doi: 10.1111/1346-8138.12553
Journal of Dermatology 2014; 41: 709–715
ORIGINAL ARTICLE
Distinct temperament and character profiles in first onset vitiligo but not in alopecia areata Gamze ERFAN,1 Yakup ALBAYRAK,2 M. Emin YANIK,1 Ozden OKSUZ,2 Kaan TASOLAR,1 Birol TOPCU,3 Cuneyt UNSAL2 Departments of 1Dermatology, 2Psychiatry, and 3Biostatistics, Faculty of Medicine, Namık Kemal University, Tekirdag, Turkey
ABSTRACT Alopecia areata (AA) and vitiligo (V) are diseases that are correlated with psychiatric disorders before, during and after diagnosis. The Temperament and Character Inventory (TCI) is a well-established approach for investigating personality traits in various psychosomatic diseases. The aim of this study is to compare and investigate the differences in the TCI between patients with first onset AA, patients with V and healthy controls (HC). Participants in the study included 42 patients with first onset AA, 50 adult patients with V and 60 HC who had no history or diagnoses of psychiatric or dermatological disorders. All participants were assessed with the TCI and the Dermatology Life Quality Index (DLQI). Among the temperament traits, the extravagance, disorderliness and total novelty-seeking scores were lower, and the worry and pessimism scores were higher in patients with V compared with patients with AA and the HC. The mean score of the enlightened second nature and the total selfdirectedness score of the character traits were higher in patients with V compared with patients with AA and the HC group. In the AA group, there was a negative correlation only between the reward dependence total score and the DLQI score. This study suggests that patients with first onset V have a distinct temperament, such as being unenthusiastic and unemotional, and character profiles, such as worry and pessimism, independent of their psychiatric comorbidities, and patients with AA do not have a different personality from the non-affected population.
Key words:
alopecia areata, character, Temperament and Character Inventory, vitiligo.
INTRODUCTION Skin diseases are usually associated with psychiatric symptomatology. Because skin diseases can be seen by others and this state can create stressful events for the individual, it is difficult to establish whether psychiatric disorders are the causes of the skin disease.1 Alopecia areata (AA) is a clinical condition that presents with a non-scarring hair loss that can be seen on the scalp and hair-covered areas without skin changes.2 The lifetime prevalence of AA is approximately 1.7%. Environmental and genetic factors are suspected in the etiology of AA.3 Emotional stress is an important part of the environmental factors in the etiology of AA.3,4 Evidence has shown that various psychiatric disorders such as anxiety disorders, paranoid disorders and depression are seen in patients who suffer from AA.5–7 The lifetime prevalence of any psychiatric disorder has been estimated at approximately 74%, and major depressive disorder and generalized anxiety were reported as the most common psychiatric disorders among patients with AA.8 In addition to this high percentage of psychiatric comorbidities in patients with AA,
studies have concluded that there is no association between the onset of AA and mood and anxiety disorders.9,10 Furthermore, no association was reported between hair regrowth and psychological well-being in patients with AA in a study conducted by Kose et al.11 The prevalence of vitiligo (V) is estimated at approximately 1–4%.12 It does not cause pain or physical limitations; however, patients with V experience a high degree of social functional impairment.13 Numerous studies have investigated the association between psychiatric disorders or symptoms and V. Patients with V have been reported to have high anxiety scores, depressive disorder, generalized anxiety disorder, social phobia, obsessive symptoms and hypochondria, high rates of alexithymia and avoidant behavior, and high rates of sleep disturbances.14–18 Furthermore, stigmatization may have a strong negative psychosocial impact on patients who suffer from V.19 In addition, a limited number of studies have aimed to identify the temperament and character profiles of patients with V. To our knowledge, only two studies (one in adults and one in a pediatric group) have examined temperament and character traits in patients with V.20,21
Correspondence: Gamze Erfan, M.D., Department of Dermatology, Namık Kemal Universitesi Uygulama ve Arastırma Hastanesi Dermatoloji, Poliklinigi Tunca Cad. 100. Yıl mah, Tekirdag, Turkey. Email: [email protected] Received 25 March 2014; accepted 4 June 2014.
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The Temperament and Character Inventory (TCI) is a wellestablished approach for investigating personality traits in various psychiatric disorders as well as various psychosomatic diseases. The TCI has been proposed as a psychobiological model by Cloninger et al., and increasing evidence has linked some TCI properties to various biological mechanisms.22 To our knowledge, no study has compared personality with the TCI for patients with AA, patients with V and healthy controls (HC). In this study, we aimed to compare temperament and character traits with the TCI between patients with first onset AA, patients with first onset V and HC, and investigate whether there are differences between patients with first onset AA, patients with first onset V and HC in terms of temperament and character traits.
