Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study

Psychopathology and Alexithymia in Patients with Moderate-to-Severe Psoriasis: Development of a Novel Index with Prognostic Value

BACKGROUND

Psoriasis is a chronic, relapsing, inflammatory disease with a high risk of developing mental health difficulties.

OBJECTIVE

The purposes of the study were to evaluate in moderate-to-severe psoriasis (a) the prevalence of depression and psychopathology, (b) the relationship between depression, psychopathology symptoms, and alexithymia, including its three dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF), and externally oriented thinking (EOT), and (c) to establish a novel index for the development of depression according to patients' psychopathological profile.

METHODS

In 104 patients, alexithymia was evaluated with the Toronto Alexithymia Scale (TAS-20), depression with the Beck Depression Inventory (BDI), and psychopathology with the Brief Symptom Inventory SCL-90 (SCL90). A psychopathology index that combines information from the BDI and SCL90 scales was constructed and the performance of the index with alexithymia was examined.

RESULTS

Female patients and active smokers score higher on BDI and SCL90 scales. Overweight patients tend to score arithmetically higher. The psychopathology index developed correlates significantly with age, DIF, DDF, and TAS-20. DIF, DDF, and TAS-20 are significant predictors of the psychopathology index. Patients with alexithymia/possible alexithymia are six times as likely to score higher in one of the psychopathology scales.

CONCLUSIONS

Alexithymia is a significant factor in the development of psychopathology in psoriasis patients. The use of the proposed novel psychopathology index could be essential in order to identify patients with moderate-to-severe psoriasis who are more likely to experience depression and psychopathology. This could have an impact on the decision-making of psoriasis treatment and monitoring of the patient.

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.

Psychological Distress, Alexithymia and Alcohol Misuse in Patients with Psoriasis: A Cross-Sectional Study

This study investigates (a) the prevalence of psychological distress, alexithymia and alcohol misuse in psoriasis patients; and (b) the relationship between psoriasis severity, alexithymia, alcohol and psychological distress in patients with psoriasis. A cross-sectional study was conducted. Outpatients (n = 184) with moderate to severe psoriasis completed a psychological screening battery. Measures included the Hospital Anxiety and Depression Scale, the Penn State Worry Questionnaire, the twenty-item Toronto Alexithymia Scale, the Dermatology Life Quality Index, the Psoriasis Area and Severity Index, the Self-Administered Psoriasis Area and Severity Index, and the Alcohol Use Disorders Identification Test. Demographic, clinical details and information on knowledge of psychosocial issues, alcohol and confidence on coping with distress and talking to others about psoriasis was also gathered. Alexithymia was associated with anxiety, depression and worry; subjective psoriasis severity was associated with worry. Alcohol misuse was related to anxiety and worry, but not to depression. Appropriate identification and treatment of alcohol difficulties and psychological distress of patients with psoriasis is needed.

Addictive behaviors, cardiovascular and metabolic comorbidities in North African psoriatic patients: case-control study

We propose to study the epidemiological aspects of North African psoriasis and determine the cardiovascular comorbidities and addictive behaviors associated with psoriasis. This is a North African case-control study which was conducted over a five year period (October 2008 through August 2013), involving 671 psoriatic patients and 1,242 controls identified in various Algerian, Tunisian and Moroccan university hospitals. For each patient, epidemiological characteristic, addictive behaviors, and cardiovascular pathologies associated with psoriasis were noted. Six hundred and seventy one psoriasis patients and 1,242 controls were included in this study. The average age was 47.24 years and the M/F sex-ratio was 1.11 (354 men and 317 women). Statistical analysis showed that psoriasis patients were more likely to develop addictive behaviors than controls (smoking p<10-5 and alcohol consumption: p < 10-5), together with dyslipidemia (30.1% of patients p < 10-5), obesity (23.8% of patients p < 10-4), hypertension (22.3% of patients p < 10-5), diabetes (21.7% of occurrences p < 10-5) and metabolic syndrome (37.4% of patients p<10-5). The relative risk for developing psoriasis was 1.9 in hypertensive patients, 1.7 in diabetic patients, 3.9 in dyslipidemic patients, 1.8 in obese patients, 2.6 in those with metabolic syndrome, 2.1 in smokers and 2.8 in alcoholics. Our work confirms the high incidence of addictive behaviors and of cardiovascular and metabolic comorbidities during the North-African psoriasis, hence the need for a multidisciplinary comprehensive care based on a guideline suited to the characteristics of North-African psoriatic patients.

Perceived stress, life events, fatigue and temperament in patients with psoriasis

Objective

To evaluate the perceived stress, life events, fatigue and temperament profile in patients with psoriasis and to investigate the relationship between these factors.

Methods

This cross-sectional study included patients with psoriasis and healthy control subjects. The two groups were compared regarding the number of life events, Perceived Stress Scale (PSS) and Multidimensional Assessment of Fatigue scores. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire was used to evaluate the personality traits among the two groups.

Results

A total of 75 patients with psoriasis (mean ± SD age, 44.94 ± 13.62 years) and 75 healthy controls (mean ± SD age, 41.10 ± 8.89 years) were included in the study. A statistically significant difference was found between the two groups in terms of the presence of life events, PSS score, fatigue and temperament profiles. Patients with psoriasis with depressive, cyclothymic and anxious temperament profiles were found to have higher PSS scores. In the psoriasis group, the PSS scores were positively correlated with the number of life events.

