Acne and Anxiety Disorders

[David Baxter PhD]

Acne and Anxiety Disorders (Part 1)
by Mike
March 30, 2009

Acne would seem to be a strange topic for a blog on the Anxiety Disorders.

But acne is one of the leading causes of Anxiety among adolescents and adults. A recent study published in the British Journal of Dermatology found that acne sufferers experienced social, psychological, and emotional consequences at the same level of those with chronic health problems, such as epilepsy, diabetes, and arthritis.

Adults have acne, too, on into their 30?s and 40?s and beyond. And they are more likely than adolescents to feel that acne negatively affects their lives, regardless of how severe their acne is. This may be because there is a greater social stigma for adults with acne. It can lead to clinical Anxiety Disorders, depression, unemployment, and social isolation.

How many people have acne?
Acne vulgaris, more commonly known simply as acne, affects at least 85 percent of adolescents and young adults.¹ That?s no surprise. But did you know that acne affects 25% of all adult men and 50% of adult women at some time in their adult lives? People can develop unpleasant acne or have an acne recurrence in their 20s, 30s, 40s and beyond.² It can be difficult to cope with no matter your age, and can cause Anxiety Disorders and depression in an adult the same way it can in a teen.

How acne affects your life
Acne affects more than just your skin. It can affect your entire life in very real ways. Your family and friends may not fully understand or appreciate how acne influences your self-esteem, self-confidence, and your outlook in general. Even mild breakouts can negatively impact how you feel about yourself.³

Dr. Jerry K. L. Tan, Director of the Acne Research and Treatment Centre, Windsor, Canada, says:⁴

While the physical features of acne are readily apparent to us all, the emotional and social impact of acne is often underestimated by non-sufferers. This can be manifested as anxiety, depression, and social withdrawal. ?tudies have shown that those with acne are dissatisfied with their appearance, embarrassed, self-conscious and lack self-confidence. Problems with social interactions with the opposite gender, appearances in public, and with strangers have also been observed. ​

Of particular concern is the rate that acne sufferers of all ages go on to develop Anxiety Disorders, depression, and other mental disorders. One study showed that 44 percent of acne patients reported severe Anxiety, and 18 percent serious depression. To further illustrate the depth of despair experienced by those living with this condition, more than a third of patients in one study reported thinking about committing suicide.⁵

Acne severity does not seem to be a factor in the level of Anxiety or depression. Those with mild acne are just as likely to suffer from these conditions as those with more severe cases.⁶ Some patients with only minor acne suffer from disturbed body image. Even in the absence of lesions, they consider they have severe acne and may suffer many of the psychological and social symptoms described above. They are said to have ?dysmorphophobic acne.? Some severe cases of dysmorphophobia have a more global mental disorder similar to anorexia nervosa.⁷

Acne and quality of life
Acne especially affects a person?s quality of life. That is no surprise, given the many corollary problems it introduces, such as depression, Anxiety, personality problems, emotions, self-concept, self-esteem, social isolation, social assertiveness, social anxiety, and body dissatisfaction.⁸ Acne sufferers report deficits in quality of life are as great as those reported by patients with chronic disabling asthma, epilepsy, diabetes, or arthritis.⁹

Acne, most especially when found in the face, provokes cruel scoffs from other individuals. Also, acne sufferers may have a difficult time in building new relationships, particularly with the opposite gender. Consequently, such individuals will lack more confidence to meet new acquaintances and create bonds. They would even find it difficult to establish eye contact when communicating. They become introverted and withdrawn from the society.

For some, acne influences daily decisions. A woman may be so self-conscious of her appearance that she won?t pose in family pictures during a reunion. A teenage boy might decline an invitation to go swimming with friends because his back acne embarrasses him.¹⁰ Some sufferers have trouble looking others in the eye, while others completely avoid all social situations.¹¹

Many people do not participate in exercise or sports because of their acne. Dr Martyn Standage, a lecturer in the School for Health at the University of Bath, states that:¹²

The skin is the most visible organ in the human body and, as such, is an important part of personal image. Fear of having one?s skin evaluated by others has implications for physical and social wellbeing. Sport and exercise activities provide many opportunities for the skin to be exposed to evaluation. Due to this, acne sufferers may become so anxious about their appearance that it prevents them from participating in physical activity.​

Adult acne
As mentioned, acne affects 25% of all adult men and 50% of adult women. Older adults with acne reported greater overall effects in quality of life than their younger counterparts. This contradicts the prevailing perception of younger patients as being more susceptible to the psychosocial effects of acne.¹³

Adult patients with acne reported emotional effects of their skin condition that were similar in magnitude to those reported by patients with psoriasis, which is traditionally regarded as a skin condition causing significant disability.¹⁴ This may be because of the duration of disease, poor response to treatment, or the social implications of acne in an adult population.

