LITERATURE STUDY 

2.5 THE PSYCHOLOGICAL IMPACT OF ACNE  

2.5.1 Self-esteem, body image, identity and acne

According to Reber and Reber (2001:661) self-esteem refers to the degree to which one values oneself. This is a subjective evaluation of the self that is, in part, based on the reaction of others to the self. Good self-esteem is vital as a sense of self-worth is absolutely essential for emotional health and well being (Donald, Lazarus & Lolwana 2002:352).

Thompson et al. (1990) is quoted in Papadopoulos et al (2000:432) as being of the opinion that the relevance of self-esteem in relation to acne lies in its close association with body image. An adolescent’s body image is often distorted by the onset of a cosmetically disfiguring disease like acne and this has correspondingly negative effects on the adolescent’s self-esteem.

Furthermore, the face is of critical importance to body image due to its high visibility. Since acne typically presents on the face, it is highly visible and thus may have serious adverse effects on body image evaluations and self-esteem. Murray and Rhodes (2005:184) mention a study done by Picardi et al. (2000) that supports these findings by stating that research participants with acne had lower self-esteem and body-image evaluations than controls.

Bernstein (1989) is quoted in Kellet and Gilbert (2001:24) as saying that during adolescence the awareness of body image and body ideal are particularly intensified. It becomes extremely important during this time to look attractive to others. As girls and boys enter their teenage years, one of their most important concerns becomes looking beautiful or attractive. They often constantly compare themselves to the ideal expressions of beauty as seen in magazines. A smooth and flawless skin is coveted by all as it symbolizes perfection in itself – it defines beauty and implies success (Day 2005:1).

Therefore, acne may be particularly damaging due to its onset in the adolescent years and have a devastating impact upon previously clear-skinned individuals. In fact, Macgregor, Abel, Bryt and Laver (1953) in Kellet and Gillbert (2001:15) found that for some individuals a minor dermatological defect, such as acne can be as damaging to their self-concept as major inherited or accident-related facial deformity.

According to Reber and Reber (2001:338), identity refers to a person’s essential and continuous self, the internal, subjective concept of oneself as an individual. Identity formation begins early in life, but is a particularly important during the teenage years. An ideal psychological state is characterised by the formation of a stable identity in all aspects of the self (UNISA: 2001:25).

According to a study done by Murray and Rhodes (2005:191) “the unpredictable nature of acne clearly impacted upon participants’ sense of identity, which as the severity of their acne fluctuated took on a fluid quality.” In other words: sufferers’ outlook and self-evaluations changed according to how unappealing they experienced their acne to be, resulting in their self-identity being in a constant state of flux.

Murray and Rhodes (2005:192) also found that although the participants in their study did not view appearance as more important than character or intellect, they felt unable to escape the primacy of their appearance on their overall self-image. Therefore the perception of one’s appearance can negatively affect the way one perceives and values oneself as a whole.

2.5.2 Acne and depression 

The relationship between acne and depression has been examined by various studies. According to Krejci-Manwarring et al (2006:122)”clinically significant depression has been observed in as many as 6% of persons with acne compared to 3% of general medical patients and it is estimated that more that 30% of acne sufferers, suffer from psychological disorders, typically anxiety or depression”. However, according to Kellet and Gilbert (2001:18) no studies have been done to clearly establish the direction and strength of the association between acne and depression and more research is needed in this area.

What compounds the problem is the fact that an ingredient called Isotretinion, which is found in many successful pharmaceutical treatments for acne, has been linked to depression and suicide in its users. Isotretinoin is an oral retinoid from the vitamin A family of compounds. Most dermatologists recommend oral isotretinoin treatment (sold under the name Accutane or Roaccutane) for acne that can cause scarring, inflammatory acne that does not respond to conventional therapy and chronic acne that keeps reoccurring after any other given treatment (Day 2004:121).

Hull and D’Arcy (2003:493) state that the Federal Drug Administration (FDA), the American drug reaction monitoring body, received 431 reports of depression, suicidal ideation, suicide attempts and suicide in an 18-year period in Isotretinoin users.

