JEADV
DOI: 10.1111/j.1468-3083.2009.03542.x
ORIGINAL ARTICLE
Well being, psychopathology and coping strategies in psoriasis compared with atopic dermatitis: a controlled study V Leibovici,†,* L Canetti,‡ S Yahalomi,† R Cooper-Kazaz,§ O Bonne,§ A Ingber,† E Bachar‡ †
Department of Dermatology, Hadassah University Medical Center, Jerusalem, Israel Department of Psychology Hebrew University of Jerusalem and Department of Psychiatry, Hadassah University Medical Center, Jerusalem, Israel § Department of Psychiatry, Hadassah University Medical Center Jerusalem, Jerusalem, Israel *Correspondence: V Leibovici. E-mail:
[email protected] ‡
Abstract Background There is a vast literature describing the association between psoriasis, atopic dermatitis (AD) and psychological distress. Some of these studies were uncontrolled and others used non-dermatological diseases as control, but only a few used chronic skin diseases as controls. Objective To compare well being, psychopathology and coping strategies of psoriatic, AD and healthy controls in a prospective case-control study. Methods Thirty-seven psoriatic patients and 31 AD patients were recruited from the Hadassah Ein Karem Hospital, Jerusalem, Israel, outpatient and inward clinic. The participants in the control group were 31 healthy workers and volunteers with no dermatological diseases from Kaplan Hospital, Rehovot, Israel. We used self-report questionnaires [Mental Health Inventory (MHI) and Adjustment to Chronic Skin Diseases Questionnaire (ACSD)], a projective technique (Hand Test) and assessment tools (Clinical Global Impression). Results Psoriatic patients experienced reduced well being (P = 0.007) and more anxiety and depression (P = 0.018) than normal controls. Psoriatic patients also displayed more severe psychopathology (P = 0.039) a more passive attitude towards life, and loss of meaning in life (P = 0.001) as measured by the projective technique compared with AD patients and normal controls. Conclusions We propose two explanations, derived from the psychological and the psycho-neuro-immunological domains. First, greater mental distress in psoriasis is because of the greater stigma it bears compared with AD. Alternatively, we hypothesize that the psoriatic inflammatory process may possibly have a direct central nervous system effect. Received: 12 September 2009; Accepted: 17 November 2009
Keywords atopic dermatitis, psoriasis, psychopathology
Conflict of interest None declared.
Introduction Psoriasis is a chronic, relapsing inflammatory skin disease with a prevalence of 2.2%.1 While the aetiology remains to be fully elucidated, psoriasis is now regarded as a T-cell-dependent autoimmune disease, in which both genetic and environmental factors play an important role.2 Atopic dermatitis (AD) is a chronic, pruritic, inflammatory disease of unknown origin. The prevalence of AD is rising and currently affecting up to 15–20% of young children3 and 1–3% of adults.4 AD is a multifactorial disease, caused by a genetic
JEADV 2010, 24, 897–903
predisposition and triggered by environmental factors. Thus, mutations in the filaggrin genes are considered to lead to transepidermal penetration of environmental allergens, increased transepidermal water-loss and inflammation.5 Psychosocial aspects in psoriasis have been well reviewed in three studies: Gupta et al.6, Ginsburg7 and Fortune et al.8 Many studies document the disruptive impact psoriasis has on patients’ lives. It is detrimental to body image9,10 and sexual functioning.11 Patients report having difficulties establishing social contacts and relationships.12 Psoriatic patients experience interpersonal anxiety
ª 2010 The Authors Journal compilation ª 2010 European Academy of Dermatology and Venereology
Leibovici et al.
