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Phenomenology and psychopathology of excessive indoor tanning Aymeric Petit1, MD, Laurent Karila2, MD, PhD, Florence Chalmin1, PhD, and Michel Lejoyeux1, MD, PhD
1 Department of Psychiatry and Addiction Medicine, Bichat-Claude Bernard Hospital, ^pitaux de Paris Assistance Publique Ho (AP-HP), Paris, France, and 2Addiction Research and Treatment Center, Paul Brousse Hospital, AP-HP, Villejuif, France
Abstract Excessive indoor tanning, defined by the presence of an impulse towards and repetition of tanning that leads to personal distress, has only recently been recognized as a psychiatric disorder. This finding is based on the observations of many dermatologists who report the presence of addictive relationships with tanning salons among their patients despite being given diagnoses of malignant melanoma. This article synthesizes the existing literature on
Correspondence Aymeric Petit, MD Department of Psychiatry and Addiction Medicine Bichat-Claude Bernard Hospital 46 Rue Henri Huchard 75877 Paris Cedex 18, France E-mail: [email protected] Funding: Aymeric PETIT receives consulting fees from Otsuka and Astra Zeneca Pharmaceuticals. Laurent KARILA receives consulting fees from with GM Santé, BMS, Euthérapie, Astra Zeneca, Lundbeck, Gilead, Sanofi Aventis, D & A Pharma, Bouchara-Recordati, and Reckitt Benckiser.
excessive indoor tanning and addiction to investigate possible associations. This review focuses on the prevalence, clinical features, etiology, and treatment of this disorder. A literature review was conducted, using PubMed, Google Scholar, EMBASE and PsycINFO, to identify articles published in English from 1974 to 2013. Excessive indoor tanning may be related to addiction, obsessive-compulsive disorder, impulse control disorder, seasonal affective disorder, anorexia, body dysmorphic disorder, or depression. Excessive indoor tanning can be included in the spectrum of addictive behavior because it has clinical characteristics in common with those of classic addictive disorders. It is frequently associated with anxiety, eating disorders, and tobacco dependence. Further controlled studies are required, especially in clinical psychopathology and neurobiology, to improve our understanding of excessive indoor tanning.
Conflicts of interest: Michel Lejoyeux and Florence Chalmin report no conflict of interest.
Introduction
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Socially valued, tanning, like other forms of behavior, can take on an addictive aspect. This claim is based on the observations of many dermatologists who report an addictive relationship with tanning cabins among their patients, including in those who are given a diagnosis of malignant melanoma. Excessive indoor tanning has been described from the early 2000s. Warthan et al.1 were the first to propose a theoretical framework for the diagnosis and assessment of the degree of addiction. Recently, Zillhouse et al.2 proposed the Structured Interview for Tanning Abuse and Dependence (SITAD) for exploring tanning dependence. These diagnostic criteria refer to symptoms such as craving, the feeling of loss of control, and the continuing of the behavior despite the knowledge International Journal of Dermatology 2014, 53, 664–672
of negative consequences. An equivalent of withdrawal can be identified when tanners experience anxiety and negative feelings if they cannot tan as they feel they need to. However, excessive indoor tanning has not yet been recognized as a diagnostic category in either the World Health Organization’s International Classification of Diseases (ICD-10) or the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, 4th edn, Revised (DSM-IV-R). Excessive indoor tanning is a complicated phenomenon that is not easily defined. There is currently no consensus on the definition of the concept nor any recommendations on the therapeutic management of this disorder. The purpose of this review is to synthesize the existing literature on excessive indoor tanning in order to investigate possible associations and to identify what constitutes dependence ª 2014 The International Society of Dermatology
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in order to include excessive indoor tanning in the spectrum of behavioral addiction. This review focuses on the prevalence, clinical features, etiology, and treatment of this disorder. We investigate different models to determine how excessive tanning behaviors meet these criteria. Definition and diagnosis
Excessive indoor tanning was first described in the 2000s but has not yet been recognized as a diagnostic category in either ICD-10 or DSM-IV-R.3 There is currently no consensus on the definition of the concept. We propose to apply the DSM-IV Text Revision (DSM-IV-TR) diagnostic criteria for dependence to distinguish excessive indoor tanning from normal exposure to the sun. Excessive indoor tanning leads to clinically significant impairment or distress, as manifested by: (i) loss of control of indoor tanning activity; (ii) repeated failure to resist the urge to tan in salons; (iii) a psychological sense of tension prior to a sense of relief at the waning of the desire to tan; and (iv) the spending of an excessive amount of time in tanning salons. Excessive tanners spend a great deal of time obtaining, using, or recovering from tanning. Excessive indoor tanning is always taken in larger amounts or over a longer period than intended. Tanning becomes a priority in the subject’s life, in which the time spent on concerns related to tanning lengthens to the detriment of the individual’s social and professional life. For example, individuals may absent themselves from social engagements, work, school, or recreational activities in order to visit a tanning salon, thus initiating trouble at work or with family or friends. Tolerance is defined as the need to spend more and more time on a tanning bed in order to maintain the tan, either through a need to significantly increase the degree of tanning to achieve the desired effect or because the individual perceives the continued practice of the same amount of tanning to produce a diminished effect. An equivalent of withdrawal can be identified when tanners experience anxiety and negative feelings if they cannot tan in salons as they feel they need to. Conflicts arise when social, occupational, or recreational activities are abandoned in favor of indoor tanning. Continuance occurs when indoor tanning is continued despite the subject’s knowledge of the increase in the social, psychological, and physical problems (i.e. skin cancer, sunburn) that result from this practice. In order to be categorized as tanning-dependent, a person is required to meet three or more of these criteria.2 A diagnosis of tanning abuse is determined if the subject does not meet at least three of the criteria for tanning dependence but instead demonstrates one (or more) of the following behaviors: (i) recurrent tanning resulting in
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the failure to fulfill major role obligations at work, school, or home; (ii) recurrent tanning that is physically hazardous; and (iii) continued tanning despite persistent or recurrent social or interpersonal problems that are caused or exacerbated by the behavior. These diagnostic criteria allow us to distinguish among tanning dependence, tanning abuse, and normal behavior in relation to exposure to the sun. To evaluate an individual’s potential dependence on ultraviolet light (UVL) tanning, Warthan et al.1 modified two assessment tools widely used to identify substancerelated disorders (SRDs): the CAGE (cut down, annoyed, guilty, eye-opener) Questionnaire, which consists of four questions used for screening for alcoholism,4 and the APAs DSM-IV, Text Revision (DSMIV-TR),5 which outlines seven diagnostic criteria for SRD. Two or more affirmative responses to questions on the modified DSM-IV-TR (m-DSM-IV-TR) during the same 12-month period were tabulated as evidence for UVL tanning dependence. Materials and methods We conducted a literature review using PubMed, Google Scholar, EMBASE, and PsycINFO, using the following keywords alone or in combination: tanning; addiction; sunbeds; ultraviolet radiation; skin cancer; prevention; and treatment. We selected English-language articles published from 1974 to 2013, inclusive. Results Excessive indoor tanning may be related to addiction, obsessive-compulsive disorder, impulse control disorders, seasonal affective disorder, anorexia, body dysmorphic disorder, and depression. The study by Warthan et al.1 represented the first such demonstrative study. In it, the authors interviewed 145 tanning adepts on a Texas beach.1 The same two questionnaires were subsequently used to interview 375 Seattle students aged 17–30 years,6 421 northeast US students,7 100 people who attended tanning salon sessions in Dallas frequently and on a regular basis,8 and 400 volunteers from a Virginia university,3 with comparable results. Recently, the SITAD demonstrated some evidence of validity, with tanning-dependent participants reporting regular indoor tanning and higher indoor tanning frequency.2 The SITAD is a new tanning dependence assessment based on opioid use items2 adapted from the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID).9
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Epidemiology
Prevalence Very few studies have assessed the prevalence of excessive indoor tanning in the general population. Using these scales, Warthan et al. found that in a sample of 145 Texas beachgoers, 26% met the modified CAGE criteria and 53% met the modified DSM-IV-TR criteria for tanning dependence.1 Screening surveys suggest that approximately 70% of people who undergo frequent indoor tanning8 (defined as attendance at > 40 tanning sessions per year) meet a tanning-modified version of the CAGE criteria for alcohol dependence or the m-DSM-IV criteria for a substance abuse or dependence disorder.10 However, these epidemiology studies raise some reservations concerning the methodology used (the relevance of the two scales) and the relatively small groups of subjects investigated. Demographic and socioeconomic characteristics Zeller et al.11 reported the mean age of subjects who engaged in excessive indoor tanning to lie between 17 years and 30 years. The mean age of initiation was 14.7 years.11 Elsewhere, 81.2% of subjects indicated that their tanning bed use began at 13–17 years of age.8 A sex difference has been identified: female adolescents have been found to be 5.3 times12 or 6.2 times1 more likely than male teens to have tanned indoors in the last year. Studies show women are more likely to be addicted, with the greatest tendencies occurring among women of White European ethnicity aged 16–49 years, and peaking in women in their teens and 20s.10,11 This phenomenon was found among socio-professional categories with the lowest incomes.11 Heckman et al.3 observed that a lower level of education was significantly associated with excessive indoor tanning. A correlation between employment status and excessive indoor tanning has been identified.13 Individuals of skin phototypes III and IV are the most commonly represented.3 Comorbidity Mosher and Danoff-Burg7 reported that patients who undergo excessive indoor tanning have a history of anxiety disorders (50%) and substance abuse or dependence significantly more often than control group subjects. Similar findings have been reported elsewhere with reference to alcohol (18%,3 91.7%1), tobacco (16%,3 35.8%14), and cannabis (33.3%5) use. However, studies do not show any link between excessive indoor tanning and consumption of cocaine or amphetamines.1–7 Depressive symptoms did not vary significantly according to indoor tanning addiction status.6 A study of female undergraduate students reported that 80% of frequent tanners (individuals International Journal of Dermatology 2014, 53, 664–672
