Emotion Regulation in Patients with Psoriasis: Correlates of Disability, Clinical Dimensions, and Psychopathology Symptoms

Factors associated with worsened clinical symptoms of psoriasis and disease-related quality of life during the COVID-19 lockdown: A cross-sectional study

Objective

In this cross-sectional study, we aimed to evaluate the factors associated with psoriasis symptom worsening and impaired quality of life (QoL) in individuals with psoriasis during the COVID-19 pandemic lockdown.

Methods

During the second COVID-19 national lockdown (January-April 2021) in Lithuania, individuals diagnosed with psoriasis were invited to fill in an anonymous online survey including sociodemographic and life-style factors, psoriasis-related clinical symptoms, the Dermatology Life Quality Index (DLQI) and the Patients' Health Questionnaire (PHQ).

Results

A total of 297 respondents completed the survey. The majority of them (52.5%) reported worsened clinical symptoms of psoriasis during the COVID-19 lockdown period. In total, 43.1% of responders reported significant depressive symptoms (PHQ-9 ≥ 10) and 23.6% reported impaired disease-related QoL (DLQI > 10). The strongest predictor of psoriasis symptoms worsening was the need for changes in psoriasis treatment, with an odds ratio (OR) of 2.73 (95% CI 1.37-5.44, p = 0.004) and decreased income (OR = 2.33, 95% CI 1.30-4.17, p = 0.004). The strongest predictor of impaired QoL was male sex (OR = 3.35, 95% CI 1.70-6.59, p < 0.001). Contribution of specific depressive symptoms was evident for both models.

Conclusion

Worsening of psoriasis symptoms during the COVID-19 lockdown was associated with decreased income, psoriasis treatment changes and depression symptoms. Impaired QoL was associated with male sex, symptom worsening and depression. Specific depression symptoms may have contributed to more symptom worsening and impaired QoL than the depressive symptomatology as a whole.

Epidemiology of Psoriasis and Comorbid Diseases: A Narrative Review

Psoriasis is a chronic autoimmune inflammatory disease that remains active for a long period, even for life in most patients. The impact of psoriasis on health is not only limited to the skin, but also influences multiple systems of the body, even mental health. With the increasing of literature on the association between psoriasis and extracutaneous systems, a better understanding of psoriasis as an autoimmune disease with systemic inflammation is created. Except for cardiometabolic diseases, gastrointestinal diseases, chronic kidney diseases, malignancy, and infections that have received much attention, the association between psoriasis and more systemic diseases, including the skin system, reproductive system, and oral and ocular systems has also been revealed, and mental health diseases draw more attention not just because of the negative mental and mood influence caused by skin lesions, but a common immune-inflammatory mechanism identified of the two systemic diseases. This review summarizes the epidemiological evidence supporting the association between psoriasis and important and/or newly reported systemic diseases in the past 5 years, and may help to comprehensively recognize the comorbidity burden related to psoriasis, further to improve the management of people with psoriasis.

Influence of psoriasis lesions' location and severity on psychosocial disability and psychopathology. Observational study and psychometric validation of the SAPASI Portuguese version

OBJECTIVES

The psychosocial impact of psoriasis is well documented. However, the contributing role of clinical disease characteristics is not satisfactorily explored. This study aimed to validate the Self-administered Psoriasis Area and Severity Index (SAPASI) to a Portuguese population (SAPASI-PT) and to perform its cross-validation, assessing how the results will generalize to an independent data set, with the Psoriasis Area and Severity Index (PASI), in order to assess the influence of psoriasis' severity on psychosocial disability and psychopathology.

METHODS

A cross-sectional study with 228 patients with psoriasis was carried out. Data was collected through a sociodemographic and clinical questionnaire, SAPASI-PT, the Psoriasis Disability Index (PDI) and the Brief Symptoms Inventory (BSI). The cultural and linguistic adaptation of SAPASI to a Portuguese version and the cross validation with PASI was carried out. Multiple associations between psychosocial disability, psychopathology and severity, discomfort and location of lesions were investigated through logistic regression models.

RESULTS

A good adjustment model for SAPASI-PT is found. Also, associations between psychosocial disability, psychopathology and the psoriasis severity and discomfort are found. The existence of lesions is positively associated with the severity of the disease. Patients with lesions in hands or genitals are those reporting a greater discomfort. The presence of lesions in hands is positively associated with PDI, i.e., with leisure and with treatment, marginally. Additionally, patients scoring higher in the personal dimension are found to have a significantly greater percentage of lesions in the genitals.

CONCLUSIONS

The psoriasis severity and location of lesions are important determinants of patients´ quality of life. Lesions on face, hands and genitals are associated with a higher impact on psychosocial wellbeing of patients. Psychological counselling should be considered within psoriasis treatment context in patients with the described disease manifestations.

