The psychology of the dermatology patient is a relatively under-researched area and so suffers from a relative lack of clarity. We have substantially covered the psychosocial effect that skin disease can have upon an individual and their social system but, just as important, is the way that the patient represents their illness. Understanding these dermatological illness representations might play a fundamental role in understanding treatment compliance, behavioural adaptation, impact upon relationships, the way a person copes with the often episodic nature of the disease and a number of other crucial aspects of the skin disease experience discussed throughout the book. Yet, so little is still known about how people actually conceptualise their disease along a number of cognitive dimensions. The literature indicates that there are generally higher levels of psychological distress amongst people with skin conditions but crucially, there is also evidence to suggest that there is considerable individual variation. Several studies have found only a weak association between disease severity and psychological functioning (Finlay et al., 1990; Fortune et al., 1997, 2002) and, as previously stated, lay beliefs about the origin and maintenance of skin conditions abound and may differ across cultures. Beliefs within the domain of illness representations have been shown to be influential in medical help-seeking. The use of outpatient services, disease-related distress, disability, avoidance and the use of concealment behaviours are all the common social anxiety-related adjustment strategies, and depend heavily on the way that people represent their illness.
Indeed, the mother-child relationship may be affected by a child with a skin condition and the considerable variation between mothers with respect to how they respond to a skin condition depends on factors related to the appearance of the baby but also the mother's own beliefs and attitudes concerning skin diseases and physical appearance (Walters, 1997). Some mothers can react to the illness by exhibiting overprotection and overindulgence of the child whereas others can feel that the condition impinges on their ability to bond with their child and can lead to great distress. Furthermore, the recent development of the Illness Perception Questionnaire for children shows that the way that children represent their skin condition is also of considerable importance (Walker et al., 2004).
Schober and Lacroix (1991) argue that modern contemporary illness models, as the explanatory framework of health and illness, are fundamentally based in the
Hippocratic-Galenic medicine of classic Greek antiquity. Today it is thought that identity (symptoms), cause, consequences, cure and timeline appear to be the major attributes of illness representations (Leventhal et al., 1997), and that they are a loosely organised set, defining the objective problem or associated danger.
Each feature of a great many patients' representations of illness can generate strong affective reactions. These reactions can be provoked either by an abstract label (e.g. vitiligo) or by the concrete component (depigmentation of the skin) of the representation and we can distinguish three broad sources of information that people draw upon for the elaboration of illness representations (Leventhal et al., 1984). These are:
• The generalised pool of illness information current in the culture.
• Social communication or information obtained in direct contact with other people, particularly practitioners.
• The individual's personal illness experience. The local culture of the family and medical care system, the mass media and the openness of other patients as points of comparison as well as the individual's own private experience of disease and its treatment.
As touched upon earlier, Leventhal et al. (1984) identified four principal attributes that appear common to many illness representations.
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