898
along with shame and embarrassment, difficulties at work (such as limited opportunities), difficulty in functioning, family friction and depression.13 Many studies have dealt with the association between psoriasis and psychological distress. Patients with psoriasis were found to be more depressed than controls when utilizing the Beck Depression Inventory, and to have generally higher rates of depression or psychopathology than patients with lichen planus, leprosy and vitiligo. The percentage of psoriatic patients suffering from depression in these studies ranged from 22% to 58%14,15 Another study found a greater prevalence of depression and suicidal thoughts among patients with severe psoriasis compared with patients with acne, alopecia areata, AD or general medical conditions.16 Gupta et al.,17showed that the degree of depression increased with the degree of pruritus, which in itself was not related to psoriasis severity. Gupta et al.18 also reported that perception of stigmatization was the most significant factor in predicting depression in psoriasis. Anxiety among psoriatic patients is even more common than depression. Richards et al.19 found that 43% of psoriatic outpatients were diagnosed with anxiety, a rate higher than other diseases such as cancer.20 Social anxiety ⁄ avoidance is reported to be higher in patients with psoriasis than in patients with AD, contact dermatitis, acne or vitiligo.21 Many studies implicate the role of stress in precipitating and exacerbating psoriasis. While some of these studies were uncontrolled,22–24 others used non-dermatological diseases as controls,25,26 and only a few used chronic dermatological diseases as controls. In her review, Buske-Kirschbaum et al.27 showed that AD has a great impact on the mental health and quality of life of those suffering from the disease as a result of intense itching, unpredictability of the disease and feeling of disfigurement caused by the skin lesions. Positive correlations were found between pruritus severity and depression28 and between learned-scratch-response and anxiety.29 Several studies showed the severity of AD symptoms to be altered by stress.30,31 Prior studies suffered from methodological problems referring only to retrospective life events. More recent studies have shown that even minor everyday stressors reported the day before assessment can affect and predict symptom severity.32 Psychosocial stress and symptomatology might be bidirectionally related. Gil et al.33 found that AD children experienced increased levels of distress as a consequence of the chronic illness and the amount of stress was positively correlated with the skin condition, intensity of scratching or medication taken. Buske-Kirschbaum et al. 27 concluded that it is not clear whether stress aggravates the skin condition, whether the symptom severity elevates the stress level or whether an additional factor increases both of them. Schmitt et al.34 found an independent association between AD and attention-deficit ⁄ hyperactivity disorder (ADHD) in a population-based study of children and adolescents, possibly related to AD severity. The authors state that it is unclear what the
JEADV 2010, 24, 897–903
possible causal relationship or the association directions are. It remains unclear whether the observed association is as a result of shared aetiological factors, or whether itching, sleep disturbance or psychosocial stressors found in AD might induce or exacerbate ADHD symptoms in a subgroup of patients. Although several studies indicate an association between psoriasis, AD and psychopathological problems, only a few have used chronic dermatological diseases as controls. In all of the studies reviewed above, researchers made use of clinical interviews and self-report questionnaires to study distress, psychopathology and psychological well-being. To the best of our knowledge, projective technique has not been used until now in dermatological studies. Projective techniques are psychological testing in which the subject is confronted with a set of stimuli, mostly pictures or inkblots, His response represents his own associations and ideas of what might be in the picture. There is no correct, definite or expected answer. Responses are considered as reflecting deeper layers of mental functioning, those which are not tapped by clinical questioning or self-report questionnaires. The purpose of the present study was to assess and compare psychopathology, well being and coping strategies among patients suffering from psoriasis, AD and healthy controls. Assessment used self-reporting measures and a ‘projective’ technique.
Methods Participants
The participants of the study were 37 psoriatic patients, 31 AD patients and 31 controls. The psoriatic and AD patients were recruited from the dermatologic department and outpatient clinic of Hadassah University Hospital, Jerusalem, Israel. The participants in the control group were healthy workers and volunteers, with no dermatological diseases of Kaplan Medical Center, Rehovot, Israel. Exclusion criteria included patients not fluent in Hebrew, patients under the age of 18 and patients receiving biological or immunosuppressive therapies that potentially could affect the mood. The groups were balanced in their demographic characteristics: no significant differences were found among the three groups in age, gender, marital status, country of origin, education and income (Table 1). In addition, no significant differences were found in age of illness onset or years since diagnosis between psoriatic and AD patients (Table 2). The study was approved by the Hadassah Medical Center’s ethics committee for clinical trials and informed consent was obtained from all participants, following an explanation of the study. Instruments
Self-report questionnaires. 1 A Socio-Demographic Questionnaire was compiled to assess age, marital status, country of origin, education, income, age at onset of illness and duration of illness.
ª 2010 The Authors Journal compilation ª 2010 European Academy of Dermatology and Venereology
Psoriasis, atopic dermatitis and psychopathology
899
Table 1 Study population
Age
Psoriasis (n = 37)
Atopic dermatitis (n = 31)
Control (n = 31)
F- ⁄ v2-value
P-value
49.5 (16.3)
41.7 (18.8)
41.2 (11.6)
2.9
ns
0.6
ns
6.7
ns
1.9
ns
3.5
ns
0.8
ns
Gender, n (%) Male
15 (40.5)
15 (48.4)
15 (48.4)
Female
22 (59.5)
16 (51.6)
16 (51.6)
Marital status, n (%) Single
7 (18.9)
9 (29.0)
5 (16.7)
Married
24 (64.9
20 (64.5)
22 (73.3)
Divorced
3 (8.1)
2 (6.5)
3 (10)
Widowed
3 (8.1)
0
0
Country of origin, n (%) Israel
22 (59.5)
21 (67.7)
America-W. Europe
4 (10.8)
3 (9.7)
20 (66.7) 1 (3.3)
East Europe
6 (16.2)
4 (12.9)
5 (16.7)
Asia-Africa
5 (13.5)
3 (9.7)
4 (13.3)
19 (51.4)
10 (32.3)
11 (36.7)
6 (16.2)
6 (19.4)
12 (32.4)
15 (48.4)
Education, n (%) High school Undergraduate Graduated
4 (13.3) 15 (50)
Income, n (%) Lower than average
9 (24.3)
7 (22.6)
Average
16 (43.2)
15 (48.4)
Higher than average
12 (32.4)
9 (29)
8 (26.5) 15 (50) 7 (23.3)
ns, not significant.