attending > 40 tanning sessions per year) had seasonal affective disorder (SAD) or sub-syndromal seasonal affective disorder (s-SAD).15 The investigators suggested that tanners use tanning beds for their mood-enhancing effects as bright light therapy, the most common treatment for SAD. It might be expected that excessive indoor tanning will be associated with other health-related variables such as weight and exercise.3 Demko et al. found that eating disorders (in dieters) that tend towards anorexia and exercise dependence (in individual sports such as running and fitness regimens but not in team sports or martial arts) are frequently associated with tanning dependence.16 Dieters or exercisers might be expected to tan more often because they are concerned about their appearance.17,18 Cokkinides et al. observed a significant relationship between excessive indoor tanning and a family history of tanning.18 Adolescents’ perceptions of whether or not their parents will allow them to tan indoors emerged as the strongest predictor of teen tanning in a multivariate model, with modeling, parental cognitions (both gatekeeping and non-gatekeeping), and peer factors also showing associations but to a lesser degree.12 Adolescents who said that their parents would allow them to tan indoors were 5.6 times more likely to have tanned indoors.12 Etiology
Addiction According to DSM-IV,5 dependence is diagnosed by the presence of three (or more) of the following symptoms in a 12-month period: loss of control; tolerance; withdrawal; use of the substance in greater quantity or for a longer duration than intended; repeated or unsuccessful efforts to decrease substance use; the inappropriate or excessive allocation of time to obtaining the substance or to removing the effects of the substance; the reduction of social, occupational, or recreational activities as a result of substance use; and the use of the substance despite knowledge of adverse health consequences (i.e. [in tanning] the development of melanoma, basal and squamous cell carcinomas). Tanning bed use has been linked with numerous adverse health effects, such as acute sunburn, photoinduced reactions to medications, polymorphous light eruption, atypical melanocytic lesions, skin fragility and blistering, the suppression of cutaneous DNA repair and immune function, and ocular disorders. We have been exploring the idea that some indoor tanners exhibit dependence-like behaviors, such as tanning obsessions, physical and psychological tolerance (a form of tolerance to UVL that is beyond the level the skin can withstand, analogous to tolerance in individuals who conª 2014 The International Society of Dermatology
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sume dangerous amounts of alcohol or opioids in order to experience the effects of reward that others experience at much lower doses), and loss of control. These are consequences of tanning that parallel the endogenous effects of opioid use and demonstrate cognitions that reflect dissatisfaction with the subject’s own skin color. One of the most revealing studies is a recent survey which investigated college students’ perceptions regarding indoor tanning and the adverse effects associated with exposure to artificial UVL.19 An overwhelming majority of past (93%) and current (91%) tanners believed that skin cancer was a possible consequence of the use of tanning beds.19 Another study revealed that almost half of tanners consider radiation generated by sunbeds to be somewhat dangerous.20 A survey study carried out to determine whether excessive indoor tanning leads to dependence revealed that factors related to other addictive behaviors, such as age of initiation and frequency of use, correlated with difficulty in quitting tanning.11 A few other studies have noted associations and similarities between excessive indoor tanning and substance use.1,4,16 Demko et al. found that among 6903 nationally representative Caucasian adolescents, those who used two or three substances were three times more likely to be excessive indoor tanners than others.16 Several other studies have found relationships between excessive tanning and substance use such as cigarette smoking.1–3 In a double-blind controlled study, Kaur et al. compared two cohorts of 16 volunteers aged 18–34 years, of whom eight regularly attended tanning sessions (eight to 15 times per month) and eight rarely attended tanning sessions (fewer than 12 sessions per year).21 Each group was randomly submitted to a radiation charged with either white light or UVL. Occasional tanners distinguished no difference between the two types of ray, whereas frequent tanners described a preference for UVL. The administration of an opioid receptor antagonist, naltrexone, triggered withdrawal symptoms among half of the frequent tanners and no symptoms among the occasional tanners.21 These results show that excessive indoor tanning can implicate neurobiological circuits in a manner similar to that in other addictions so that withdrawal symptoms occur under the effect of an opioid receptor antagonist. This study21 represents the only attempt to date to go beyond descriptive aspects to suggest a neurobiological explanation for excessive indoor tanning behavior. It was, however, based upon a very small sample, and the mechanism remains hypothetical. Two other studies have failed to demonstrate this effect.22,23 A recent trial suggested that tanning has reinforcing properties.22 Another recent study used a doubleblind controlled trial design to determine whether a ª 2014 The International Society of Dermatology
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physiological preference for UVL compared with nonUVL exists.24 Frequent tanners were found to exhibit an overwhelming preference (95%) for UV-emitting tanning beds, suggesting that UV tanning might have reinforcing properties.24 In a double-blind controlled study, Feldman and associates found that UVL induced cutaneous endorphin production in frequent indoor tanners.24 Follow-up studies have shown withdrawal symptoms in frequent tanners to whom naltrexone was administered, supporting this physiological hypothesis.24,25 This evidence of a physiological basis for pathological tanning is supported by studies demonstrating that UV radiation (UVR) induction of pigmentation results in the secretion of a-melanocytestimulating hormone, a cleavage product of the prohormone peptide pro-opiomelanocortin (POMC).26 Recent studies involving the role of tumor-suppressor protein p53 in the secretion of a-melanocyte-stimulating hormone and POMC provide a potential biochemical mechanism for tanning dependence. Ultraviolet light-induced p53 expression stimulates the POMC promoter, thus increasing two levels of POMC derivates: the endogenous opioids, b-endorphins, and adrenocorticotrophic hormone (ACTH).27 These molecules may contribute to tanning behavior by exerting an anti-inflammatory effect, thus alleviating the irritation and local inflammation associated with exposure to UVL. In addition, b-endorphins exert analgesic effects and promote feelings of relaxation and well-being. The respective anti-inflammatory and analgesic properties of these endogenous steroid and opioid byproducts of POMC are thought to translate into the relief from pain and irritation in the skin associated with UVL. Ultraviolet radiation is also a well-known inducer of dermal immune suppression and is used to treat patients with overactive dermal immune activity, such as those with psoriasis.28 Other studies demonstrate that UVL tanning relieves pain.24 The accumulated evidence suggests that there may be a physiological basis, in the form of dependence on opioids, for excessive indoor tanning behaviors.25 Obsessive-compulsive disorder In some circumstances, tanning practices may represent a form of obsessive-compulsive disorder (OCD).29 Patients with uncontrolled indoor tanning behavior described recurrent, intrusive thoughts and irresistible urges or impulses to tan that resembled obsessions. Indoor tanning impulses may occupy center stage and become intensely preoccupying in the form of a constant desire to tan or a continual search for a place to sunbathe.29 Uncontrolled indoor tanning may result from an obsessive desire to be thin and a compulsion to expose to the sun. Two-thirds of subjects described having at least some urges or thoughts International Journal of Dermatology 2014, 53, 664–672
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about tanning which they referred to as intrusive.29 Tanning itself resembled a compulsion in that it was a repetitive behavior performed in response to an urge and in an attempt to reduce the anxiety related to the obsession, or to neutralize uncomfortable feelings. Tanning may be accompanied by a feeling of constraint, in which the defensive function is clearly apparent.29 The same study found that 82% of uncontrolled indoor tanners report having made attempts to resist tanning (by avoiding tanning salons).29 However, in most cases, attempts to resist were unsuccessful and an urge to tan was followed by eventual submission.29 The diagnostic criteria for OCD require the presence of either obsessions or compulsions or both. Similarly, some patients present tanning impulses (obsessions) or excessive tanning (compulsions) or both. These are responsible for actions recognized as irrational, repeated, and pervasive by the person.29 Impulse control disorders Excessive indoor tanning can also be considered within the realm of impulse control disorders.5 Individuals with impulse control disorders suffer from an inability to resist the impulse to perform an action that is harmful to themselves or others.5 Seasonal affective disorder Seasonal affective disorder refers to a pattern of major depressive episodes that occur in conjunction with the changes of seasons. The most common form of SAD is the autumn-onset or winter depression type, which is treated with light therapy.30 Recent studies investigating the relationship between excessive indoor tanning and affective disorders have demonstrated a positive relationship between excessive indoor tanning and SAD symptoms. These individuals may be utilizing indoor tanning for its mood-enhancing properties, and thus such tanning might perhaps be viewed as a form of self-medication.31 The presence of SAD was assessed with the Seasonal Pattern Assessment Questionnaire used to screen for such individuals.31,32 In this instrument, respondents rate six critical items (sleep length, mood, social activity, weight, energy, and appetite) according to the degree of change affected by the season on a scale of 0 (no change) to 4 (extremely marked change). The total score represents a scale of 0–24 with which to screen for depressive seasonal symptoms, which can be used to categorize individuals as having SAD, sub-syndromal SAD, or no symptoms of SAD. The Global Seasonality Score has good internal consistency33 and good test–retest reliability and factor structure.34 Anorexia and lack of positive self-image We expected individuals of low to average weight to be at greater risk for excessive indoor tanning than overInternational Journal of Dermatology 2014, 53, 664–672