Individual Differences in Emotion Dysregulation and Social Anxiety Discriminate between High vs. Low Quality of Life in Patients with Mild Psoriasis

A deeper understanding of how health-related quality of life relates to the clinical and individual characteristics of patients is essential for the delivery of patient-centered dermatological care. The current study aimed to examine the role of individual differences in emotion dysregulation and social anxiety in modulating quality of life in psoriatic patients. A total of 130 patients affected by psoriasis were consecutively enrolled in the study as they approached the Dermatology Unit of Sant'Orsola-Malpighi Hospital of Bologna. Clinical information gathered included illness severity, assessed with the Psoriasis Area and Severity Index (PASI) and the Body Surface Area (BSA); illness onset; familiarity; and prescribed treatment. The patient-reported outcome measures were the Dermatology Life Quality Index (DLQI), measuring the patient's quality of life; the Psoriasis Skin Appearance Bothersomeness scale (PSAB), measuring patient's perception of illness severity; the Difficulties in Emotion Regulation Scale (DERS), assessing emotion dysregulation traits; and the Social Interaction Anxiety Scale (SIAS), measuring anxiety about social interactions. Patients with moderate-to-severe psoriasis reported significantly lower quality of life compared to mildly affected patients. In addition, of the patients affected by mild psoriasis, those characterized by emotion dysregulation and social anxiety traits showed significantly lower levels of quality of life. Our findings suggest that individual differences in emotion dysregulation and social anxiety contribute to health-related quality of life in addition to illness severity. Therapeutic approaches that combine dermatological care with psychological support, especially focused on emotional regulation skills, may be useful to improve clinical outcomes in patients with psoriasis.

Positive Psychological Factors Are Associated With Better Spiritual Well-Being and Lower Distress in Individuals With Skin Diseases

In this study we examined whether aspects of positive functioning [reappraisal, sense of coherence (SOC), and positivity] were associated with spiritual well-being and psychological distress after controlling for negative functioning (skin-related symptoms, type of disease, and expressive suppression) in individuals with skin diseases. We also examined whether negative functioning aspects were linked to spiritual well-being and distress when controlling for aspects of positive functioning. The study used a cross-sectional design with a sample of 192 individuals with psoriasis and systemic sclerosis (SSc) (M age = 51.6 years, SD = 16.5). Two hierarchical multiple regressions were conducted to determine whether spiritual well-being and psychological distress were accounted for by skin-related symptoms, type of disease, emotion regulation strategies, SOC, and positivity. Positivity was the most important contributor to better spiritual well-being, followed by both the comprehensibility/manageability and meaningfulness SOC subscales, after controlling for the other variables. High skin-related symptoms and expressive suppression were associated with lower psychological distress, whereas high SOC and reappraisal correlated with higher psychological distress. The findings of this study pave the way for further research on how SOC and positivity may reduce the effects of both skin-related symptoms and emotion dysregulation and facilitate spiritual well-being of individuals with skin diseases. Interventions aimed to enhance inner resources of these individuals and help them to find a meaning in their experience of skin disease might reduce psychological distress and improve spiritual well-being. Our findings suggest that healthcare professionals should consider positive functioning aspects in future interventions for individuals with skin diseases.

Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis

Psoriasis is a chronic dermatological condition that is frequently associated with problematic patterns of emotional reactivity (the way in which patients react to stimuli), alexithymia (their ability to recognize and label the emotional reaction), and emotion regulation (the ability to enhance or reduce their own emotional reaction). A research in the peer-reviewed scientific literature was conducted in order to identify articles describing the association of psoriasis and affective problems. In particular, we first evaluate studies that have investigated abnormal emotional reactivity (in terms of duration, frequency, or type of the experienced emotions) and its impact on patients' quality of life; next, we review the role of alexithymia and emotion regulation in modulating the relationship between emotional reactivity and quality of life in this population. From a critical analysis of the reviewed studies, we highlight that altered emotional processing might be particularly important in the characterization of this condition. In particular, we show that this condition is related to an emotional reactivity characterized by negative emotions that have a stronger impact on patients' quality of life when emotion regulation abilities are weak, especially if patients have alexithymia. Finally, we present suggestions for future directions in both clinical and research fields.