2 The ACSD was designed by Stangier, Ehlers and Gieler21 to assess patients’ adaptation to chronic skin disorders. It consists of 51 items arranged in five sub-scales: social anxiety ⁄ avoidance, itch-scratch cycle, helplessness, anxious-depressive mood and impact on quality of life. The questionnaire showed high test–retest reliability and construct validity. In our study, the internal consistency of the scale was high (a = 0.97). 3 The MHI is a 38-item questionnaire composed of two inversely correlated sub-scales: 24 items of psychological distress including anxiety, depression and loss of behavioural-emotional control and 14 items of well being including general positive affect and emotional ties. Psychometric support was found for the use of a total score of all 38 items.35 The two sub-scales are scored inversely so that higher total scoring reflects greater well being. In our study, the internal consistency of the scale was high (a = 0.97).
Assessment tools. 1 The Clinical Global Impression – Severity Scale (CGI) developed by Guy36, is a clinician observational scale to assess global severity of illness. The scale scores range from 1, ‘normal, no illness’ to 7, ‘seriously ill’. The scale has high inter-rater reliability (0.75–0.90).36
JEADV 2010, 24, 897–903
2 The Hand Test is a projective test aimed to assess patients’ coping strategies. The test consists of ten cards depicting a single hand in different positions. The cards are presented consecutively in a standardized order and subjects are requested to answer a single question: ‘What does this hand look like it might be doing?’ Answers are classified in 15 subcategories which combine to form four categories: (1) interpersonal (consisted of subcategories; affection, dependence, communication, exhibition, direction and aggression); (2) environmental (acquisition, active and passive); (3) maladjustive (tension, crippled and fear) and (4) Withdrawal (description, bizarre and failure). The test has high test–retest reliability and criterion validity.37 3 The Psoriasis Area and Severity Index (PASI) is based on four different parameters: erythema, scaling, thickness and itching combined with the area of affected skin in four anatomical areas of the body.38 4 Visual Analogue Scale (VAS) is a 100 mm long line representing intensity of itching. One side represents the lowest intensity of itching and the other is the highest itching intensity. Patients are required to mark a spot that represents their itching intensity. The score consists of the length in millimetres. 5 The Severity Scoring of Atopic Dermatitis (SCORAD) combines six clinical features of disease intensity: erythema,
ª 2010 The Authors Journal compilation ª 2010 European Academy of Dermatology and Venereology
Leibovici et al.
900
Table 2 Comparison between psoriatic, atopic dermatitis and controls on the variables of the study Psoriasis (n = 37)
Atopic dermatitis (n = 31)
Control (n = 31)
F- ⁄ v2value
P-value
M-W K-W
Age of illness onset
33.9 (16.7)
25.8 (21.6)
1.73
ns
396
ns
Duration of illness
16.1 (15)
15.9 (16.9)
0.062
ns
503
ns
SCORAD ⁄ PASI
14.9 (12.6)
40.0 (9.2)
N⁄A
Need to scratch
2.57 (3.04)
4.42 (3.07)
)2.5
4.2 (1.3)
4.3 (0.9)
)0.19
Well being
51.1 (13.8)
53.3 (11.9)
60.5 (10.5)
5.1
0.007
9.5
Psychological distress
61.4 (22.5)
55.7 (18.2)
48.8 (12.1)
3.9
0.025
6.3
0.042
157.7 (34.7)
165.5 (28.2)
179.8 (21.0)
4.8
0.010
8.3
0.013
Social anxiety ⁄ avoidance
33.8 (19.3)
26.6 (10.5)
481.5
ns
Itch-scratch cycle
19.6 (9.7)
21.5 (9.0)
)0.8
ns
471.5
ns
Helplessness
21.6 (11.4)
18.1 (8.3)
1.5
ns
488
ns
Anxious-depressive mood
19.1 (8.1)
17.0 (7.4)
1.1
ns
468
ns
Impact on quality of life
13.1 (8.9)
10.3 (3.8)
1.7
0.046*
498.5
ns
Direction
4.8 (6.5)
5.2 (5.4)
9.5 (8.2)
4.9
0.009
9.0
0.010
Acquisition
4.2 (5.8)
5.3 (8.0)
1.4 (4.0)
3.3
0.040
6.6
0.038
Description
2.2 (4.5)
1.2 (2.8)
0.0 (0.0)
4.0
0.021
7.4
0.018
Failure
4.0 (6.3)
1.8 (3.7)
1.3 (3.4)
3.0
0.053
4.0
ns
Interpersonal
44.0 (13.0)
50.2 (17.1)
56.2 (14.1)
5.9
0.004
10.1
Environmental
32.1 (16.2)
32.0 (17.6)
23.9 (12.1)
2.9
Maladjustive
17.0 (14.0)
14.5 (12.4)
18.5 (12.9)
0.7
ns
6.9 (7.7)
3.2 (4.6)
1.3 (3.4)
8.5
