# The mediating role of psychological inflexibility and social avoidance in relationship between body image disturbance and depression among young adults with acne in China

## TL;DR

This study explores how body image issues in people with acne in China lead to depression through psychological inflexibility and social avoidance.

## Contribution

The study identifies psychological inflexibility and social avoidance as key mediators linking body image disturbance to depression in acne patients.

## Key findings

- Body image disturbance significantly influences depression through psychological inflexibility and social avoidance.
- Psychological inflexibility alone accounts for 70.8% of the indirect effect on depression.
- Acne severity is a significant predictor of psychological inflexibility.

## Abstract

Acne impairs physical appearance and triggers significant psychological distress, particularly depression, in young adults, but the underlying psychological mechanisms remain underexplored.

This study aimed to examine the potential mediating associations of psychological inflexibility and social avoidance in the relationship between body image disturbance and depressive tendencies among young adults with acne in East China, based on the Acceptance and Commitment Therapy (ACT) framework.

A cross-sectional survey was conducted among 201 young adults (18–29 years, 72.1% female) with acne from two tertiary hospitals in East China between December 2024 and February 2025. Validated instruments were used to assess body image disturbance (BIDQ), psychological inflexibility (AAQ-II), social avoidance (SADS-SA), and depression (PHQ-9). A serial mediation model (PROCESS Model 6) was analyzed via SPSS 29 with 5,000 bootstrap samples.

Correlation analysis showed significant positive relationships between body image disturbance, psychological inflexibility, social avoidance, and depression (all p < 0.01). Mediation analysis revealed that body image disturbance had a significant total effect on depression [Effect = 0.147, 95% CI (0.088, 0.205)], while its direct effect was non-significant. Two indirect pathways accounted for 84.1% of the total effect: (1) a single mediation through psychological inflexibility (70.8% of the effect); and (2) a serial mediation through psychological inflexibility and social avoidance (7.4% of the effect). Additionally, acne severity significantly predicted psychological inflexibility (β = 0.184, p = 0.012).

Body image disturbance indirectly influences depression primarily through the pathways of psychological inflexibility and social avoidance. Integrating ACT into dermatological care to enhance psychological flexibility may effectively alleviate depressive symptoms in acne patients.