Dermatology Original Article · Originalarbeit
Psychosomatics
Dermatologie
Psychosomatik
Living with Vitiligo: A Controlled Investigation into the
Effects of Group Cognitive-Behavioural and
Person-Centred Therapies
L. Papadopoulosa C. Walkerb
a Department of Psychology, London Metropolitan University,
b Department of Psychiatry and Behavioural Sciences, University College London, Great Britain
Key Words
Vitiligo · Group psychotherapy · Cognitive-behavioural
therapy · Self-esteem · Body image
Summary
Background: Vitiligo is a progressive condition involving
a loss of pigmentation in the skin. It can be disfiguring
and no fully effective treatment or cure exists. Although
medical effects of vitiligo have been studied extensively,
less attention has been paid to its psychological impact.
Methods: This research compared the efficacy of group
cognitive-behavioural therapy (CBT) and group person-
centred therapy with respect to ameliorating the dis-
abling effects of the condition. Participants were ran-
domly allocated to either the control group, the CBT
treatment group or the person-centred treatment group.
Participants underwent 8 consecutive weeks of therapy
and psychological and physiological gains were record-
ed before therapy, after therapy and at 6 and 12-month
follow-up. The study used a mixed factorial design for
the questionnaire analysis. The independent factor was
the three different experimental conditions; control, CBT
and person-centred therapy and the repeated measures
factor was assessment point; pre-treatment, post-treat-
ment, 6-month follow-up and 12-month follow-up. Re-
sults: Unlike previous work with different psychotherapy
formats, little psychosocial or physiological benefits
were gained as a result of the two group therapy pro-
grammes. Conclusion: This research helps us to under-
stand more fully the efficacy of psychological therapy
with a vitiligo population and will help direct health pro-
fessionals to the most appropriate format for future use.
© 2004 S. Karger GmbH, Freiburg
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Dermatol Psychosom 2004;5:172–177
L. Anthisa
Schlüsselwörter
Vitiligo · Gruppentherapie · Kognitive Verhaltenstherapie ·
Selbstwert · Körperbild
Zusammenfassung
Leben mit Vitiligo: Eine kontrollierte Untersuchung der
Therapieeffekte von kognitiv-behavioraler und person-
zentrierter Gruppenpsychotherapie
Hintergrund: Vitiligo ist eine chronisch-progressive Er-
krankung, die mit einem Verlust der Hautpigmentierung
einhergeht. Sie kann entstellend sein und bislang nicht
vollständig behandelt oder geheilt werden. Obwohl die
medizinischen Auswirkungen von Vitiligo intensiv unter-
sucht worden sind, wurde dessen psychologische Be-
deutung bisher wenig beachtet. Methoden: Die vorlie-
gende Studie vergleicht die Effekte einer kognitiv-verhal-
tenstherapeutischen Gruppentherapie (KVT) und einer
personzentrierten Gruppentherapie auf die einschrän-
kenden Auswirkungen der Erkrankung. Die Teilnehmer
wurden zufällig der Kontrollgruppe, der KVT oder der
personzentrierten Gruppentherapie zugewiesen. Die Teil-
nehmer erhielten 8 Wochen Therapie. Psychische und
physiologische Veränderungen wurden vor, unmittelbar
nach sowie 6 und 12 Monate nach Therapieabschluss
untersucht. Die Studie verwendete ein faktorielles Design
mit Messwiederholung. Der unabhängige Faktor waren
die drei unterschiedlichen experimentellen Bedingungen
KVT, personenzentrierte Gruppentherapie und Kontroll-
gruppe. Der Messwiederholungsfaktor waren die Mess-
zeitpunkte vor und nach der Therapie sowie zur 6- und
12-Monats-Katamnese. Ergebnisse: Anders als bei frühe-
ren Therapievergleichsstudien führten die beiden psy-
chotherapeutischen Interventionen nur zu geringen
psychosozialen oder physiologischen Verbesserungen.
