From Negative Body Image to Social Appearance Anxiety The Indirect Role of Psychological Flexibility

Abstract

Negative body image is closely associated with anxiety about how one’s appearance is evaluated in social contexts, yet the psychological correlates underlying this association remain insufficiently understood. Using a cross-sectional online survey, this study examined whether higher negative body image (NBI) was indirectly connected to higher social appearance anxiety (SAA) through lower psychological flexibility (PF). Participants were 394 adults aged between 18-40 (M = 25.46, SD = 5.12). The hypothesized associations were tested using structural equation modeling (SEM), which was followed by measurement invariance and multigroup SEM analyses across female and male participants. In the full sample, NBI was negatively associated with PF and positively associated with SAA, whereas PF was negatively associated with SAA. The indirect association between NBI and SAA through PF was statistically significant (β = .185, 95% CI [.104, .281]), while the direct association remained significant (β = .496, 95% CI [.363, .621]). The indirect association represented approximately 27% of the total NBI-SAA association. The indirect association was also statistically significant among female participants (β = .202, 95% CI [.116, .289]), but not among male participants (β = .051, 95% CI [−.255, .356]). Overall, the results show that PF emerged as a relevant psychological correlate of the connection between NBI and SAA and provide a foundation for further investigation of this relationship.

Keywords

• Negative body image
• Psychological flexibility
• Social appearance anxiety
• Structural equation modeling

References

1. Acar, S. (2022). Mediator role of social appearance anxiety in the relationship between socio-cultural attitudes towards appearance and body image flexibility. International Journal of Psychology and Educational Studies, 9(2), 332–339. https://doi.org/10.52380/ijpes.2022.9.2.481
2. Andini, S., & Hamidah, H. (2022). Body image and social anxiety of obese young women. Biopsikososial: Jurnal Ilmiah Psikologi Fakultas Psikologi Universitas Mercubuana Jakarta, 6(1), 1–11. https://doi.org/10.22441/biopsikososial.v6i1.15904
3. Arıkan, F., Kartöz, F., Karakuş, Z., Altınışık, M., Özer, Z., & Korcum Şahin, A. F. (2024). Body image and social appearance anxiety in patients with cancer undergoing radiotherapy: A cross-sectional study. BMC Psychology, 12(1), 363. https://doi.org/10.1186/s40359-024-01856-w
4. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.
5. Brichacek, A. L., Neill, J. T., Murray, K., Rieger, E., & Watsford, C. (2024). The distinct affect regulation functions of body image flexibility and inflexibility: A prospective study in adolescents and emerging adults. Body Image, 41, 1–10. https://doi.org/10.1016/j.bodyim.2024.101123
6. Cash, T. F. (2012). Encyclopedia of body image and human appearance. Elsevier.
7. Çelikbaş, Z., & Akbayrak, A. (2025). The multiple mediating roles of experiential avoidance and mindfulness between cognitive fusion and social appearance anxiety among patients with acne vulgaris. Psychotherapy Research, 14(1), 52–60. https://doi.org/10.14744/JCBPR.2024.16024
8. Chen, F. F. (2007). Sensitivity of goodness of fit indexes to lack of measurement invariance. Structural Equation Modeling: A Multidisciplinary Journal, 14(3), 464–504. https://doi.org/10.1080/10705510701301834