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weight or obese persons. It is likely that obese individuals are more concerned about their weight than about having tanned skin and may not feel comfortable in exposing their bodies in the manner necessary to receive high levels of UVR. Individuals with anorexia are known to exhibit undue concern about a defect in appearance and to possess a distorted image of their own body because of the way in which they interpret their appearance. In anorexia, the control of calorie intake is a repeated behavior that is conducted with the purpose of fulfilling a goal, and thus this control itself is not the source of pleasure. This aspect of anorexia distinguishes it from the model in which the addictive behavior is repeated as a source of pleasure. The initial pleasure gained from tanning is in opposition to the self-restrictive behavior that occurs in anorexia. Moreover, health represents an issue of increasing concern in contemporary society. In this context, skin that appears to have been made coppery by the sun is perceived as bearing witness to a healthy body, whereas pale skin is considered to express anemia, depression, or illness. The subject uses the tan as a window into a healthy lifestyle and thereby to purvey an image of good health. Fashion and advertising constantly convey esthetic concerns about weight. In this context, the individual is persuaded that he or she should be thin, beautiful, and tanned, that these characteristics can be maintained through sport, diet, and tanning, and that their fulfillment promises personal and social development. This seductive dynamic, which includes exposure to the sun, is part of a modern quest for the ideal physique which is to be achieved by weight control through the application of a strict diet in which the individual may demonstrate behavior close to anorexic, and the practice of intensive and repeated sporting activity. This type of sport (running, fitness, and body toning) does not stretch the body properly. It is practiced out of the fear of becoming fat and the failure to maintain a beautiful plastic appearance. According to current and widely disseminated standards of beauty, tanning makes the individual more beautiful and attractive. In a survey conducted by Boldeman et al.35, sunbed use was found to be significantly correlated with low self-perceived physical attractiveness. Fiala et al. suggested that by helping sunbed users to achieve their ideal of beauty, the possession of a tanned skin enables individuals to devalue other people and thus possibly to protect themselves from close relationships.36 They point out that the goal of sun-worshippers seems to be to look attractive and to give an outward impression of health, without in fact leading a truly healthy life, and that in addition to social attractiveness, a tan raises the subject’s self-esteem, even if this is at the cost of his or ª 2014 The International Society of Dermatology
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her health.36 However, in some cases, these attempts at seduction are not thought to be intended to create a more fulfilling love life but instead to regain self-esteem by reinforcing the certainty that others will be attracted to one. The majority of sunbed users consider an improved appearance to be a positive effect associated with the use of tanning beds.20 Furthermore, almost 60% of frequent tanners consider relaxation to be a positive effect of the use of tanning beds; this may be predominantly attributable to their warmth and the relaxation to be derived from lying down and closing the eyes.20 Individuals who engage in intensive tanning are able to derive a positive image of themselves through the receipt of remarks such as “You look well” and “You are glowing.” The assumed admiration and envy conveyed by such comments reinforce the practice that has provoked them. Thus, intensive tanning behavior is perceived to increase positive interactions with other people. This initial enjoyment in the behavior may subsequently give way to anguish caused by anxiety about failing to maintain this image and losing the power of attraction. It is here that the psychological suffering that will lead the individual into pathological behavior begins. In this context, excessive indoor tanning reflects a lack of positive self-image and self-esteem. Just as the anorexic sees himself as obese in the mirror, the indoor tanner perceives herself to be as white as a turnip, despite an increasingly tanned skin. This image reflected by the mirror is unbearable and may cause great mental suffering. Dependence is based on the desire or obsession to have a perfect tan. Many excessive indoor tanners multiply the number of tanning sessions they engage in to increase their level of tan in order to restore their positive image of themselves. Body dysmorphic disorder For a certain subset of individuals who tan, excessive indoor tanning may reflect a form of body dysmorphic disorder (BDD).37 According to DSM-IV-TR, BDD is defined by a preoccupation with a perceived defect in appearance which causes significant distress or impairment.5 These individuals may be motivated to darken their skin color because they are preoccupied with an imagined defect in appearance.37 They believe they look ugly, deformed, or disfigured, when in reality they look normal.37 Preoccupations with appearance most often focus on perceived defects of the skin (acne or scarring), hair (hair loss), or nose.38,39 Phillips et al. assessed the prevalence of BDD-related indoor tanning in 200 individuals with BDD, as well as the clinical features of BDD in tanning subjects.17 Indoor tanning related to BDD was defined as any behavior that involved darkening one’s ª 2014 The International Society of Dermatology
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skin color by direct exposure to sunlight or artificial light. This behavior must have been motivated by a desire to alter or improve a perceived appearance defect.17 The study found that 25% of subjects engaged in BDD-related indoor tanning and that for 84% of these individuals, the skin was the most common area of preoccupation,40 and that primary aspects of concern included acne, scarring, other marks, and skin color.17 Individuals tan to diminish the appearance of non-existent or slight acne and blemishes, to darken pale skin, and to make uneven or blotchy skin a more homogeneous color. Some patients tan to diminish the appearance of wrinkles, as did one of our own study subjects, who reported tanning for 2–3 hours per day in order to obscure facial lines.17 Although we did not systematically determine why our study subjects tanned, some reported that they used tanning as a type of camouflage. Patients may also tan to minimize the appearance of perceived cellulite, to make body areas (body size or stomach) appear smaller, or to distract people from looking at ugly body areas.17 These findings offer an alternative explanation for the motivation for indoor tanning and behavior in some individuals. Outcome expectancy refers to the belief that a given behavior will lead to a certain positive outcome. The development of expectancy networks is unconscious and automated and can be viewed as contributing to the loss of control, experience of craving, and difficulty in quitting associated with drug dependence. Depression Negative emotions, especially sadness, frustration, and irritation, increase a tanner’s propensity to tan.1–3 Excessive indoor tanning can be used as a mechanism by which to escape from depressive feelings. The main link between excessive indoor tanning and depression may be low selfesteem. Individuals who feel empty and sad tan compulsively in an attempt to restore a depleted self and to increase their sense of well-being. Usually, indoor tanning is associated with positive emotions, such as happiness and feelings of relaxation. Ultraviolet light may help individuals to cope by enhancing positive affect, diminishing negative affect (anxiety, stress), providing distraction or escape, and increasing performance. Treatment
The provision of information on the dangers of exposure to UVL has not been found to alter the propensity of people with paler skin for engaging in indoor tanning. We hypothesized that interventions on the risks of excessive indoor tanning in no circumstance represented an assured way of modifying tanning practices and that the most informed people were often those who adopted the International Journal of Dermatology 2014, 53, 664–672
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most risky behavior.41 There is no specific recommendation concerning the support of these patients. The administration of medications that block the effects of endogenous endorphins, such as naltrexone, to treat excessive and addictive indoor tanning behaviors is promising but requires further research.8–10 We were unable to find any studies on the benefits of chemotherapy in the literature. Future pharmacologic interventions may offer options to compulsive tanners. Given the correlation between tanning and SAD, medications that increase levels of serotonin and norepinephrine, which are effective for SAD patients, may help frequent tanners.10 When present, psychiatric comorbidities may represent a motive for consultation among some frequent tanners. The existence of anxiety disorders is associated with a higher demand for healing and psychotropic prescriptions. The use of tanning creams constitutes one method through which frequent tanners can be helped to maintain the tan on which their equilibrium depends, but it fails to achieve the relaxing effects derived from the process of indoor tanning. Subsequent research should further explore motivations for tanning and develop interventions that might target individuals prior to the age of 17 years. Such interventions should reduce the importance placed on appearance in general and, specifically, that placed on tanning as enhancing the individual’s appearance.1–42 To our knowledge, no such interventions have been initiated in France. Interventions may benefit from the adoption of approaches that integrate the treatment of body dissatisfaction and subsequent maladaptive behaviors.42 The recognition of excessive indoor tanning as a potential SRD has implications for future strategies to prevent and decrease excessive indoor tanning. Although education has long been used to inform individuals about the dangers of exposure to UVR, it seems likely that additional measures are required for that subset of the population which meets the criteria for excessive indoor tanning. Tailored interventions may address individual motivations for tanning and their relation to maladaptive behavior, such as dissatisfaction with appearance or need for relaxation because of anxiety.31 Most of the recent literature suggests that its effect on appearance is the primary motivation for indoor tanning.1–3 It is thus of little wonder that educational interventions focusing on skin safety and cancer awareness have fallen short in terms of changing actual tanning behavior.1,3,11 One educational intervention based on appearance was successful in decreasing indoor tanning in female college students.43 These findings may also suggest that people’s UVR protective behaviors may be modified more effectively by focusing on the appearance-based, rather than cancerrelated, effects of UVR exposure.12 International Journal of Dermatology 2014, 53, 664–672