Schlussfolgerung: Die Studie trägt dazu bei, die Wirk-
samkeit psychologischer Therapien bei Vitiligopatienten
besser zu verstehen, und kann Medizinern helfen, künftig
die am besten geeignete Therapieform zu wählen.
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Dr. Carl Walker
Department of Psychiatry and Behavioural Sciences
Royal Free and University College Medical School
Rowland Hill Street, GB-London, NW3 2PF
Glasgow Univ.Lib.
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Tel. +44 208 472 6830
E-mail c.walker@rfc.ucl.ac.uk
Until recently [Kent, 2000; Van Moffaert, 1992; Gil et al.,
1987], there has been relatively little interest in the psycho-
logical aspects of disfiguring medical conditions. Much of the
research in this area has been published in medical journals,
where the primary concern has been the assessment of the so-
cial and personal difficulties that can be associated with der-
matological diseases, burns and cranio-facial abnormalities.
Research into the manifestations of psychocutaneous disor-
ders has led to an increasing awareness that there are psy-
chosocial effects associated with skin disease. These include
depression, an impaired sense of body image, decreased self-
esteem, sexual and relationship difficulties and a general re-
duction in quality of life [Papadopoulos et al., 1999; Porter et
al., 1987; Obermeyer, 1985; Dungey and Busselmeir, 1982].
They also include a reduced sense of control, predictability
over one’s life and reduced social support [Gieler et al., 2000;
Thompson and Kyle, 2000; Picardi et al., 2003].
The visibility of most dermatoses has psychological conse-
quences and can often carry connotations of contagion or a
lack of hygiene [Papadopoulos and Walker, 2003; Kleinman,
1988]. This may cause patients to feel ostracised and the re-
sulting self-depreciative feelings may lead to social fear and
shame. Indeed, dysmorphic disorder is characterised by a sub-
jective feeling of ugliness, cosmetic defect or deformity in
one’s appearance.
Vitiligo is a progressive skin condition involving the apparent
destruction of the pigment-producing cells in the skin. The af-
fected areas lose their pigmentation resulting in the appear-
ance of irregular white, non-scaly lesions over the surface of
the skin. Although the general appearance of the patient can
change, the health of the patient is not affected in any other
way and patients report no physical pain or discomfort [Hann
and Nordlund, 2000]. It is for this reason that the impact of the
condition is often minimised and addressed only in cosmetic
terms.
Papadopoulos et al. [1998] undertook a rigorous analysis of
the relationship between vitiligo and stressful life experiences
and showed that vitiligo patients experienced a significantly
higher proportion of stressful life events in the year preceding
the onset of their condition than matched controls.
Papadopoulos et al. [1999] showed that an 8-week course of
individual cognitive-behavioural therapy (CBT) significantly
improved vitiligo patients’ self esteem, quality of life and body
image. It appears that the CBT programme had a particular
impact on the reduction of negative thoughts as opposed to a
particular increase in positive thoughts. This supports Hart’s
[1982] work with anxious and depressed patients. Further-
more, and of great interest, the participants who undertook
CBT also showed a general decrease in vitiligo depigmenta-
tion, possibly as a result of the development of stress inocula-
tion techniques.
This research was crucial but limited in that it had a small
sample and only tested the comparative effect of one type of
therapy against a non-treatment control. In an investigation
Group Cognitive-Behavioural and Person-
Centred Therapies of Vitiligo
with a larger sample and a non-treatment control group and
a control group consisting of vitiligo patients receiving indi-
vidual person-centred therapy, Papadopoulos et al. [personal
data] showed that only individual CBT effectively addressed
the body image, self-esteem and quality of life of vitiligo pa-
tients. This work suggested that the specific tenets and for-
mat of individual CBT effectively addressed the above vari-
ables rather than a generic therapeutic alliance. No change
was recorded in the vitiligo depigmentation for any of the
groups.