Conclusions

Stress and life events were found to be correlated with psoriasis. In the patients with psoriasis, depressive, cyclothymic and anxious temperament profiles seemed to be associated with higher perceived stress.

The associations between psychological stress and psoriasis: a systematic review

Psoriasis is estimated to affect around 2-3% of the general population. More than one-third of Australians report having a significant level of distress in their daily lives. Psychological stress has long been shown to play an important role in the natural history of psoriasis, but the details of this relationship remain to be clearly defined. We performed a systematic review of the literature with the aim of determining whether there is a temporal association between psychological stress as the predictor and onset and/or exacerbation of psoriasis as the outcome measure. Our secondary aim was to establish whether there is a relationship between the degree of psychological stress and clinical severity of psoriasis. Our systematic review demonstrates a probable temporal association between different measures of psychological stress and onset, recurrence, and severity of psoriasis. In the light of this, we suggest clinicians include "stress" as a trigger factor in their psoriasis assessment and consider psychological interventions as adjuncts, particularly in those who identify as "stress-responders".

Psychological stress and psoriasis: a systematic review and meta-analysis

BACKGROUND

Psychological stress has long been linked with the exacerbation/onset of psoriasis.

OBJECTIVES

To determine if antecedent psychological stress is associated with the exacerbation/onset of psoriasis.

METHODS

A search of the PubMed, PsycINFO, Cochrane library and ClinicalTrials.gov databases was performed. Surveys evaluating beliefs about stress reactivity were analysed separately. Suitable studies were meta-analysed.

RESULTS

Thirty-nine studies (32 537 patients) were included: 19 surveys, seven cross-sectional studies, 12 case-control studies and one cohort study. Forty-six per cent of patients believed their disease was stress reactive and 54% recalled preceding stressful events. Case-control studies evaluating stressful events rates prior to the exacerbation (n = 6) or onset (n = 6) of psoriasis varied in time lag to recollection (≤ 9 months to ≥ 5 years). Pooling five studies evaluating stressful events preceding onset of psoriasis gave an odds ratio (OR) of 3·4 [95% confidence interval (CI) 1·8-6·4; I² = 87%]; the only study evaluating a documented stress disorder diagnosis reported similar rates between patients and controls (OR 1·2, 95% CI 0·8-1·8). Four studies evaluating stressful events prior to psoriasis exacerbation reported comparable rates with controls, whereas two found more frequent/severe preceding events among patients with psoriasis. A small prospective cohort study reported a modest association between stress levels and exacerbation of psoriasis (r = 0·28, P < 0·05).

CONCLUSIONS

The association between preceding stress and exacerbation/onset of psoriasis is based primarily on retrospective studies with many limitations. No convincing evidence exists that preceding stress is strongly associated with exacerbation/onset of psoriasis.

Psychopathology and alexithymia in patients with psoriasis

Background

Psoriasis is a chronic, inflammatory, relapsing skin disease that has a psychosocial impact on the patients' life.

Objective

This study aimed to investigate psychopathology in patients with psoriasis based on a valid psychometric instrument, as well as on the relationship between psychopathology and alexithymia.

Methods

108 patients with psoriasis were included in the study. Psychopathology was evaluated with the Symptom Checklist-90-Revised (SCL-90-R) and alexithymia with the Toronto Alexithymia Scale (TAS-20). Disease severity was clinically assessed using the Psoriasis Area and Severity Index.

Results

As regards the psychopathological dimensions, female patients presented with statistically significant higher somatization, depression, anxiety, phobic anxiety, and psychoticism than males. Patients with alexithymia presented with statistically significant higher somatization, interpersonal sensitivity, anxiety, and phobic anxiety than non-alexithymic patients. Alexithymia positively correlated with somatization (r = 0.26, p < 0.01), interpersonal sensitivity (r = 0.24, p < 0.05), depression (r = 0.27, p < 0.01), anxiety (r = 0.26, p < 0.01), and phobic anxiety (r = 0.26, p < 0.01). In addition, alexithymia also contributed to the prediction of these conditions.

Study Limitations

A larger study sample could yield safer generalized results. Nevertheless, to the best of our knowledge, this was the first study to investigate various psychopathological dimensions in patients with psoriasis.

Conclusions

Our study results indicate that alexithymia and female sex were associated with several psychopathological dimensions in patients with psoriasis. It may be suggested that alexithymia constitutes an important factor in the development of mental disorders among patients with psoriasis.

The relationship between alexithymia and general symptoms of pregnant women

INTRODUCTION

Alexithymia is related to poor emotion regulation strategies as well as higher rates of somatic disorders. The aim of the present study was to assess the relationship between alexithymia and the general symptoms experienced by the pregnant women.

MATERIAL AND METHODS

In a cross-sectional study, a total number of 350 pregnant women, attending the antenatal clinics, were randomly selected. A standardized Toronto Alexithymia Scale (TAS-20) was used to elicit responses from participants with alexithymia. The general symptoms scores were measured using the Iranian version of the Symptom Checklist-90-Revised, 90 items. The statistical associations between alexithymia and the general symptoms were then investigated through liner regression.

