Excessive Tanning: Some Psychopathological Explanations

| June 29, 2010 | 0 Comments


by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2010;7(6):13–17

Funding: There was no funding for the development and writing of this article.

Financial disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words:
sunbathing, sun tanning, tanning, pathological tanning

ABSTRACT

Excessive tanning appears to be evident in about one quarter of regular sunbathers. Susceptible individuals are likely to be young Caucasians from Western societies. Despite ongoing education by the media to the public about the risks of excessive exposure to ultraviolet radiation and the availability of potent sunscreens, there seems to be a concurrent proliferation of tanning facilities. What might be potential psychological explanations for excessive or pathological tanning? Psychopathological explanations may exist on both Axes I and II and include substance use, obsessive-compulsive, body dysmorphic, and borderline personality disorders. While there is no known treatment for pathological sunbathing, we discuss several treatment interventions from the literature that have been successfully used for the general public.

INTRODUCTION

Excessive tanning, either through direct sun exposure or tanning facilities, remains a serious public health concern due to the associated risks of various skin cancers (e.g., malignant melanoma, squamous cell carcinoma). Yet, a substantial percentage of younger Western Caucasians engage in purposeful exposure to ultraviolet radiation. For example, Demko et al[1] determined that among United States adolescents between the ages of 13 and 19 years, 37 percent of Caucasian  girls and 11 percent of Caucasian  boys have been to a tanning facility at least once in their lives, with 28 percent and seven percent, respectively, having used such services on three or more occasions. Jones, Harris, and Chrispin[2] examined United Kingdom college students and found that the majority reported engaging in and enjoying sunbathing. Gordon and Guenther[3] found that the prevalence of tanning-bed use by 10th grade Canadian students was 14 percent. Interestingly, these epidemiological patterns in young Caucasian populations may be transcending to other racial/ethnic groups. For example, Gorell et al[4] found that Asian Americans may be adopting Western cultural beliefs that promote sun exposure.

In conjunction with the preceding epidemiological patterns, tanning facilities are ubiquitous. Hoerster et al[5] examined the density of indoor tanning facilities in 116 United States cities; they found a mean of 42 facilities per city, with 12 facilities per 100,000 persons. Hirst et al[6] described their concerns about the “expanding solarium industry” in Australia and actually calculated the savings in healthcare costs (i.e., reduction in expenditures for the treatment of skin cancers) if these facilities underwent stricter regulation.

In conjunction with the younger population’s interest in “sun time,” the media has genuinely attempted to contribute to the public’s awareness of the risks of excessive exposure to ultraviolet radiation. In this regard, Henneghan et al[7] examined the prevalence of sun-exposure themes in news articles in the New York Times. Between the years 1980 and 2004, the New York Times published 874 articles in this area.[7] The majority focused on malignant melanoma (29%), but other articles addressed sunscreens (11%), tanning (9%), basal cell carcinoma (7%), squamous cell carcinoma (3%), sunbathing (2%), and tanning facilities (2%).

Given the continued interest in sunbathing coupled with an increasing public awareness of risk, one would wonder about the evolving role of sunscreens (i.e., the availability of products with sun protection factor (SPF). In examining the use of sunscreens in the general population, as expected, a number of individuals do not use any type of product. As an example, in a study by Cokkinides et al[8] of more than 1,000 United States adolescents, 31 percent of participants indicated that they did not practice any sun-protective behaviors.

Not surprisingly, sunscreen use may be tempered by a variety of social factors. For example, Mosher and Danoff-Burg[9] found among undergraduates that sunscreen use by participants was associated with sunscreen use by immediate family members. Likewise, Peacey et al[10] found that sunscreen use in young Europeans was higher among the well educated.
With the current availability of more potent sunscreens with remarkably high SPF values (e.g., Neutrogena’s Ultra Sheer Dry-Touch Sunblock with an SPF of 100+), there is substantial empirical data to suggest that the overall result is an intentional increase in exposure to the sun.[11,12] In other words, increases in sunscreen SPF appear to be resulting in greater exposure to ultraviolet radiation by the user. In contrast to this literature, there is one 2005 French study of attendees at four beach resorts who reported no differences in sun exposure in relationship to the degree of sunscreen SPF.[13] However, on closer examination of this study, the lack of sun-exposure differences between the low- and high-SPF groups occurred because the former group applied more sunscreen to extend their sun-exposure time.

To summarize, current evidence indicates that a substantial percentage of young Western Caucasians intentionally sunbathe or frequent tanning facilities. Meanwhile, the media continues to actively highlight to the public the risks of excessive exposure to ultraviolet radiation. Finally, with the increasing availability of more potent sunscreens with remarkably high SPFs, sunbathers may be engaging in even longer exposures to the sun. Overall, these findings suggest that sunbathing is relatively normative behavior, particularly among younger Caucasians, despite the obvious risks.

Pathological Tanning

For the ensuing discussion, our focus will be on the subgroup of individuals who excessively tan—i.e., those with an extreme or pathological version of sunbathing. According to Hillhouse et al,[14] pathological tanning is characterized by opioid-like reactions to tanning, dissatisfaction with natural skin tone, perceiving tanning as a problem, and developing tolerance to the effects of tanning.