9. Doğan, T. (2010). Adaptation of the social appearance anxiety scale (SAAS) to Turkish: A validity and reliability study. Hacettepe University Journal of Education, 39, 151–159.
10. Fang, S., Ding, D., Ji, P., Huang, M., & Hu, K. (2022). Cognitive defusion and psychological flexibility predict negative body image in the Chinese college students: Evidence from acceptance and commitment therapy. International Journal of Environmental Research and Public Health, 19(24), 16519. https://doi.org/10.3390/ijerph192416519
11. Fardouly, J., Diedrichs, P. C., Vartanian, L. R., & Halliwell, E. (2015). Social comparisons on social media: The impact of Facebook on young women's body image concerns and mood. Body Image, 13, 38–45. https://doi.org/10.1016/j.bodyim.2014.12.002
12. Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7(2), 117–140. https://doi.org/10.1177/001872675400700202
13. Fredrickson, B. L., & Roberts, T.-A. (1997). Objectification theory: Toward understanding women's lived experiences and mental health risks. Psychology of Women Quarterly, 21(2), 173–206. https://doi.org/10.1111/j.1471-6402.1997.tb00108.x
14. Gao, J., Feng, Y., Xu, S., Wilson, A., Li, H., Wang, X., Sun, X., & Wang, Y. (2023). Appearance anxiety and social anxiety: A mediated model of self-compassion. Frontiers in Public Health, 11, 1105428. https://doi.org/10.3389/fpubh.2023.1105428
15. Göbel, P., Sanlier, N., & Kocabaş, Ş. (2023). Social appearance anxiety and self-esteem in women: Could body mass index have a mediating role? Behavioral Psychology/Psicologia Conductual, 31(1), 25–37. https://doi.org/10.51668/bp.8323102n
16. Grogan, S. (2016). Body image: Understanding body dissatisfaction in men, women, and children (3rd ed.). Routledge.
17. Hai, R., & Yang, Y. (2022). Social network site appearance comparison's prediction of anxiety among Chinese females: The mediation effect of body area satisfaction, overweight preoccupation, and self-esteem. Frontiers in Psychiatry, 13, 775782. https://doi.org/10.3389/fpsyt.2022.775782
18. Hart, T. A., Flora, D. B., Palyo, S. A., Fresco, D. M., Holle, C., & Heimberg, R. G. (2008). Development and examination of the social appearance anxiety scale. Assessment, 15, 48–59. https://doi.org/10.1177/1073191107306673
19. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
20. Henseler, J., Ringle, C. M., & Sarstedt, M. (2015). A new criterion for assessing discriminant validity in variance-based structural equation modeling. Journal of the Academy of Marketing Science, 43, 115–135. https://doi.org/10.1007/s11747-014-0403-8
21. Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications. Cognitive Behaviour Therapy, 36(4), 193–209. https://doi.org/10.1080/16506070701421313
22. Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1
23. Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118
24. İnik, H., Akçakesea, A., & Demirel, D. (2024). Exploring gender differences, perceptions, and behaviors: The interplay between social media addiction and social appearance anxiety among young adults. Studies in Psychological Science, 2(3), 35–55. https://doi.org/10.56397/sps.2024.09.05
25. International Society of Aesthetic Plastic Surgery [ISAPS]. (2022). Global survey on aesthetic/cosmetic procedures [Annual report]. https://www.isaps.org/discover/about-isaps/global-statistics/
26. Jin, Y., Xu, S., Chen, C., Wilson, A., Gao, D., Ji, Y., Sun, X., & Wang, Y. (2022). Symptom association between social anxiety disorder, appearance anxiety, and eating disorders among Chinese university students: A network analysis to conceptualize comorbidity. Frontiers in Public Health, 10, 1044081. https://doi.org/10.3389/fpubh.2022.1044081
27. Karaaziz, M., Razzaghi, P., & Keskindag, B. (2024). Brief report: A feasibility study of acceptance and commitment therapy in group format for social appearance anxiety. Current Psychology, 43, 4798–4802. https://doi.org/10.1007/s12144-023-04693-z
