Remember the New Jersey "Tanning Mom," Patricia Krentcil, who was arrested in 2012 for allegedly taking her 5-year-old daughter into a tanning booth? Krentcil, a self-proclaimed "tanorexic" (a slang term used to describe a person who is psychologically or physically dependent on tanning) admits she loves to tan and has been sunbathing and going to tanning beds her whole life.
"I don't know Patricia, and have never talked to her, but at one point I heard she said she just needs to be really dark, and that it's hard for her to not be that way. If her obsession with tanning was putting her children at risk, it seems it got out of control," says Sherry Pagoto, Ph.D., associate professor at the University of Massachusetts Medical School. Pagoto is currently conducting a National Cancer Institute study about why people indoor tan.
Krentcil isn't the only one to go to extreme measures to have dark skin. In fact, despite all the information available to the public about the hazards of sun tanning, especially that ultraviolet rays are a known cancer-causing agent, people still continue to tan. This has led many researchers to believe that factors besides lack of knowledge are driving some people to tan.
A matter of the mind
A recent paper that was published in the March issue of the Journal of the American Academy of Dermatology reveals some reasons behind excessive tanning. The paper discusses results from a study of 533 tanning students at Bowling Green State University. The findings show that being female and screening positive for Obsessive Compulsive Disorder (OCD) -- an anxiety disorder that is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors -- and Body Dysmorphic Disorder (BDD) -- a chronic mental illness in which a person can't stop thinking about a flaw (or imagined flaw) in his or her appearance -- were significantly associated with tanning dependence.
Since tanorexia or tanning addiction are not included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the researchers modified the CAGE alcohol screener from the fourth edition of the manual to identify if participants were considered to have problematic tanning.
When used to screen problematic drinking, CAGE asks the following:
C: Have you ever felt you should cut down on your drinking?
A: Have people annoyed you by criticizing your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
Participants who answered yes to two of the four questions on the tanning-specific version of the CAGE questionnaire were considered to have problematic tanning.
Why BDD and OCD?
Jenifer Cullen, Ph.D., a clinical psychologist in Belmont, Massachusetts who specializes in OCD and BDD, says people with OCD and BDD both show obsessive behavior, but when someone obsesses about a body part or something related to their appearance, then it falls within the category of BDD.
"Some people speculate that Michael Jackson had BDD around the appearance of his nose. The thought is that he kept having surgeries to try to fix what he saw as a flaw," says Cullen. "If somebody has BDD around their skin needing to be a certain color, or they have fears and anxiety that their skin looks too pale, they may head off to tan. Tanning in this sense is what we call a ritual. Once their skin is brown enough then they feel good for a while. When they believe the tan is fading or not the color they want it to be, their anxiety rises again and they head back to the tanning bed."
Not always about looks
When appearance isn't behind the drive to excessively tan, mood altering may be the motivation. Studies over the years have looked at the affect that ultraviolet rays (UV) have on mood, and many researchers and dermatologists believe that UV rays can be addictive.
"I've seen many people who stop tanning once they are diagnosed with skin cancer, but I've also seen patients who continue to tan in beds despite a family history of cancer or being diagnosed with it themselves. For these people it seems logical that they have some sort of dependence on tanning," says Robin Hornung, M.D., MPH, dermatologist at The Everett Clinic in Everett, Washington.
A study published in June in the journal Cell reported that exposing mice to a daily dose of UV light increased their blood levels of beta-endorphins within a week. Beta-endorphins are "feel-good" hormones that affect the same parts of the brain that opioid drugs like heroin and morphine do. Furthermore, when UV light was blocked from these same mice, they showed withdrawal symptoms, including shaking, trembling, and teeth chattering.
A 2006 study published in the Journal of the American Academy of Dermatology looked at similar effects on humans. Researchers gave frequent and occasional tanners the drug naltrexone before they were exposed to UV rays. Naltrexone is given to people with substance dependence to help them overcome opioid addiction by blocking the euphoric effects of drugs and alcohol when taken. After tanning, the participants who were frequent tanners exhibited withdrawal symptoms, including nausea and jitteriness. These symptoms were not observed in participants who occasionally tan.
