Chronic idiopathic urticaria, psychological co-morbidity and posttraumatic stress: the impact of alexithymia and repression

[Which augmentation and trigger factors are relevant in urticaria?]

The aim of this review is to present relevant trigger as well as augmentation factors that can induce or exacerbate urticaria on the basis of a current, PubMed-based literature search. In addition to a brief description of relevant influencing factors in acute and chronic inducible urticaria, the focus will be on chronic spontaneous urticaria. In particular, the aggravating role of medication, stress, food, psychological and metabolic comorbidities, infections and inflammation as well as hormonal processes will be discussed.

Psychosocial factors and chronic spontaneous urticaria: a systematic review

BACKGROUND

Psychosocial factors have been informally associated with Chronic Spontaneous Urticaria (CSU); however, the relationship between psychosocial factors and CSU remains relatively unexplored in the scientific literature.

OBJECTIVE

This review aims to provide an evaluation of peer reviewed studies exploring psychosocial factors and CSU.

METHODS

A systematic search was performed over four databases identifying studies exploring psychosocial factors in relation to CSU published between the years 1995 and 2022.

RESULTS

Eighteen studies were included for narrative analysis, and 33 psychosocial factors were identified. These were split into two subgroups: psychosocial factors that were associated with CSU symptoms aggravation/onset (n = 20), and psychosocial factors expected to be impacted by CSU symptoms (n = 13).

CONCLUSION

This review has highlighted a need for more research and interventions to support individuals with psychosocial factors involved in CSU.

Two-year impact of COVID-19 pandemic on hospitalized patients with skin diseases in China

To investigate the clinical characteristics of skin disorders among hospitalized patients before and during the coronavirus disease 2019 (COVID-19) pandemic, a retrospective study was conducted based on hospitalized patients with skin diseases from Xiangya Hospital of Central South University, the largest hospital in the south-central region of China, between January 1, 2018, and December 31, 2021. A total of 3039 hospitalized patients were enrolled in the study, including 1681 patients in the prepandemic group and 1358 patients in the pandemic group. The total number of hospitalized patients in the pandemic group decreased by 19.2%, with an increased proportion of patients over 60 years of age (39.8% vs. 35.8%). Moreover, compared with the prepandemic group, there were decreases in the occurrence of most skin diseases in the pandemic group, but the proportions of keratinolytic carcinoma (6.6% vs. 5.2%), dermatitis (24.0% vs. 18.9%), and psoriasis (18.0% vs. 14.8%) were higher in the pandemic group. In addition, longer hospital stays (β = 0.07, SE = 0.02, P = 1.35 × 10^-3 ) and higher hospital costs (β = 0.06, SE = 0.03, p = 0.031) were found in the pandemic group through general linear models, even after the corresponding adjustment. In summary, the COVID-19 pandemic has had a lasting impact on patients with skin diseases, with fewer hospitalized patients, increased proportions of older patients, longer hospital stays, and increased hospital costs. These findings will facilitate better preparation for the most effective response to future pandemics.

Asthma and posttraumatic stress disorder (PTSD): Emerging links, potential models and mechanisms

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating mental health condition. A better understanding of contributory neurobiological mechanisms will lead to effective treatments, improving quality of life for patients. Given that not all trauma-exposed individuals develop PTSD, identification of pre-trauma susceptibility factors that can modulate posttraumatic outcomes is important. Recent clinical evidence supports a strong link between inflammatory conditions and PTSD. A particularly strong association has been reported between asthma and PTSD prevalence and severity. Unlike many other PTSD-comorbid inflammatory conditions, asthma often develops in children, sensitizing them to subsequent posttraumatic pathology throughout their lifetime. Currently, there is a significant need to understand the neurobiology, shared mechanisms, and inflammatory mediators that may contribute to comorbid asthma and PTSD. Here, we provide a translational perspective of asthma and PTSD risk and comorbidity, focusing on clinical associations, relevant rodent paradigms and potential mechanisms that may translate asthma-associated inflammation to PTSD development.

Psychological impact of the COVID-19 pandemic on patients with allergic diseases

BACKGROUND

On March 2020, World Health Organization (WHO) declared COVID-19 to be a pandemic disease. Interactions between allergy-related inflammatory and psychiatric disorders including depression, anxiety, and post-traumatic stress disorder (PTSD) have been documented. Therefore, those who have pre-existing allergic conditions may have an increased psychiatric reaction to the stresses of the COVID-19 pandemic.

OBJECTIVE

Identify the psychological impact of COVID-19 in patients with allergic diseases and determine if these individuals have a greater risk of presenting with post-traumatic stress disorder (PTSD).