Group psychotherapy as it is known today can differ along a
series of dimensions including group composition, format,
goals and duration. The benefits of group therapy include the
installation of hope, universality (participants may be able to
benefit from the simple therapeutic value that lies in the reali-
sation that they are not the only person suffering from the ef-
fects of this condition) and the development of socialising
techniques [Gilbert and Shmukler, 1996]. However, good re-
search knowledge on group psychotherapy in this medical
context is more scarce than in other areas of medical psy-
chotherapy [Cunningham et al., 1978]. A review of group ther-
apy with a number of medical conditions has shown some suc-
cess [Ornish et al., 1998; Linden et al., 1996; Bergin and
Garfield, 1994; Kelly et al., 1993; Parker et al., 1993; Fawzy et
al., 1993] on a number of psychosocial variables including hos-
tility, depression, anxiety, symptom management, problem
solving and psychiatric symptoms.
The following work has been conducted such that CBT in a
group format can be compared to group person-centred thera-
py and an untreated control in order to test whether the group
format of CBT is similarly efficacious to the individual format.
As such, the recruitment process, length of therapy, selection
of counselling psychologists, therapeutic protocols and facili-
ties have been modelled on Papadopoulos et al.’s [1999] previ-
ous work.
Methods
Participants
Participants were recruited through an advertisement in the UK Vitiligo
Society’s quarterly newsletter in June 2000. Participants were also recruit-
ed over the summer of 2000 from St. Thomas’ Hospital, Whipps Cross
Hospital, The Ealing Hospital, and The Royal Free Hospital in London.
Local research ethics approval was secured before recruitment.
It was necessary that volunteers:
– were over 18 years of age;
– were formally diagnosed by a dermatologist;
– had not previously undergone, or were receiving counselling to help
them cope with their condition;
– had the condition for at least 1 year;
– were not taking any form of psychotropic medication.
A power analysis using GPOWER was carried out in order to determine
the appropriate sample size that would enable treatment effects to be reli-
ably established [Faul and Erdfelder, 1992]. A treatment effect of 0.5 and
a power of 0.8 revealed that a sample size of 45 (15 participants in each
group) would be necessary to reliably detect this treatment effect.
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Table 1. Number of participants, mean age and standard deviation by Table 3. Ethnicity split by condition
condition
Person-centred CBT Control
Age, years Participants, n
 Caucasian 9 9 9
mean SD
Asian 3 2 5
Afro-Caribbean 2 4 1
Person-centred 35.847 11.718 14
Total 14 15 15
CBT 36.385 12.051 15
Control 37.708 11.094 15

In the case of the person-centred treatment group, it is not possible to

Table 2. Sex split by condition
Person-centred CBT Control
Female 9 10 12
Male 5 5 3 Two therapists provided counselling, one whose principal therapeutic
Total 14 15 15
The 45 participants were matched for age, sex and ethnicity and were then
allocated either to the control, the CBT treatment group or the person-
centred treatment group (tables 1–3). Due to the need to establish effec-
tive group dynamics, a decision was made to facilitate two smaller groups
of 8 participants within each treatment. The first CBT group contained
8 participants and the second CBT group contained 7 participants, due to
one participant’s failure to arrive at the first session. The first person-
centred group contained 6 participants (due to 2 participants’ failure to
arrive at the first session) and the second person-centred group contained
8 participants.
The participants who were allocated to the treatment groups were given
psychological therapy from a chartered counselling psychologist in one
of the counselling rooms at London Metropolitan University. Therapy
lasted for approximately 90 minutes and 1 session per week and was
undertaken for 8 consecutive weeks. Participants allocated to the control
group were not offered counselling and received no change to their
treatment status. The conventional treatment status of all participants
was ‘no medical treatment’ which is common for vitiligo patients be-
cause neither steroids nor PUVA can be used over extended periods.
This lack of treatment status also allowed the conclusion that any
changes in the pigmentary status of the participants would not be due to
external treatment.