28. Kılıç, S., & Kabasakal, Z. (2025). The role of psychological flexibility in the relationship between body image and life satisfaction in adult women. Journal of Turkic World Women Studies, 4(6), 32–43. https://doi.org/10.5281/zenodo.15108812
29. Kim, J., & Chung, M. (2016). The effects of social appearance anxiety, negative body image and appearance importance on appearance management behavior and cosmetic surgery intention. The Korean Fashion and Textile Research Journal, 18(5), 625–636.
30. Kline, R. B. (2015). Principles and practice of structural equation modeling (4th ed.). Guilford Press.
31. Levinson, C. A., Rodebaugh, T. L., White, E. K., Menatti, A. R., Weeks, J. W., Iacovino, J. M., & Warren, C. S. (2013). Social appearance anxiety, perfectionism, and fear of negative evaluation: Distinct or shared risk factors for social anxiety and eating disorders? Appetite, 67, 125–133. https://doi.org/10.1016/j.appet.2013.04.002
32. Liao, J., Xia, T., Xu, X., & Pan, L. (2023). The effect of appearance anxiety on social anxiety among college students: Sequential mediating effects of self-efficacy and self-esteem. Behavioral Sciences, 13(8), 692. https://doi.org/10.3390/bs13080692
33. Linardon, J., Fairburn, C. G., Fitzsimmons-Craft, E. E., Wilfley, D. E., & Brennan, L. (2021). The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review. Clinical Psychology Review, 89, 102079. https://doi.org/10.1016/j.cpr.2021.102079
34. Little, T. D., Cunningham, W. A., Shahar, G., & Widaman, K. F. (2002). To parcel or not to parcel: Exploring the question, weighing the merits. Structural Equation Modeling: A Multidisciplinary Journal, 9(2), 151–173. https://doi.org/10.1207/S15328007SEM0902_1
35. Masuda, A., Boone, M. S., & Timko, C. A. (2011). The role of psychological flexibility in the relationship between self-concealment and disordered eating symptoms. Eating Behaviors, 12(2), 131–135. https://doi.org/10.1016/j.eatbeh.2011.01.007
36. Maxwell, S. E., & Cole, D. A. (2007). Bias in cross-sectional analyses of longitudinal mediation. Psychological Methods, 12(1), 23–44. https://doi.org/10.1037/1082-989X.12.1.23
37. Mendes, A. L., Canavarro, M. C., & Ferreira, C. (2021). How psychological inflexibility mediates the association between general feelings of shame with body image-related shame and eating psychopathology severity? Appetite, 163, 105228. https://doi.org/10.1016/j.appet.2021.105228
38. Ministry of Transport and Infrastructure [MTI]. (2025, May 8). Social media usage is increasing [Press release]. https://www.uab.gov.tr/haberler/sosyal-medya-kullanimi-artiyor
39. Özer, P., & Güzel, Ş. (2023). The relationship of social appearance anxiety and social media addiction and the perception of aesthetic procedure. Vizyoner Journal, 14(40), 1412–1432. https://doi.org/10.21076/vizyoner.1258228
40. Perloff, R. M. (2014). Social media effects on young women’s body image concerns: Theoretical perspectives and an agenda for research. Sex Roles, 71(11), 363–377. https://doi.org/10.1007/s11199-014-0384-6
41. Polat, K., & Çiftçi, S. (2021). Direct and indirect effects of body respect on social appearance anxiety: The role of self-compassion. The Journal of International Education Science, 8(29), 31–52. https://doi.org/10.29228/INESJOURNAL.52476
42. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891. https://doi.org/10.3758/BRM.40.3.879
43. Sandoz, E. K., Wilson, K. G., & Merwin, R. M. (2013). Assessment of body image flexibility: The body image-acceptance and action questionnaire. Journal of Contextual Behavioral Science, 2(1–2), 39–48. https://doi.org/10.1016/j.jcbs.2013.03.002
44. Santos-Pereira, G., Coimbra, M., & Ferreira, C. (2024). From shame to dysmorphic concern and anxiety: The role of body image-related psychological flexibility. Journal of American College Health, 73(2), 243–251. https://doi.org/10.1080/07448481.2024.2398140