The parents of adolescents represent an important population for the targeting of primary prevention of skin cancer as they are able to influence their adolescent children by promoting healthy attitudes towards and practices in UVR exposure. Primary prevention campaigns on sun protection in children should be aimed at parents, not only because parents can control the degree to which young children are exposed to sunlight but also because they serve as an example to adolescents.44,45 However, to our knowledge, there have been no primary prevention campaigns related to sunlight exposure in children in France. The International Agency for Research on Cancer (IARC) has recently reclassified tanning devices into the highest cancer risk category: carcinogenic to humans.28 Strong positions against indoor tanning have been taken by the US National Institutes of Health and the American Cancer Society.46–48 The American Academy of Dermatology has recommended banning the non-medical use of indoor tanning booths and, as an interim measure, prohibiting the use of tanning booths by minors.49 Conclusions The issue of excessive indoor tanning illustrates how the concept of addiction applies to an increasing variety of behaviors considered as dangerous. We think there are indices in favor of an addictive dimension in the search for excessive tanning among some people: their behavior leads to a strong sensation of pleasure and is at the origin of feelings of loss of control and psychological suffering. However, the methodologies of the studies reviewed in the current paper lead us to emit some reservations based on the small sample sizes used in the studies, the many recruitment and selection biases, the supposed validity of the diagnostic scales (modified CAGE, DSM-IV, SITAD), the pertinence of some of the questions asked (modified CAGE, modified DSM-IV, SITAD), and the absence of questions concerning withdrawal symptoms. There is no current reference standard for diagnosing tanning dependence.2 These results need to be replicated in a larger, broader, and more representative sample. They should also be investigated with reference to outdoor tanning behavior. Current psychiatric nosology does not recognize this disorder as a clinical entity, and thus there are no recommendations for the treatment of excessive tanners. However, the concept of addiction is increasingly accepted by the public at large and is consensual among health professionals. We consider that excessive indoor tanning can be included in the spectrum of addictive behaviors because it holds clinical characteristics in common with classic addictive disorders. These provide a variety of other models, which may offer an explanation for or insight into ª 2014 The International Society of Dermatology
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excessive indoor tanning behavior. Excessive indoor tanning is frequently associated with the presence of anxiety, eating disorders, and tobacco dependence. Thus, excessive indoor tanning behaviors can be evaluated in a similar manner to the behaviors associated with close but distinct concepts such as impulse control disorders, BDD, OCD, and eating disorders, all of which are recognized and described by the APA in DSM-IV-TR. It is important to note that not all tanning behavior or even frequent tanning behavior should be seen as indicative of tanning dependence. More qualitative research approaches exploring indoor tanning behavior and its psychopathological and neurobiological aspects are necessary to improve our understanding of the phenomenon and the treatment of people who engage in it. References 1 Warthan M, Uchida T, Wagner R. UV light tanning as a type of substance-related disorder. Arch Dermatol 2005; 141: 963–966. 2 Hillhouse JJ, Baker MJ, Turrisi R, et al. Evaluating a measure of tanning abuse and dependence. Arch Dermatol 2012; 148: 815–819. 3 Heckman CJ, Egleston BL, Wilson DB, et al. A preliminary investigation of the predictors of tanning dependence. Am J Health Behav 2008; 32: 451–464. 4 Mayfield D, McLeod G, Hall P. The CAGE Questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974; 131: 1121–1123. 5 American Psychiatric Association, Task Force on DSM IV. Diagnosis and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, DC: APA Task Force on DSM-IV, 2000. 6 Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007; 56: 375–379. 7 Mosher CE, Danoff-Burg S. Addiction to indoor tanning. Arch Dermatol 2010; 146: 412–417. 8 Harrington CR, Beswick TC, Leitenberger J, et al. Addictive-like behaviors to ultraviolet light among frequent indoor tanners. Clin Exp Dermatol 2010; 36: 33–38. 9 First M, Spitzer R, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). New York, NY: New York State Psychiatric Institute Biometrics Research Department, 1995. 10 Kourosh AS, Harrington CR, Adinoff B. Tanning as a behavioral addiction. Am J Drug Alcohol Abuse 2010; 36: 284–290. 11 Zeller S, Lazovich D, Forster J, et al. Do adolescent indoor tanners exhibit dependency? J Am Acad Dermatol 2006; 54: 589–596. 12 Hoerster K, Mayer P, Woodruff S. The influence of parents and peers on adolescent indoor tanning behavior: findings from a multi-city sample. J Am Acad Dermatol 2007; 57: 990–997. ª 2014 The International Society of Dermatology
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13 Diehl K, Litaker D, Greinert R, et al. The prevalence of current sunbed use and user characteristics: the SUN-STUDY 2008. Int J Public Health 2010; 55: 513–516. 14 Mahler HI, Hulik JA, Harrell J, et al. Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors. Arch Dermatol 2005; 141: 373–380. 15 Neinstein LJM, Shapiro J. Psychological development in normal adolescents. In: Health Adolescent Care: a Practical Guide. Baltimore, MD: Williams & Wilkins, 1996: 42–44. 16 Demko CA, Borawski EA, Debanne SM, et al. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med 2003; 157: 854–860. 17 Phillips KA, Conroy M, Dufresne RG, et al. Tanning in body dysmorphic disorder. Psychiatr Q 2006; 77: 129–138. 18 Cokkinides V, Bandi P, Weinstock M, et al. Sunburns, sun protection and indoor tanning behaviors, and attitudes regarding sun protection benefits and tan appeal among parents of US adolescents – 1998 compared to 2004. Pediatr Dermatol 2010; 27: 9–18. 19 Knight JM, Kirincich AN, Farmer ER, et al. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol 2002; 138: 1311–1315. 20 Dissel M, Rotterdam S, Altmeyer P, et al. Indoor tanning in north Rhine–Westphalia Germany: a self-reported survey. Photodermatol Photoimmunol Photomed 2009; 25: 94–100. 21 Kaur M, Liguori A, Fleisher AB, et al. Side effects of naltrexone observed in frequent tanners: could frequent tanners have ultraviolet-induced high opiod levels? J Am Acad Dermatol 2005; 52: 916. 22 Gamblicher T, Barder A, Vojvodic M, et al. Plasma levels of opioid peptides after sunbed exposures. Br J Dermatol 2002; 147: 1207–1211. 23 Wintzen M, Ostijn DM, Polderman MC, et al. Total body exposure to ultraviolet radiation does not influence plasma levels of immunoreactive beta-endorphin in man. Photodermatol Photoimmunol Photomed 2001; 17: 256–260. 24 Feldman SR, Liguori A, Kucenic M, et al. Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004; 51: 45–51. 25 Kaur M, Liguori A, Lang W, et al. Introduction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006; 54: 709–711. 26 Cui R, Wildlund H, Feige E, et al. Central role of p53 in the suntan response and pathologic hyperpigmentation. Cell 2007; 128: 853–864. 27 Van Steensel MA. UV addiction: a form of opiate dependency Arch Dermatol 2009; 145: 211. 28 Brady MS. Public health and the tanning bed controversy. J Clin Oncol 2012; 30: 1571–1573.
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29 Nolan B, Taylor S, Liguori A, et al. Tanning as an addictive behavior: a literature review. Photodermatol Photoimmunol Photomed 2009; 25: 12–19. 30 Saeed SA, Bruce TJ. Seasonal affective disorders. Am Fam Physician 1998; 57: 1340–1346. 31 Hillhouse J, Stapleton J, Turrisi R. Association of frequent indoor UV tanning with seasonal affective disorder. Arch Dermatol 2005; 151: 485–491. 32 Kasper S, Wehr TA, Bartko JJ, et al. Epidemiological findings of seasonal changes in mood and behavior: a telephone survey of Montgomery County Maryland. Arch Gen Psychiatry 1989; 46: 823–833. 33 Magnusson A. Validation of the Seasonal Pattern Assessment Questionnaire (SPAQ). J Affect Disord 1996; 40: 121–129. 34 Young M. Integrating psychological and physiological mechanisms of SAD: the dual-vulnerability model. Biol Rhythms Bull 1999; 1: 4–6. 35 Boldeman C, Jansson B, Nilsson B, et al. Sunbed use in Swedish urban adolescents related to behavioral characteristics. Prev Med 1997; 26: 114–119. 36 Fiala B, Kopp M, Gunther V. Why do young women use sunbeds? A comparative psychological study. Br J Dermatol 1997; 137: 950–954. 37 Phillips KA. Body dysmorphic disorder. In: Phillips KA, ed. Somatoform and Factitious Disorders. [Review of Psychiatry Series, Vol. 20, No. 3; Oldham JM, Riba MB, series eds.] Washington, DC: American Psychiatric Publishing, 2001. 38 Hollander E, Cohen LJ, Simeon D. Body dysmorphic disorder. Psychiatric Annals 1993; 23: 359–364. 39 Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder: a survey of fifty cases. Br J Pyschiatry 1996; 169: 196–201.
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40 Hunter-Yates J, Dufresne RG Jr, Phillips KA, et al. Tanning in body dysmorphic disorder. J Am Acad Dermatol 2007; 56(Suppl.): 107–109. 41 Lake JR, Thomson CS, Twelves CJ, Davies EA. A qualitative investigation of the motivations, experiences and views of female users under the age of 18 in England. J Public Health (Oxf) 2013; 30. 42 Blashill AJ. Psychosocial correlates of frequent indoor tanning among adolescent boys. Body Image 2013; 10: 259–262. 43 Hillhouse JJ, Turrisi R. Examination of the efficacy of an appearance-focused intervention to reduce UV exposure. J Behav Med 2002; 25: 395–400. 44 Grob JJ, Guglielmina C, Gourvenet J, et al. Study of sunbathing habits in children and adolescents: application to the prevention of melanoma. Dermatology 1993; 186: 94–98. 45 Geller A, Colditz G, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics 2002; 109: 1009–1014. 46 Zhang M, Qureshi AA, Geller AC, et al. Use of tanning beds and incidence of skin cancer. J Clin Oncol 2012; 30: 1588–1593. 47 West SE, Martin KL, Ailor SK. Tanning themselves to death: a new teen fad. Mo Med 2012; 109: 166–170. 48 Lostritto K, Ferrucci LM, Cartmel B, et al. Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates. BMC Public Health 2012; 12: 118. 49 American Academy of Dermatology. Position statement on indoor tanning. http://www.aadassociation.org/Policy/ tanning.html [accessed 30 November 2004].
