Aggression and Its Associations in Patients With Skin Disease

P. Magin


The British Journal of Dermatology. 2017;176(5):1118-1119. 

There has been increasing recognition over the last three decades of the psychological aspects of patients' experience of skin disease.[1,2] This recognition has encompassed both the prevalence of psychological morbidity in patients with skin disease and the impact of this psychological morbidity on patients' well-being and quality of life.[3,4]

Furthermore, there is increasing understanding of the nature of psychological morbidity in patients with skin disease. Much initial research focused on defined psychiatric disorders – especially depression and anxiety disorders. However, increasing evidence is elucidating a far-wider range of psychological constructs in patients with skin disease. This includes embarrassment, shame, anger, aggression, stigmatization, self-esteem, social withdrawal and self-consciousness. What is also being increasingly explored and defined are the complex interrelationships of these psychological morbidities. So, too, have factors exacerbating or attenuating psychological impacts of skin disease and mediating or modulating psychological morbidities' interrelationships been explored. Skin condition location (including visibility), social support, personality traits and patient demographics are among these factors. The effect of disease severity generally has been found to be quite modest.

In this issue of the BJD, Coneo et al. provide a further piece in the complex mosaic of psychodermatology.[5] In a cross-sectional study they recruited 91 dermatology outpatient clinic patients and explored these patients' psychological functioning within a theoretical model of appearance concern. A role for anger and aggression in maladaptive responses to skin disease has been suggested by previous research.[6] Coneo et al. examined the associations of their outcome factor, a measure of aggression, with optimism, social support, social acceptance, social anxiety, appearance-related concerns, depression and anxiety.[5] In their analysis, aggression was found to be significantly associated with lower levels of optimism and lower satisfaction with social support, and with anxiety. The association with lower levels of optimism was particularly strong.

The appraisal of these findings and an assessment of their clinical implications must acknowledge some limitations of the study. The study employed a convenience sample and so the generalizability of the findings to other outpatient dermatology populations is uncertain. Further uncertainty relates to the generalizability of the findings to patients with skin disorders managed in primary care (who constitute the majority of patients with skin disease). The study of a general dermatology population and the modest sample size means that psychological relationships in patients with particular skin conditions are beyond the granularity of this study's data. And, as the authors point out, the associations found in this cross-sectional study indicate a need for examination of possible causal relationships in longitudinal studies.

However, the results are of potential clinical utility. Given the burden of psychological distress in patients with skin disease, provision of interventions to address this distress are vital.[4,7–9] The complexity of the psychological constructs underlying this distress suggests that the characteristics of patients to be included and the primary targets of psychological interventions must be carefully chosen and the balance of psychological content in the interventions carefully constructed.[3,6,10] The study by Coneo et al. suggests aggression, optimism, social support and anxiety (all being amenable to change) are factors to be considered.