Disease and treatment factors

As previously stated, the literature suggests that objective factors, such as age of onset, severity, type of skin condition and type of treatment received, are only weak or poor predictors of adjustment. Whilst, qualitative accounts clearly testify to the potential for treatments to be predictive factors related to distress, there have been few studies that have actually looked at this with any sufficient rigour. Indeed, there is some evidence to suggest that treatment factors are not significantly associated with disability or quality of life (Fortune et al., 1997).

Numerous studies have found only a weak association between disease severity and psychological functioning (Finlay et al., 1990; Clark et al., 1997; Fortune et al., 1997; Fortune et al., 2002). Clinician and self-report measures of severity generally do not correlate, nor do clinical ratings of severity and measures of disability. Whilst, Finlay et al. (1990) found a moderate correlation between clinically measured severity and disability (as measured by the Psoriasis Disability Index (PDI)), the majority of other studies have not found such a relationship. For example, Root et al. (1994) also used the PDI in their study of psoriasis and found that there was not a correlation between clinician-rated severity, and distress or disability. However, they found that there were 'moderately high' correlations between self-rated severity and disability and distress. Their analyses further suggested that the relationship between self-rated severity and distress was mediated by disability. They consequently concluded that self-rated severity was associated with social avoidance, which in turn was related to psychological distress. However, the problem with many of the studies that have looked at self-rated severity is that they have largely failed to define what severity means to the sufferer and it maybe that severity, disability and distress are perceived synonymously.

Given the stigmatising reactions of others, it could be expected that increased visibility would be associated with heightened levels of psychological distress. There is some evidence for this but even here the findings are equivocal. Hughes et al. (1983) found that 70% of their sample with visible skin conditions had heightened the levels of psychological distress. Picardi et al. (2001) found that visibility was an important predictive factor for psychological distress for women. However, Fortune et al. (1997) in their study of psoriasis sufferers found only a modest association.

Whilst, the potential for heightened levels of psychological distress have been found across the range of chronic skin conditions, there is some evidence that there may be differences between specific conditions. Porter et al. (1986) reported poorer adjustment amongst their participants with psoriasis as opposed to those with vitiligo, although both groups experienced lower self-esteem than a control group. Interestingly, the people with psoriasis also reported experiencing more negative reactions from others than the vitiligo group. Type of condition is often also associated with age of onset, insofar as some conditions are congenital whilst others are typically acquired in adolescence and others later in life. This makes it difficult to disentangle disease-specific factors from developmental factors. Again the literature relating to age of onset is also somewhat equivocal. For example, although Porter and Beuf (1988) found a difference between age groups amongst people living with vitiligo, they reported that there was much variation within their age groups, suggesting factors other than age are important. It seems likely that the relationship between disability, distress and disease-related factors is likely to be mediated by other 'higher order' factors, which will be discussed below.

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