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Phenomenology and psychopathology of excessive indoor tanning Aymeric Petit1, MD, Laurent Karila2, MD, PhD, Florence Chalmin1, PhD, and Michel Lejoyeux1, MD, PhD
1 Department of Psychiatry and Addiction Medicine, Bichat-Claude Bernard Hospital, ^pitaux de Paris Assistance Publique Ho (AP-HP), Paris, France, and 2Addiction Research and Treatment Center, Paul Brousse Hospital, AP-HP, Villejuif, France
Abstract Excessive indoor tanning, defined by the presence of an impulse towards and repetition of tanning that leads to personal distress, has only recently been recognized as a psychiatric disorder. This finding is based on the observations of many dermatologists who report the presence of addictive relationships with tanning salons among their patients despite being given diagnoses of malignant melanoma. This article synthesizes the existing literature on
Correspondence Aymeric Petit, MD Department of Psychiatry and Addiction Medicine Bichat-Claude Bernard Hospital 46 Rue Henri Huchard 75877 Paris Cedex 18, France E-mail: [email protected] Funding: Aymeric PETIT receives consulting fees from Otsuka and Astra Zeneca Pharmaceuticals. Laurent KARILA receives consulting fees from with GM Santé, BMS, Euthérapie, Astra Zeneca, Lundbeck, Gilead, Sanofi Aventis, D & A Pharma, Bouchara-Recordati, and Reckitt Benckiser.
excessive indoor tanning and addiction to investigate possible associations. This review focuses on the prevalence, clinical features, etiology, and treatment of this disorder. A literature review was conducted, using PubMed, Google Scholar, EMBASE and PsycINFO, to identify articles published in English from 1974 to 2013. Excessive indoor tanning may be related to addiction, obsessive-compulsive disorder, impulse control disorder, seasonal affective disorder, anorexia, body dysmorphic disorder, or depression. Excessive indoor tanning can be included in the spectrum of addictive behavior because it has clinical characteristics in common with those of classic addictive disorders. It is frequently associated with anxiety, eating disorders, and tobacco dependence. Further controlled studies are required, especially in clinical psychopathology and neurobiology, to improve our understanding of excessive indoor tanning.
Conflicts of interest: Michel Lejoyeux and Florence Chalmin report no conflict of interest.
Introduction
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Socially valued, tanning, like other forms of behavior, can take on an addictive aspect. This claim is based on the observations of many dermatologists who report an addictive relationship with tanning cabins among their patients, including in those who are given a diagnosis of malignant melanoma. Excessive indoor tanning has been described from the early 2000s. Warthan et al.1 were the first to propose a theoretical framework for the diagnosis and assessment of the degree of addiction. Recently, Zillhouse et al.2 proposed the Structured Interview for Tanning Abuse and Dependence (SITAD) for exploring tanning dependence. These diagnostic criteria refer to symptoms such as craving, the feeling of loss of control, and the continuing of the behavior despite the knowledge International Journal of Dermatology 2014, 53, 664–672
of negative consequences. An equivalent of withdrawal can be identified when tanners experience anxiety and negative feelings if they cannot tan as they feel they need to. However, excessive indoor tanning has not yet been recognized as a diagnostic category in either the World Health Organization’s International Classification of Diseases (ICD-10) or the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, 4th edn, Revised (DSM-IV-R). Excessive indoor tanning is a complicated phenomenon that is not easily defined. There is currently no consensus on the definition of the concept nor any recommendations on the therapeutic management of this disorder. The purpose of this review is to synthesize the existing literature on excessive indoor tanning in order to investigate possible associations and to identify what constitutes dependence ª 2014 The International Society of Dermatology
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in order to include excessive indoor tanning in the spectrum of behavioral addiction. This review focuses on the prevalence, clinical features, etiology, and treatment of this disorder. We investigate different models to determine how excessive tanning behaviors meet these criteria. Definition and diagnosis
Excessive indoor tanning was first described in the 2000s but has not yet been recognized as a diagnostic category in either ICD-10 or DSM-IV-R.3 There is currently no consensus on the definition of the concept. We propose to apply the DSM-IV Text Revision (DSM-IV-TR) diagnostic criteria for dependence to distinguish excessive indoor tanning from normal exposure to the sun. Excessive indoor tanning leads to clinically significant impairment or distress, as manifested by: (i) loss of control of indoor tanning activity; (ii) repeated failure to resist the urge to tan in salons; (iii) a psychological sense of tension prior to a sense of relief at the waning of the desire to tan; and (iv) the spending of an excessive amount of time in tanning salons. Excessive tanners spend a great deal of time obtaining, using, or recovering from tanning. Excessive indoor tanning is always taken in larger amounts or over a longer period than intended. Tanning becomes a priority in the subject’s life, in which the time spent on concerns related to tanning lengthens to the detriment of the individual’s social and professional life. For example, individuals may absent themselves from social engagements, work, school, or recreational activities in order to visit a tanning salon, thus initiating trouble at work or with family or friends. Tolerance is defined as the need to spend more and more time on a tanning bed in order to maintain the tan, either through a need to significantly increase the degree of tanning to achieve the desired effect or because the individual perceives the continued practice of the same amount of tanning to produce a diminished effect. An equivalent of withdrawal can be identified when tanners experience anxiety and negative feelings if they cannot tan in salons as they feel they need to. Conflicts arise when social, occupational, or recreational activities are abandoned in favor of indoor tanning. Continuance occurs when indoor tanning is continued despite the subject’s knowledge of the increase in the social, psychological, and physical problems (i.e. skin cancer, sunburn) that result from this practice. In order to be categorized as tanning-dependent, a person is required to meet three or more of these criteria.2 A diagnosis of tanning abuse is determined if the subject does not meet at least three of the criteria for tanning dependence but instead demonstrates one (or more) of the following behaviors: (i) recurrent tanning resulting in
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the failure to fulfill major role obligations at work, school, or home; (ii) recurrent tanning that is physically hazardous; and (iii) continued tanning despite persistent or recurrent social or interpersonal problems that are caused or exacerbated by the behavior. These diagnostic criteria allow us to distinguish among tanning dependence, tanning abuse, and normal behavior in relation to exposure to the sun. To evaluate an individual’s potential dependence on ultraviolet light (UVL) tanning, Warthan et al.1 modified two assessment tools widely used to identify substancerelated disorders (SRDs): the CAGE (cut down, annoyed, guilty, eye-opener) Questionnaire, which consists of four questions used for screening for alcoholism,4 and the APAs DSM-IV, Text Revision (DSMIV-TR),5 which outlines seven diagnostic criteria for SRD. Two or more affirmative responses to questions on the modified DSM-IV-TR (m-DSM-IV-TR) during the same 12-month period were tabulated as evidence for UVL tanning dependence. Materials and methods We conducted a literature review using PubMed, Google Scholar, EMBASE, and PsycINFO, using the following keywords alone or in combination: tanning; addiction; sunbeds; ultraviolet radiation; skin cancer; prevention; and treatment. We selected English-language articles published from 1974 to 2013, inclusive. Results Excessive indoor tanning may be related to addiction, obsessive-compulsive disorder, impulse control disorders, seasonal affective disorder, anorexia, body dysmorphic disorder, and depression. The study by Warthan et al.1 represented the first such demonstrative study. In it, the authors interviewed 145 tanning adepts on a Texas beach.1 The same two questionnaires were subsequently used to interview 375 Seattle students aged 17–30 years,6 421 northeast US students,7 100 people who attended tanning salon sessions in Dallas frequently and on a regular basis,8 and 400 volunteers from a Virginia university,3 with comparable results. Recently, the SITAD demonstrated some evidence of validity, with tanning-dependent participants reporting regular indoor tanning and higher indoor tanning frequency.2 The SITAD is a new tanning dependence assessment based on opioid use items2 adapted from the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID).9
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Epidemiology
Prevalence Very few studies have assessed the prevalence of excessive indoor tanning in the general population. Using these scales, Warthan et al. found that in a sample of 145 Texas beachgoers, 26% met the modified CAGE criteria and 53% met the modified DSM-IV-TR criteria for tanning dependence.1 Screening surveys suggest that approximately 70% of people who undergo frequent indoor tanning8 (defined as attendance at > 40 tanning sessions per year) meet a tanning-modified version of the CAGE criteria for alcohol dependence or the m-DSM-IV criteria for a substance abuse or dependence disorder.10 However, these epidemiology studies raise some reservations concerning the methodology used (the relevance of the two scales) and the relatively small groups of subjects investigated. Demographic and socioeconomic characteristics Zeller et al.11 reported the mean age of subjects who engaged in excessive indoor tanning to lie between 17 years and 30 years. The mean age of initiation was 14.7 years.11 Elsewhere, 81.2% of subjects indicated that their tanning bed use began at 13–17 years of age.8 A sex difference has been identified: female adolescents have been found to be 5.3 times12 or 6.2 times1 more likely than male teens to have tanned indoors in the last year. Studies show women are more likely to be addicted, with the greatest tendencies occurring among women of White European ethnicity aged 16–49 years, and peaking in women in their teens and 20s.10,11 This phenomenon was found among socio-professional categories with the lowest incomes.11 Heckman et al.3 observed that a lower level of education was significantly associated with excessive indoor tanning. A correlation between employment status and excessive indoor tanning has been identified.13 Individuals of skin phototypes III and IV are the most commonly represented.3 Comorbidity Mosher and Danoff-Burg7 reported that patients who undergo excessive indoor tanning have a history of anxiety disorders (50%) and substance abuse or dependence significantly more often than control group subjects. Similar findings have been reported elsewhere with reference to alcohol (18%,3 91.7%1), tobacco (16%,3 35.8%14), and cannabis (33.3%5) use. However, studies do not show any link between excessive indoor tanning and consumption of cocaine or amphetamines.1–7 Depressive symptoms did not vary significantly according to indoor tanning addiction status.6 A study of female undergraduate students reported that 80% of frequent tanners (individuals International Journal of Dermatology 2014, 53, 664–672