The majority of adults, when asked what bothered them the most about acne, say that they were bothered by acne?s appearance. Interestingly, appearance is most troublesome to patients aged 30 to 39 years. One explanation for this difference among age groups is that patients younger than 30 years are closer to adolescence and feel that acne is accepted by their peers, whereas those aged 40 years and older may have themselves accepted acne.¹⁵

Those adults with acne who suffer the most are women with high ?social sensitivity,? or heightened concern about being judged and accepted by others. For both women and men, higher social sensitivity is associated with poorer social outcomes and quality of life. For men, it interacts with acne severity more than for women, who can be relatively free of acne and still have these problems. Dermatologist Jennifer Krejci-Manwaring at Wake Forest University School of Medicine in Winston-Salem, North Carolina, says:¹⁶

Men and women with severe acne have the most trouble in social interactions with both friends and strangers. However, women who are more sensitive even when their skin is clear have much more difficulty when they have outbreaks.​

More troubling is how acne can affect employment. The unemployment rate for adults with acne is 7 percent higher than for those without.¹⁷ Dr. Jerry K. L. Tan, Director of the Acne Research and Treatment Centre, Windsor, Canada, states:¹⁸

Acne can ? affect one?s ability to earn a livelihood. A previous study has shown that those with acne were more likely to be unemployed than those unaffected. A recent Canadian study also observed that those with more severe acne were more likely to be unemployed than those with lesser involvement. It is uncertain whether these findings are due to the patient?s psychosocial impairment or the negative response by potential employers to those affected by acne.​

FOOTNOTES

1. Hanna, Shannon; Sharma, Jasdeep; Klotz, Jennifer. (2003). Acne vulgaris: More than skin deep. Retrieved March 21, 2009 from Acne vulgaris: More than skin deep
2. Kern, Daniel W. (2008). Adult acne. Retrieved March 26, 2009 from Adult acne
3. Aktan, S.; Ozmen E.; Sanli, B. (2000). Anxiety, depression, and nature of acne vulgaris in adolescents. Retrieved March 21, 2009 from Anxiety, depression, and nature of acne vulgaris i...[Int J Dermatol. 2000] - PubMed Result
4. Tan, Jerry K.L. (2008). The Unseen Impact of Acne: There is help for those suffering. Retrieved March 21, 2009 from The Unseen Impact of Acne
5. Tan. (2008).
6. Palmer, Angela. (2008, December 5). Acne and Your Self Esteem. Retrieved March 21, 2009 from Acne - Acne and Self Esteem
7. Staff of the New Zealand Dermatology Society. (2008, December 30). Psychological effects of acne. Retrieved March 21, 2009 from Psychological effects of acne. DermNet NZ
8. Lasek, Rebecca Jane; Chren, Mary-Margaret. (1998). Acne Vulgaris and the Quality of Life of Adult Dermatology Patients. Retrieved March 25, 2009 from Acne Vulgaris and the Quality of Life of Adult Dermatology Patients -- Lasek and Chren 134 (4): 454 -- Archives of Dermatology
9. Hanna. (2003). Quality of life.
10. Loney, Tom; Standage, Martyn; Lewis, Stephen. (2008). Not Just ?Skin Deep.? Retrieved March 21, 2009 from the Journal of Health Psychology Not Just `Skin Deep': Psychosocial Effects of Dermatological-related Social Anxiety in a Sample of Acne Patients -- Loney et al. 13 (1): 47 -- Journal of Health Psychology
11. Palmer. (2008)
12. Staff of Medindia.com. (2008, March 9). Social Anxiety Prevents Acne Patients from Participating in Sports, Exercise. Retrieved March 21, 2009 from Social Anxiety Prevents Acne Patients from Participating in Sports, Exercise
13. Lasek. (1998). Comment.
14. Lasek. (1998). Comment.
15. Lasek. (1998). Comment.
16. Krejci-Manwaring, Jennifer; Kerchner, Katherine; Feldman, Steven R.; Rapp, Derek A.; Rapp, Stephen R. (2006). Social sensitivity and acne: the role personality in negative social consequences and quality of life. Retrieved March 25, 2009 from BiomedExperts: Social sensitivity and acne: the role of personality in negative social consequences and quality of life.
17. Lasek. (1998). Comment.
18. Tan. (2008).

 

[David Baxter PhD]

Acne and Anxiety Disorders (Part 2)
by Mike
March 31, 2009

Acne can cause Anxiety and can lead to Anxiety Disorders and depression.

