Excessive Tanning an Addiction?

Deborah Brauser

March 05, 2014

Underlying psychiatric distress, including anxiety disorders and substance abuse, may explain why some individuals continue to tan even after experiencing serious negative consequences, such as skin cancer, new research suggests.

A study of more than 500 college students who tan showed that 31% met the criteria for tanning dependence and 12% met the criteria for problematic tanning.

Both tanning classifications were significantly associated with scoring positive on measures of obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). In addition, tanning dependence was significantly linked to hazardous drinking and drug abuse.

"It's possible that some OCD and [BDD] symptoms may be driving some of the excessive tanning," lead author Lisham Ashrafioun, a doctoral candidate in clinical psychology at Bowling Green State University in Ohio, told Medscape Medical News.

"But the results also make the argument that there seems to be something else going on besides those 2 disorders. And it could be that there's also an addiction piece to it," he added.

Overall, coinvestigator Erin Bonar, PhD, assistant professor of psychiatry at the University of Michigan Addiction Research Center in Ann Arbor, noted in a release that although more research is needed, the findings suggest that some young adults who tan excessively experience mental health symptoms that warrant further clinical evaluation.

"For these people, prevention messages and public health campaigns may not be as helpful, but further assessment and treatment could be," she said.

The study is published in the March issue of the Journal of the American Academy of Dermatology.

Ignoring the Risk

According to the investigators, approximately 76,900 new cases of melanoma were diagnosed in 2013. Because it is often caused by exposure to ultraviolet radiation, skin cancer is considered to be one of the most preventable types of cancer.

Lisham Ashrafioun

"The public is generally aware of this potential harm, yet many continue to tan purposefully," they write.

Previous research has suggested that excessive tanning is a symptom of BDD or OCD or that it is a behavioral addiction. However, assessing additional characteristics of the disorder "may help clarify its conceptualization and may guide the development of screening and intervention protocols."

The researchers first recruited 684 psychology course undergraduates at a large Midwestern university during the fall semester of 2011. They then evaluated the 533 participants (72% women; mean age, 19.5 years) who reported having tanned before, either through tanning in the sun or in a tanning bed.

Criteria for substance-related disorders from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were modified for tanning as a measure to assess tanning dependence (known as Tanning-DSM). Tanning dependence was defined as meeting 3 or more of the 8 criteria asked about in the questionnaire.

In addition, a 4-item tanning-specific version of the CAGE alcohol screener questionnaire (Tanning-CAGE) was used to measure problematic tanning.

Other measures used included the Dysmorphic Concerns Questionnaire, the Obsessive Compulsive Inventory–Revised, the Alcohol Use Disorder Identification Test–Consumption, and the Drug Abuse Screening Test–10. The Patient Health Questionnaire was used to screen for depression.

Self-medicating Strategy?

Although 31% of the participants met the criteria for tanning dependence, Ashrafioun questioned the validity of that number, and noted that the Tanning-DSM may have overestimated the self- reported rates.

"That's a study limitation. I would not say that a third of the people we polled actually have a true tanning addiction. That's why it's important to come up with better measures or screeners that might be a little more sensitive," he said.

Still, results showed that screening positive for BDD or OCD was significantly associated with tanning dependence (P < .001 and P = .005, respectively) and with problematic tanning (P = .019 and P < .001, respectively), as was being female (P < .001 for both).

Screening positive for depression was not associated with either type of tanning classification. But hazardous drinking and drug abuse were significantly associated with tanning dependence (P < .001 and P = .036, respectively).

"It may be that some individuals in our sample engage in excessive tanning because of obsessive thoughts about or the compulsion to tan or because tanning is a strategy for relaxation to decrease OCD symptoms," explained Ashrafioun in the release.

However, "if problem tanning is conceptualized as an addictive disorder, obsessions and compulsions…may instead represent craving to tan," he added.

The strongest correlate for the tanning classifications was tanning frequency. The odds ratio (OR) of meeting the screening criteria for problematic tanning was 17.41 for those who tanned at least 9 times in the previous 30 days vs those who tanned fewer than 2 days (95% confidence interval [CI], 7.07 - 42.90; P < .001).

The OR for tanning dependence for those in the highest tanning frequency group vs those in the lowest frequency group was 8.26 (95% CI, 4.44 - 15.35; P < .001).

Overall, "we see this as more potential evidence and firepower for continuing to research the conceptualizing of excessive tanning as an addiction," said Ashrafioun.

"Previously, clinicians educated patients on the harms of tanning, [but] it's probably more than that. Most people know there are harms, but they continue to do it. We need to be more focused on intervention than just telling people it's bad for them," he added.

New Screening Tool

In the same issue of the journal, the investigators published a letter that discussed screens for tanning dependence, and they reported their findings when assessing a tanning adaptation of the Short-Rutgers Alcohol Problem Index, known as the Tanning Problem Index (TPI).

The 11-item TPI was administered online to 414 college students who reported tanning indoors and/or outdoors. Results showed that the participants who screened positive for tanning dependence on the Tanning-DSM had significantly higher scores on the TPI than those who screened negative (P < .001).

In addition, higher TPI scores were significantly linked to greater perceived difficulty in stopping tanning, more frequent past-month tanning, and greater amount of money spent on tanning (all, P < .001). The higher TPI scores were also associated with using sunscreen less frequently (P = .003).

"This appears to be a brief, psychometrically sound instrument that clinicians could administer to assess frequency of tanning-related problems and to potentially enhance motivation to change tanning behaviors," write the researchers.

"Trying to help people, whether they be dermatologists or primary care physicians, to use a screen like this will help them determine if they should assess individuals further," added Ashrafioun.

He reported that the investigators have also just submitted a paper on a craving measure with respect to excessive tanning.

The study authors have reported no relevant financial relationships.

J Am Acad Dermatol. 2014;70:474-480. Abstract

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