Influence of disease phase on embitterment and emotional dysregulation in psoriatic patients

This study aimed to evaluate the psychosocial differences between patients with psoriasis in different phases of the disease. Seventy-one patients in exacerbation and 83 in remission were evaluated regarding sociodemographic, clinical and psychological variables, on the premise that the visibility of lesions (exacerbation phase) may impact the emotional regulation and embitterment. A regression analysis was performed to identify the variables that contribute to explain embitterment: a diagnosis of anxiety and/or depression and psoriasis severity are the identified ones. The results point to higher values of emotional dysregulation and embitterment, as well as more critical clinical variables in patients with active disease, namely, alcohol and coffee consumption, smoking and less satisfaction with current treatment, more diagnoses and more family history of anxiety and depression, more psychology/psychiatry consultations and more use of anxiolytics and antidepressants. However, only the results referring to alcohol consumption and embitterment are significantly higher in subjects in the exacerbation phase of the disease. Particular clinical attention should be provided to patients in exacerbation phase regarding psychotherapeutic approach.

Expressive Suppression and Negative Affect, Pathways of Emotional Dysregulation in Psoriasis Patients

The main goal of this study was to assess the emotion regulation (ER) mechanisms, such as expressive suppression and cognitive reappraisal, in patients with psoriasis, as compared with healthy persons not afflicted by dermatological diseases. Moreover, the study intended to carry on a multidimensional assessment of emotional mechanisms in persons with psoriasis, highlighting the differences between psoriasis patients and healthy participants, in order to identify the specific patterns of emotion dysregulation (ED) in psoriasis. Another goal of the study was to investigate the predictors of ED among different emotional patterns. We presumed that the maladaptive ER mechanisms are higher in psoriasis patients than in the control group and there are specific dysregulation patterns in psoriasis patients as negative emotions tendency. This cross-sectional study was performed on 192 individuals aged between 35 and 75 years (mean age 59). The sample was divided in two groups: the clinical group including 91 patients with a diagnosis of psoriasis vulgaris and the control group including 101 healthy persons. The results of the present study suggest that psoriasis patients more frequently used emotional suppression - a maladaptive ER mechanism - as well as ED patterns - i.e., impulse control difficulties, and nonacceptance of emotional responses. They also displayed trait tendency to a negative emotional response. In fact, in people with psoriasis, the presence of suppression mechanism and negative affect of trait could predict that 35% of patients will show emotional dysregulated patterns, while living with higher levels of ED. The results of our study are important in the clinical practice, helping clinicians to better understand the emotional vulnerability of people that live with psoriatic disease, and to optimize the disease management and patient care in an interdisciplinary approach.

Study on the psychological health and related risk factors in 245 patients with psoriasis in Inner Mongolia

To investigate the psychological health and related risk factors in patients suffering from psoriasis. A total of 245 inpatients and outpatients with psoriasis were selected from January 2014 to December 2015. Patients with psoriasis were assessed a homemade questionnaire as well as the Psoriasis Area and Severity Index (PASI), Selfrating Anxiety Scale, Self-rating Depression Scale, Trait Coping Style Questionnaire and Social Avoidance and Distress Scale.Differences in sex, age, marital status, type of medical payment, occupation, economic situation, disease severity, and type of psychological state of psoriasis patients were significant, there was no significant difference in psychological health between psoriasis patients with different levels of educational attainment. Scores for anxiety, depression, social avoidance, and social distress were positively correlated with disease severity and negative-coping scores, but a significant negative correlation was observed with scores for social support and positive coping. Stepwise regression analysis of factors influencing psychological health showed that total social support and negative-coping scores could explain 65.2% of the variation. Patients with psoriasis can suffer from anxiety, depression, social distress, and social avoidance. Physicians should pay greater attention to deterioration in mental health of psoriasis patients.

Physiological and behavioral reactivity to social exclusion: a functional infrared thermal imaging study in patients with psoriasis

Recent studies have shown that sympathetic nervous system (SNS) activity can be heavily impacted not only by basic threats to survival but also by threats to social bonds. In this study we explored the behavioral and physiological consequences of social exclusion/inclusion in patients with psoriasis, a disease frequently associated with the experience of being ostracized and with deficient emotion regulation skills. We employed a virtual ball-tossing game (Cyberball) to induce the experience of social exclusion/inclusion. We then used a Trust Game to measure the effects of this social modulation on trust. During Cyberball, infrared thermal imaging was used to record participants' facial temperature and thus obtain an online measure of SNS activation. Behavioral data showed that social exclusion shifted participants' trust toward unfamiliar players who had not previously excluded them. Physiological data indicated that in control participants, social exclusion triggered higher SNS activation than inclusion. No such effect was found in patients with psoriasis, whose SNS activity was the same during inclusion as it was during exclusion, suggesting that they benefit less from inclusive experiences than control participants. In addition, in patients but not in controls, higher SNS activation during social exclusion was linked to higher monetary investment toward unfamiliar players, a result in keeping with the social reconnection hypothesis, according to which emotions triggered by social rejection can be regulated by investing in new social interactions. We also found that an increase in periorbital temperature is accompanied by a decrease in happiness ratings after social exclusion was experienced during the Cyberball game. NEW & NOTEWORTHY Previous research on emotional processes in psoriasis has mainly employed self-report measures. In this study we used thermal imaging to obtain an online measure of the sympathetic nervous system (SNS) activity during social exclusion and tested how this experience influenced subsequent trust. We found that being included was a less positive experience for patients compared with controls and that SNS activity during exclusion had a stronger influence on subsequent trust in patients than in controls.

