Psychological effects of androgenetic alopecia on women: Comparisons with balding men and with female control subjects

Psychological effects of androgenetic alopecia on women: Comparisons with balding men and with female control subjects

Journal of the American Academy of Dermatology October 1993 Cash et al. major late antigen of human cytomegalovirus. Proc Natl Acad Sci 1984;81 :4965...

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Journal of the American Academy of Dermatology October 1993

Cash et al. major late antigen of human cytomegalovirus. Proc Natl Acad Sci 1984;81 :4965-9 . 26. Ruger B, Klages S, Walla B, et a!. Primary structure and transcription of the genes coding for the two virion phosphoproteins pp65 and pp71 of human cytomegalovirus. J ViroI1987;61:446-53. 27. LaFemina R, Hayward GS. Constitutive and retinoic acid-inducible expression of cytomegalovirus mediate early genes in human teratocarcinoma cells. J ViroI1986;58:43440. 28. Pao CC, Yen TSB, You JB, et at. Detection and identification of Mycobacterium tuberculosis by DNA amplification. J Clin MicrobioI1990;28 :1877-80.

29. Sambrook J, Fritsch EF, Maniatis T. Molecular cloning, New York: Cold Spring Harbor Laboratory Press, 1989:5167. 30. Burgess GH, Mehregan AH, Drinnan AJ. Eosinophilic ulcer of the tongue. Arch DermatoI1977;I13:644-5. 31. Mintz GA, Rose SL. Diagnosis of oral herpes simplex virus infections: practical aspects of viral culture. Oral Surg Oral Med Oral Pathol 1984;58:486-92. 32. Kameyama T, Rutami M, Nakayoshi N, et al. Shedding of herpes simiplex virus type 1 into saliva in patients with orofacial fracture. J Med Viral \989;28:78-80.

Psychological effects of androgenetic alopecia on women: Comparisons with balding men and with female control subjects Thomas F. Cash, Phl)," Vera H. Price, MD,b and Ronald C. Savin, MDC Norfolk, Virginia;

San Francisco, California; and New Haven, Connecticut Background: Several studies have examined the psychological impact of androgenetic alopecia on men but scientific evidence is absent regarding its effects on women. Objective: Our purpose was La determine the psychosocial sequelae of androgenetic alopecia in women and, comparatively, in men. Methods: Subjects were newly referred patients with androgenetic alopecia (96 women and 60 men) and 56 female control patients. Subjects completed standardized questionnaires to assess their psychological reactions to their respective conditions and to measure body image, personality, and adjustment. Results: Androgenetic alopecia clearly was a stressful experience for both sexes, but substantially more distressing for women. Relative to control subjects, women with androgenetic alopecia possessed a more negative body image and a pattern of less adaptive functioning. Specific correlates of the adversity of patients' hair-loss experiences were identified. Conclusion: The results confirm the psychologically detrimental effects of androgenetic alopecia, especially on women. The implications for patient care are discussed. (J AM ACAD DERMATOL 1993;29:568-75.) Recent research has delineated the psychosocial effects of androgenetic alopecia on men. 1-4 As one study revealed.I male-pattern baldness represents an From the Department of Psychology, Old Dominion University, Norfo1k"; and the Departments of Dermatology, Kaiser Perrnanente Medical Center, San Francisco.P and Yale University , New Haven," Supported by a grant from The Upjohn Company, Kalamazoo, Mich. Accepted for publication April 19, 1993. Reprint requests: Thomas F. Cash , PhD, Department of Psychology, Old Dominion University, Norfolk, VA 23529-0267. Copyright w 1993 by the American Academy of Dermatology, Inc. 0190-9622/93 $1.00


+ .10


unwanted and moderately stressful experience for most men. Although hair loss diminishes their body-image satisfaction, balding men actively cope with their distress, and most seem to retain the integrity of their personality functioning. Androgenetic alopecia in women is a hereditary hair-loss pattern of diffuse central thinning. There is a surprising lack of research on its psychosocial sequelae in women. Extant evidence- indicates that, relative to men, women have a greater psychological investment in their appearance and are especially reactive to appearance-disrupting events. Women's

