk 1.48±0.35 PRE vs 18wk p= ±1.20 PRE vs 18wk p=0.615 SIBID 24wk 1.16±1.05 PRE vs 24wk p= ±1.33 PRE vs 24wk p=0.573 Appearance Evaluation PRE 2.87± ±0.35 Appearance Evaluation POST 3.13±0.36 PRE vs POST p= ±0.47 PRE vs POST p=0.587 Appearance Evaluation 18wk 3.19±0.34 PRE vs 18wk p= ±0.41 PRE vs 18wk p=0.704 Appearance Evaluation24wk 3.19±0.90 PRE vs 24wk p= ±0.86 PRE vs 24wk p=0.720 Appearance Orientation PRE 3.43± ±0.49 Appearance Orientation POST 3.13±0.49 PRE vs POST p= ±0.38 PRE vs POST p=0.452 Appearance Orientation 18wk 3.13±0.61 PRE vs 18wk p= ±0.41 PRE vs 18wk p=0.151 Appearance Orientation 24wk 3.36±0.46 PRE vs 24wk p= ±0.35 PRE vs 24wk p=0.953 Overweight Preoccupation PRE 2.68± ±1.40 Overweight Preoccupation POST 2.40±0.58 PRE vs POST p= ±1.07 PRE vs POST p=0.724 Overweight Preoccupation 18wk 2.33±0.75 PRE vs 18wk p= ±0.94 PRE vs 18wk p=0.245 Overweight Preoccupation 24wk 2.63±0.44 PRE vs 24wk p= ±0.94 PRE vs 24wk p=0.157 Weight Class PRE 3.50± ±0.45 Weight Class POST 3.70±0.89 PRE vs POST p= ±0.50 PRE vs POST p=0.178 Weight Class 18wk 3.54±0.93 PRE vs 18wk p= ±0.55 PRE vs 18wk p=0.778 Weight Class 24wk 3.38±0.69 PRE vs 24wk p= ±0.45 PRE vs 24wk p=0.242 Body Area Satisfaction Scale PRE 2.38± ±0.25 Body Area Satisfaction Scale POST 2.82±0.90 PRE vs POST p= ±0.34 PRE vs POST p=0.918 Body Area Satisfaction Scale 18wk 3.06±0.92 PRE vs 18wk p= ±0.36 PRE vs 18wk p=0.852 Body Area Satisfaction Scale 24wk 2.96±0.76 PRE vs 24wk p= ±0.62 PRE vs 24wk p=

9 The proposed intervention seems feasible, but there were challenges. Many dimensions of BI are modifiable in SLE. Improvements in BI persisted at 18 & 24 weeks after the intervention Being in Body Image Group and Having Body Image Improvement was related to improvements in QOL Body image is important Body image is associated with depression & QOL Don t assume everyone has body image concerns Pay attention to medication changes related to hair loss, recommending sun protection Reflect on how you are engaging with your patients Are you focusing on the whole person or just the problem areas? Are you receptive and compassionate to your patients and their worth and beauty as a whole person? Body Image can Improve Refer to Psychologists and Counselors with expertise in CBT and/or Mindful Acceptance Butters, J.W. & Cash, T. (1987). Cognitive behavioral treatment of women s body image dissatisfaction. Journal of Consulting & Clinical Psychology, 55, Cash, T.F. & Smolak, L. (2011) Body image: A handbook of science, practice, and preventions. (2 nd ed). New York, NY: Guildford Press. See chapters 5, 25, 40, & 47. Cash, T.F. (2008). The body image workbook: An eight-step program for learning to like your looks (2 nd ed.). Oakland, CA: New Harbinger. Cornwell, C.J. & Schmitt, M.H. (1990). Perceived health status, self-esteem and body image in women with rheumatoid arthritis or systemic lupus erythematosus. Research in Nursing & Health, 13(2), Flynn, K. & Fitzgibbon, M. (1998). Body images and obesity risk among Black females: A review of the literature. Annals of Behavioral Medicine, 20, Moses, N., Wiggers, J., Nicholas, C., Cockburn, J. (2005). Prevalence and correlates of perceived unmet needs of people with systemic lupus erythematosus. Patient Education & Counseling, 57(1), Jarry. J.L. & Berardi, K. (2004). Characteristics and effectiveness of stand-alone body image treatments: A review of the empirical literature. Body Image, 1(4), Jolly, M., Mikolaitis, R.A., Cornego, J., Sequeira, W., Cash, T.F., et al (2011). Body image in patients with systemic lupus erythematosus. International Journal of Behavioral Medicine, doi: /s Stein, H., Walters, K., Dillon, A., & Schulzer, M. (1986). Systemic lupus erythematosus: A medical and social profile. Journal of Rheumatology, 13, Our patients Dr. Jolly and her research staff Dr. Block, Section Chief 9