45. Saylan, E., & Soyyiğit, V. (2022). Dimensions of body image: Body Image Scale. Turkish Psychological Counseling and Guidance Journal, 12(65), 229–247. https://doi.org/10.17066/tpdrd.1138273
46. Seekis, V., Bradley, G., & Duffy, A. (2020). Appearance-related social networking sites and body image in young women: Testing an objectification-social comparison model. Psychology of Women Quarterly, 44, 377–392. https://doi.org/10.1177/0361684320920826
47. Seki, T., & Dilmaç, B. (2015). Predictor relationships between the values the adolescents have and their levels of subjective well-being and social appearance anxiety: A model proposal. Education and Science, 40(179). https://doi.org/10.15390/eb.2015.3663
48. Shepherd, L., Reynolds, D. P., Turner, A., O'Boyle, C. P., & Thompson, A. R. (2019). The role of psychological flexibility in appearance anxiety in people who have experienced a visible burn injury. Burns, 45(4), 942–949. https://doi.org/10.1016/j.burns.2018.11.015
49. Şimşir, Z., Seki, T., & Dilmaç, B. (2019). Gender differences in social appearance anxiety: A meta-analysis study. OPUS International Journal of Society Researches, 10(17), 615–637. https://doi.org/10.26466/opus.519967
50. Sunilkumar, A. (2020). Influence of gender and self-esteem on appearance anxiety among undergraduate college students. International Journal for Research in Applied Science and Engineering Technology, 8, 2079–2083. https://doi.org/10.22214/ijraset.2020.4334
51. Tabachnick, B. G., & Fidell, L. S. (2013). Using multivariate statistics (6th ed.). Pearson.
52. Thompson, J. K., Heinberg, L. J., Altabe, M., & Tantleff-Dunn, S. (1999). Exacting beauty: Theory, assessment, and treatment of body image disturbance. American Psychological Association. https://doi.org/10.1037/10312-000
53. Titchener, K., & Wong, Q. (2015). A weighty issue: Explaining the association between body mass index and appearance-based social anxiety. Eating Behaviors, 16, 13–16. https://doi.org/10.1016/j.eatbeh.2014.10.005
54. Turkish Statistical Institute [TSI]. (2024). Hanehalkı bilişim teknolojileri kullanım araştırması, 2024 [Household information technologies usage survey, 2024]. https://data.tuik.gov.tr
55. Uygur, S. S., & Karaca, R. (2020). Psychological flexibility scale: Development, validity, and reliability. Turkish Studies–Education, 15(5), 3797–3826. https://doi.org/10.47423/TurkishStudies.44949
56. Webb, J. B., Healy, C. M., & Vaughn, M. (2020). Psychosocial correlates of body image flexibility among college women: The unique contributions of self-compassion and intuitive eating. Body Image, 32, 113–120. https://doi.org/10.1016/j.bodyim.2019.12.007
57. Wu, A. D., Li, Z., & Zumbo, B. D. (2007). Decoding the meaning of factorial invariance and updating the practice of multi-group confirmatory factor analysis: A demonstration with TIMSS data. Practical Assessment, Research & Evaluation, 12(3), 1–26. https://doi.org/10.7275/mhqa-cd89
58. Xu, F., Chong, M. C., Zhou, Y., Chen, J., Ruan, J., Sun, Y., Tang, J., & Yahaya, N. A. (2026). The mediating role of psychological inflexibility and social avoidance in the relationship between body image disturbance and depression among young adults with acne in China. Frontiers in Public Health, 14, 1771242. https://doi.org/10.3389/fpubh.2026.1771242
59. Yang, C., Nay, S., & Hoyle, R. H. (2010). Three approaches to using lengthy ordinal scales in structural equation models: Parceling, latent scoring, and shortening scales. Applied Psychological Measurement, 34(2), 122–142. https://doi.org/10.1177/0146621609338592
60. Zucchelli, F., White, P., & Williamson, H. (2019). Experiential avoidance and cognitive fusion mediate the relationship between body evaluation and unhelpful body image coping strategies in individuals with visible differences. Body Image, 32, 121–127. https://doi.org/10.1016/j.bodyim.2019.12.002