Journal of the American Academy of Dermatology Volume 29, Number 4

hair is imbued with special cultural and personal meanings related to gender identity, sexuality, and attractiveness. Moreover, because of a more visible hair-loss pattern and a greater public awareness of this condition in men than in women, it may be regarded as more "normal" or expected for and by men. Therefore, relative to men, women are hypothesized to experience the condition as especially stressful and threatening to their body image and sense of self. The current research compared the psychosocial effects of androgenetic alopecia on men versus women and further compared the latter with afemale control group. The study also examined correlates of patients' psychological reactions to hair loss, METHODS

Subjects Three groups of patients (N = 212) were paid volunteers, selected from each of two dermatology centers in San Francisco and New Haven. They were consecutive referrals or private patients who met the study's diagnostic and treatment criteria. The female androgenetic alopecia (FAA) group of 96 women averaged 36.6 years old and were predominantly white (78%); 50% were unmarried. The male androgenetic alopecia (MAA) group of 60 men averaged 31.3 years old and were mostly white (78%); 70% were unmarried. On participating, 80% were not yet in treatment and 20% had just begun treatment (for an average of less than 2 weeks). Otherwise, 98% had no prior hairloss treatment. Dermatologists' Ludwig ratings of patients with FAA classified 53% as grade I, 42% as grade II, and 4% as grade III. Their Norwood-Hamilton ratings of patients with MAA indicated 50% types II or ITa, 33% types III, lIla, or IIIv, and 17% types IV to VII. The female control subjects (Fe) were 56 women without androgenetic alopecia, who sought treatment for cutaneous conditions that were notpublicly visible (especially not on the head or face) and were not sexually transmitted diseases. The majority had nevi (15), seborrheic keratoses (12), warts (9), skin tags (4), or cysts (3). Other conditions represented were tinea pedis, keloids, lipoma, eczema, psoriasis, dermatitis, and fungal infections. FC patients were comparable to the FAA group in age (mean 37.2 years), race (82% white), and marital status (54% unmarried).

Procedure and assessments Qualified patients received a precoded packet containing a cover letter, informed consent form, the study's

Cash et al. 569 questionnaires, and an envelope to return the anonymously completed materials to the principal investigator. Of the 219 volunteers, compliance rates were 93% for the FAA group and 100% for both MAA and FC groups.

Measures of body image, personality, and psychosocial adjustment Standardized inventories were administered. The 13item Social Desirability Scale'' provides a validity index, assessing the influence of defensive response sets. The 69item Multidimensional Body-Self Relations Questionnaire (MBSRQ)?' 8 assesses multiple facets of body-image attitudes-including the Appearance Evaluation scale to measure feelings of attractiveness and satisfaction with one's overall appearance, the specific Hair Satisfaction scale, and the Appearance Orientation scale to assess the extent of psychological investment in appearance. The 16-item Texas Social Behavior Inventory? assesses social self-esteem. The 24-item Levenson Locus of Control Scale (LaC) 10 measures internality (belief in self-determined control over life events), chance externality (belief that life events are largely controlled by fate, chance, or circumstances), and powerful others externality (belief that powerful people and institutions control one's life). The 13-item Self-Consciousness Scale! I, 12 assesses the intensity of self-as-object experiences in social contexts (i.e., public self-consciousness) and social anxiety. Two multiple-item indices (a total of 10 items) assess subjects' life satisfactionl' and psychosocial well-being.f The 15item Impact of Event Scale l 4, 15 measures the past-week stressfulness of the condition for which the patient was consulting the physician.

Measures of psychosocial reactions to hair loss These instruments were administered to FAA and MAA patients to assess perceptions, feelings, and reactions concerning their hair loss. The Hair Loss Information Questionnaire (HLIQ), adapted from previous research.? contains items (including Ludwig and NorwoodHamilton charts) for self-description ofvarious aspects of reactions to past, recent, and future hair loss. The Hair Loss Effects Questionnaire (HLEQ)2 assesses the psychosocial effects that patients attribute to their hair loss. Each of 69 effects is rated on a 5-point scale (from - 2 "much less" to 0 = "no change" to +2 = "much more"). Itern analyses of the HLEQ revealed three multiple-item subscales: (1) Adverse Psychosocial Effects (i.e., cognitive, emotional, and social events), (2) Positive Events, and (3) Behavioral Coping. For the present samples, all instruments were acceptably reliable (Cronbach's alphas of .78 to .96). Regarding validity, influences of socially desirable responding were negligible.