Procedure
The counselling protocol used for the first group was originally adapted
from the CBT model [Beck, 1976]. The therapy itself focussed on examin-
ing and attempting to change negative thought patterns that may be re-
sponsible for the individual’s low mood or avoidance of certain situations
and behaviours. In conjunction with techniques drawn from CBT, the
counselling protocol also incorporated the teaching of practical skills that
can be used to address some of the problems that individuals with a visi-
ble skin disorder may encounter such as staring and comments from
strangers. This specific CBT protocol is drawn from Papadopoulos et al.’s
[1999] work with vitiligo patients.
The person-centred approach is based on concepts from humanistic psy-
chology. Founded by Carl Rogers in the 1950’s [Woolfe and Dryden,
1996], the basic assumptions state that people are essentially trustworthy,
that they have a vast potential for understanding themselves and resolving
their own problems without direct intervention on the therapist’s
part. From the beginning, Rogers emphasises the attitudes and personal
characteristics of the therapist and the quality of the client-therapist
relationship.
construct a counselling protocol as such, since this therapy is non-direc-
tive, requiring the therapist to follow the client’s lead and reflect and em-
pathise with the client’s experience. However, core person-centred thera-
peutic conditions such as empathic reflecting, summarising and uncondi-
tional positive regard were observed.
model is CBT and one whose approach is person-centred. This minimised
the possibility of bias due to the therapists’ expertise and expectations.
Participants completed the first set of questionnaires 1 week before the
sessions. Participants were sent questionnaires after the 8-week thera-
py course, at 6 months and at 12 months. Participants also came into
the university to be photographed before the treatment schedule, as
well as 6 and 12 months after the completion of the schedule in order to
monitor the spread of the participant’s vitiligo.
A letter was sent to participants explaining the photograph procedure and
it was emphasised that if the participant felt uncomfortable with having
the photographs taken then they would not be taken. Similarly, partici-
pants were informed that they could drop out of the research process at
any time without giving a reason and that all data that was recorded
would be treated confidentially. Participants were asked to have full body
shots taken, front and back. Of the 44 participants, 29 participants con-
sented to having the photographs taken. Several participants indicated
that they were only comfortable having the relevant area(s) of depigmen-
tation photographed. They were given this choice but agreed that if new
lesions were to appear then they would to have these new lesions pho-
tographed also.
Instruments
The outcome measures consisted of photographs and a battery of vali-
dated and reliable questionnaires. The photographs were taken in the
photography department at London Metropolitan University. They were
assessed by researchers who acted as ‘blind’ raters. All photographs were
assessed using the Pajant Photoshop computer analysis package that pro-
duces objective estimates of any changes in vitiligo spread prior to and
following treatment. The use of this package involves tracing round le-
sions and calculating spread as a percentage of body area using pixel
counts. Spread was calculated as a percentage in order to account for
minor differences due to the camera angle and distance from the lens.
Photographs were scrutinised by dermatologists in order to assess the
presence and visibility of vitiligo.
The questionnaires used included the Rosenberg Self-Esteem Scale
[Rosenberg, 1965], The Body Image Automatic Thoughts Question-
naire (consisting of two scales which record positive and negative
thoughts independently) [Cash, 1987], The Situational Inventory of
Body Image Dysphoria [Cash, 1994], The General Health Question-
naire [GHQ; Goldberg and Williams, 1988], The Perceived Stress
Scale [Cohen et al., 1983] and The Dermatology Quality of Life
Index [Finlay and Khan, 1994]. Evidence of the reliability and valid-
ity of the above measures is satisfactory and has been reported in
several studies [i.e. Finlay and Khan, 1994; Cash, 1994; Rosenberg,
1965].
