The Appearance Anxiety Inventory (AAI) is a 10 question self-report scale that measures the cognitive and behavioural aspects of body image anxiety in general, and body dysmorphic disorder (BDD) in particular.  This scale is useful in a cosmetic context as part of a screening procedure for BDD. The questionnaire is also sensitive to change through treatment, so is a useful way to track how your patients’ body image may change over a cosmetic treatment journey.

Validity and Reliability

The AAI was developed by Veale et al (2014). They examined the psychometric properties in a clinical BDD sample and non-clinical community sample in the UK.  The AAI was found to have good convergent validity, with correlations of .55 with the clinician rated YBOCS-BDD and .58 with the PHQ9.  Internal consistency was high, with a Cronbachs Alpha of .86. Two subscales were found using factor analysis; Avoidance and Threat Monitoring. 

The Avoidance scale assesses the degree to which an individual may be avoiding certain situations, or looking at themselves in photos/videos/mirrors because of how they are feeling about their appearance.

The Threat Monitoring scale assesses the degree to which an individual may be engaging in attempts to check, fix or compare their appearance to others. 

The BDD validation sample (n = 139) had a median age of 28 and was 51.8% female.  A subgroup of 12 participants had a median AAI score of 26 at diagnosis and 10.50 after CBT treatment. 

The non-clinical community sample (n = 108) was used to establish the normal levels of appearance anxiety among relatively healthy individuals.  The group had a median age of 28.5 and 75.9% were female. The mean score was 15.45 (SD = 8.68).

The AAI is a screening tool, and is therefore not designed to provide a diagnosis of body dysmorphic disorder (BDD). Patients who score above the cut-off on the AAI should be referred to a mental health professional for further assessment. 

The AAI is designed to inform your assessment and evaluation of your patient, but not as a standalone tool. If you have identified other concerns or risks during your consultation, please use clinical judgement as to whether or not to proceed with treatment or if referral to a mental health professional is indicated.

The AAI may also be susceptible to dishonest responding, especially if a patient really wants to receive a cosmetic procedure. You should consider these results along with your consultation to determine how open the patient has been about their true motivations and expectations for treatment. If you would like to assess patient openness as well as their BDD scores, please use the Cosmetic Readiness Questionnaire (CRQ). 

Scoring and Interpretation 

Scores consistent of a total raw score derived by summing each item as well as two subscales.

• Avoidance (items 1, 3, 4, 7, 9 and 10) 
• Threat Monitoring (items 2, 4, 6 and 8) 

Two percentiles are presented to indicate how AAI scores compare to a body dysmorphic disorder group and a community sample. A BDD percentile of 50 indicates average symptoms for someone with a BDD diagnosis before treatment, while the community percentile represents scores in comparison to a normal population.

Veale et al. (2014) did not define a cut-off score for BDD diagnosis but Mastro et al. (2016) suggested a cutoff score of 20 as being indicative of high risk of clinical problems.

Therefore, in a cosmetic setting if a patient scores above 20 on the AAI they may be at greater risk of having BDD. It is recommended that you refer this patient to a mental health professional for further assessment before conducting aesthetic treatments. 

Developer 

Veale, D., Eshkevaria, E., Kanakama, N., Ellisona, N., Costa, A., and Werner, T. (2014). The Appearance Anxiety Inventory: Validation of a Process Measure in the Treatment of Body Dysmorphic Disorder. Behavioural and Cognitive Psychotherapy, 42, 605-616.

References

Mastro, S., Zimmer-Gembeck, M. J., Webb, H. J., Farrell, L., & Waters, A. (2016). Young adolescents’ appearance anxiety and body dysmorphic symptoms: Social problems, self-perceptions and comorbidities. Journal of Obsessive-Compulsive and Related Disorders, 8, 50-55.