attending > 40 tanning sessions per year) had seasonal affective disorder (SAD) or sub-syndromal seasonal affective disorder (s-SAD).15 The investigators suggested that tanners use tanning beds for their mood-enhancing effects as bright light therapy, the most common treatment for SAD. It might be expected that excessive indoor tanning will be associated with other health-related variables such as weight and exercise.3 Demko et al. found that eating disorders (in dieters) that tend towards anorexia and exercise dependence (in individual sports such as running and fitness regimens but not in team sports or martial arts) are frequently associated with tanning dependence.16 Dieters or exercisers might be expected to tan more often because they are concerned about their appearance.17,18 Cokkinides et al. observed a significant relationship between excessive indoor tanning and a family history of tanning.18 Adolescents’ perceptions of whether or not their parents will allow them to tan indoors emerged as the strongest predictor of teen tanning in a multivariate model, with modeling, parental cognitions (both gatekeeping and non-gatekeeping), and peer factors also showing associations but to a lesser degree.12 Adolescents who said that their parents would allow them to tan indoors were 5.6 times more likely to have tanned indoors.12 Etiology
Addiction According to DSM-IV,5 dependence is diagnosed by the presence of three (or more) of the following symptoms in a 12-month period: loss of control; tolerance; withdrawal; use of the substance in greater quantity or for a longer duration than intended; repeated or unsuccessful efforts to decrease substance use; the inappropriate or excessive allocation of time to obtaining the substance or to removing the effects of the substance; the reduction of social, occupational, or recreational activities as a result of substance use; and the use of the substance despite knowledge of adverse health consequences (i.e. [in tanning] the development of melanoma, basal and squamous cell carcinomas). Tanning bed use has been linked with numerous adverse health effects, such as acute sunburn, photoinduced reactions to medications, polymorphous light eruption, atypical melanocytic lesions, skin fragility and blistering, the suppression of cutaneous DNA repair and immune function, and ocular disorders. We have been exploring the idea that some indoor tanners exhibit dependence-like behaviors, such as tanning obsessions, physical and psychological tolerance (a form of tolerance to UVL that is beyond the level the skin can withstand, analogous to tolerance in individuals who conª 2014 The International Society of Dermatology
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sume dangerous amounts of alcohol or opioids in order to experience the effects of reward that others experience at much lower doses), and loss of control. These are consequences of tanning that parallel the endogenous effects of opioid use and demonstrate cognitions that reflect dissatisfaction with the subject’s own skin color. One of the most revealing studies is a recent survey which investigated college students’ perceptions regarding indoor tanning and the adverse effects associated with exposure to artificial UVL.19 An overwhelming majority of past (93%) and current (91%) tanners believed that skin cancer was a possible consequence of the use of tanning beds.19 Another study revealed that almost half of tanners consider radiation generated by sunbeds to be somewhat dangerous.20 A survey study carried out to determine whether excessive indoor tanning leads to dependence revealed that factors related to other addictive behaviors, such as age of initiation and frequency of use, correlated with difficulty in quitting tanning.11 A few other studies have noted associations and similarities between excessive indoor tanning and substance use.1,4,16 Demko et al. found that among 6903 nationally representative Caucasian adolescents, those who used two or three substances were three times more likely to be excessive indoor tanners than others.16 Several other studies have found relationships between excessive tanning and substance use such as cigarette smoking.1–3 In a double-blind controlled study, Kaur et al. compared two cohorts of 16 volunteers aged 18–34 years, of whom eight regularly attended tanning sessions (eight to 15 times per month) and eight rarely attended tanning sessions (fewer than 12 sessions per year).21 Each group was randomly submitted to a radiation charged with either white light or UVL. Occasional tanners distinguished no difference between the two types of ray, whereas frequent tanners described a preference for UVL. The administration of an opioid receptor antagonist, naltrexone, triggered withdrawal symptoms among half of the frequent tanners and no symptoms among the occasional tanners.21 These results show that excessive indoor tanning can implicate neurobiological circuits in a manner similar to that in other addictions so that withdrawal symptoms occur under the effect of an opioid receptor antagonist. This study21 represents the only attempt to date to go beyond descriptive aspects to suggest a neurobiological explanation for excessive indoor tanning behavior. It was, however, based upon a very small sample, and the mechanism remains hypothetical. Two other studies have failed to demonstrate this effect.22,23 A recent trial suggested that tanning has reinforcing properties.22 Another recent study used a doubleblind controlled trial design to determine whether a ª 2014 The International Society of Dermatology
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physiological preference for UVL compared with nonUVL exists.24 Frequent tanners were found to exhibit an overwhelming preference (95%) for UV-emitting tanning beds, suggesting that UV tanning might have reinforcing properties.24 In a double-blind controlled study, Feldman and associates found that UVL induced cutaneous endorphin production in frequent indoor tanners.24 Follow-up studies have shown withdrawal symptoms in frequent tanners to whom naltrexone was administered, supporting this physiological hypothesis.24,25 This evidence of a physiological basis for pathological tanning is supported by studies demonstrating that UV radiation (UVR) induction of pigmentation results in the secretion of a-melanocytestimulating hormone, a cleavage product of the prohormone peptide pro-opiomelanocortin (POMC).26 Recent studies involving the role of tumor-suppressor protein p53 in the secretion of a-melanocyte-stimulating hormone and POMC provide a potential biochemical mechanism for tanning dependence. Ultraviolet light-induced p53 expression stimulates the POMC promoter, thus increasing two levels of POMC derivates: the endogenous opioids, b-endorphins, and adrenocorticotrophic hormone (ACTH).27 These molecules may contribute to tanning behavior by exerting an anti-inflammatory effect, thus alleviating the irritation and local inflammation associated with exposure to UVL. In addition, b-endorphins exert analgesic effects and promote feelings of relaxation and well-being. The respective anti-inflammatory and analgesic properties of these endogenous steroid and opioid byproducts of POMC are thought to translate into the relief from pain and irritation in the skin associated with UVL. Ultraviolet radiation is also a well-known inducer of dermal immune suppression and is used to treat patients with overactive dermal immune activity, such as those with psoriasis.28 Other studies demonstrate that UVL tanning relieves pain.24 The accumulated evidence suggests that there may be a physiological basis, in the form of dependence on opioids, for excessive indoor tanning behaviors.25 Obsessive-compulsive disorder In some circumstances, tanning practices may represent a form of obsessive-compulsive disorder (OCD).29 Patients with uncontrolled indoor tanning behavior described recurrent, intrusive thoughts and irresistible urges or impulses to tan that resembled obsessions. Indoor tanning impulses may occupy center stage and become intensely preoccupying in the form of a constant desire to tan or a continual search for a place to sunbathe.29 Uncontrolled indoor tanning may result from an obsessive desire to be thin and a compulsion to expose to the sun. Two-thirds of subjects described having at least some urges or thoughts International Journal of Dermatology 2014, 53, 664–672
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about tanning which they referred to as intrusive.29 Tanning itself resembled a compulsion in that it was a repetitive behavior performed in response to an urge and in an attempt to reduce the anxiety related to the obsession, or to neutralize uncomfortable feelings. Tanning may be accompanied by a feeling of constraint, in which the defensive function is clearly apparent.29 The same study found that 82% of uncontrolled indoor tanners report having made attempts to resist tanning (by avoiding tanning salons).29 However, in most cases, attempts to resist were unsuccessful and an urge to tan was followed by eventual submission.29 The diagnostic criteria for OCD require the presence of either obsessions or compulsions or both. Similarly, some patients present tanning impulses (obsessions) or excessive tanning (compulsions) or both. These are responsible for actions recognized as irrational, repeated, and pervasive by the person.29 Impulse control disorders Excessive indoor tanning can also be considered within the realm of impulse control disorders.5 Individuals with impulse control disorders suffer from an inability to resist the impulse to perform an action that is harmful to themselves or others.5 Seasonal affective disorder Seasonal affective disorder refers to a pattern of major depressive episodes that occur in conjunction with the changes of seasons. The most common form of SAD is the autumn-onset or winter depression type, which is treated with light therapy.30 Recent studies investigating the relationship between excessive indoor tanning and affective disorders have demonstrated a positive relationship between excessive indoor tanning and SAD symptoms. These individuals may be utilizing indoor tanning for its mood-enhancing properties, and thus such tanning might perhaps be viewed as a form of self-medication.31 The presence of SAD was assessed with the Seasonal Pattern Assessment Questionnaire used to screen for such individuals.31,32 In this instrument, respondents rate six critical items (sleep length, mood, social activity, weight, energy, and appetite) according to the degree of change affected by the season on a scale of 0 (no change) to 4 (extremely marked change). The total score represents a scale of 0–24 with which to screen for depressive seasonal symptoms, which can be used to categorize individuals as having SAD, sub-syndromal SAD, or no symptoms of SAD. The Global Seasonality Score has good internal consistency33 and good test–retest reliability and factor structure.34 Anorexia and lack of positive self-image We expected individuals of low to average weight to be at greater risk for excessive indoor tanning than overInternational Journal of Dermatology 2014, 53, 664–672