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Table 4. ANOVA results for interactions between group and time point Table 6. T test results for general health at different time points for the
for the multiple dependent variables group therapy comparison

Variable Interaction: group × time point t df p


F df p
CBT
– T1 vs. T2 3.030 7 0.019
Self-esteem 2.874 6 0.123
– T1 vs. T3 3.936 6 0.0170
Dermatology quality of life 2.048 6 0.122
– T1 vs. T4 2.862 5 0.024
Body image feelings 0.967 6 0.475
Person-centred
Positive thoughts 1.561 6 0.226
– T1 vs. T2 1.818 8 0.107
Negative thoughts 2.232 6 0.097
– T1 vs. T3 2.580 7 0.036
Perceived stress 1.676 6 0.195
– T1 vs. T4 4.703 6 0.042
General health 3.020 6 0.039*

* = Significant.

Photograph Analyses: Physiological Change

Table 5. One-way ANOVA results for general health for each group
A multiple analysis of variance with time point as the repeat-
F df p ed measures factor and experimental group as the indepen-
dent factor showed that there were no overall improvements
CBT 8.553 3 0.014 in pigmentation over time for any of the experimental groups
Control 0.899 3 0.534
(F = 1.379, df = 4, p = 0.321) (table 7).
Person-centred therapy 7.344 3 0.020

Design
The study used a 3 × 4 mixed factorial design for the questionnaire analy-
sis. The independent factor was the experimental condition; control, CBT
and person-centred therapy, and the repeated measures factor was assess-
ment point; pre-treatment (T1), post-treatment (T2), 6-month follow-up
(T3) and 12-month follow-up (T4). The study further used a 3 × 3 mixed
factorial design for photograph analysis. The independent factor was the
experimental condition; control, CBT and person-centred therapy, and
the repeated measures factor was assessment point; pre-therapy (T1),
6-month follow-up (T3) and 12-month follow-up (T4). No immediate
post-treatment assessment was taken for the vitiligo pigmentation as it
was expected that there would be a delay before any changes in pigmen-
tation would be realised.
Results
Multivariate analyses of variance were judged inappropriate
due to the theoretical diversity of the dependent variables. A
multiple analysis of variance was carried out for each depen-
dent variable and the interaction between the between-partic-
ipants variable (experimental group) and the within-partici-
pants variable (time point) was not significant.
Tables 4, 5 shows that the CBT and person-centred groups
made significant improvements only in general health. For the
CBT groups, improvements were noticeable directly post-
treatment and maintained over the duration of the follow-ups.
For the person-centred groups, improvements were only visi-
ble at 6-month and 12-month follow-up but no improvement
was found immediately after therapy (table 6). There were no
significant changes in the responses obtained from the control
group on any of the above variables at any time point.
Discussion
Following on from the recent finding that individual CBT was
effective for vitiligo in the context of psychological and social
adjustment [Papadopoulos et al., personal data], group CBT
was compared to group person-centred therapy trials. Results
have shown that the groups of vitiligo patients who undertook
the 8 consecutive sessions of group CBT showed no signifi-
cant improvement in all of the psychosocial variables used in
test with the exception of general health. This included posi-
tive and negative thoughts, body image feelings, perceived
stress, self-esteem and quality of life. No gains were shown at
6-month and 12-month follow-up. The participants in the per-
son-centred therapy paradigm also showed prolonged im-
provement in general health but not in any other psychosocial
variable. Unlike the group CBT results, there was a delay in
general health improvement. The improvement was not
shown immediately after therapy but at 6 months. This sup-
ports previous work [Bergin and Garfield, 1994] that has
found a delay in gains made due to person-centred therapy.
The intensity, direction and structure of CBT may lend itself
to more immediate gains in general health whereas changes
made in the person-centred process may take longer to realise,
post-therapy. Further work might explore this disparity. Final-
ly, individuals in the control group showed no improvement in
any of the psychological and social instruments used in the
protocol. It is possible that the reason for the effective change
in general health for both CBT and person-centred groups
concerns the GHQ emphasis on the recording of anxiety and
depression. It may be that the group therapies are able to ad-
dress generalised anxiety and depression in clients’ lives with-
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Table 7. Mean vitiligo spread (%) and standard
deviation for the three experimental groups
over the 3 time points
Control
CBT
Person-centred
out particularly addressing issues that pertain to their skin
condition.
