Difficulties in communication

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Secrecy and self-disclosure are two opposite forms of communication that can alter couple functioning by shaping what issues couples' feel able to discuss with one another and how needs for closeness and separateness are managed (Feeney & Noller, 1996). Secrecy in skin disease involves safety behaviours such as making excuses to avoid activities involving exposure of the skin and concealing affected areas through the use of clothes or cosmetics. In existing relationships, even if a skin condition is openly acknowledged, secrecy may operate if conversations about the disease are subtly avoided. Partners may be equally anxious over what to say or how to set a fitting tone of conversation without saying the wrong thing and potentially embarrassing themselves or their partner. Sometimes, the location of a condition is not immediately apparent, thus the decision as to whether or when to tell a new romantic partner can be delayed (Papadopoulos & Walker, 2003). Ginsburg (1996) argues that the status of a patient's self-esteem and body image prior to disease onset is clinically important in determining how they are likely to cope with an altered appearance. Secrecy may lessen opportunities for embarrassment (Miles, 2002) however, as a communication strategy, it reflects significant anxiety related to appearance (Kent & Thompson, 2002). Cosmetic products are useful for many patients in that they lower anxiety by improving appearance, which in turn can increase self-confidence regarding romantic acceptance (Leary & Kowalski, 1995). There is a danger however that if improved self-esteem stimulates further interest in appearance, 'camouflaging' may become a psychological tool for maintaining social functioning (Meli & Giorgini, 1984).

Avoidant Attachment Style: 'I never leave the house without makeup, even if it's to go to the shop next door. On a bad day, I won't even leave my bedroom without makeup (I live with three men). What I hate is the time it takes. People always make fun of me (in a nice way ...) about how long it takes me to get ready and I wish I could be ready in 5 minutes because applying all the makeup is really a problem. Sometimes it takes up to half an hour. I know I can look great with make-up on, and no one even notices I have a problem if I'm covering it up, but I live in terror of people seeing how I "really" look. I won't go swimming in the summer and when I'm dating someone (as I am now) I make up a million excuses as to why they can't stay the night, to the point of ruining the relationship. I don't want to have to tell everyone in my life . how insecure I am about the way I look' (Female acne patient).

In contrast, self disclosure is a communication strategy that aims to curtail the fear of'being seen', or 'being discovered'. Mikulincer and Nachshon (1991) investigated the relationship between attachment style and self-disclosure in couples. They found that secure and anxious-ambivalent individuals reported more self-disclosure than avoidant individuals, and secure adults showed the most reciprocity and flexibility over the range of issues discussed with partners.

Secure Attachment Style: 'As far as relationships go, my personal opinion is that my partner would have to be comfortable with my skin because it plays such a huge part in my life. Also, being honest and open about things at the beginning of a relationship avoids any embarrassing and "nasty" surprises further on down the line. I don't expect non-eczema suffers to understand completely the emotions I experience, but I would like them to be a bit compassionate about my condition, especially if I'm going to have a long-term relationship with them' (Female eczema patient).

Self-disclosure is a central provision in intimate relationships (Monsour, 1992), however, certain individuals prefer not to threaten their relationship with self-presentations of depression and anxiety, even if that is their emotional state. 'Being open' carries the risk of being judged as poorly adjusted (Glick et al., 1974) and this is especially so when society tends to admire people who 'bear their cross' (Lyons et al., 1995a). For some individuals or couples, hiding emotional distress or avoiding conflict acts as a form of'protective buffering' that may minimize disruption in a couple's relationship and lifestyle. This style of coping depicts how couples use different strategies to try to protect their relationship during times of stress (Coyne & Smith, 1991).

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