METHODS This was a cross-sectional study. The study was conducted at the Namık Kemal University Medical Faculty, Departments of Dermatology and Psychiatry, between January 2013 and January 2014. Consecutive patients who were admitted to the dermatology outpatient service with a diagnosis of first onset AA and first onset V were included. The definition of first onset and inclusion criteria were set clinically for both patient groups as patients who were admitted as dermatology outpatients, who had been diagnosed with AA and V for the first time, and who had never been diagnosed with a skin disease before the present admission. All patients were referred to a senior psychiatrist for evaluation. Subjects who were younger than 18 years and older than 60 years, who had a history of any psychiatric disorders or who had been diagnosed with a psychiatric disorder after a psychiatric examination, who had another dermatological disease and/or who did not want to participate in the study were excluded. After elimination by exclusion criteria, 42 patients with first onset AA and 50 patients with first onset V were included in the present study. In addition, 60 HC, consisting of hospital staff members and relatives of patients, were recruited. The patients and the HC gave informed consent and agreed to participate in the study. The institutional ethics committee approved the study protocol. The patients and the healthy control group were assessed with the TCI, and the patient groups were also assessed with the Dermatology Life Quality Index (DLQI). The severity of AA was assessed with the Severity of Alopecia Tool (SALT) and the severity of V was assessed with the Rule of Nine.
Instruments TCI. Temperament and character were assessed using the TCI, a 240-question self-evaluated questionnaire.22,23 The TCI was validated in Turkish in healthy and psychiatric Turkish populations.24 According to the Cloninger model, the temperament dimension novelty seeking (NS) is described as a tendency to respond to novelty, impulsiveness, and quick loss of temper and active avoidance of frustration. The second temperament
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dimension, harm avoidance (HA), is bias in inhibiting behaviors, such as pessimistic worry, passive dependent behaviors and rapid fatigability. The third temperament dimension, reward dependence (RD), is a bias toward maintaining habitual behaviors and is shown in social adaptation and dependence on others’ approval. Persistence (P) is defined as a tendency to persevere despite frustration and fatigue. The character dimension, called self-directedness (SD), represents self-determination, self-esteem, and the ability of an individual to control, adapt and regulate behavior to fix the situation according to personal goals and values. The second character dimension, cooperativeness (CO), consists of individual differences in identifying with and accepting other people and measures aspects associated with agreeability, self-centered aggression and hostility. Self-transcendence (ST) refers to spiritual maturity, transpersonal identification and selfforgetfulness. DLQI. The DLQI is an easy, self-administered, 10-item questionnaire. It is the most commonly used questionnaire. It consists of questions that evaluate patients’ perception of the impact of skin diseases on categories including feelings, daily activities, leisure, work and school, and personal relationships, and side-effects of the treatment over the previous week. The total score is 30, and higher scores define greater impairment of quality of life.25,26 SALT. Visually determining the amount of terminal hair loss in each of the four views of the scalp and adding these together with a maximum score of 100% determine this scale. In this score, the right and left temporal regions compose 18%, the occipital region 24%, and the frontal and parietal regions 40% of the scalp.27 Rule of Nine. The Rule of Nine assessment calculates as the head and neck, each arm, leg, and the four trunk quadrants each composing 9% and genitalia 1% of the total body surface area. According to Wood’s lamp examination of the depigmentation of patients with V, the severity of the disease is assessed with the Rule of Nine, which is subjective and based on visual assessments.28
Statistical methods Data were analyzed with the Statistical Package for the Social Sciences, PC version 18.0 (SPSS, Chicago, IL, USA). A confidence interval (CI) of 95% and a two-tailed P-value less than 0.05 were statistically significant for all analyses. The Levene test was used to test the homogeneity of the variance of the variables. All numerical variables were tested with the Kolmogorov–Smirnov test for normality of distribution. Differences between the groups in age, education years, and TCI temperament scores such as NS, HA, RD, S and the subscores, and character scores such as SD, CO and ST and the subscores were tested with a series of one-way ANOVA. Tukey’s honestly significant difference test was applied in a post-hoc analysis for multiple comparisons of the three groups. The DLQI scores were tested with independent sample Student’s t-tests.
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Temperament and character profiles in vitiligo
Differences between the sexes were compared with the v2test. The Pearson correlation test was used to analyze the correlation coefficients between the TCI scores and the DLQI scores.
