The social and psychological impact of skin conditions

To some extent skin conditions are unique from many other diseases in so far as they are often visible to others, and as a result social factors associated with both appearance and illness are relevant to the adjustment process. There is no doubt that living with a chronic skin condition can be stigmatising (Kent, Chapter 4, this volume). As early as 1976 Jobling found that for psoriasis sufferers the greatest psychosocial impact of having the condition were interpersonal difficulties. It is now widely established that individuals with a disfiguring skin condition can suffer negative and intrusive reactions from others as well as experiencing interpersonal difficulties, such as in the formation of relationships (e.g. Jowett & Ryan, 1985; Lanigan & Cotterill, 1989). The following quote typifies the simple intrusive reactions that people living with a skin condition can experience:

'I mean it does get you sometimes. If you see them actually staring at you'. (Quote from a woman with vitiligo cited in Thompson et al. (2002, p. 219))

Studies using confederates made up to look as if they had some form of facial blemish, such as a birth-mark, have found that people tend to be less helpful, less charitable, and offer less sympathy to people with a disfigurement across a range of settings (Samerotte & Harris, 1976; Bull & Stevens, 1981; Rumsey et al., 1982; Kerr et al., 1985). Indeed there is emerging evidence that people hold negative implicit attitudes (attitudes that have not been subject to modification in response to factors, such as social desirability) towards people with visible skin conditions (Grandfield et al., 2004).

Although the tendency of others to react negatively towards people with visible skin conditions is well established, relatively little theoretical or experimental consideration has been given to exploring the causes of this phenomenon. Hypotheses to account for these reactions have revolved around evolutionary theory (Kellett & Gilbert, 2001; Thompson & Kent, 2001), fear and uncertainty (Partridge, 1996) and primitive beliefs often linked to concepts of'fate'or a 'just world' (Shaw, 1981). Certainly, a whole collection of negative, culturally bound, beliefs relating to skin conditions exist, often related to the occurrence and maintenance of the condition as relating to personality flaws in the sufferer. For example, Alderman (1989) has described a collection of'acne myths' relating to such ideas as acne being caused by poor diet and hygiene. Beuf (1990) has reported a belief amongst the Black American population, that the depigmenting condition vitiligo occurs as a punishment for harbouring hidden desires to be white.

Further research is needed to explore the degree to which such stigma relates to stereotypes or that evolutionary predisposed mechanisms are linked to avoiding contamination and maintaining rank, although it is likely that both are involved (Thompson & Kent, 2001). However, what is clear is that such an 'ongoing socio-cultural' context forms an additional stressor for those living with skin condition to have to cope with. This context may also be instrumental in the formation of an individuals' own representations/beliefs concerning their condition and the values they attribute to appearance generally, and as such is likely to be crucially implicated in adjustment. The role of such cognitive factors will be discussed later.

Perhaps not surprisingly given the potential, social, and physical consequences previously described, elevated levels of psychological morbidity have been reported within the literature (Harlow et al., 2000; Picardi et al., 2001; Picardi et al., 2003a). The kind of psychological difficulties commonly found have included: anxiety (e.g. Jowett & Ryan, 1985); depression including risk of suicide (e.g. Hughes et al., 1983; Cotterill & Cunliffe, 1997; Humphreys & Humphreys, 1998); lowered self-esteem (e.g. Jowett & Ryan, 1985; Porter & Beuf, 1988; Van der Donk et al., 1994); feelings of shame (e.g. Jowett & Ryan, 1985; Salzer & Schallreuter, 1995; Thompson et al., 2002); and concerns with body image (e.g. Papadopoulos et al., 1999b; Benrud-Larson et al., 2003).

Indeed, the association between self-concept and appearance is supported by a range of studies (Thompson & Kent, 2001) and there are vivid qualitative accounts of the potential impact on the overall self-concept provided within the literature as the following quote demonstrates:

'No matter what the objective reality, in my heart I think of myself as I was in my teens. I will always be a freak, someone deeply unworthy, someone lurking on the fringes of humanity.' (Richardson, 1997, p. 61)

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