To further support the notion that tanning may be addictive to some, the latest edition of the Principals of Addiction Medicine, published by the American Society of Addiction Medicine, includes a section on excessive tanning. Clinicians, doctors, and researchers rely on this book to define the terminology of addiction and provide a comprehensive overview of the diagnosis and treatment.
"The section talks about how for many years having pale skin was a sign of affluence and high society and then in 1929 Coco Chanel made a statement that the 1929 girl should have a golden tan. Since then people have associated being tan as looking good," says Susan Blank, M.D., addiction psychiatrist and Founder of the Atlanta Healing Center in Georgia.
Blank adds that the section also stresses ruling out OCD and BDD as the reason for the excessive tanning before treating the behavior as an addiction.
"With OCD, the person has an obsessive thought, and they feel more and more anxious. When they do the behavior, they'll have a release of the anxiety, which lasts for a period of time until they feel they need to engage in the behavior again," explains Blank.
In instances of BDD, Blank agrees with Cullen. "The person is very focused on her body and has shame and anxiety around how she looks. These people tan to 'fix' the color of their skin, which they see as flawed," she says.
If addiction is the reason behind tanning, Blank says the behavior is not anxiety-driven. "I've had patients get in trouble at work because they're leaving to go tan, and many of them get irritable if they can't tan, so they're going to the tanning beds several times a week. They may have anxiety afterwards or guilt and shame, but they're not anxious before they go to tan, they're excited. Before they engage in the action, they're getting 'high' driving to the tanning salon. It's the beginning of euphoria in their mood state as they're making their plan to go use. When they tan, they feel euphoric, energized and happy with their behavior," Blank says.
What are the signs?
Cullen and Blank say the following may be cause for concern:
• Tanning three or four times a week or year-round
• Missing out on important activities, such as work and family commitments to tan
• Becoming anxious when asked not to tan, and saying things like "but I have to" or "I won't feel right if I don't tan"
• Tanning to get their skin a specific color
• Feeling like they don't look tan despite being dark
• Spending a lot of money on tanning and creams to maintain the tan
• Acting defensive if told they're too tan or their skin looks wrinkled
• Being diagnosed with skin cancer, yet still continuing to tan
Pagoto notes that not all tanning is a sign of an underlying mental health issue. "We're not talking about people who temporarily go to a tanning bed because they have a wedding or vacation coming up and they want to look tan. While all tanning is bad for your skin health, when the tanning begins to interfere with their daily commitments and functioning, it may be a sign of a mental health issue as well."
What is a safe amount of tanning?
When it comes to tanning beds, Hornung says there's no safe amount. "I did a study in North Carolina where we measured the amount of ultraviolet light emitted from tanning beds. We looked at UVA [ultraviolet long waves] and UVB [ultraviolet short waves]. On average, in tanning beds UVA was four times the amount compared to noon day sun and UVB was twice the amount of noon day sun in a southern state," she says. "There's a huge amount of radiation in these beds. In addition, people may not realize that when the bulbs are changed in the beds, a brand new bulb can give you extra rays."
This isn't an excuse to "bake" in the sun though, adds Hornung. "While the sun may be safer, think of it this way; being suntan means your skin is literally baking. That's why it's turning brown."
While it's difficult to quantify a healthy amount of sun exposure, Hornung says your skin type may help clue you in. "Having darker skin means you have more pigment in the skin, and that pigment acts like a natural sunscreen to some degree. With that said, someone with darker skin could spend more time in the sun compared to someone who is fair skinned, yet anyone who spends all day in the sun is vulnerable to sunburn or skin cancer if they're not wearing sunscreen and protective clothing," she adds.
The safest bet is to get one's exposure in the morning or later afternoon when the sun isn't as intense. However, if you are going to be in the sun, Hornung recommends sunscreen between SPF 30 to 50. "Anything above this may be giving people a false sense of security. In fact, the Food and Drug Administration is talking about joining other countries and capping the SPF value that is printed on sunscreen to 50 or 50+. In reality, you're not getting much more protection from anything over 50," says Hornung. She also adds that since sunscreens are not perfect, it is also important to wear sun-protective clothing, hats and sunglasses, and to seek shade as much as possible.
What about Vitamin D?