METHODS

It is a cross-sectional, survey-based study designed to assess the degree of symptoms of depression and the risk of PTSD using the Patient Health Questionnaire (PHQ-9) and the Impact of Event Scale-Revised (IES-R), respectively, in allergic patients.

RESULTS

A total of 4106 surveys were evaluated; 1656 (40.3%) were patients with allergic disease, and 2450 (59.7%) were non-allergic (control) individuals. Of those with allergies, 76.6% had respiratory allergic disease including asthma and allergic rhinitis. Individuals with allergic disease reported higher scores regarding symptoms of PTSD on the IES-R scale (p = 0.052, OR 1.24 CI 0.99-1.55) as well as a higher depression risk score in the PHQ-9 questionnaire (mean 6.82 vs. 5.28) p = 0.000 z = -8.76.The allergy group presented a higher score in the IES-R questionnaire (mean 25.42 vs. 20.59), being more susceptible to presenting PTSD (p = 0.000, z = -7.774).The individuals with allergic conditions were further divided into subgroups of those with respiratory allergies such as allergic rhinitis and asthma vs those with non-respiratory allergies such as drug and food allergy, urticaria and atopic dermatitis. This subgroup analysis compares respiratory versus non-respiratory allergic patients, with similar results on the IES-R (mean 25.87 vs 23.9) p = 0.0124, z = -1.539. There was no significant difference on intrusion (p = 0.061, z = -1.873) and avoidance (p = 0.767, z = -0.297), but in the hyperarousal subscale, patients with respiratory allergy had higher scores (mean 1.15 vs. 0.99) p = 0.013 z = -2.486.

CONCLUSIONS

Psychological consequences such as depression and reported PTSD are present during the COVID-19 pandemic causing an impact particularly in individuals with allergic diseases. If we acknowledge the impact and how it is affecting our patients, we are able to implement interventions, follow up, and contribute to their overall well-being.

Patients with chronic urticaria have a higher risk of psychiatric disorders: a population-based study

BACKGROUND

The prevalence of psychiatric comorbidities in patients with chronic urticaria (CU) in a national population is largely unknown.

OBJECTIVES

To investigate the prevalence of psychiatric disorders and psychiatric medication use in patients with CU in Taiwan.

METHODS

Data were sourced from Taiwan's National Health Insurance Research Database for 2011. Patients who had a primary/secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 708·1, 708·8 or 708·9 during 2011 with at least two outpatient visits and an antihistamine prescription were identified as CU cases. Patients with CU were classified into three disease severity groups according to their medication types. Psychiatric disorders were identified by patients having three outpatient visits with a primary or secondary diagnosis of a given psychiatric disease. Psychiatric medication use was defined by having at least four outpatient visits with prescriptions for anxiolytics, antidepressants or sleeping pills in 2010 or 2011.

RESULTS

Of the 167 132 patients with CU, 82·5% had mild CU, 17·0% had moderate CU and 0·4% had severe CU. Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication prescription than control groups. The relative risk (RR) of psychiatric disorders was 1·43 for patients with mild, 1·50 for patients with moderate and 2·32 for patients with severe CU vs. the controls (P < 0·001). For psychiatric medication prescription, the RRs were 1·95, 2·70 and 2·09, respectively, vs. controls (P < 0·001).

CONCLUSIONS

Patients with CU had a higher prevalence and risk of psychiatric disorders and psychiatric medication prescription than control groups. What's already known about this topic? Previous studies have shown a high prevalence of psychiatric comorbidities in patients with chronic urticaria (CU), with rates ranging from 35% to 60%. Anxiety, depression and somatoform disorders have been reported as the most prevalent mental disorders in patients with CU. What does this study add? Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication use than control groups in the general population. The relative risk (RR) of psychiatric disorders was 1·43 for those with mild CU, 1·50 for those with moderate CU and 2·32 for those with severe CU vs. controls. The RR for psychiatric medication use was 1·95 for those with mild CU, 2·70 for those with moderate CU and 2·09 for those with severe CU vs. controls. Mental health evaluations and management are important elements in CU management.

Post-traumatic stress disorder and asthma risk: A nationwide longitudinal study

BACKGROUND

Increasing evidence suggests that post-traumatic stress disorder (PTSD) interferes with the immunological system and is correlated with cardiovascular disease, respiratory disease, and chronic pain conditions. However, the association between PTSD and asthma remains unknown.

METHODS

A total of 5518 patients with PTSD and 22,072 age- and sex-matched healthy individuals were enrolled between 2001 and 2009 and followed until the end of 2011. Individuals who developed asthma during the follow-up period were identified.

