The authors have written a book targeted at clinicians working at the higher levels of a “stepped care” approach of delivering psychosocial interventions to individuals with appearance anxiety.

Clarke and colleagues use the first three of ten chapters to take the reader through the background of appearance anxiety, detailing factors that may influence an individual's response to visible differences. The cornerstone of CBT is that assessment, formulation and treatment of distress is based on specific psychological theories, helping to understand the origins and maintenance of a specific disorder or area of distress. It is therefore reassuring that the authors acknowledge there is limited evidence for specific cognitive or behavioural maintenance factors for the general term “appearance anxiety”. So, in order to try and understand how appearance anxiety is maintained, the authors present existing maintenance models of anxiety and psychological theories that they hypothesize to be useful in this area, particularly drawing on Clark and Well's (1995) model of social phobia. More specific to the subject matter, the authors present a framework that highlights factors involved in adjustment to disfiguring conditions, including: predisposing factors (e.g. gender, visibility to others); intervening cognitive processes (e.g. dispositional style, satisfaction with social support); and outcomes (e.g. depression, anxiety). The number of models and frameworks is perhaps overwhelming and, taken together, the resulting overall diagrammatic formulation presented by the authors is all encompassing, integrating elements from areas such as social phobia, social skills, behavioural concepts and the findings of a research project carried out by the authors. It is also bold given the time limited nature of the therapy one assumes is provided at the level of stepped care this book is targeted at. The formulation model itself encompasses schemas, core beliefs, predisposing factors, precipitating factors, rules and assumptions, compensatory strategies, resilience and strength, and protective factors, with the familiar “hot cross bun” at its heart. Both diagrammatically and within in the text, the theoretically relevant change mechanisms specific to appearance anxiety are less clear.

Although the book cover suggests that the anxiety experienced by the individual should be due to a visible difference in appearance, the authors declare that the term appearance anxiety is used independent of any diagnoses, such as Body Dysmorphic Disorder (BDD) or PTSD where a treating clinician might encounter appearance anxiety (e.g. adjustment to facial scarring following an RTA). The authors see BDD as just one end of a continuum anchored at the other end with “normal preoccupation with appearance” versus a categorical DSM-V definition. The result is a book that mainly focuses on appearance anxiety resulting from visible differences in appearance or disfigurements, but one that is also peppered with examples of cases that would meet a diagnosis of BDD or where there is no visible difference. Encompassing such a range of presentations results in quite a generic approach to treating appearance anxiety and it is confusing to the reader as to what framework might be most applicable to different presentations.

Following the formulation and assessment chapters, the next three chapters provide guidance on intervention: “social skills and coping strategies”, “CBT”, and then a more lengthy chapter giving useful examples of session by session interventions used by the authors for a range of presentations involving appearance anxiety. Although the book assumes a relatively high level of knowledge of CBT, the multitude of techniques presented with different theoretical underpinnings (some decidedly questionable with regards to being CBT techniques) mean the rationale for their use is at times unclear. For example, behavioural experiments, exposure underpinned by the principles of habituation with the use of hierarchies, distraction, relaxation and social skills training are all presented across the intervention chapters. What is categorized under social skills training is reminiscent of the days when this was suggested as a treatment for social phobia, implying patients have a deficit in social skills when actually the behaviours that are problematic in social situations could be better conceptualized as safety seeking behaviours. By conceptualizing certain behaviours in this way, the authors possibly detract from and dilute the very real point they make - that many individuals with visible disfigurements might need to rehearse and discuss how to respond to questions/people staring during social interactions.

The useful aspects of this book include a thorough discussion on clinical outcome measures, which is helpful for clinicians in order to monitor progress in treatment and screen for disorders such as BDD. The final chapters discuss potential points to consider when working with children transitioning to adult services and a helpful chapter on psychological assessment for cosmetic surgery. Both these are very relevant for dilemmas faced in clinical practice when working with appearance anxiety (e.g. patients presenting as wanting a physical solution/surgery for their difficulties).

Much of what is presented in this book is the result of research the authors have carried out; strangely for a “how to” book for clinicians, around a third of the whole book is dedicated to a large appendix, which presents the results of several of the authors’ recent studies. Overall, it is hard to follow the thread of what theoretically is hypothesized to be maintaining appearance anxiety and therefore what interventions to apply within different presentations. This book is perhaps most useful for those working with individuals where appearance anxiety is the result of an observable visible disfigurement as this is clearly the main focus of the book.