On the other hand some studies report that Isotretinoin treatment has also been shown to significantly improve anxiety and depressive symptoms in acne patients, because of clearing the disfiguring acne. Hull and D’Arcy (2003:502) mention studies done by Rubinow et al. and Layton et al. that advocate the early use of isotretinoin to reduce anxiety, depression and interpersonal sensitivity in acne sufferers.

Although a possible association between Isotretinoin and depression has been suspected for over 15 years, no causal relationship has been established by reliable research (Chee, Tam, Celi, Tate & Schweitzer 2002:262). It would appear that the difficulty in establishing such a relationship is mainly due to inherent problems in research design, including a lack of reliable and valid measures and adequate sample sizes. Also, a variety of clinical variables may influence the incidence of depression, like the duration of the condition, the presence of scarring, the response to treatment, the severity of the acne, individual psychological attributes and a past history of depression (Hong & Schweitzer: 2003: 81).

Furthermore, in order to prove causality one would need a treatment group who receives the drug and a control group who only receives placebos. One would then need to compare the incidents of clinical depression between these two groups. However, it would not be ethically appropriate to deprive one group of Isotretinoin therapy, especially since it has been proven to be such an effective method for treating severe acne (Hong & Schweitzer: 2003:81).

Finally, it seems logical to assume that acne patients develop depression because of the disfiguring nature of the disease, whether they are treated with Isotretinoin or not. Strahan and Raimer (2006:789) suggest that a double blind, randomised, placebo-controlled study is required to investigate the possible causal relationship between Isotretinoin use and depression and suicide.

In the meantime, for the practitioner, the obvious benefit of Isotretinoin in treating acne supports its continued use, as it is such a highly efficacious treatment. However, Hull and D’Arcy (2003:503) suggest that patients and relatives must be thoroughly prepared and clearly informed of the risks and be encouraged to report depressive symptoms promptly. The patient must be alerted to monitor any mood changes, persistent feelings of sadness, loss of interest in normal activities, loss of appetite or sleeping problems as these symptoms could indicate a possible depressive episode. Amichai and Grunwald (2000:232) concur that proper pre-treatment counselling and careful monitoring of possible side effects will help to ensure successful and safe treatment.

2.5.3 Anger, anxiety and acne

Murray and Rhodes (2005:184) refer to a study done by Wu, Kinder, Trunnell and Fulton (1988) that examined the relationship between levels of anger and anxiety and acne severity. Results found higher levels of anger and anxiety where acne was rated as severe, either by the patients themselves or by a dermatologist.

According to Kellet and Gilbert (2002:18) research has illustrated that individuals with cystic acne report elevated levels of both state and trait anxiety. Acne patients often live in a state of anxious expectation and fear of their condition worsening. They experience an intense sense of helplessness and frustration as a result of the unpredictability of the condition and their perceived lack of control to improve it (Murray & Rhodes 2005:198). Meeren, van der Schaar and van den Hurk (1985) in Kellet and Gilbert (2002:18) also found elevated levels of social anxiety in a sample of acne patients in comparison to community norms.

Kellet and Gilbert (2002:19) state that a close and reciprocal relationship between acne and anger has been reported by many commentators from different theoretical schools within psychodermatological literature. Psychoanalytical theorists propose a relationship between acne and repressed angry emotions towards early authority figures, while the stress-diathesis model found increased acne pustules after anger was induced in an experimental situation.

However, despite a widespread opinion that a link exists between anger or repressed anger and the development and maintenance of acne, the literature concerning such a linkage is scarce and no empirical evidence can currently prove this viewpoint.  

2.5.4 Shame, embarrassment and acne 

Kellet and Gilbert (2002:11) distinguish between internal and external shame. Internal shame refers to seeing oneself as inadequate or flawed, while external shame refers to the belief that others see one as inferior or rejectible. Although these two types need not always co-occur, acne patients often suffer from a combination of both types of shame.

According to Kellet and Gilbert (2002:12) acne-related shame is a painful emotional state, which often leads to a variety of self-handicapping behaviours. Furthermore they postulate that acne patients suffer from embarrassment and shame, because of a discrepancy between their desired and perceived self-presentation. They covet a clear skin but are confronted with unsightly lesions and pustules on a daily basis.   Schachter, Pantel, Glassman and Zweibelson in Kellet and Gilbert (2002:13) found that acne patients also often feel embarrassed to be in the company of clear-skinned people.