RESULTS The mean ages were 35.66 9.72, 34.88 4.23 and 34.78 5.21 years in the AA, V and HC groups, respectively. The mean age was similar between the groups (F = 0.91, P = 0.61). The male/female ratio and the mean years of education were similar between groups the (Table 1). Among the temperament traits, the NS3, NS4 and total NS scores were significantly different between the groups (F = 9.912, P < 0.001; F = 5.373 P = 0.006; F = 8.258, P < 0.001, respectively). The post-hoc test revealed that the NS3, NS4 and total NS scores were significantly lower in the V group compared with the AA and HC groups (P < 0.001, P = 0.001; P = 0.005, P = 0.05; P = 0.005, P = 0.001, respectively). Among the HA scores, HA1 was significant between the groups (F = 3.885, P = 0.023). The HA1 score was significantly higher in the V group compared with the HC group (P = 0.031); however, the HA1 score was similar between the AA and HC groups and the AA and V groups (P > 0.05). There were no differences between the groups in terms of the other subscores and the total HA score. The RD subscores and total score and the P score were similar between groups (P > 0.05). The comparisons of the total and subscores of the temperament dimension of the TCI are presented in Table 2. Among character traits, there were significant differences between the groups in terms of the SD5 score and the total SD score (F = 5.469, P = 0.005; F = 3.304, P = 0.039, respectively). The mean SD5 score was significantly higher in the V group compared with the AA and HC groups (P = 0.017; P = 0.015, respectively). The total SD score was higher in the V group compared with the HC group (P = 0.05). The other SD subscores were similar between the groups (P > 0.05). The total CT and ST scores and subscores were also similar between the groups (P > 0.05). Table 3 shows comparisons of the total scores and subscores of the TCI character dimension.
The mean SALT score in patients with AA was 12.58 15.07, and according to the Rule of Nine, the mean of the V surface depigmentation area was 5.40 2.47. In the AA group, there was a significant negative correlation only between the total RD score and the DLQI score (r = 0.318, P = 0.045). A significant negative correlation was found between the total SD score and the DLQI score in the V group (r = 0.318, P = 0.001) (Table 4). The power analyses for the NS, HA, RD, P, SD, C and ST between V and AA, HC and AA, V and HC were 88.3%, 5.7% and 96.1%; 20.3%, 9.2% and 51.81%; 5.0%, 9.9% and 11.93%; 7.0%, 11.9% and 16.9%; 5.9%, 47.4% and 67.8%; 5.5%, 43.9% and 43.1%; and 7.7%, 10.3% and 5.3%, respectively.
DISCUSSION The temperament and character traits of patients who suffer from numerous psychiatric disorders as well as several diseases that may be associated with psychiatric diseases have been investigated in recent years. In the present study, we investigated the temperament and character traits of patients with AA and V that are associated with stressful events and several psychiatric disorders.29 Although numerous studies have investigated psychopathology in patients with AA and the effects of psychopathology on the symptom severity of AA, few studies have investigated personality traits in patients with AA. Carrizosa et al.30 reported that patients with AA did not have different personality traits compared with those of patients who had other skin diseases. Alfani et al.31 compared patients with AA and HC in terms of personality traits with the Minnesota Multiphasic Personality Inventory (MMPI-2) and revealed that patients with alopecia appeared to experience more depressive, hysterical and anxiety feelings, have more hypochondriac tendencies, and were more in conflict with their social environment. To our knowledge, only one study investigated personality traits with the TCI in patients with AA. In this recent study, Annagur et al. reported that patients with AA had low NS, RD and ST scores compared with healthy participants. The researchers also found that patients with AA had a higher psychopathology index and higher depression scores than HC.32 Regarding
Table 1. Mean age, sex and mean years of education in alopecia areata, vitiligo and healthy control groups Alopecia (n = 42)
Vitiligo (n = 50)
Healthy control (n = 60)
Statistic
Age (years)
35.66 9.72
34.88 4.23
34.78 5.21
F = 0.91 P = 0.65
Sex Male Female Education (years)
28 (66.7%) 14 (33.3%) 9.61 2.32
21 (42%) 29 (58%) 8.78 3.13
30 (50%) 30 (50%) 9.63 3.26
v2 = 5.71 P = 0.57 F = 1.01 P = 0.69
Severity of disease Rule of Nine Severity of Alopecia Tool