RESULTS

During the follow-up period, the patients with PTSD had an increased risk of asthma (hazard ratio [HR] = 2.27), particularly those belonging to the youngest age group (HR = 4.01). The findings were consistent in subsequent sensitivity analyses after the exclusion of the first year of surveillance or allergic disorders.

DISCUSSION

This study showed a significant link between PTSD and asthma after adjusting for demographic data and related comorbidities. The risk of developing asthma in patients with PTSD was consistently higher than that in the controls during the study period. Additional studies are necessary to clarify the underlying mechanisms involved in this association between PTSD and asthma.

Posttraumatic Stress Disorder and Chronic Idiopathic URTICARIA: the Role of Coping and Personality

This study compared the severity of chronic idiopathic urticaria (CIU) and psychiatric symptoms between patients with different levels of posttraumatic stress disorder (PTSD) and investigated a model depicting the interrelationship between PTSD from past trauma, personality traits, coping strategies, CIU severity and psychiatric symptom severity. One hundred CIU and 60 allergy patients participated in the study, completing measures on PTSD, psychiatric symptoms, personality traits and coping strategies. The results showed that for CIU patients, 7%, 40 and 34% met the diagnostic criteria for no-PTSD, partial-PTSD and full-PTSD respectively whereas for allergy patients, 15%, 45 and 18% met the same criteria. Apart from CIU, psychiatric symptom severity differed significantly between diagnostic groups. PTSD was associated with coping strategies which were in turn associated with CIU severity and psychiatric symptom severity. PTSD was not significantly associated with personality. Emotion-focused coping mediated PTSD and CIU severity, PTSD and psychiatric symptom severity and neuroticism and CIU severity. To conclude, psychiatric symptom severity varies depending on the level of PTSD among CIU patients. Neurotic patients with a high level of PTSD from past trauma show raised CIU and psychiatric symptom severity when using emotion-focused coping strategies.

Association between sleep disorders and subsequent chronic spontaneous urticaria development: A population-based cohort study

Patients with chronic spontaneous urticaria (CSU) often have sleep disorders (SDs) because of pruritus. However, SDs might also contribute to the development of CSU. Here, we present the first population-based cohort study on the association between SDs and subsequent CSU development.This study investigated whether SDs increase the risk of CSU by using a population-based database in Taiwan.This retrospective matched-cohort study included 105,892 patients with new-onset SDs (SD cohort) and 105,892 randomly selected controls (control cohort). Each patient was monitored for 10 years to individually identify patients who were subsequently diagnosed as having CSU during the follow-up period. A Cox proportional hazard regression analysis was conducted to determine the risk of CSU in patients with SDs compared with the controls.All relevant comorbidities were more prevalent in the SD cohort than in the control cohort (P < .001). During the follow-up period, the incidence rates of CSU among the patients with SDs and controls were 53.4 and 28.3 per 10,000 person-years, respectively. After adjustment for age, sex, and comorbidities, the adjusted hazard ratio for CSU in the SD cohort was 1.83 (95% confidence interval = 1.73-1.93, P < .001).The risk of CSU was higher in the patients with SDs than in the controls.

Associations of chronic urticaria with atopic and autoimmune comorbidities: a nationwide population-based study

BACKGROUND

Most cases of chronic urticaria (CU) are idiopathic. Circumstantial evidence suggests that some CU cases have an autoimmune pathogenesis. Previous research indicates that a substantial percentage of patients with CU have an atopic background.

OBJECTIVES

This study aims to examine the association between CU, and atopic and autoimmune diseases.

METHODS

This population-based retrospective cohort study identified 9,332 patients with CU and 37,328 controls matched for age, sex, and number of dermatological clinic visits from the Taiwan National Health Insurance Research Database for 2004-2009. Using multiple logistic regression, we estimated odds ratios (OR) and 95% confidence intervals (CI) for associations of CU with atopic and autoimmune diseases.

RESULTS

CU was most strongly associated with Kawasaki disease (modified OR, 2.76; 95% CI 1.15-6.63), followed by Henoch-Schönlein purpura (HSP), atopic dermatitis (AD), systemic lupus erythematosus (SLE), allergic rhinitis (AR), autoimmune thyroid diseases, Sjögren syndrome, inflammatory bowel disease (IBD), and asthma, which had the lowest adjusted OR (1.11; 95% CI 1.01-1.22) among comorbidities significantly associated with CU. The associations varied in relation to age, group, and sex. Among women, CU was significantly associated with AD, AR, autoimmune thyroid diseases, SLE, vitiligo, and HSP. Among men, CU was significantly associated with AD, AR, autoimmune thyroid diseases, Kawasaki disease, and IBD.