Journal of the American Academy of Dermatology October 1993

570 Cash et al. Table I. Comparisons of female (FAA) and m ale (MAA) androgenetic alopecia patients on degrees of past and current reactions to their hair loss

Table II. Comparisons of FAA and MAA patients on the specific effects attributed to hair loss

Group Pa st and current reactions

Past negative effects Means (SDs) Modestly to moderately negative (%) Very to extremely negative (%) Current negative effects Means (SDs) Modestly to moderately negative (%) Very to extremely negative (%) Past emotional distress Means (SDs) Modestly to moderately upset


Group MAA

Adverse 2.74 (1.35) 2.22 ( 1.08) 58 49


2.64 (1 .27) 60


2.17 (1.02)




3.84 (0.99) 2.90 (1.02) 67 30


Very to extremely 28 70 upset (%) Current emotional distress 3.59 (1.00) 2.73 (1 .06) Means (SDs) Modestly to 62 47 moderately upset (%) 27 Very to extremely 52 upset (%) NOTE : On each variable, FAA and MAA groups significantly differ. Statistical comparisons are given in the text.

RESULTS The psychological experience of hair loss: Women versus men FAA and MAA groups were compared on four HLIQ items: the general effect of hair loss on their lives, in the past and present, and their degree of emotional upset about the hair loss, in the past and present. Then, on the HLEQ, groups were compared on the specific psychosocial effects that they attributed to their hair loss. Table I summarizes the results. General effects. On scales from 1 = "no negative effect" to 5 = "extremely negative effect," patients rated the past and the current effects of their hair loss on their lives. A 2 (FAA vs MAA) X 2 (past vs current effects) analysis of variance (ANOVA) revealed that women reported more adverse past and current effects than did men (F[l,154] = 6.31,

P < 0.02).

Effects attributed to hair loss


Positive events Behavioral coping

FAA 1.09 (0.4 8)

-0.22 (0.47) 0.95 (0.44)




0.89 (0.4 5) -0.07 (0.46) 0.69 (0.42)

6.23* 3.63t 13.35*

General distress. On scales, from 1 = "not at all upset" to 5 = "extremely upset," patients indicated both past and current effects of hair loss on their lives. The 2 X 2 ANOVA revealed that for both past and present distress, women reported being more upset than men did (F[l,154] = 34.05, P < 0.001). Both sexes regarded their past distress as even more intense than their current distress (F[ 1, 154] =

11.43, P < 0.001). Specific effects attributed to hair loss. The HLEQ contains three reliable, multiple-item subscales: (1) Adverse Psychosocial Effects, (2) Positive Events, and (3) Behavioral Coping. Because a multivariate analysis of variance (MANOVA) comparing FAA and MAA groups indicated a significant difference (p < 0.01), univariate ANOVAs were conducted for each subscale. As shown in Table II, F AAs experienced more adverse psychosocial effects of h air loss, a slightly greater reduction of positive life events, and more cop ing efforts than did MAAs. For descriptive purposes, Table III lists experiences reported by the majority of FAA or MAA patients. For each HLEQ event, percentages were calculated of the FAA and MAA subjects who reported an increase (i.e., rating of + lor +2) or a decrease (i .e., rating of -lor - 2), depending on which was more prevalent. Of the 69 HLEQ items, 35 were reported by most F AAs, 37 by most MAAs, and 32 by the majority of both sexes. Another comparison was carried out between the MAA sample and a nonclinical sample of 103 balding men from previous research.l For each sample, the percentage of men was determined who reported increased adversity on each of the 28 Adverse Effects items. Levels of preoccupation and distress were clearly higher in the present sample than in the