– 12.58 15.07
5.40 2.47 –
– –
– –
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Table 2. Comparisons of total scores and subscores of temperament of Temperament and Character Inventory of subjects Alopecia (n = 42) Novelty seeking Exploration–excitability (NS1)
Vitiligo (n = 50)
Healthy control (n = 60)
5.76 1.85
5.66 2.04
5.86 1.86
Impulsiveness (NS2)
4.33 2.03
3.80 1.84
4.40 2.01
Extravagance (NS3)
4.71 1.91
3.22 1.61
4.58 1.97
Disorderliness (NS4)
4.07 1.95
3.2 1.59
4.28 1.82
18.88 5.01
15.68 4.66
19.13 4.71
Harm avoidance Worry and pessimism (HA1)
5.19 2.22
6.2 2.12
5.15 2.23
Fear of uncertainty (HA2)
4.33 1.69
4.62 1.56
3.95 1.70
Shyness (HA3)
3.28 2.41
3.72 1.94
3.30 2.04
Fatigability (HA4)
4.02 2.44
3.72 2.26
3.65 2.12
16.83 6.71
18.32 5.82
16.05 6.07
Reward dependence Sentimentality (RD1)
7.19 2.07
7.48 1.64
6.75 1.80
Attachment (RD3)
3.97 1.80
3.96 1.64
4.20 1.79
Dependence (RD4)
2.66 1.52
2.34 0.93
2.38 1.31
13.78 3.13
13.79 2.51
13.36 3.40
4.80 1.95
5.30 1.86
5.13 1.79
Total
Total
Total Persistence
these studies, Annagur et al.’s study had the most similar methodology to our study for discussing our results. In contrast to their findings, we did not find any differences in the TCI main scores and subscores in patients with AA compared with patients with V and the HC. These differences may be associated with including first onset patients and excluding patients who had been diagnosed with psychiatric disorders. The personality traits of patients with AA do not differ from the nonaffected population, and our results are in line with those of Carrizosa et al., who reported similar personality traits in patients with AA and patients who suffered from other skin diseases. Similar to AA, a limited number of studies have investigated the relation between personality and V. Salzer and Schallreuter33 investigated impaired catecholamine metabolism and its association with personality in patients with V and reported no specific personality in patients with V compared with HC. A study that investigated psychological characteristics in patients with V by using MMPI revealed that patients with common V had impaired social adaptation.34 To our knowledge, only one study has investigated temperament and character traits in
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Statistic F = 0.158 P = 0.854 F = 1.437 P = 0.241 F = 9.912 P = 0.000 F = 5.373 P = 0.006 F = 8.258 P = 0.000 F = 3.885 P = 0.023 F = 2.270 P = 0.107 F = 0.676 P = 0.510 F = 0.359 P = 0.699 F = 1.865 P = 0.159 F = 2.209 P = 0.113 F = 0.323 P = 0.724 F = 0.880 P = 0.417 F = 0.336 P = 0.715 F = 0.807 P = 0.448
€ler et al.21 compared adult patients with V. In this study, Gu personality traits between patients with psoriasis, neurodermatitis and V, and HC by TCI and revealed that patients with V had lower NS2 scores (impulsiveness) compared with patients €ler et al.’s study, we found with psoriasis and HC. Similar to Gu significantly lower NS3 (extravagance), NS4 (disorderliness) and total NS scores in patients with V compared with patients with AA and HC. Individuals who have low total NS scores were slow, unenthusiastic, unemotional, reflective, reserved, tolerant of monotony, systematic and orderly.35 Reserved, controlled or restrained individuals have low extravagance subscale (NS3) scores. They can delay gratification when they are frustrated longer than most people. These individuals do not waste their money, energy and feelings. However, they can give the impression of being ungenerous or frugal because of their unwillingness to spend or acquire things.22,35 People who scored low on the NS4 subscale tend to be organized, orderly, methodical and systematic. They often prefer activities with strict rules and regulations.34,35 In addition, variation in the dopamine transporter gene affects the expression of NS. Our results may identify why patients with V are socially isolated
© 2014 Japanese Dermatological Association
Temperament and character profiles in vitiligo
Table 3. Comparisons of total and subscores of character dimension of Temperament and Character Inventory of subjects Alopecia (n = 42)
Vitiligo (n = 50)
4.28 2.23
4.40 2.26
4.20 2.08
Purposefulness (SD2)
5.38 2.29
5.74 1.72
5.01 2.09
Resourcefulness (SD3)
3.19 1.08
3.22 1.26
3.11 1.31
Self-acceptance (SD4)
6.28 2.50
6.28 2.59
5.25 2.52
Enlightened second nature (SD5)
7.76 1.77
8.72 1.67
7.65 2.32
27.95 7.22
28.36 6.57
25.23 7.02
5.92 1.68
5.92 1.63
5.45 1.64
Empathy (C2)
4.50 1.48
4.22 1.25
4.21 1.48