While Hornung says she sees many patients who have vitamin D deficiencies from lack of sunlight, she stresses that sun tanning isn't the only way to get appropriate amounts. "You don't have to brown or bake your skin to get efficient amounts of vitamin D. Little amounts of sun exposure and/or taking supplements can keep people at efficient levels," she says. However, Hornung adds that some people don't absorb Vitamin D supplements well. "It has to be taken with fatty foods, given it is a fat-soluble vitamin, or it won't absorb well," she notes.
Pagoto adds that the kind of UV light in tanning beds is not a good source of vitamin D. "You'd get more vitamin D from the sun. There is no sense in exposing yourself to so much radiation just for a small amount of vitamin D in a tanning bed," she says. "All this talk about vitamin D deficiency can be a setback for skin cancer prevention efforts," Pagoto says.
What treatments can help?
For BDD patients who excessively tan, Cullen says she uses a type of therapy called Exposure and Response Prevention. "We expose them to exactly whatever it is that they fear; in this case, pale skin, and at the same time work with them to resist doing the ritual by weaning them off it, whether that's going tanning or excessively applying bronzer," she says. "If they go once a day, we'd start by having them go every other day. Really what we're getting them to do is to feel the exact thing that they don't want to, as well as getting them to be okay with what they perceive as an imperfection of their body."
The goal isn't to get them to like their skin, adds Cullen. "They may never like the color of their skin, but we're trying to get them to a point to accept their skin without tanning so they can go to work, on dates, socialize and function in society," she says.
For people who tan to mood-alter, Blank says she uses a similar approach. "It's really hard for people to give up what they're dependent on to give them those feel-good rushes. But like with any behavioral addiction, defining abstinence is the key," she says, adding that the Principles of Addiction Medicine suggests sending people to a dermatologist to have their skin damage assessed and having them look at other people to get some idea of what's normal in terms of body color.
Pagoto is looking into another way to reduce tanning in her research with the National Cancer Institute. "In a previous study, we went to beaches to educate tanners about the risks of tanning and encouraged them to use sunless tanners or makeup bronzes instead of sun tanning or going to tanning beds if they felt driven to tan despite the risks. We gave them samples of sunless tanners with a fact sheet on how to use them and had people try it right then and there so they could see the color right away," she says. "The people who were more open to trying the sunless tanners expressed more concerned about the risks of tanning and said they tanned to look good. People who were resistant to using the sunless tanners seemed driven by the way the UV light makes them feel and how it affects their mood. This made us realize that tan skin isn't the only reason people tan, and that's why we started our current study."
In the study of women ages 18 to 30, Pagoto and other researchers are showing participants alternative ways to relieve stress and deal with their body image. "We've discovered that what these women like about tanning is that it relaxes them and makes them feel good about themselves. They've expressed that they get similar feelings from spa-like experiences so we're offering self-care options like massages, yoga, pedicures and manicures as alternative ways to get what they get from tanning. Instead of just saying 'don't tan,' we're trying to figure out other ways to get their needs met," she says.
Results of the study should be available later this year.
Easy to slip through the cracks
While overly-tanned people are easy to spot, they may not find their way to treatment easily. "I don't think people think of tanning as a mental health issue, and those who tan too much most likely are going to avoid the dermatologist, so the issue could easily get missed," says Pagoto. "Primary care physicians may have the best opportunity to spot it since people may go to them for other treatments. Pediatricians should be on the lookout too if they see teenagers with dark tans."
If you're concerned about a loved one, Blank says reach out to his or her healthcare providers. "Even with privacy laws, you can call a person's doctor or therapist and give them information about them. They won't be able to give you information, but you can express your concerns and ask the provider to address them at the person's next appointment," she says.
Can legislation help?
As with cigarettes and alcohol, Hornung says studies show that the earlier people begin to suntan and go to tanning beds, the more likely they'll become dependent on them. "I hope we get to a point where tanning beds are considered as harmful as cigarettes," she says. "I applaud the many states that are moving toward tighter regulations on tanning beds and those that are banning tanning beds among minors."
Anybody second that?
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
Cathy Cassata is a regular contributor to The Fix. She recently wrote about video game addiction and exercise addiction.