LAUSR

This issue of the BJD includes an important paper on the role of attachment style and its influence on how patients cope with skin conditions. There are very few studies on this topic in dermatology and the work by Krasuska et al. on the role of adult attachment and coping offers an interesting contribution. The study describes how the two dimensions of attachment orientation, avoidance and anxiety, can affect adjustment to skin conditions and lead to poorer health outcomes. The authors suggest that people with insecure attachment might benefit from psychological interventions that target underlying attachment orientation. This suggestion about the possible need for psychotherapy may result in challenges for health professionals. Psychologists are aware that underlying attachment issues can greatly influence individuals and their quality of life. However, how can dermatologists become more aware of their patients’ needs? Remember that patients usually appreciate you asking about the impact of their skin condition on their life. Empathetic listening can be very therapeutic. You are not required to ‘cure’ emotional issues; however, you need to be aware of how they are affecting the course of the illness. Once a relationship of trust has been established, it will be easier to suggest a referral to a mental health professional in those cases you consider could benefit from therapy. Patients with insecure attachment styles tend to report a greater number of physical symptoms compared with secure individuals. This is probably because individuals with secure attachment patterns tend to be more competent in regulating affect in stressful situations than people with insecure attachment styles. Attachment insecurity predicts different cortisol patterns, associated with physiological responses to stress, and the release of cortisol influences the metabolic, immune and nervous systems, which play important roles in health and disease. But why has so little attention been paid to attachment in dermatology? Psychological concepts are rarely focused on by dermatologists, but there has been some attention to attachment. Robles et al. examined the association between attachment and skin barrier recovery and found that individual differences in the attachment system are related to the skin’s ability to heal. They demonstrated that elevated cortisol responses to social interactions predict slower skin barrier recovery. Another study of over 3000 dermatology patients across Europe revealed that attachment styles of dermatological patients are predictors of perceived stress. In the group of patients with secure attachment there was a higher percentage of nonstressed patients, compared with the group of patients with insecure attachment. A similar pattern of attachment styles was found in controls. It’s important to remember that bonding and attachment are essential to survival. Babies form attachment relationships with their main carers to protect them against danger and ensure their wellbeing. Securely attached children usually have more effective coping strategies and self-confidence. Early life experiences with caregivers lead to variations in the attachment dimensions of anxiety and avoidance, and as we have seen, this can ultimately affect how we adjust to skin conditions. Krasuska et al. suggest that insecure attachment affects psychological adjustment negatively, which can result in higher appearance-related distress and poorer quality of life. The results of the study link insecure attachment to poorer coping strategies, resulting in poorer outcomes. However, further studies are necessary to look into other types of coping mechanisms that might mediate between attachment and psychological adjustment, as well as with specific skin conditions.