RESULTS

A total number of 186 of pregnant women with alexithymia were compared with the 164 cases without alexithymia. The high scores on Total Toronto Alexithymia Scale-20 and the difficulties to identify feelings emerged as major predictors for the current psychopathology on all SCL-90-R subscales. The difficulty in describing feelings features of alexithymia is positively associated with interpersonal sensitivity and paranoid ideation, but it is inversely associated with the phobic anxiety dimension.

CONCLUSION

This study showed that the pregnant women with difficulty in describing feelings features of alexithymia are likely to show a broad range of psychopathology. Therefore, it is necessary to emphasize the benefits of specific psychotherapeutic techniques to improve self-differentiation so that we can reduce the likelihood of mental illnesses in pregnant women.

Alexithymia in different dermatologic patients

Alexithymia is a personality trait characterized by difficulties in differentiating and describing feelings. Research indicates that alexithymia can be considered as a possible risk factor for a variety of medical conditions. The purpose of our study was to compare and assess the prevalence of alexithymia in patients with psoriasis, alopecia areata, vitiligo and acne vulgaris. 120 consecutive subjects referred to dermatologic clinic with psoriasis, alopecia areata, vitiligo and acne vulgaris and 30 subjects selected from hospital staff and relatives of patients were enrolled in patient and control groups of our study respectively. Toronto Alexithymia Scale (TAS-20) was used to assess the prevalence of alexithymia. Statistical analysis showed significant differences between the vitiligo, alopecia areata, psoriasis patients and the control group in terms of alexithymia score (p≤0.05), but did not find any significant difference between acne patients and control group (p=0.06). This study has demonstrated high score of alexithymia in patients with psoriasis, alopecia areata and vitiligo compared with control group; however, such association was not found in individuals with acne vulgaris. Hence it is proposed that the evaluation and management of alexithymia would better the treatment of skin disorders and improve the quality of life in patients.

Health-related quality of life and its association with alexithymia and difficulties in emotion regulation in patients with psoriasis

BACKGROUND

Health-related quality of life (HRQoL) in psoriasis patients could be negatively affected by medical (e.g., obesity) and psychological (e.g., depression, anxiety, and alexithymia) conditions the presence of which suggests difficulties in understanding and regulating inner states and emotions. Thus, the aim of this study was to investigate HRQoL and its association with obesity and difficulties in understanding and regulating inner states and emotions in patients with psoriasis. A second objective was to examine whether the presence of difficulties in understanding and regulating inner states and emotions may mediate the association between psoriasis and poor HRQoL.

METHOD

One hundred adult outpatients and 97 healthy controls were administered a checklist assessing major socio-demographic variables, and measures of HRQoL, difficulties in emotion regulation, alexithymia, anxiety, depression, and food craving.

RESULTS

Psoriasis patients (compared to controls) reported more frequently obesity, alexithymia, anxiety, depression and food craving, and reported lower scores on the mental and physical components of HRQoL. A mediation model, with mental health as the dependent variable, indicated significant direct and indirect (through BMI, difficulties in emotion regulation, anxiety, depression, and food craving) effects of psoriasis on the quality of life, so that psoriasis was associated with worse mental health. A second mediation model with physical health as dependent variable indicated only a significant indirect effect (through BMI and depression) of psoriasis on the quality of life.

CONCLUSIONS

Psoriasis is characterized by poor HRQoL and the presence of difficulties in understanding and regulating inner states and emotions. In patients with psoriasis the possible influence of food craving on abnormal eating habits should be carefully assessed.

[Psychological and biological background of the correlation between psoriasis and stress]

Stress is considered as a major contributor to the development and exacerbation of psoriasis by a significant proportion of patients and dermatologists. As both stressor and its effects are subject-dependent, thus extremely difficult to measure, our understanding of the exact role of stress in disease development was limited for a long time. In the past decade several new studies were carried out which expanded our knowledge on the pathophysiologic processes linking stress to psoriasis via with their objective measurements and the applied new techniques. The authors review the current literature of both psychological (alexithymia, personality, affect) and biological (cortisol, epinephrine, neurogenic inflammation) factors influencing stress perception and response in psoriasis. Results of recent investigations support previous reports about the interaction between stress and psoriasis with objective evidence. Knowing how effective stress-reducing psychopharmacologic and psychotherapeutic interventions are in the treatment of psoriasis the authors hope that this review contributes to a wider acceptance of the psychosomatic attitude in everyday dermatologic practice.

Alexithymia, anxiety and depression in patients with psoriasis: a case-control study

BACKGROUND

Alexithymia, the difficulty in describing or recognizing emotions, has been associated with various psychosomatic pathologies including psoriasis. The aim of this study was to examine the prevalence of alexithymia and its association with anxiety and depression in patients with psoriasis compared with healthy participants, while taking into consideration demographic and clinical variables.

METHODS

One hundred and eight psoriatic patients and 100 healthy participants from the general population completed the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale (HADS). The severity of patients' psoriasis was clinically assessed using the Psoriasis Area and Severity Index (PASI).