Journal of theAmerican Academy of Dermatology Volume 29, Number 4

Cash et al. 571

Table III. Description of FAA and MAA patients ' specific effects attributed to hair loss FAA Effects attributed to hair loss

( %)

Table III. Cont'd

MAA (%)

Adverse effects

Wish that I had more hair. Think about my hair loss. Try to figure out if I am losing more hair (e.g., by inspecting my head, my brush, my sink) Feel frustrated or helpless about my hair loss. Spend time looking at my hair/head in the mirror. Worry about my looks. Feel self-conscious about my looks. Have negative thoughts about my hairjhead. Worry about whether others will notice my hair loss. Worry about how much hair I am goingto lose. Notice people who are balding. Think about how I used to look. Notice what other people look like. Have the thought, "Why me?" Think that I am not as attractiveas I used to be. Wonder what other people think about my looks. Have thoughts that I am unattractive. Try to imagine what I would look like with more hair loss. Feel sexy looking. Feel depressed or despondent. Worry about getting older. Worry that my spouse or partner will find me less attractive. Feel embarrassment. Feel envious of good-looking people of my sex. Feel physically attractive. Feel sensitive to personal criticism. Am conscious of how others react to me. Feel I look older than I am. People comment about my hair loss. Get friendly teasing or kidding from others.

98 97 95

90 93 87















83 78 78



90 73


68 73







-65 63 62 60

-35 38 62 52

55 53


-53 50

-35 53



42 36

70 65




NOTE: Positive percentages refer to the percentage of each group who

reported an increase in the event (i.e., + 1 or +2 rating). Similarly, negative percentages reflect report ed decreases (i.e., - lor -2 rating) in events. Of th e 69-item ]-]LEQ, only those items endorsed by a maj ority of FAA and /or MAA patients are listed.

Effeets attributed to hair loss





Behavioral coping

Try to figure out what to do about my hair loss. Try to hidemy hair loss. Talk to my hairstylist/barber about myhair loss. Try to improve my hairstyle. Do thingsto improve my looks. Talk to friends of my own sex about my hair loss. Spend timeon my appearance. Talk to my partner about my hair loss. Seek reassurance about my looks. Try to improve my figure or physique.



94 82

63 58

79 75 71

63 55 52

70 64

55 57





nonclinical sample (z = 9.07, p < 0.001). The majority of the MAA group reported increased adversity on 24 (86%) of the 28 items. In contrast, the majority of the nonclinical sample endorsed only 12 items ( 4 3%). Thus men seekingmedical help for hair lossmay be moredistressed by the condition than the "typical balding man." Comparisons of androgenetic alopecia groups and female control subjects Stress. The Impact of Event Scale was administered to all subjectsto compare androgenetic alopecia and FC patients with respect to both the intrusion and avoidance of stress caused by their respective conditions during the past week. Given a significant MANGV A effect of groups (p < 0.001), ANOVAs and Newman-Keuls tests were conducted for each stress scale. As Table IV indicates, FAA patients reported more intrusion and avoidance of stress th an did either the MAA or FC group Cps < 0.001); MAA patients reported more stress than Fe patients Cps < 0.00l). Body image. Analyses compared the three groups on the MBSRQ body-image scales. A MANOVA revealed a significant effect of groups (p < 0.00 1), as did each subsequent univariate ANOVA. Table V summarizes the comparisons. On Appearance Evaluation, FAA patients reported more negative feelings about their appearance than did either MAA or Fe patients whodidnot differ. On Hair Satisfaction, FAA patients were more dissatisfied than MAA

Journal of the American Academy of Dermatology October 1993

572 Cash et al.

Table IV. Comparisons of FAA, MAA, and female control (FC) groups on the past-week stressfulness of their conditions Group Stress index

Stress intrusion Stress avoidance




F ratio

10.55a (5.75) 10.82a (5.14)

7.65b (4.70) 8.75b (5,42)

2.64c (3.79) 3.41c (4.31)