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weight or obese persons. It is likely that obese individuals are more concerned about their weight than about having tanned skin and may not feel comfortable in exposing their bodies in the manner necessary to receive high levels of UVR. Individuals with anorexia are known to exhibit undue concern about a defect in appearance and to possess a distorted image of their own body because of the way in which they interpret their appearance. In anorexia, the control of calorie intake is a repeated behavior that is conducted with the purpose of fulfilling a goal, and thus this control itself is not the source of pleasure. This aspect of anorexia distinguishes it from the model in which the addictive behavior is repeated as a source of pleasure. The initial pleasure gained from tanning is in opposition to the self-restrictive behavior that occurs in anorexia. Moreover, health represents an issue of increasing concern in contemporary society. In this context, skin that appears to have been made coppery by the sun is perceived as bearing witness to a healthy body, whereas pale skin is considered to express anemia, depression, or illness. The subject uses the tan as a window into a healthy lifestyle and thereby to purvey an image of good health. Fashion and advertising constantly convey esthetic concerns about weight. In this context, the individual is persuaded that he or she should be thin, beautiful, and tanned, that these characteristics can be maintained through sport, diet, and tanning, and that their fulfillment promises personal and social development. This seductive dynamic, which includes exposure to the sun, is part of a modern quest for the ideal physique which is to be achieved by weight control through the application of a strict diet in which the individual may demonstrate behavior close to anorexic, and the practice of intensive and repeated sporting activity. This type of sport (running, fitness, and body toning) does not stretch the body properly. It is practiced out of the fear of becoming fat and the failure to maintain a beautiful plastic appearance. According to current and widely disseminated standards of beauty, tanning makes the individual more beautiful and attractive. In a survey conducted by Boldeman et al.35, sunbed use was found to be significantly correlated with low self-perceived physical attractiveness. Fiala et al. suggested that by helping sunbed users to achieve their ideal of beauty, the possession of a tanned skin enables individuals to devalue other people and thus possibly to protect themselves from close relationships.36 They point out that the goal of sun-worshippers seems to be to look attractive and to give an outward impression of health, without in fact leading a truly healthy life, and that in addition to social attractiveness, a tan raises the subject’s self-esteem, even if this is at the cost of his or ª 2014 The International Society of Dermatology
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her health.36 However, in some cases, these attempts at seduction are not thought to be intended to create a more fulfilling love life but instead to regain self-esteem by reinforcing the certainty that others will be attracted to one. The majority of sunbed users consider an improved appearance to be a positive effect associated with the use of tanning beds.20 Furthermore, almost 60% of frequent tanners consider relaxation to be a positive effect of the use of tanning beds; this may be predominantly attributable to their warmth and the relaxation to be derived from lying down and closing the eyes.20 Individuals who engage in intensive tanning are able to derive a positive image of themselves through the receipt of remarks such as “You look well” and “You are glowing.” The assumed admiration and envy conveyed by such comments reinforce the practice that has provoked them. Thus, intensive tanning behavior is perceived to increase positive interactions with other people. This initial enjoyment in the behavior may subsequently give way to anguish caused by anxiety about failing to maintain this image and losing the power of attraction. It is here that the psychological suffering that will lead the individual into pathological behavior begins. In this context, excessive indoor tanning reflects a lack of positive self-image and self-esteem. Just as the anorexic sees himself as obese in the mirror, the indoor tanner perceives herself to be as white as a turnip, despite an increasingly tanned skin. This image reflected by the mirror is unbearable and may cause great mental suffering. Dependence is based on the desire or obsession to have a perfect tan. Many excessive indoor tanners multiply the number of tanning sessions they engage in to increase their level of tan in order to restore their positive image of themselves. Body dysmorphic disorder For a certain subset of individuals who tan, excessive indoor tanning may reflect a form of body dysmorphic disorder (BDD).37 According to DSM-IV-TR, BDD is defined by a preoccupation with a perceived defect in appearance which causes significant distress or impairment.5 These individuals may be motivated to darken their skin color because they are preoccupied with an imagined defect in appearance.37 They believe they look ugly, deformed, or disfigured, when in reality they look normal.37 Preoccupations with appearance most often focus on perceived defects of the skin (acne or scarring), hair (hair loss), or nose.38,39 Phillips et al. assessed the prevalence of BDD-related indoor tanning in 200 individuals with BDD, as well as the clinical features of BDD in tanning subjects.17 Indoor tanning related to BDD was defined as any behavior that involved darkening one’s ª 2014 The International Society of Dermatology
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skin color by direct exposure to sunlight or artificial light. This behavior must have been motivated by a desire to alter or improve a perceived appearance defect.17 The study found that 25% of subjects engaged in BDD-related indoor tanning and that for 84% of these individuals, the skin was the most common area of preoccupation,40 and that primary aspects of concern included acne, scarring, other marks, and skin color.17 Individuals tan to diminish the appearance of non-existent or slight acne and blemishes, to darken pale skin, and to make uneven or blotchy skin a more homogeneous color. Some patients tan to diminish the appearance of wrinkles, as did one of our own study subjects, who reported tanning for 2–3 hours per day in order to obscure facial lines.17 Although we did not systematically determine why our study subjects tanned, some reported that they used tanning as a type of camouflage. Patients may also tan to minimize the appearance of perceived cellulite, to make body areas (body size or stomach) appear smaller, or to distract people from looking at ugly body areas.17 These findings offer an alternative explanation for the motivation for indoor tanning and behavior in some individuals. Outcome expectancy refers to the belief that a given behavior will lead to a certain positive outcome. The development of expectancy networks is unconscious and automated and can be viewed as contributing to the loss of control, experience of craving, and difficulty in quitting associated with drug dependence. Depression Negative emotions, especially sadness, frustration, and irritation, increase a tanner’s propensity to tan.1–3 Excessive indoor tanning can be used as a mechanism by which to escape from depressive feelings. The main link between excessive indoor tanning and depression may be low selfesteem. Individuals who feel empty and sad tan compulsively in an attempt to restore a depleted self and to increase their sense of well-being. Usually, indoor tanning is associated with positive emotions, such as happiness and feelings of relaxation. Ultraviolet light may help individuals to cope by enhancing positive affect, diminishing negative affect (anxiety, stress), providing distraction or escape, and increasing performance. Treatment
The provision of information on the dangers of exposure to UVL has not been found to alter the propensity of people with paler skin for engaging in indoor tanning. We hypothesized that interventions on the risks of excessive indoor tanning in no circumstance represented an assured way of modifying tanning practices and that the most informed people were often those who adopted the International Journal of Dermatology 2014, 53, 664–672
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most risky behavior.41 There is no specific recommendation concerning the support of these patients. The administration of medications that block the effects of endogenous endorphins, such as naltrexone, to treat excessive and addictive indoor tanning behaviors is promising but requires further research.8–10 We were unable to find any studies on the benefits of chemotherapy in the literature. Future pharmacologic interventions may offer options to compulsive tanners. Given the correlation between tanning and SAD, medications that increase levels of serotonin and norepinephrine, which are effective for SAD patients, may help frequent tanners.10 When present, psychiatric comorbidities may represent a motive for consultation among some frequent tanners. The existence of anxiety disorders is associated with a higher demand for healing and psychotropic prescriptions. The use of tanning creams constitutes one method through which frequent tanners can be helped to maintain the tan on which their equilibrium depends, but it fails to achieve the relaxing effects derived from the process of indoor tanning. Subsequent research should further explore motivations for tanning and develop interventions that might target individuals prior to the age of 17 years. Such interventions should reduce the importance placed on appearance in general and, specifically, that placed on tanning as enhancing the individual’s appearance.1–42 To our knowledge, no such interventions have been initiated in France. Interventions may benefit from the adoption of approaches that integrate the treatment of body dissatisfaction and subsequent maladaptive behaviors.42 The recognition of excessive indoor tanning as a potential SRD has implications for future strategies to prevent and decrease excessive indoor tanning. Although education has long been used to inform individuals about the dangers of exposure to UVR, it seems likely that additional measures are required for that subset of the population which meets the criteria for excessive indoor tanning. Tailored interventions may address individual motivations for tanning and their relation to maladaptive behavior, such as dissatisfaction with appearance or need for relaxation because of anxiety.31 Most of the recent literature suggests that its effect on appearance is the primary motivation for indoor tanning.1–3 It is thus of little wonder that educational interventions focusing on skin safety and cancer awareness have fallen short in terms of changing actual tanning behavior.1,3,11 One educational intervention based on appearance was successful in decreasing indoor tanning in female college students.43 These findings may also suggest that people’s UVR protective behaviors may be modified more effectively by focusing on the appearance-based, rather than cancerrelated, effects of UVR exposure.12 International Journal of Dermatology 2014, 53, 664–672