Up to 60 percent of acne sufferers show significant levels of Anxiety. Some researchers even think that acne can cause these mental disorders. It is certain that stress can cause acne and exacerbate existing Anxiety Disorders and depression.

What is not apparent is how many suicides are attributable to acne. Thirty-five percent of teenagers with bad acne have suicidal thoughts, and more than 10 percent have tried to kill themselves. The numbers are not available for adult suicide ideation and attempts, but there is reason to believe that they are similar.

Acne and Anxiety
Acne often leads to mental disorders, especially the Anxiety Disorders.¹ Acne is associated with a greater psychological burden than a variety of other disparate chronic disorders.² Some researchers believe that acne can actually cause psychological problems, rather than just exacerbating them among those with susceptibility.³ Shannon Hanna, of Dalhousie University Medical School Halifax, Nova Scotia, Canada, says:⁴

Acne vulgaris has the potential to cause significant psychiatric and psychological complications, while negatively affect[ing] quality of life. Many factors influence the nondermatological aspects of acne including personality, perceptions, age, and social and cultural factors, as well as disease characteristics (duration, severity, scarring). ​

The Anxiety Disorders, especially Social Phobia, are the most prominent among acne patients. Up to 60 percent of acne sufferers show significant levels of Anxiety. As might be expected, people with a more severe degree of acne show higher Anxiety values in studies.⁵ Women with acne have a higher level of Anxiety, and are more vulnerable than males to the negative psychological effects of acne.⁶ The rates of Anxiety increase among those with a higher education.⁷

Acne and stress
Stress is a constant in our lives, but for the acne sufferer it can be especially troubling. It has been found that stress can actually cause acne to get worse and can make any psychological conditions worse, as well. Dr. Jerry K. L. Tan, Director of the Acne Research and Treatment Centre, Windsor, Canada, says:⁸

The mental stress of sufferers with acne can be greater than that associated with other chronic diseases such as asthma, epilepsy, diabetes, back pain, arthritis, and heart disease.​

There seems to be a two-way street with acne and stress; Acne can cause stress and negative emotions, and stress and negatives can cause and worsen acne. Any effective acne treatment should address both the acne and the emotional state of the person with acne.⁹ (See Get Help below.)

For those who have mental disorders, the stress caused by acne can exacerbate the condition. And for those who are predisposed to psychological factors, acne?s stress can cause mental disorders to become active.¹⁰

Dr. John Koo, of the University of California, San Francisco?s Psoriasis Treatment Center and Phototherapy Unit, states that psychological factors may play a significant role in acne in at least three ways:¹¹

1. Emotional stress can exacerbate acne.
2. It is common for patients to develop psychiatric problems as a consequence of acne, such as those related to low self-esteem, Social Phobias, or depression.
3. Primary psychiatric illnesses such as Obsessive-Compulsive Disorder and psychosis may be based on a complaint that is focused on acne.

It is obvious that to properly control acne, a sufferer?s stress must be addressed as well, especially if the stress is making their Anxiety Disorders or depression worse. A professional mental health practitioner is the best source of help, and should be considered as essential as a good dermatologist.

Warning signs that your mental condition is getting out of control
In a society that places great emphasis on appearance, acne sufferers often feel uncomfortable or embarrassed. The prevalence of myths regarding acne development may even lead some to feel a sense of guilt or shame, as if they are somehow responsible for their acne.¹²

These feelings lead to social withdrawal and to avoiding social situations. This avoidance is a primary reason that Anxiety Disorders get a toe-hold in your life, and avoidance is the main way that Anxiety Disorders grow and flourish. Avoiding going out with friends, finding excuses to not attend family functions or generally having little interest in socializing with others may be warning signs that acne is seriously affecting your life.¹³

But the danger of acne goes beyond just Anxiety Disorders and depression. Many people, especially adolescents, contemplate or actually attempt suicide due to their acne.

Thirty-five percent of teenagers with bad acne have suicidal thoughts, and more than 10 percent have tried to kill themselves.¹⁴ I have not seen any studies about suicide among adult acne sufferers, but it is logical that there is some degree of these numbers holding true in adults.