RESULTS

Psoriatic patients had higher levels of alexithymia compared with healthy participants. While a rather high rate of psoriatic patients presented anxiety and depression as defined by the HADS, the differences that were found in comparison with the control group were not significant. Neither alexithymia nor its dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF) and externally oriented thinking (EOT), were associated with gender or psoriasis severity. Age was associated only with EOT, which was independent of depression and anxiety. Higher anxiety and depression were connected with higher alexithymia and DIF, while higher anxiety with higher DDF as well.

CONCLUSIONS

The alexithymia prevalence was higher in psoriatic patients than that in healthy participants, while it was positively correlated with anxiety and depression. Difficulty in identifying feelings was connected with both anxiety and depression, whereas difficulty in describing them was only with anxiety. Finally, externally oriented thinking was predicted only from age.

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.

Psychosomatic factors in pruritus

Pruritus and psyche are intricately and reciprocally related, with psychophysiological evidence and psychopathological explanations helping us to understand their complex association. Their interaction may be conceptualized and classified into 3 groups: pruritic diseases with psychiatric sequelae, pruritic diseases aggravated by psychosocial factors, and psychiatric disorders causing pruritus. Management of chronic pruritus is directed at treating the underlying causes and adopting a multidisciplinary approach to address the dermatologic, somatosensory, cognitive, and emotional aspects. Pharmcotherapeutic agents that are useful for chronic pruritus with comorbid depression and/or anxiety comprise selective serotonin reuptake inhibitors, mirtazapine, tricyclic antidepressants (amitriptyline and doxepin), and anticonvulsants (gabapentin, pregabalin); the role of neurokinin receptor-1 antagonists awaits verification. Antipsychotics are required for treating itch and formication associated with schizophrenia and delusion of parasitosis (including Morgellons disease).

The evaluation of primary idiopathic focal hyperhidrosis patients in terms of alexithymia

The aim of this study was to evaluate the primary focal hyperhidrosis patients in terms of alexithymia. Participants ( n = 50) diagnosed with primary focal hyperhidrosis by a dermatologist were referred to a psychiatrist and evaluated via Structured Clinical Interview for DSM-IV Axis I Disorders and Toronto Alexithymia Scale-20. The rate of alexithymia was 45.6 percent and 18.2 percent, respectively, for primary focal hyperhidrosis and control participants ( n = 44). Multivariate analysis of variance results showed that the primary focal hyperhidrosis group scored significantly higher than the control group in Difficulty Identifying Feelings and Difficulty Describing Feelings subscales, and total score. Psychotherapeutic interventions can increase the chances of dermatological treatment success and can have a positive impact on the quality of life in chronic cases.

Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments

Psoriasis is a common dermatologic disorder with psychiatric comorbidity that often goes undetected and untreated. Psoriasis has higher associations with psychiatric illness than do other dermatologic conditions. We conducted a comprehensive qualitative review of all published medical literature on psoriasis and psychiatric comorbidities since 2005. We found that psoriasis patients suffer psychiatric and psychosocial morbidity that is not commensurate with the extent of cutaneous lesions. Biologic therapies and nonpharmacologic psychosocial interventions show promise in treating comorbid psychiatric illness. The main limitations of this review are the low quality of published studies and the infrequent use of basic science endpoints in reporting treatment outcomes. The literature examining the psychiatric comorbidity of psoriasis is expanding but remains of variable quality. Stronger studies will be necessary to more accurately estimate comorbidities and help identify and comprehensively treat suffering patients.

Alexithymia and acne vulgaris: a case control study

OBJECTIVE

To assess relationship between alexithymia and acne vulgaris in young people.

METHODS

A hundred and eleven subjects between 15 and 25 years of age referred to out-patient clinic of dermatology with acne and 78 subjects applied to family physician for complaints other than acne were included in patient and control groups of the study, respectively. A questionnaire to determine demographic characteristics, an acne classification to determine severity of acne and Toronto Alexithymic Scale (TAS) to assess alexithymia were used.

RESULTS

The mean scores of TAS were 52.7±10.8 and 51.7±10.7 in patient and control groups, respectively. Alexitymia was determined in 23.4% of the subjects in acne group and in 24.4% of control group. No significant differences were found between groups in terms of alexithymia, intermediate alexitymia and three-factors of TAS.

CONCLUSION

Alexithymia does not appear to be related to acne vulgaris.

Life events involvement in psoriasis onset/recurrence

BACKGROUND

The purpose of the study was to evaluate the possible role of stress before the onset/extension/recurrence of psoriasis.

PATIENTS AND METHOD

One hundred and sixty-nine outpatients with psoriasis and 169 age and gender matched controls were enrolled. The design was a case-control study (controls had skin diseases with low psychosomatic component). Stressful life events were evaluated using Holmes and Rahe's Social Readjustment Rating Scale.

RESULTS

In the psoriatic group, there was a female predominance (66%) and a median age 47.55 years (SD = 20.32). In all, 10.65% of patients had family history of psoriasis. More than 54% of cases experienced at least one stressful event (47.36% for onset, 63.51% for recurrence/extension), compared with 19.52% of controls (chi(2) = 42.71, P < 0.0001). The odds ratio was 4.92. There was a significant difference in the mean number of stressful events between patients and controls (P < 0.0001). Women with psoriasis vulgaris and men with guttate psoriasis seemed to be more sensitive to stressful events. We divided the events described by Holmes and Rahe into three categories: family, personal, and job/financial problems. Family matters were mentioned by 42.7% of psoriatic patients, statistically significant compared with controls (P < 0.0001). In 35% of psoriatic cases, "the stressful event" was represented by the illness/death of someone dear. Both "personal" (25.6%; P = 0.02) and "job/financial problems" (31.6%; P < 0.0001) were significantly different compared with controls.