Cognitive load and emotional processing in psoriasis: a thermal imaging study

Psoriasis is a chronic dermatologic disease which is frequently associated with psychological distress. Although studies suggest a relationship between this condition and difficulties in emotion regulation, behavioral and physiological evidence about this link is scarce. We measured implicit emotion regulation abilities of psoriasis patients and a healthy control group by examining the impact of distracting emotional (positive, negative or neutral) images on a working memory task ("Emotional N-Back") which could present high (2-back) or low (1-back) cognitive workload. Moreover, we used Functional Infrared Thermal Imaging to record participants' facial temperature and obtain a measure of the activation of the autonomic system. Rising of temperature over the peri-orbital areas and the nose tip are believed to reflect the activation and the de-activation of the sympathetic system, respectively. Patients scored higher than controls on the "Lack of emotional clarity" sub-scale of the Difficulties in Emotion Regulation Scale. Compared to controls, who performed much better in the low vs. high cognitive load condition, patients showed a smaller accuracy difference between the two conditions. Moreover, patients showed less sympathetic (lower peri-orbital and higher nasal tip temperature) activity (especially in the negative and neutral blocks) during the high vs. low cognitive load condition, suggesting that the former condition might be less emotionally demanding for them. Patients benefit more than controls from the load-dependent interference effect when dealing with emotional information; thus, therapeutic techniques aiming at teaching how to use cognitive strategies to downregulate emotions might be particularly appropriated for them.

Childhood trauma and resilience in psoriatic patients: A preliminary report

AIMS

Psoriasis is a chronic inflammatory skin disease with a complex etiology, involving the immune system, genetic factors, and external/internal triggers, with psychosomatic aspects. The aim of the study was to investigate childhood trauma and resilience in a psoriatic sample compared with healthy controls. Correlations between childhood trauma, resilience, quality of life, clinical data and psoriatic features were also evaluated.

METHODS

Seventy-seven psoriatic patients and seventy-six homogeneous healthy controls were enrolled. We used the Psoriasis Area and Severity Index (PASI) to assess the severity of psoriasis and the Skindex-29 to measure health-related quality of life. The psychometric battery included the Childhood Trauma Questionnaire (CTQ) and the Connor-Davidson Resilience Scale (CD-Risc) to assess trauma exposure and resilience, respectively.

RESULTS

Psoriatic patients showed a significant prevalence of childhood trauma and a lower resilience level compared to healthy controls. Associations between traumatic experiences, low resilience and reduced quality of life in psoriatic subjects were also observed.

CONCLUSIONS

A multidisciplinary approach is helpful to investigate clinical aspects, trigger factors and psychophysiological stress response in psoriatic subjects. Improving resilience with an early psychological intervention focused on self-motivation and strengthening of self-efficacy could facilitate the management of psoriasis.

Development and Validation of a Novel Questionnaire for Adherence with Topical Treatments in Psoriasis (QATOP)

BACKGROUND

Self-report measures are the most used methodologies for the evaluation of adherence to psoriasis topical treatment, although currently there is no standard questionnaire for this purpose.

OBJECTIVE

The present study aimed at developing a novel questionnaire (Questionnaire for Adherence to TOPical treatment [QATOP]) for the assessment of adherence to topical treatment in psoriasis.

METHODS

A questionnaire containing nine items organized into two parts (part 1: current patient treatment; part 2: adherence to treatment, amount used, and treatment-associated variables) was developed, supported by a systematic literature review, qualitative patient focus interviews, and expert-group input. Its content validity was determined by a pilot study of six patients. Adherence to topical treatment was then assessed in 35 patients with psoriasis, after 45 days of treatment, using the QATOP and a medication log. Associations between different items of the QATOP and the log were investigated.

RESULTS

Adherence results were 63.5 ± 29.2% for the log and 60.9 ± 24.4% for the QATOP, and were strongly correlated (R = 0.819, p < 0.001). Distinct posologic regimens were reported by patients, which, in some cases, were not the usual doses. Patients also reported using doses of medicine on each application that were markedly lower than required.

CONCLUSION

The QATOP is a valid and reliable self-report measure of adherence to topical treatment in patients with psoriasis. The use of this standard questionnaire could improve the methodological quality of adherence studies. Improvement of the clarity of posologic instructions is clearly urgently needed.