Cognitive factors personality characteristics and core beliefs

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Predisposing developmental factors are clearly linked to the development of several personality characteristics that are emerging as having predictive power in explaining some of the variability in adjustment. Whilst disrupted attachments in childhood have been discussed as having the potential to lead to stable attachment styles in adulthood, few studies have actually explored the role of attachment, and those that have, were unable to relate this directly back to early experiences. Picardi et al. (2003b, c, d) found higher levels of insecure and avoidant attachment styles in a small sample of people with newly diagnosed or recently exacerbated vitiligo and alopecia areata. Interestingly, their participants also had poorer levels of social support and it was hypothesised that this might result from difficulties in accessing social support as a result of the underlying attachment style.

Shame-proneness is another personality factor linked to early relationships (Tangey & Fischer, 1995; Gilbert & Miles, 2002). Feelings of shame have frequently been described by some people living with chronic skin conditions (e.g. Jowett & Ryan, 1985). Indeed, it has been argued that shame, self-esteem, appearance consciousness, fear of negative evaluation, and social anxiety are all similar concepts, in terms of their developmental origins, their relation to one's sense of being accepted by others, and their underlying cognitive processes (Thompson, 1998). This may explain why some earlier studies have found self-esteem to be closely related to adjustment (Porter et al., 1990; Van der Donk et al., 1994).

Further support to the important role played by these overlapping concepts is provided by the findings of Fortune et al. (1997) with a group of people living with psoriasis. Whilst, they found only a modest association between visibility and distress, their analyses revealed that stress resulting from anticipating negative reactions from others accounted for more of the variance in disability scores than any other disease-related factor. This finding is lent further support by qualitative research which suggests 'social vulnerability' is a key concern for those living with a skin condition (Thompson et al., 2002; Wahl et al., 2002). Further, quantitative evidence is provided by Leary et al. (1998) and Kent and Keohane (2001) who made use of the Brief Fear of Negative Evaluation Scale (FNE: Leary, 1983) and found that this conceptually-related factor moderated the degree of distress experienced. Papadopoulos et al. (1999b) and Kent (2002) have also found heightened levels of appearance-related negative thoughts and beliefs, respectively in samples of vitiligo and camouflage service users.

Two other cognitive factors have recently attracted attention in this area, alex-ithymia and illness representations. Alexithymia has been described as a set of stable personality difficulties related to moderating affect.Alexithymics are described as having difficulty with both emotional expression and experiencing, and possibly have heightened sensitivity to anxiety. Such traits may impact negatively on physical health via heightening physiological arousal to misperceived threats (Kauhanen et al., 1994; Fortune et al., 2002). Elevated levels of alexithymia have recently been reported amongst people with vitiligo (Picardi et al., 2003b), psoriasis (Allegranti et al., 1994; Fortune et al., 2002; Picardi et al., 2003c), and alopecia areata (Picardi et al., 2003d). Fortune et al. (2002) found that people with psoriasis who scored highly on a measure of alexithymia also scored highly on a measure of anxiety, even after illness perceptions and coping factors (which will be discussed below) were accounted for. Alexithymia was also associated, although to a lesser extent, with higher depression, stress and worrying, but not with higher disability.

As already stated, beliefs concerning illness development are likely to be important factors in adjustment. Leventhal et al. (1980,1992) have developed a model of illness representations to define key areas of common sense beliefs that appear important in adjustment to chronic illness. Illness representations are concerned with causal attributions, perceived consequences, beliefs associated with control and treatment, duration, and illness identity (symptom perception). As previously stated, lay beliefs about the origin and maintenance of skin conditions abound and may differ across cultures. Beliefs within the illness representation domains have been shown to be influential in medical help-seeking. Scharloo et al. (2000) found that people with psoriasis made greater use of outpatient services if they believed that their condition had serious consequences, was controllable, and they had a heightened illness identity. Fortune et al. (2002) have reported that illness perceptions were the most useful variables (in comparison to coping factors and alexithymia, which were also important) in accounting for psoriasis-related distress, stress and disability. Further, Fortune et al. (2004) have shown that such beliefs are amenable to psychosocial intervention.

Clearly, these cognitive personality factors warrant further study in order to examine their role in interventions. In addition, clarification is needed as to whether they actually do represent underlying stable personality traits or whether they are best thought of as situationally applied coping mechanisms. However, what is clear is that they are related to and possibly instrumental in the types of coping strategies deployed.

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