The parents of adolescents represent an important population for the targeting of primary prevention of skin cancer as they are able to influence their adolescent children by promoting healthy attitudes towards and practices in UVR exposure. Primary prevention campaigns on sun protection in children should be aimed at parents, not only because parents can control the degree to which young children are exposed to sunlight but also because they serve as an example to adolescents.44,45 However, to our knowledge, there have been no primary prevention campaigns related to sunlight exposure in children in France. The International Agency for Research on Cancer (IARC) has recently reclassified tanning devices into the highest cancer risk category: carcinogenic to humans.28 Strong positions against indoor tanning have been taken by the US National Institutes of Health and the American Cancer Society.46–48 The American Academy of Dermatology has recommended banning the non-medical use of indoor tanning booths and, as an interim measure, prohibiting the use of tanning booths by minors.49 Conclusions The issue of excessive indoor tanning illustrates how the concept of addiction applies to an increasing variety of behaviors considered as dangerous. We think there are indices in favor of an addictive dimension in the search for excessive tanning among some people: their behavior leads to a strong sensation of pleasure and is at the origin of feelings of loss of control and psychological suffering. However, the methodologies of the studies reviewed in the current paper lead us to emit some reservations based on the small sample sizes used in the studies, the many recruitment and selection biases, the supposed validity of the diagnostic scales (modified CAGE, DSM-IV, SITAD), the pertinence of some of the questions asked (modified CAGE, modified DSM-IV, SITAD), and the absence of questions concerning withdrawal symptoms. There is no current reference standard for diagnosing tanning dependence.2 These results need to be replicated in a larger, broader, and more representative sample. They should also be investigated with reference to outdoor tanning behavior. Current psychiatric nosology does not recognize this disorder as a clinical entity, and thus there are no recommendations for the treatment of excessive tanners. However, the concept of addiction is increasingly accepted by the public at large and is consensual among health professionals. We consider that excessive indoor tanning can be included in the spectrum of addictive behaviors because it holds clinical characteristics in common with classic addictive disorders. These provide a variety of other models, which may offer an explanation for or insight into ª 2014 The International Society of Dermatology
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excessive indoor tanning behavior. Excessive indoor tanning is frequently associated with the presence of anxiety, eating disorders, and tobacco dependence. Thus, excessive indoor tanning behaviors can be evaluated in a similar manner to the behaviors associated with close but distinct concepts such as impulse control disorders, BDD, OCD, and eating disorders, all of which are recognized and described by the APA in DSM-IV-TR. It is important to note that not all tanning behavior or even frequent tanning behavior should be seen as indicative of tanning dependence. More qualitative research approaches exploring indoor tanning behavior and its psychopathological and neurobiological aspects are necessary to improve our understanding of the phenomenon and the treatment of people who engage in it. References 1 Warthan M, Uchida T, Wagner R. UV light tanning as a type of substance-related disorder. Arch Dermatol 2005; 141: 963–966. 2 Hillhouse JJ, Baker MJ, Turrisi R, et al. Evaluating a measure of tanning abuse and dependence. Arch Dermatol 2012; 148: 815–819. 3 Heckman CJ, Egleston BL, Wilson DB, et al. A preliminary investigation of the predictors of tanning dependence. Am J Health Behav 2008; 32: 451–464. 4 Mayfield D, McLeod G, Hall P. The CAGE Questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974; 131: 1121–1123. 5 American Psychiatric Association, Task Force on DSM IV. Diagnosis and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, DC: APA Task Force on DSM-IV, 2000. 6 Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007; 56: 375–379. 7 Mosher CE, Danoff-Burg S. Addiction to indoor tanning. Arch Dermatol 2010; 146: 412–417. 8 Harrington CR, Beswick TC, Leitenberger J, et al. Addictive-like behaviors to ultraviolet light among frequent indoor tanners. Clin Exp Dermatol 2010; 36: 33–38. 9 First M, Spitzer R, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). New York, NY: New York State Psychiatric Institute Biometrics Research Department, 1995. 10 Kourosh AS, Harrington CR, Adinoff B. Tanning as a behavioral addiction. Am J Drug Alcohol Abuse 2010; 36: 284–290. 11 Zeller S, Lazovich D, Forster J, et al. Do adolescent indoor tanners exhibit dependency? J Am Acad Dermatol 2006; 54: 589–596. 12 Hoerster K, Mayer P, Woodruff S. The influence of parents and peers on adolescent indoor tanning behavior: findings from a multi-city sample. J Am Acad Dermatol 2007; 57: 990–997. ª 2014 The International Society of Dermatology
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13 Diehl K, Litaker D, Greinert R, et al. The prevalence of current sunbed use and user characteristics: the SUN-STUDY 2008. Int J Public Health 2010; 55: 513–516. 14 Mahler HI, Hulik JA, Harrell J, et al. Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors. Arch Dermatol 2005; 141: 373–380. 15 Neinstein LJM, Shapiro J. Psychological development in normal adolescents. In: Health Adolescent Care: a Practical Guide. Baltimore, MD: Williams & Wilkins, 1996: 42–44. 16 Demko CA, Borawski EA, Debanne SM, et al. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med 2003; 157: 854–860. 17 Phillips KA, Conroy M, Dufresne RG, et al. Tanning in body dysmorphic disorder. Psychiatr Q 2006; 77: 129–138. 18 Cokkinides V, Bandi P, Weinstock M, et al. Sunburns, sun protection and indoor tanning behaviors, and attitudes regarding sun protection benefits and tan appeal among parents of US adolescents – 1998 compared to 2004. Pediatr Dermatol 2010; 27: 9–18. 19 Knight JM, Kirincich AN, Farmer ER, et al. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol 2002; 138: 1311–1315. 20 Dissel M, Rotterdam S, Altmeyer P, et al. Indoor tanning in north Rhine–Westphalia Germany: a self-reported survey. Photodermatol Photoimmunol Photomed 2009; 25: 94–100. 21 Kaur M, Liguori A, Fleisher AB, et al. Side effects of naltrexone observed in frequent tanners: could frequent tanners have ultraviolet-induced high opiod levels? J Am Acad Dermatol 2005; 52: 916. 22 Gamblicher T, Barder A, Vojvodic M, et al. Plasma levels of opioid peptides after sunbed exposures. Br J Dermatol 2002; 147: 1207–1211. 23 Wintzen M, Ostijn DM, Polderman MC, et al. Total body exposure to ultraviolet radiation does not influence plasma levels of immunoreactive beta-endorphin in man. Photodermatol Photoimmunol Photomed 2001; 17: 256–260. 24 Feldman SR, Liguori A, Kucenic M, et al. Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004; 51: 45–51. 25 Kaur M, Liguori A, Lang W, et al. Introduction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006; 54: 709–711. 26 Cui R, Wildlund H, Feige E, et al. Central role of p53 in the suntan response and pathologic hyperpigmentation. Cell 2007; 128: 853–864. 27 Van Steensel MA. UV addiction: a form of opiate dependency Arch Dermatol 2009; 145: 211. 28 Brady MS. Public health and the tanning bed controversy. J Clin Oncol 2012; 30: 1571–1573.
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29 Nolan B, Taylor S, Liguori A, et al. Tanning as an addictive behavior: a literature review. Photodermatol Photoimmunol Photomed 2009; 25: 12–19. 30 Saeed SA, Bruce TJ. Seasonal affective disorders. Am Fam Physician 1998; 57: 1340–1346. 31 Hillhouse J, Stapleton J, Turrisi R. Association of frequent indoor UV tanning with seasonal affective disorder. Arch Dermatol 2005; 151: 485–491. 32 Kasper S, Wehr TA, Bartko JJ, et al. Epidemiological findings of seasonal changes in mood and behavior: a telephone survey of Montgomery County Maryland. Arch Gen Psychiatry 1989; 46: 823–833. 33 Magnusson A. Validation of the Seasonal Pattern Assessment Questionnaire (SPAQ). J Affect Disord 1996; 40: 121–129. 34 Young M. Integrating psychological and physiological mechanisms of SAD: the dual-vulnerability model. Biol Rhythms Bull 1999; 1: 4–6. 35 Boldeman C, Jansson B, Nilsson B, et al. Sunbed use in Swedish urban adolescents related to behavioral characteristics. Prev Med 1997; 26: 114–119. 36 Fiala B, Kopp M, Gunther V. Why do young women use sunbeds? A comparative psychological study. Br J Dermatol 1997; 137: 950–954. 37 Phillips KA. Body dysmorphic disorder. In: Phillips KA, ed. Somatoform and Factitious Disorders. [Review of Psychiatry Series, Vol. 20, No. 3; Oldham JM, Riba MB, series eds.] Washington, DC: American Psychiatric Publishing, 2001. 38 Hollander E, Cohen LJ, Simeon D. Body dysmorphic disorder. Psychiatric Annals 1993; 23: 359–364. 39 Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder: a survey of fifty cases. Br J Pyschiatry 1996; 169: 196–201.
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40 Hunter-Yates J, Dufresne RG Jr, Phillips KA, et al. Tanning in body dysmorphic disorder. J Am Acad Dermatol 2007; 56(Suppl.): 107–109. 41 Lake JR, Thomson CS, Twelves CJ, Davies EA. A qualitative investigation of the motivations, experiences and views of female users under the age of 18 in England. J Public Health (Oxf) 2013; 30. 42 Blashill AJ. Psychosocial correlates of frequent indoor tanning among adolescent boys. Body Image 2013; 10: 259–262. 43 Hillhouse JJ, Turrisi R. Examination of the efficacy of an appearance-focused intervention to reduce UV exposure. J Behav Med 2002; 25: 395–400. 44 Grob JJ, Guglielmina C, Gourvenet J, et al. Study of sunbathing habits in children and adolescents: application to the prevention of melanoma. Dermatology 1993; 186: 94–98. 45 Geller A, Colditz G, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics 2002; 109: 1009–1014. 46 Zhang M, Qureshi AA, Geller AC, et al. Use of tanning beds and incidence of skin cancer. J Clin Oncol 2012; 30: 1588–1593. 47 West SE, Martin KL, Ailor SK. Tanning themselves to death: a new teen fad. Mo Med 2012; 109: 166–170. 48 Lostritto K, Ferrucci LM, Cartmel B, et al. Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates. BMC Public Health 2012; 12: 118. 49 American Academy of Dermatology. Position statement on indoor tanning. http://www.aadassociation.org/Policy/ tanning.html [accessed 30 November 2004].
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