As with all behavior, there is a continuum with extremes at either end. The extremes are more likely to harbor various types of psychopathology. In the case of excessive tanning, the most likely types of psychopathology are various Axis I disorders, including substance use disorder (i.e., an addiction), obsessive-compulsive disorder, and body dysmorphic disorder. On Axis II, one possibility is borderline personality disorder. While the genuine prevalence of pathological tanning in the general population is unknown, the following studies have examined small samples of such patients and appear to confirm these possible underlying psychopathologies.

Substance use disorder. A number of authors indicate that excessive tanning may represent an addiction.[15–19] To support this impression, Warthan et al[16] sampled 145 beachgoers with the CAGE20 questionnaire, a measure that is used to assess alcohol use/abuse. These authors found that about one quarter of participants met the criteria for a tanning-based, substance-related disorder. In a second more recent study, Heckman[17] undertook an online survey of 400 young adult participants to explore tanning dependence and found that 27 percent of the sample met study criteria—i.e., very similar findings to Warthan et al. To augment these data, Nolan et al[15] emphasize that excessive tanning truly has a substance-dependent texture, indicated by the excessive use of tanning, use of tanning despite harm, and a knowledge of adverse health consequences that does not deter tanning.

In a more dramatic vein, van Steensel[18] suggests that excessive tanning may be conceptualized as a form of “opiate dependency.” He advises viewing this behavior as addictive and as a bona-fide form of substance abuse. Van Steensel[18] and Nolan et al[15] both suggest the possibility that excessive tanning may precipitate the self-rewarding release of endogenous opioids. In keeping with this theory, Kaur et al[19] found that when administered to regular sunbathers, naloxone induced withdrawal symptoms. As with every addiction, there is the heightened possibility of comorbid borderline personality disorder, based upon the core self-regulation difficulties encountered in this particular Axis II disorder.

Obsessive-compulsive disorder. According to Nolan et al,[15] excessive tanning may represent an obsession, compulsion, or both. In support of this possibility, Leary, Saltzman, and Georges[21] examined 175 adults who were actively sun tanning and found that participants who scored high in both appearance motivation and obsessive-compulsive tendencies spent the most time in the sun, were less likely to use sunscreen, and were more likely to use tanning facilities.

Body dysmorphic disorder. Body dysmorphic disorder, which consists of a distressing and pathological preoccupation with an imagined or slight defect in appearance, is also a diagnostic possibility. While rarely studied from this perspective, Phillips et al[22] examined 200 participants with body dysmorphic disorder with regard to tanning practices. In this sample, 25 percent of participants reported body-dysmorphic-related tanning practices, with most of this subsample being female and single. Among this subsample, 52 percent had sought and received dermatological treatment for body-dysmorphic concerns, usually with little relief. In addition, individuals in this subsample were more likely to compulsively pick their skin (obsessive-compulsive undertones?). While most were Caucasian, a small percentage was Hispanic, Native American, Asian, and Native Alaskan.

Borderline personality disorder. Another psychopathological possibility underlying excessive tanning may be borderline personality disorder. While there are no formal empirical studies, it may be that excessive tanning functions as a self-injury equivalent (i.e., the use of excessive sun exposure to intentionally burn oneself). In the authors’ experience, a small minority of women with eating disorders demonstrates excessive tanning behavior, and a number of these suffer from borderline personality disorder. In the eating-disorder/borderline-personality population, excessive tanning is likely to be mediated by body image difficulties.[23]

The presence of borderline personality may also explain suggestions in the literature that excessive tanning may be associated with impulse control disorders.[15] This association is particularly relevant, given that these disorders are defined by the inability to resist the impulse to perform an action that is harmful to oneself.

Empirical Interventions

We did not encounter any empirical literature on the treatment of excessive or pathological tanning other than the importance of targeting the underlying psychopathology. However, in more normative populations, a number of interventions have been explored to reduce sun exposure. To date, encouraging interventions include providing printed information to adolescents and parents on the risks of excessive sun exposure,[24] imparting feedback to participants that is mediated through consultation with a physician,[25] presenting to participants an ultraviolet photo demonstrating skin damage,[26,27] and enrolling participants in a sun-protection program that incorporates media personalities endorsing paleness.[28]

Conclusion

Both in primary care and psychiatric settings, clinicians encounter patients who engage in excessive or pathological tanning. Current data indicate that about one quarter of sunbathers engage in an excessive degree of exposure. Affected individuals are most likely to be young, Caucasian, and living in Westernized societies. At its extreme, excessive tanning may be associated with various Axis I and II disorders, most commonly substance use disorder (i.e., an addiction), obsessive-compulsive disorder, body dysmorphic disorder, and borderline personality disorder. Effective treatment with these extreme individuals is unknown, but unlikely until the underlying psychopathology is identified and given consideration. At this juncture, identification and treatment of the underlying psychiatric disorder appear to be the most salient avenues of intervention.

References
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Category: Mental Disorders, Past Articles, Primary Care, Psychiatry, The Interface

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