CONCLUSION

CU is associated with atopic/autoimmune diseases. Increased awareness of atopic and autoimmune comorbidities may be warranted for patients with CU.

Posttraumatic stress disorder, emotional suppression and psychiatric co-morbidity in patients with chronic idiopathic urticaria: a moderated mediation analysis

BACKGROUND

There is evidence suggesting that posttraumatic stress disorder (PTSD) symptom severity and CIU severity are linked and partially mediated by the high-anxious defense mechanism. What is unclear is whether emotional suppression, as a defense serving the opposite purpose for high-anxious defense, can also act as a mediator and whether this mediational effect is partly influenced by time since trauma and trauma type.

AIMS

To investigate whether emotional suppression mediated the links between PTSD and CIU symptom severities, and PTSD and psychiatric co-morbid symptom severities. It then examined whether the mediating effect would be moderated by how long ago the trauma occurred and trauma type.

METHODS

One hundred CIU patients were compared with 60 allergy patients. They completed questionnaires measuring PTSD, psychiatric co-morbidity and emotional suppression.

RESULTS

Suppressing depression mediated the relationship between PTSD and psychiatric co-morbidity. How long ago the trauma occurred and trauma type moderated the mediational effect of suppressing depression.

CONCLUSIONS

Following a past trauma, CIU patients may develop PTSD symptoms which influence their psychological well-being through using different levels of emotional suppression, especially suppressing depression. The levels depend on the severity of PTSD symptoms, trauma history and whether they experienced interpersonal traumas.

Posttraumatic Stress Disorder Following Stillbirth: Trauma Characteristics, Locus of Control, Posttraumatic Cognitions

This study examined the incidence of PTSD and psychiatric co-morbidity among women who experienced stillbirth and investigated the relationship between locus of control, trauma characteristics of stillbirth, posttraumatic cognitions, PTSD and co-morbid psychiatric symptoms following stillbirth. Fifty women recorded information on stillbirth experiences, and completed the Posttraumatic Stress Diagnostic Scale, General Health Questionnaire-28, Edinburgh Post-natal Depression Scale, Rotter's Locus of Control Scale and the Posttraumatic Cognitions Inventory. 60, 28 and 12 % met the diagnostic criteria for probable full-PTSD, partial and no-PTSD respectively. Sixty-two percent and 54 % scored at or above the cutoff of the General Health Questionnaire-28 and postnatal depression respectively. Women who experienced stillbirth reported significantly more psychiatric co-morbid and post-natal depressive symptoms than the comparison group. Both groups were similar in locus of control. Women who experienced stillbirth reported negative cognitions about the self the most. After adjusting for postnatal depression, trauma characteristics were significantly correlated with Posttraumatic cognitions which, in turn, were significantly correlated with PTSD and psychiatric co-morbidity. Locus of control was not significantly correlated with psychological outcomes. Mediational analyses showed that negative cognitions about self mediated the relationship between trauma characteristics and psychiatric co-morbidity only. Women reported a high incidence of probable PTSD and co-morbid psychiatric symptoms following stillbirth. Stillbirth trauma characteristics influenced how they negatively perceived themselves. This then specifically influenced general psychological problems rather than PTSD symptoms.

Posttraumatic Stress Disorder Among Older Patients with Chronic Obstructive Pulmonary Disease

This study explored (1) the incidence of posttraumatic stress disorder (PTSD) resulting from past trauma among older patients with COPD and (2) whether PTSD and COPD severity would relate to psychiatric co-morbidity and health-related quality of life. Eighty-five older patients completed the Hospital Anxiety and Depression Scale, the Chronic Respiratory Questionnaire, the Posttraumatic Stress Diagnostic Scale and the Medical Outcomes Short Form 12. The results showed that 55, 39 and 6 % had no, partial and full-PTSD respectively. Partial least squares showed that PTSD was significantly correlated with COPD severity which in turn was significantly correlated with health-related quality of life and psychiatric co-morbidity. Mediational analysis showed that the emotional symptoms of COPD mediated between PTSD and the mental health functioning of health-related quality of life and between PTSD and depression. To conclude, PTSD from past trauma was related to the severity of COPD for older patients. In particular, it impacted on the elevated emotional arousal of COPD severity. In turn, COPD severity impacted on older patients' general psychological well-being and depression.