CONCLUSIONS

Stressful events could be highly related to psoriasis (especially in recurrences/extensions). Problems related to family are the most often involved with counseling being suggested.

Psychological factors involved in prurigo nodularis: A pilot study

Emotional stresses and psychological disorders seem to be concurrent factors in some cases of prurigo nodularis (PN), a chronic skin condition with a difficult therapeutic approach. In order to improve the therapeutic strategies, we performed a psychometric study on 20 patients affected by generalized and histological proven PN. Specific questionnaires were employed to examine the hypotheses (General Health Questionnaire, State Trait Anxiety Inventory - form Y, Beck Depression Inventory-II, and Eysenck Personality Questionnaire). The results show that symptoms of anxiety and depression associated with PN are more severe than in the control group and that some specific traits of personality are more frequently represented in such subjects. The results of our study represent a first attempt to analyze the psychological problems and the personality dimensions which seem to characterize PN patients. Such evidence supports the importance of a psychological approach in the clinical management of PN, which should always include psychological assessment and treatment together with the other therapeutic options.

Depression and quality of life in psoriasis

Psoriasis is a chronic inflammatory hyperproliferative disease of the skin, scalp, nails, and joints. The physical symptoms of psoriasis include itching, irritation, burning/stinging, sensitivity, and pain. Patients also suffer psychological distress, especially as a result of stigmatization, self-consciousness, and embarrassment, which can in turn affect employment and social activities. Relatively high rates of depression are reported in patients with psoriasis. Inflammatory cytokines such as tumor necrosis factor alpha, interferon gamma, and other type 1 cytokines play an important role in the pathogenesis and comorbidities of psoriasis. Data from both animal and human studies suggest that these cytokines are linked to depression. Some psoriasis treatments have demonstrated improvements in symptoms of psoriasis as well as in measures of depression and health-related quality of life. Physicians managing patients with psoriasis must be aware of the psychological effects of psoriasis and need to use a multifaceted approach to managing this disease, focusing on both the physical and psychological aspects.

Combined effects of HLA-Cw6 and cigarette smoking in psoriasis vulgaris: a hospital-based case-control study in China

BACKGROUND

Psoriasis is not only related to genetic factors but also to environmental factors. However, the combined effect of genetic and environmental factors in the development of psoriasis has still been unclear.

OBJECTIVE

The study was to analyze the combined effect of HLA-Cw6 and smoking on psoriasis vulgaris.

METHODS

A hospital-based case-control was conducted study. One hundred seventy-eight cases and 178 controls received this epidemiological investigation and HLA typing by polymerase chain reaction utilizing sequence-specific primers.

RESULTS

The risk of psoriasis was related to smoking, the adjusted odds ratio (OR) being 2.07 (P < 0.01), and there is a graded positive association between the risk of psoriasis and intensity or duration of smoking. Stressful life events increased the risk of psoriasis (OR = 7.87, P < 0.01). We found the waist-hip ratio (WHR) increased the risk of psoriasis vulgaris, and OR was 2.67 (P < 0.01) in China. Individuals harboring the HLA-Cw6 gene obviously increased the risk of psoriasis, OR being 9.93 (P < 0.01) after adjusted for potential confounder factors, while the OR of psoriasis for HLA-B57 was 2.41 (P < 0.05). Significant combined effect between HLA-Cw6 and HLA-B57 for psoriasis was found (OR = 10.51, P < 0.01). A striking finding is that the risk of psoriasis for smokers with HLA-Cw6 increased about 11-fold than non-smokers without HLA-Cw6, and the risk increased some 20-fold in individuals with HLA-Cw6 having stressful life events compared with one without HLA-Cw6 and stressful life events.

CONCLUSION

Our study suggested that the combined effect between HLA-Cw6 and cigarette smoking or stressful life events may play an important role in the development of psoriasis vulgaris in Han Chinese population.

[Alexithymia and psoriasis: a case-control study of 53 patients]

INTRODUCTION

Alexithymia was originally defined as the inability to recognize and verbalize emotions. It is characterized by an emptiness of feelings, poverty of imagination or of a life fantasy and difficulties in communicating with other people, as well as lack of positive emotions and a high prevalence of negative emotions. Its presence has been incriminated in the genesis and in the maintenance of various psychosomatic pathologies. Psoriasis, a frequent dermatitis, is classified among psychosomatic pathologies. In fact, the psychological dimension seems important, either in the appearance of the illness, in its evolution or in its prognosis.

AIMS OF THE STUDY

Estimate the prevalence of alexithymia among patients with psoriasis. Study the relationship between them. PATIENTS' CHARACTERISTICS: Fifty-three patients with psoriasis consulted the Dermatology Department of the Hedi Chaker University Hospital, in Sfax, Tunisia. Patients' mean age was 42 years (min: 18 years; max: 76 years). The majority was married (58%), coming from middle to low social economic status (86%), and having a primary or secondary school level (84%). Psoriasis was vulgar for 47 patients (89%) and pustular for the others (11%).