43.89* 38.33*

Data expressed as meanwithstandarddeviation given in parentheses. NOTE: Row means not sharinga common superscript (a, b, c) are significantly different (p < 0.05). *p
Table V. Comparisons of FAA, MAA, and FC groups on measures of body image, personality, and psychosocial adjustment Group Body image, personality, and adjustment measures

Hair satisfaction Appearance evaluation Appearance orientation Self-esteem Social anxiety Public self-consciousness LOC-Internality LOC-Chance LOC-Powerfulothers Life satisfaction Psychosocial well-being

FAA 3.15a (0.67) 3.94u (0.67) 54.5u (11.6) 10.08a (4.64) 15.56 (4.26) 36.1a (5.0) 22.7a (5.8)


(6.5) 20.0u (6.7) 3.9l a (0.92)




2.27b (0.88) 3.80b (0.63) 3.60b (0.63) 58.8b (9.1) 8,47b (4.27) 15.58 (4,44) 38.0b (5.0) 21.8u (6.3) 23,4u (7.0) 22.7b (5.3) 4.52b (0.66)


F ratio

3.73c (1.10) 3.55b (0.63) 3.92u (0.63) 59.3b (9.1) 7.79b (4.16) 14.84 (4.28) 37.7b

66.05* 14.26* 5.74t 4.66t 5,45t <1 3.99:1:


19.5 b (6.1) 19.0b (6.0) 23,4b (6.8) 4.62b (0.92)

5.00t 6.65t 6.03t 15.26*

LOC, Locusof control. NOTE: Row means not sharing a common superscript (a, b, c) are significanliy different (p < 0.05). *p < 0.001.

tp < 0.01. +p
patients, and both were more dissatisfied than was the FC group. Personalityjpsychosocial adjustment. Because the MANDVA was significant comparing groups on personality/adjustment measures (p < 0.00 1), ANDVAs were conducted on each measure. As Table V shows, relative to controls, the FAA patients faired less well on seven of eight measures.

The FAA patients reported more externality and less internality in locus of control, higher social anxiety, lower self-esteem, poorer psychosocial wellbeing, and less life satisfaction. FAA and MAA patients differed on five measures. FAA patients reported less internality, higher social anxiety, poorer self-esteem and well-being, and less life satisfaction.

Journal of the American Academy of Dermatology Volume 29, Number 4

Correlates of psychological reactions to hair loss The HLEQ Adverse Effects scalewasselected as the mostcomprehensive indexto examine correlates of the psychological reactions to hair loss. The first set of Pearson correlations was between hair-loss parameters and the adversity of its effects. Most apparent in Table VI are four basic findings: (l) For both sexes, the greater the percentage of hair loss they perceived theyhad,the worse itseffects. (2) The more hair loss theyexpected to occurduringthe next decade, the moreadversity theyreported. (3) Among men, earlier onsets were related to more adverse effects. (4) The extent of adversity experienced by patients could not be predicted by dermatologists' LudwigjN orwood-Hamilton ratings. The second set of correlations in Table VI describes associations between body image/personality/adjustment and the adversity of hair loss. With the exception of locusof control, each measurewas significantly relatedto thestress/ distress ofhair loss. Because someempiricaloverlap exists among these predictors, their associations with the stress of hair loss are not independent. Accordingly, multiple stepwise regressions discerned the optimalindependent prediction of HLEQ Adverse Effects from hair-loss factors and body image, personality, and adjustmentvariables. F-to-enter at eachstepwasset at p < 0.05. FAA patients most negatively affected by hair loss werelesswell-adjusted women whohad considerable investment in appearanceandexpected their alopecia to progress (R = 0.51, p < 0.001). MAA patients most adversely affected were more socially self-conscious, more poorly adjusted, more dissatisfied withtheir hair,and moreinvested intheir appearance (R = 0.69, p < 0.001). DISCUSSION

This research revealed strikingly deleterious psychosocial effects ofandrogenetic alopecia onwomen. The vastmajorityreported that hair loss engendered considerable anxious preoccupation, helplessness, and feelings of diminished attractiveness. These women worried that others would notice their hair loss and that the condition would progress and become more socially noticeable. Such stress also gaveriseto active coping efforts. Most soughtinformation and selective social support, struggled to control their disruptive negative thoughts and feelings about their condition, tried to conceal hair loss with altered hairstyling, and engaged in compensa-