It was considered that group person-centred therapy might
have succeeded where individual person-centred therapy pre-
viously failed [Papadopoulos et al., personal data] because al-
though person-centred therapy is client-led, the fact that the
group was brought together under the auspice of vitiligo may
have tended to focus the group in the direction of their skin
disease and so more time may have been spent addressing this.
In light of the results, this may not have been the case. Fur-
thermore, group person-centred therapy would have allowed
participants to benefit from the experience, advice, comfort
and understanding of others in a similar position to their
own. This is obviously not an option for individual therapy
and while this may have been the case, the effect was not suffi-
cient to improve the participants’ scores on the dependent
variables.
It would appear that group CBT is an ineffective intervention
for vitiligo participants. There could have been a number of
reasons for this. One crucial point to be made and a defining
difference between the individual and group therapy is that of
the assessment process. Only a group assessment process
could be used, which did not allow the therapist to obtain the
same individual knowledge of the clients’ psychological and
social conceptualisation of their disease and its ramifications.
As such, it would make it difficult for the therapist to establish
commonality in the first session.
In many ways this problem is not only limited to the assess-
ment session. To work with 8 participants in an 8-week period
and with a detailed protocol can limit the therapist when at-
tempting to explore, assess and modify issues that can be idio-
syncratic to the experience of a particular participant. Partici-
pants come to therapy with a lifetime of experiences that have
shaped and been shaped by the schematic conceptions that
they have of their own self-worth, their body image and their
adjustment to the challenges of their disease. While one par-
ticipant may experience sexual problems due to a lack of com-
munication with their partner regarding feelings of embarrass-
ment and shame around their skin, another participant may
have developed an aversion to exposing their skin in public
places as a result of constant skin-related bullying and teasing
that they received when they were an adolescent. The very
fact that individual CBT was successful in earlier work was
likely due to the fact that it addresses deep-rooted schematic
conceptions of the self. To do this within therapy can require
176 Dermatol Psychosom 2004;5:172–177
T1 T3 T4


mean SD mean SD mean SD
13.857 13.520 12.246 12.976 14.109 15.330
18.348 15.334 17.856 16.490 19.232 14.911
9.905 10.718 10.247 13.691 12.823 15.267
time and resources that simply may not be an option in a
group format.
There were no significant physiological benefits produced by
either experimental group. As with earlier work [Papadopou-
los et al., personal data], there was significant and tangible im-
provement in some participants in all three experimental
groups. However, the differences did not extend to between-
group significance. Since the group therapies failed to signifi-
cantly benefit participants psychosocially, it was perhaps not
surprising that there was no physical improvement either. We
are forced to reason that so little is still known about the phys-
iological basis of vitiligo and the relationship between the psy-
chosocial and physiological aspects of stress that a great deal
of further research is required before we are able to make de-
finitive conclusions concerning psychological therapy and dis-
ease physiology.
Richards et al. [2001] showed that only 10% of dermatology
patients would be interested in taking part in a programme
offering psychological assistance and this could have obvious
implications for the success or failure of the therapy trials.
Working with a self-selecting sample, however, is always a
difficulty encountered in psychotherapy research and the
wide range of recruitment sources attempted to ameliorate
this issue. Another aspect of undertaking therapy trials is
that the compliance of each individual to treatment will
vary and this is especially relevant since CBT involves home-
work that is carried out away from the group. The cultural
generalisability of this project is questionable since it was
carried out only in London and only using English speakers.
Future research could test this protocol with different cul-
tural samples.
With respect to the photographic analysis, the procedure is an
effective measure of body area but there are always problems
associated with using a two-dimensional photograph as a rep-
resentation of a three-dimensional body. One problem with
the procedure concerned the fact that it may not have been
sufficiently subtle to detect minor but significant changes in vi-
tiligo pigmentation. Future work should strive to create a
more detailed and accurate procedure.
Acknowledgements
The authors would like to thank The UK Vitiligo Society for their support
with this research.
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