METHODOLOGY

We built a case-control study of 53 patients with psoriasis. The control group was formed of 53 subjects without psoriasis and paired according sex, age and school level. We evaluated psoriasis severity using the Psoriasis Area and Severity Index (PASI), a standardised instrument permitting assessment of the global severity of psoriasis. A cut off of 12 was used to diagnose severe psoriasis. Alexithymia was assessed with the 20-item version of the Toronto Alexithymia Scale (TAS-20). This instrument has shown to be the best validated instrument for measuring alexithymia. A cut off of 61 was used to diagnose alexithymia. Sociodemographical and clinical data were assessed by a questionnaire that was filled in by the doctor conducting the study. All analyses were performed using the SPSS version 11.0 and with a 95% confidence interval. Differences in groups were tested using student's independent t-test, and Chi-square.

RESULTS

The mean score of alexithymia for the patients was 56 (E: 12.1). The mean score of alexithymia for the control group was 45 (E: 9.6). Thirty-nine decimal six percent (n: 21) of patients and 13.2% (n: 7) of controls exhibited alexithymia. Our results confirm the high prevalence of alexithymia among patients with psoriasis (39.6%) compared to controls (13.2%) (p: 0.0002, RR: 3.4). A stress factor was present before the apparition of psoriasis in half of the cases. Psoriasis was severe in 50% of cases. Women with psoriasis (and not men) presented severe psoriasis when they suffered from alexithymia (p: 0.049). The relationship between alexithymia and age was significant from the age of 40 (p: 0.024). The association between psoriasis and another psychosomatic diseases was significantly more important than for the controls (p: 0.03; RR: 4.6). Psoriasis was not correlated to psychoactive substance (tobacco and alcohol, in our study). However, in the group of patients with alexithymia, alcohol consumption was associated with psoriasis severity (p: 0.05).

DISCUSSION

In alexithymia, there is a risk that physical and emotional feelings will be used without distinction as signs of psychological distress, which can explain the somatic complaint due to the lack of the expression of psychological suffering. This can lead to the apparition of psoriasis. The relationship between psoriasis and alexithymia is increasingly studied in epidemiological surveys that use different instruments to measure alexithymia. However, the results of these surveys do not concord with ours. Our results demonstrated a close link between the two conditions. Moreover, the risk of further psychosomatic diseases increases in the presence of alexithymia. The consumption of alcohol was also high in cases of severe forms of psoriasis.

CONCLUSION

Alexithymia does not appear to be a simple condition, related to psoriasis, but a worsening of the condition, exposing the patient to the association of other psychosomatic diseases and alcoholism, and thus worsening the global prognosis of these patients. The psychological approach, which favours the expression of emotions and permits a symbolic dimension, is as important as the biological approach, and necessary for the improvement of these patients.

Psoriasis and stress: a prospective study

BACKGROUND

Psoriasis is generally thought to be worsened by stress. This presumption has been supported primarily by retrospective studies using questionnaires. No controlled prospective study on this issue has been performed.

METHODS

Nine women with moderate plaque psoriasis were enrolled in the study. They all believed that their psoriasis was worsened by stress. They filled in a daily diary with estimations of actual stress levels and grades of psoriasis. The study of each patient started when her skin disease was in a stable phase and was concluded when her psoriasis was worsened by at least 25% from the starting level. Psoriasis area severity index scores were recorded at the start, as soon as possible after exacerbation and 2 weeks later. Stress-related blood samples were taken at the same visits. The study was analysed as a nine-case study.

RESULTS

No clear pattern was found between stress levels and worsening of psoriasis in our nine patients. One patient had elevated stress levels 13 days before exacerbation of psoriasis, but for at least seven patients, there were no identifiable time relationships between stress and psoriasis appearance. For two patients, there were clear elevations of stress levels after psoriasis outbreak.

CONCLUSION

This limited study does not support the assumption that stress is a worsening factor in psoriasis.

Stress, social support, and delayed skin barrier recovery

OBJECTIVE

To examine the effect of a brief laboratory stressor and social support before the stressor on cardiovascular and cortisol responses, and skin barrier recovery after skin disruption.

METHODS

Eighty-five healthy participants (mean age 22.9 +/- 4.4 years) underwent a "tape-stripping" procedure that disrupts normal skin barrier function, and were randomly assigned to a No Stress (reading task), Stress (Trier Social Stress Test), or Stress + Social Support condition (support from a confederate before the stressor). Skin barrier recovery was assessed by measuring transepidermal water loss from up to 2 hours after skin disruption.

RESULTS

Compared with the No Stress condition, the stressor delayed skin barrier recovery by 10% at 2 hours after skin disruption (effect size, r = .29), and increased anxiety (r = .24), negative affect (r = .22), cardiovascular activity (r values from .4-.6), and among male participants, cortisol levels (r = .40). Social support did not influence psychological or physiological responses or skin barrier recovery. Larger physiological responses to the tasks did not predict slower skin barrier recovery. Instead, larger systolic blood pressure responses predicted faster skin barrier recovery (r = .26).