Get help
The treatment of acne should involve more than addressing skin problems. Disturbance of the psychological state with signs of Anxiety Disorders or depression, as well as mixed depression and Anxiety Disorders, is frequently associated with acne.¹⁵

It stands to reason that any treatment plan should include both physical and psychological care. Shannon Hanna, of the Dalhousie University Medical School in Nova Scotia, says that the treating physician should consider all factors when treating acne. She continues:¹⁶

Addressing nondermatological effects of acne allows the physician to treat the whole patient and not solely the skin condition. Acne vulgaris is a common skin disease with potential complications that are more than skin deep.​

And Dr. Peter Watson of the University of Auckland states that:¹⁷

Our data suggest that doctors who see ? people with problematic acne have a particularly important role to play in screening these ? people for depression, anxiety and suicidal thoughts and behaviour.​

Patient education is very important, as well. Too many people have misguided notions of why acne occurs, which can further exacerbate emotional and mental problems. In a study of acne patients in a dermatologists care, almost 30 percent believed that poor skin hygiene was a causative factor of acne. If this belief exists among a patient population who has had some degree of education by their physicians, similar beliefs must also exist in the general population.¹⁸

Here are some suggestions for getting help with your acne:¹⁹

1. At a minimum, find a dermatologist who is sympathetic and willing to address the emotional issues that go along with acne. Be honest with your doctor. Let her know if acne is considerably affecting your self-esteem, interfering with social interactions, or causing depression or anxiety.
2. Ideally, acne should be treated early, before damage to the self-esteem has begun. People who have chronic, long-lasting acne are more likely to have psychological ramifications. If you believe you may be anxious or depressed, you may benefit from psychological counseling.
3. Seek out a support system. Having a compassionate person, or group of people, who understand what you are going through can help dispel feelings of isolation and hopelessness that are common to acne sufferers

Too often, acne is brushed off as just something that teenagers have, and that goes away quietly. The psychological, emotional, and social effects of acne never enter the mind. However, as these posts show, acne often leads to deeper problems that can linger a person?s whole life.

FOOTNOTES

1. Srivastava, S.; Bhatia, M.S.; Das, P.; Bhattacharya, S.N. (2008). A Cross-sectional study of quality of life and psychiatric morbidity in patients with Acne Vulgaris. Retrieved March 21, 2009 from JPPS-Journal Of Pakistan Psychiatric Society
2. Tan, J.K.L. (2004). Psychosocial Impact of Acne Vulgaris: Evaluating the Evidence. Retrieved March 21, 2009 from Psychosocial Impact of Acne Vulgaris: Evaluating the Evidence
3. Fried, Richard; Wechsler, Amy. (2006, September 27). Psychological problems in the acne patient. Retrieved March 25, 2009 from Wiley InterScience :: Session Cookies
4. Hanna, Shannon; Sharma, Jasdeep; Klotz, Jennifer. (2003). Acne vulgaris: More than skin deep. Retrieved March 21, 2009 from Acne vulgaris: More than skin deep
5. Asad, Faria; Qadir, Altaf; Ahmed, Lugman. (2002). Anxiety and Depression in patients with Acne Vulgaris. Retrieved March 21, 2009 from PakMediNet - View Abstract
6. Aktan, S.; Ozmen E.; Sanli, B. (2000). Anxiety, depression, and nature of acne vulgaris in adolescents. Retrieved March 21, 2009 from Anxiety, depression, and nature of acne vulgaris i...[Int J Dermatol. 2000] - PubMed Result
7. Datuashvili, M.G.; Chitashvili, M.D.; Katsitadze, A.G. (2002). Psychological Particularity in Acne Vulgaris. Retrieved March 21, 2009 from Psychological Particularity in Acne Vulgaris
8. Tan, Jerry K.L. (2008). The Unseen Impact of Acne: There is help for those suffering. Retrieved March 21, 2009 from The Unseen Impact of Acne
9. Fried, Richard. Healing Adult Acne. Oakland, CA: 2005
10. Kenyon, F.E. (1966). Psychosomatic Aspects of Acne. Retrieved March 25, 2009 from the British Journal of Dermatology, Wiley InterScience :: Session Cookies
11. Koo, John; Smith, Laura. (2008, March 20). Psychologic Aspects of Acne. Retrieved March 25, 2009 from Wiley InterScience :: Session Cookies
12. Palmer, Angela. (2008, December 5). Acne and Your Self Esteem. Retrieved March 21, 2009 from Acne - Acne and Self Esteem
13. Palmer, Angela. (2009, January 2). Is Acne Negatively Impacting Your Life? Retrieved March 21, 2009 from Acne and Depression - Acne and Depression Warning Signs
14. Purvis, D,; Robinson, E.; Merry, S.; Watson, P. (2006). Acne, anxiety, depression and suicide in teenagers. Retrieved March 21, 2009 from Acne, anxiety, depression and suicide in teenagers...[J Paediatr Child Health. 2006] - PubMed Result
15. Datuashvili. (2002).
16. Hanna. (2003), Conclusions
17. Purvis. (2006).
18. Hanna. (2003), Introduction
19. Staff of the New Zealand Dermatology Society. (2008, December 30). Psychological effects of acne. Retrieved March 21, 2009 from Psychological effects of acne. DermNet NZ