Psychosocial impact of skin diseases

Within the psychodermatological literature, there is a great degree of consensus that skin disorders have a negative impact upon the psychological and emotional functioning of some patients. Indeed, research has provided evidence that such appearance-altering diseases can have profound behavioural, emotional and cognitive impact upon sufferers (Griffiths & Richards, 2001; Thompson & Kent, 2001). A brief overview of the most commonly researched psychological implications is thus provided.

Damaged skin often carries the connotation of contagion or a lack of hygiene (Van Moffaert, 1992). Owing to a lack of health education and awareness in dermatology, some associate skin disease with such issues. This ignorance means that a skin disease patient may find that some people react negatively towards them or treat them differently because of the way they look. Consequently, the sufferer may experience distress, feel stigmatised and thus begin to avoid certain social activities that either involve the revealing of the lesions, such as swimming, or that involve potential intimacy with a third party, such as dating or physical displays of affection.

In their qualitative study with vitiligo patients, Thompson et al. (2002) found that the central recurring theme in their interviews concerned perceived differences from previous appearance and from others. Common behavioural strategies used by these patients were concealment and avoidance, which were mostly utilised in order to avoid negative reactions from others. Moreover, acne patients have been shown to limit exposure through social avoidance and to conceal skin lesions (Kellett & Gilbert, 2001). Psoriasis patients have also been found to engage in anticipatory and avoidance coping behaviours, which are unrelated to the severity of their condition and this is hypothesised to relate to stigmatisation and rejection (Griffiths & Richards, 2001). Like previous work on disfigurement and social anxiety, skin disease patients use these dysfunctional behavioural strategies to manage the impression they make on others and their frequent use illustrates the overriding concerns about social exclusion (Thompson et al., 2002).

Cognitively appearance-altering, cutaneous conditions can have a profound effect on self-concept and on body image. Any minor deformity or disfigurement can contribute to the development of heightened body awareness. Cutaneous conditions can often have a progressive and episodic course making it necessary for the patient to adapt to changes in physical appearance. Hence, patients must not only learn to cope with the challenges of living with an appearance that deviates from the norm but also to adapt to a changing body image. That is, skin disease patients must develop and maintain a sense of self-esteem without relying upon physical attractiveness. This is an extremely difficult task given the fact that the robust relationship between self-esteem and body image has been underscored in numerous studies (Papadopoulos et al., 2002).

Feelings of anxiety, uncertainty and helplessness are often cited by dermatology patients as accompanying the diagnosis of their skin condition. Without the knowledge of when or how the condition will develop, the patient may be left wondering about what behaviours or actions might be contributing to its progression. Moreover, dermatology patients experience heightened self-consciousness, which, in turn, has negative implications for interpersonal interactions and relationships. Research has shown that self-consciousness is a common reaction amongst acne patients (Kellett & Gilbert, 2001). Papadopoulos et al. (1999b) found a significantly high frequency in irrational, negative thoughts among vitiligo patients.

Studies have also highlighted a higher prevalence of psychiatric disorder in dermatology patients (Hughes et al., 1983). Although it seems a little premature to make links between dermatological disorders and psychiatric conditions based solely on evidence from cross-sectional designs, research has certainly reported the increased prevalence of conditions, such as anxiety and depression in this population. Gupta et al. (1993) found that over 5% of their sample of psoriasis patients had active suicidal ideation and almost double this figure had expressed the wish to die. Similarly, Fortune et al. (2000) found that psoriasis patients had worry scores on standardised assessment indicative of pathological worrying, with 25% of the entire sample scoring above the mean for patients with a definite diagnosis of generalised anxiety disorder. A linkage between obsessive-compulsive disorder (OCD) and dermatology has also recently been investigated. There is a specific clinical condition, acne excoriee, which is characterised by excessive picking and/or scratching of real or imagined lesions which is considered to be a dermatological variant of OCD (Kellett & Gilbert, 2001). Acne patients may also use too much soap or other vigorous cleaning methods in order to address the feelings of infection. Hence this type of behaviour may qualify as a compulsion.

As well as affecting psychosocial functioning, negative psychosocial experiences may also affect the onset and progression of cutaneous conditions. Clinical observations have suggested that stress often precedes the onset or exacerbation of many dermatological conditions that share both psychosomatic and immunological components, such as vitiligo, psoriasis and atopic dermatitis (Koblenzer, 1983; Al-Abadie et al., 1994). For example, emotional distress and stressful life events have been suggested as contributory factors in the onset of vitiligo (Papadopoulos et al., 1998).

Despite such overriding evidence concerning the impact of skin disease on the sufferer and its implicated role in aetiology, cutaneous conditions are not generally recognised as a handicap and people with such conditions often face trivialisation of their distress (Papadopoulos & Walker, 2003). Until recently, little attention was given to the psychological effects of skin conditions and the challenges faced by those who suffer from them, not only by family and/or friends but by health professionals. Since skin diseases are rarely life threatening, their impact is often minimised by health professionals. Some doctors tend to make judgements about the seriousness of a medical condition in terms of pathological severity rather than quality of life. They consequently deem many skin conditions trivial or unimportant. Patients are left feeling misunderstood or embarrassed for having taken up their doctor's time. They may also feel that they are not taken seriously or are upset by being trivialised. Hence, consultations with professionals can become quite problematic (Papadopoulos & Walker, 2003).

Of course, individual variation exists with regard to adjustment to skin disease and some people cope well with their condition. However, there exists a proportion of this population that finds it particularly difficult to cope (Papadopoulos & Bor, 1999). Clearly then, psychodermatological research has only recently begun to identify the factors that might account for successful adjustment to disfigurement. Variables, such as coping, social support and cognitive representations of illness are being investigated in order to account for psychological impact (Fortune et al., 2000; Papadopoulos et al., 2002; Thompson et al., 2002). Such research has obvious theoretical and therapeutic implications. Theoretically, any model designed to explain psychological adjustment to skin conditions will need to provide explanations for the relationship between disease and psychological distress. Therapeutically, an understanding of patients' adjustment to disease will firstly help professionals to understand patients' attitudes towards treatment and care, and improve the chances of benefiting from them. Secondly, it will elucidate patients' attitudes and representations of their illness as well as their seeking, and adherence to, treatment (Papadopoulos et al., 2002).

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