CONCLUSIONS

This study replicated the effects of short-term laboratory stressors on skin barrier recovery, further establishing the relevance of skin barrier recovery for future research. The support manipulation did not influence physiological responses or skin barrier recovery, suggesting that future research on social support, physiology, and objective health outcomes should focus on naturalistic social interactions, relationships, and stressors.

Psychological factors in prurigo nodularis in comparison with psoriasis vulgaris: results of a case-control study

BACKGROUND

It has been suggested that psychological factors such as repressing anger and altruistic interpersonal behaviour may play a role in the aetiology of chronic itching in prurigo nodularis (PN). Whether these issues are specific for PN or are also common in other chronic skin diseases, e.g. psoriasis, has not been investigated until now.

OBJECTIVES

To investigate psychosomatic problem areas and psychiatric comorbidity in patients with PN in comparison with patients with psoriasis.

METHODS

Ninety-four patients with PN and 91 patients with psoriasis were administered the Hospital Anxiety and Depression Scale, Toronto Alexithymia Scale, State-Trait Anger Expression Inventory, Inventory of Interpersonal Problems, Screening for Somatoform Disorders and the Whiteley Index for hypochondriasis.

RESULTS

After Bonferroni post hoc adjustment, the metrical scales demonstrated no significant differences between patients with PN and those with psoriasis. There was only a tendency to less 'anger-out' and to less autocratic/dominant and more insecure/submissive behaviour in the patients with PN. Patients with PN were, in general, comparable with those with psoriasis with regard to alexithymia, somatization symptoms, hypochondriasis, anxiety and depression, with 18% cases of anxiety and 22% cases of depression.

CONCLUSIONS

The hypotheses formulated in the literature on the specific aetiology of PN could not be proven for the majority of patients with PN in our study. Concerning their psychopathology, patients with PN were comparable with those with psoriasis. Therefore the clinical management of PN should include psychosomatic assessment.

Integration of Multiple Criteria for Psychosomatic Assessment of Dermatological Patients

Psychological distress has been frequently reported in the setting of skin disorders. The Diagnostic Criteria for Psychosomatic Research (DCPR) have been found to yield valuable integrative information, in addition to DSM-IV nosology, in a variety of medical diseases. The aim of this study was to verify whether this integration could also be helpful in dermatology. A consecutive series of 539 inpatients with various skin conditions was evaluated by means of structured interviews for DSM-IV and DCPR diagnoses. The prevalence of DSM-IV conditions was 38% (mostly depressive disorders and anxiety disorders), whereas that of DCPR clusters (mostly demoralization and somatization secondary to psychopathology) was 48%. Overall, DCPR diagnoses were significantly more frequent than DSM-IV categories, regardless of the presence or absence of a psychiatric disorder. Psychological assessment of patients with skin diseases needs to incorporate both clinical (DSM-IV) and subclinical (DCPR) methods of classification. The health status of these patients can be improved if their psychological problems are appropriately assessed and recognized.

Stress, social support, emotional regulation, and exacerbation of diffuse plaque psoriasis

The authors' aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis.

Psychologic Factors in Psoriasis: Consequences, Mechanisms, and Interventions

The article examines the English-language research literature concerning psychologic aspects of psoriasis published since 1995. The literature is concerned with (1) the consequences of psoriasis in terms of quality of life, disability, depression, anxiety, and stigmatization and factors that may predict such outcomes; (2) potential mechanisms of the interaction between psychologic factors, stress, and the pathophysiology of psoriasis; and (3) examination of the clinical utility of psychologic interventions on extent of psoriasis and psychologic distress. The implications of the findings are discussed with reference to future directions for research and practice.

Cigarette Smoking, Body Mass Index, and Stressful Life Events as Risk Factors for Psoriasis: Results from an Italian Case–Control Study

We conducted a case-control study to analyse the association of psoriasis of recent onset with smoking habits, body mass index (BMI) and stressful life events. Cases (n=560; median age 38) were patients with a first diagnosis of psoriasis and a history of skin manifestations of no longer than two years after the reported disease onset. Patients with a new diagnosis of skin diseases other than psoriasis (n=690; median age 36) were selected as controls. The risk of psoriasis was higher in ex- and current smokers than in never-smokers, the relative risk estimates (OR) being 1.9 for ex-smokers and 1.7 for smokers. Smoking was strongly associated with pustular lesions (32 patients, OR=5.3 for smokers). The frequency of psoriasis varied significantly in relation to a family history of psoriasis in first degree relatives, BMI (OR=1.6 and 1.9 for over weighted, BMI 26-29, and obese, BMI >/= 30, respectively) and stressful life event score (compared to the lower index quartile, the OR being 2.2 for index values >/=115). Risk estimates, when taking into consideration the combined effect of these factors with smoking habits, were consistent with a multiplicative model of risk combination with no significant statistical interaction.