PTSD, a Disorder with an Immunological Component

Post-traumatic stress disorder (PTSD) has been associated with an inflammatory state. However, few studies have addressed the mechanisms underlying this immune imbalance that favors inflammation or how this imbalance contributes to PTSD. Whether the immune imbalance influences responsiveness or unresponsiveness of patients to PTSD treatments is currently not known. This review brings forward an immune emphasis to a mental health disorder that is unprecedented in its prevalence among combat Veterans of the ongoing conflicts in Iraq and Afghanistan and which also afflicts civilians who have undergone extreme traumatic experiences, such as following natural disasters, serious accidents, or assaults. Included is an overview of the correlative associations in human subjects between PTSD and inflammation and studies in animal models of PTSD, demonstrating causal contributions of inflammation and immune dysregulation to PTSD-like behavior following stress exposure.

Sense of alexithymia in patients with anxiety disorders comorbid with recurrent urticaria

AIM

Alexithymia is associated with limited cognitive processing of emotions by an individual suffering from recurrent urticaria and alexithymia and makes them focus on somatic manifestations of emotional arousal and on poorly controlled compulsive reactions to negative stimulation. Alexithymia is considered to be a personality trait, which, along with other factors, predisposes individuals toward developing somatic diseases. The aim of the study was to assess the measurement of alexithymic features in patients with recurrent urticaria and to assess the types of concurrent anxiety disorders and overall anxiety level.

METHODS

In order to diagnose clinical anxiety symptoms in patients, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the Hamilton Anxiety Rating Scale were applied. Alexithymic features were measured by means of a shortened version of the Toronto Alexithymia Scale, characterized by high discrimination power, internal coherence, and reliability.

RESULTS

According to the Toronto Alexithymia Scale results, the greatest contributing factor was "inability to differentiate between feelings and bodily sensations". This was observed in both males and females. Most frequently, the patients were found to suffer from generalized anxiety disorder and social phobia.

CONCLUSION

Alexithymia may result from the difficulty associated with expressing emotions caused by anxiety disorders. Undergoing treatment for anxiety disorders may contribute to reduced exacerbation of urticaria.

Chronic urticaria in adults: state-of-the-art in the new millennium

Chronic urticaria has been explored in several investigative aspects in the new millennium, either as to its pathogenesis, its stand as an autoimmune or auto-reactive disease, the correlation with HLA-linked genetic factors, especially with class II or its interrelation with the coagulation and fibrinolysis systems. New second-generation antihistamines, which act as good symptomatic drugs, emerged and were commercialized over the last decade. Old and new drugs that may interfere with the pathophysiology of the disease, such as cyclosporine and omalizumab have been developed and used as treatments. The purpose of this article is to describe the current state of knowledge on aspects of chronic urticaria such as, pathophysiology, diagnosis and the current therapeutic approach proposed in the literature.

Posttraumatic stress disorder and psychiatric comorbidity following the 2010 flood in Pakistan: exposure characteristics, cognitive distortions, and emotional suppression

This study investigated the extent of posttraumatic stress disorder (PTSD) and psychiatric comorbidity among the 2010 flood victims in Pakistan and its relationship with disaster exposure characteristics, cognitive distortions, and emotional suppression. One hundred and thirty-one (F = 89, M = 42) flood victims were assessed using the Posttraumatic Diagnostic Scale, the General Health Questionnaire-28, the Cognitive Distortion Scales, and the Courtauld Emotional Control Scale. The results showed that all victims met the diagnostic criteria for PTSD and scored above the cut-off for psychiatric caseness. Partial least squares modelling showed that disaster exposure characteristics were significantly correlated with PTSD and psychiatric comorbidity. Disaster exposure characteristics were also significantly associated with cognitive distortions which in turn were also significantly associated with PTSD and psychiatric comorbidity. Cognitive distortions were also correlated with emotional suppression which, however, was not associated with PTSD or psychiatric comorbidity. To conclude, the flood victims reported PTSD and psychiatric comorbid symptoms which were related to their subjective exposure to the flood. Such exposure led to the development of dysfunctional thinking patterns which in turn influenced distress symptoms.

Stress involvement as trigger factor in different skin conditions

Dermatological conditions are intimately related to stress. There was a great interest in this field in the last years. Stress could be involved as a trigger factor for a lot of cutaneous diseases: alopecia areata, psoriasis, vitiligo, lichen planus, acne, atopic dermatitis, urticaria. For other conditions: seborrheic dermatitis, hyperhydrosis, herpes, pemphigus, a.s.o, there are anecdotal notices. On the other hand, the skin disease itself could induce a secondary stress for the patient, influencing his quality of life. The stress per se is less important than the “perceived stress”, the patient’s perception of the stressful situation. This perception could be influenced by the psychological state of the patient. Anxiety, depression could change the perception of the event. It is important to take care of these aspects during the consultation. A good cooperation with psychiatrist or/and psychologist could improve the results, besides the specific therapy.