Cash et al. 573

Table VI. Correlations with the HLEQ adverse effects scale Group Correlate


Hair-loss parameters Ludwig/Norwood 0.07 diagnosis Ludwig/Norwood 0.22* self-rating Self-rated percent hair loss o.sot Age at onset 0.02 Expected future hair loss 0.31t Body image/personality/adjustment Appearance orientation 0.25* Appearance evaluation -0.29t Hairsatisfaction -0.28t Public self-consciousness 0.28t LOC-Internality -0.09 LOC-Chance 0.21 LOC-Powerfulothers 0.17 Self-esteem -0.26* Social anxiety 0.07 Psychosocial well-being -0.36:1: Life satisfaction -0.22*



-0.04 0.26* -0.26* 0.29* 0.42+ -0.38t -0.48:1:

0.54+ -0.10 -0.01 0.21 -0.33*

0.37t -0.34t -0.10

LOC, Locus of control. "'p<0.05.

tory grooming activities to try to restore their bodyimage integrity. The experience of androgenetic alopecia wasclearly moredisturbing tothesewomen than was true of a matched control group with regard to their less visible cutaneous conditions. The psychological impactof androgenetic alopecia is more severe for women than for men. Compared withmen, about twice as many (and the majority of) women expressed that they were either "very" or "extremely upset" by their hair loss. On the HLEQ, women alsoreported significantly more negative psychosocial effects and more coping efforts than mendid. In fact, the onlyeffects that may be more difficult for men are the receipt of more teasing and social comments about their hair loss and men'sbeliefthat hairloss agestheirappearance more (see Table III). Further evidence of the negative influence of androgenetic alopecia on women appears in the differences between these women andthe FC patients on body image and psychosocial adjustment. Relative to controls, women with androgenetic alopecia not only had muchmore dissatisfaction with their hair,

574 Cash et al. but they experienced more negative overall bodyimage feelings as well. In addition, they reported more social anxiety, poorer self-esteem and psychosocial well-being, lessof a sense of control over their lives, and a less satisfying quality of life. Although it is not unreasonable to infer that the functioning ofFAA patients was diminished by their experience of hair loss, an alternative explanation is that those who were premorbidly more poorly adjusted were more likelyto seek medical help. Whatever the proper causal conclusions, the data are unequivocal on a practical, clinical level; women consulting dermatologists about androgenetic alopecia are much more distressed than the typical patient represented by our control sample. Their intense concerns require special clinical sensitivity by the physician. 16 More than one fourth of the men conveyed that their hair loss was extremely upsetting. An additional 62% expressed modest to moderate emotional distress. Cash- previouslysurveyed balding men who were not seeking dermatologic treatment. A comparison with the present MAA group supports the prediction that distress would be significantly higher in a treatment-seeking sample than in a random sample of balding men. Correlates of the degree of psychological adversity of hair loss were evident for both sexes. Perhaps the best description of these relationships emerged from the regression analyses. Those women most distressed by hair loss were more poorly adjusted, had considerable investment in their appearance, and expected their hair lossto progress. Replicating previous findings.? the men affected most adversely by their hair loss were more publicly self-conscious, poorly adjusted, strongly dissatisfied with their hair, and more invested in their appearance. Again, these correlates cannot be assigned a causal role in persons' psychological reactions to hair loss. Nevertheless, our data are consistent with an explanatory model of the origin of body-image disturbances. v 17, * Patients with androgenetic alopecia struggle to cope with the resultant distress. They worry that the condition and their own physical acceptability will worsen. They search for ways to halt or reverse the course of their condition and to restore their body*CashTF,Physical appearance, body image, and hair loss: thebody in the mind's eye. Presentation at the meeting "Hair Loss in Women: TheDiagnosis and Treatment ofAndrogenelic Alopecia," Chicago, Ill. Sponsored by TheUpjohn Company, Nov. 15-17, 1990.