Psoriasis phenotype at disease onset: clinical characterization of 400 adult cases

Psoriasis is clinically a heterogeneous disease. Detailed evaluation of phenotype at disease onset is lacking. This study is a baseline characterization of 400 adult individuals with first time incidence of psoriasis on non-hairy skin, describing clinical phenotypes and putative environmental triggers at disease onset. In total, 74 patients with guttate and 326 patients with non-guttate phenotype, the majority with plaque psoriasis, were included. Guttate phenotype was associated with younger age and recent infection in 84%, where acute streptococcal pharyngitis was verified in 63%. The predominating factor associated with onset of plaque psoriasis was a recent life crisis (46%). A positive family history for psoriasis was approximately the same in both groups. Psoriasis arthropathy was diagnosed in 5% of guttate and 15% of non-guttate patients, with enthesopathy being the dominant symptom among guttate patients. This study confirms the strong link between onset of guttate psoriasis phenotype and streptococcal throat infection, whereas onset of plaque psoriasis was highly associated with a preceding distinct stressful life event. Longitudinal follow-up of the patients will provide robust information about disease development and response to treatment.

Alexithymia in patients with psoriasis: clinical correlates and psychometric properties of the Toronto Alexithymia Scale-20

OBJECTIVE

The objective of this study was to examine the psychometric properties and clinical correlates of the 20-item Toronto Alexithymia Scale (TAS-20) in patients with psoriasis.

METHODS

Three hundred patients with psoriasis completed the TAS-20 and had the severity of their psoriasis clinically assessed. Test-retest reliability was assessed over 10 weeks in a subset of 71 patients receiving standard medical treatment for their psoriasis. Examination of the factor structure employed both exploratory (EFA) and confirmatory (CFA) factor analysis techniques.

RESULTS

The overall prevalence of alexithymia in this population of psoriasis patients, as indicated by the TAS-20, was 33%. The TAS-20 total score was not related to clinical severity, age, age at onset or duration of psoriasis. The 10-week test-retest reliability on a sample of 71 psoriasis patients, pre- and posttreatment with photochemotherapy, was found to be acceptable (r=.69; P<.001). EFA produced no stable solutions. The three-factor structure of the TAS-20 using CFA was also not replicable in this sample.

CONCLUSIONS

The findings of this study support the contention that alexithymia is not significantly influenced by either disease severity or chronicity in patients with psoriasis. It is recommended that when employing the TAS-20 in patients with psoriasis, caution is exercised in the interpretation of the scale scores and that further psychometric evaluation of the scale is undertaken as appropriate.

Successful treatment of psoriasis improves psoriasis-specific but not more general aspects of patients' well-being

BACKGROUND

Psoriasis has a detrimental effect on patients' quality of life. However, there is a relative dearth of information on which aspects of a patient's well-being are affected by successful treatment.

OBJECTIVES

To investigate whether, and to what extent, improvement in the clinical severity of psoriasis induced by photochemotherapy with psoralen plus ultraviolet A (PUVA) translates into meaningful changes in beliefs about psoriasis, coping, stress, distress or disability.

METHODS

In a prospective study, 72 patients were assessed before PUVA therapy and again when they had achieved clearance of their psoriasis.

RESULTS

Patients demonstrated significant reductions in psoriasis-related disability, psoriasis-related stress or daily hassles and in the frequency of psoriasis-related symptoms. By comparison, there were no significant differences in levels of anxiety, depression or worrying. Similarly, patients' perceptions about cure, potential chronicity, causes, consequences and coping also remained unchanged.

CONCLUSIONS

These results suggest that while clearance of psoriasis produces a significant reduction in factors specific to psoriasis (disability and stress), it does not impact upon psychological distress, on patients' beliefs about psoriasis or on coping. This observation highlights the complex features of patients' psychological experience of psoriasis and may provide further impetus for integration of psychological interventions into standard care protocols.

Anger and acne: implications for quality of life, patient satisfaction and clinical care

BACKGROUND

Acne is a common skin disorder with a significant psychological and social impact for some people. Little is known about how personality and emotional traits affect acne and its impact on quality of life and treatment. Trait anger (TA), which is related to heart disease and other morbidities, may also affect acne and patients' adjustment to it.

OBJECTIVES

To evaluate the relationship between TA and acne severity, skin-related quality of life, satisfaction with treatment, and adherence to treatment.

PARTICIPANTS AND METHODS

A sample of 479 individuals with acne completed a survey instrument to assess acne severity, skin care practices, skin-related quality of life, satisfaction with treatment, adherence, TA and demographic variables. Respondents who reported high TA were compared with individuals with low TA on outcome variables. Regression analyses adjusted for covariates and identified the significant predictors of quality of life, satisfaction and adherence.

RESULTS

High TA was unrelated to acne severity (P = 0.2) or frequency of face washing (P = 0.9). Anger was significantly related to both global quality of life (P < 0.001) and skin-related quality of life (P = 0.002) as well as to satisfaction with treatment (P = 0.001) and adherence to treatment advice (P = 0.05) in bivariate analyses. Regression analyses revealed that high TA remained a significant predictor of global (P < 0.001) and skin-related quality of life (P = 0.003) and satisfaction with treatment (P = 0.04), but not adherence to treatment advice (P = 0.8) after controlling for covariates.

CONCLUSIONS

Anger is associated with the quality of patients' lives and with their satisfaction with treatment. Care of acne patients should include attention to anger and other chronic emotional states, quality of life, as well as to clinical severity. Simple guidelines are suggested for how clinicians might approach this important aspect of care.