Journal of the American Academy of Dermatology October 1993

image integrity. Neither sex escapes the difficulties caused by hair loss. However, for women, androgenetic alopecia, coming as an unfamiliar and uncertain plight, is more stressful and disruptive of a sense of well-being. Physicians should recognize that androgenetic alopecia goes well beyond the mere physical aspects of hair loss and growth. As has been observed for other appearance-altering conditions," we found that patients' psychological reactions to hair loss were less related to clinicians' ratings than to patients' own perceptions of their extent of hair loss. Even in patients with slight hair loss, that loss is imbued with considerable emotional meaning that the physicians should not ignore. The losses at stake and gains to be had pertain not only to hair but, from the patient's perspective, are also felt in the quality of life. In addition to medical or surgical treatments and nonsurgical hair replacements, psychotherapeutic assistance may be valuable in the management of some patients' body-image difficulties.5, 17, 19 REFERENCES 1. Cash TF. Losing hair, losing points? The effects of male pattern baldness onsocialimpression formation.J ApplSoc PsycholI990;20:154-67. 2. Cash TF. The psychological effects of androgenetic alopecia in men. J AM ACAD DERMATOL 1992;26:926-31. 3. Franzoi SL, Anderson J, Frommelt S. Individual differencesin men'sperceptions ofand reactionsto thinninghair, J Soc PsycholI990;130:209-18. 4. van der DonkJ, PasschierJ, Dutree-MeulenbergROGM, et a1. Psychologic characteristics of men with alopeciaandrogenetica and their modification. Int J Dermatol 1991 ;30:22-8. 5. Cash TF, PruzinskyT, eds.Bodyimages: development, deviance, and change. New York: GUilford, 1990. 6. Zook A, Sipps GJ. Cross-validation of a short form of the Marlowe-Crowne SocialDesirability Scale. J ClinPsychol 1985;41:236-8. 7. Brown TA, Cash TF, Mikulka PJ. Attitudinal body-image assessment: factor analysis of the Body-Self Relations Questionnaire. J Pers Assess 1990;55:135-44. 8. Cash TF, Winstead BW, Janda LH. The great American shape-up: bodyimage survey report.PsycholToday 1986; 20(4):30-7. 9. Helmreich R, Stapp J. Short formsof the TexasSocialBehavior Inventory (TSBI): an objective measure of selfesteem. Bull Psychonomic Soc 1974;4:473-5. 10. Levenson H. Multidimensional locus of control in psychiatric patients. J Consult Clin Psychol 1973;41 :397-404. 11 . Buss AH. Self-consciousness and socialanxiety. San Francisco: Freeman, 1980. ]2. Scheier MF, Carver es. The Self-Consciousness Scale: a revised version for use with general populations. J ApplSoc Psycho! 1985;15:687-99. 13. Deiner E, EmmonsRA, Larsen RJ, et a1. The Satisfaction with Life Scale. J Pers Assess 1985;49:71-5. 14. Horowitz MJ, Wilner N, Alvarez W. Impact of Event

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Scale: a measure of subjective stress. Psychol Moo 1979; 41:209-18. 15. Zilberg NJ, Weiss DS, Horowitz MJ. Impact of Event Scale:a cross-validation studyand someempirical evidence supporting a conceptual model of stress response syndromes. J Consult Clin Psychol 1982;50:407-14. 16. Van Moffaert M. Training future dermatologists in psychodermatology. Gen Hosp Psychiatry 1986;8:115-8. 17. CashTF. Body-image therapy: a program forself-directed change. New York: Guilford, 1991.

Cash et al. 575 18. Pruzinsky T, Cash TF. Medical interventions for the enhancement of adolescents' physical appearance: implications for social competence. In: Gullotta TP, Adams GR, Montemayor R, eds. Developing social competency in adolescence. Newbury Park, Calif: Sage, 1990:220-42. 19. CashTF, Butters JW. Poorbody image:helping the patient tochange. MooAspects HumanSexuality 1988;22(6):6770.


All dermatology residents are now referred to as Graduate Members of the AAD.

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