Helpfulness (C3)
4.83 1.46
4.74 1.35
4.40 1.49
Compassion (C4)
7.07 2.67
6.80 2.77
6.28 2.55
Integrated conscience (C5)
6.59 1.59
7.06 1.13
6.38 1.61
29.000 6.34
28.74 5.71
26.73 6.12
6.26 2.52
5.78 2.31
6.08 2.01
Transpersonal identification (ST2)
5.40 2.01
5.08 2.20
4.88 2.19
Spiritual acceptance (ST3)
7.02 2.93
7.22 2.32
6.91 2.43
18.69 5.84
18.12 5.25
17.95 4.97
Self-directedness Responsibility (SD1)
Total Cooperativeness Social acceptance (C1)
Total Self-transcendence Self-forgetfulness (ST1)
Total
Healthy control (n = 60) F = 0.114 P = 0.892 F = 1.718 P = 0.183 F = 0.102 P = 0.903 F = 2.993 P = 0.053 F = 5.469 P = 0.005 F = 3.304 P = 0.039 F = 1.499 P = 0.227 F = 0.605 P = 0.547 F = 1.326 P = 0.269 F = 1.169 P = 0.314 F = 2.962 P = 0.055 F = 2.258 P = 0.108 F = 0.542 P = 0.583 F = 0.729 P = 0.484 F = 0.195 P = 0.823 F = 0.250 P = 0.779
Table 4. Correlations between DLQI and total score of RD and SD
DLQI (AA) DLQI (V)
Novelty seeking
Harm avoidance
Reward dependence
Persistence
Selfdirectedness
Cooperativeness
Selftranscendence
0.162 P = 0.318 0.234 P = 0.103
0.06 P = 0.971 0.301 P = 0.059
0.318 P = 0.045 0.151 P = 0.296
0.256 P = 0.106 0.224 P = 0.118
0.259 P = 0.063 0.447 P = 0.001
0.064 P = 0.694 0.113 P = 0.434
0.112 P = 0.491 0.210 P = 0.143
Bolded values indicate statistical significance. AA, alopecia areata; DLQI, Dermatological Life Quality Index; RD, reward dependence; SD, selfdirectedness; V, vitiligo.
and participate in limited activities, and provide a direction for further research in dopamine transporters in patients with V. The HA1 (worry and pessimism) score was higher in patients with V compared with the HC in our study. The H1 score is associated with two distinctive behavioral tendencies. First, these individuals are pessimistic worriers who tend to avoid harm and failure. Second, they have difficulties getting over
© 2014 Japanese Dermatological Association
injurious and dishonorable experiences; these individuals tend to ruminate about these experiences for long periods of time.36 To our knowledge, we are the first to report higher HA1 scores in patients with V. As a result, patients with V may be more pessimistic and may do more ruminating compared with HC. Among the character traits, we found that SD5 (enlightened second nature subscore) was higher in the V group compared
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with the other groups. Furthermore, the total SD score was €ler et al. higher in the V group compared with the HC group. Gu reported that there was no significant difference among character profiles between patients with psoriasis, neurodermatitis and V and HC.36 Individuals who score high on this subscale have developed a spectrum of goal-oriented, good behaviors; thus, their behaviors automatically shape according to their long-term values and goals. These behaviors become second nature by time. A high SD score means the individual is being mature, responsible, strong, self-sufficient, realistic, goal targeted, constructive, and well associated. However, these individuals might be seen as problematic in a hierarchic cycle.36 To our knowledge, the present study is the first to demonstrate different character profiles in patients with V. Regarding these characteristics, individuals with V may be identified as goaldirected, rigid, responsible and sometimes problematic. In a study that compared depression and quality of life in patients with psoriasis, V and AA, Ghajarzadeh et al. showed that the DLQI scores were significantly higher in patients with psoriasis compared to patients with V and AA. The scores for patients with V and AA were also similar.37 The DLQI findings of the present study were also similar to this study. Our study has several limitations. First, the numbers of participants who were included in the present study may not be sufficient for making a general conclusion in terms of the temperament and character profile. Regarding Cloninger et al.’s psychobiological approach, these results should be supported or associated with biological parameters; however, this should be an interest of further study for researchers. Although all participants were evaluated by a senior psychiatrist and participants who were considered to have a psychiatric diagnosis were excluded from this study, we could not provide data about this issue; this may be another limitation. Our study is the first to compare temperament and character traits between patients with V and AA and HC. We did not have an opportunity to learn the standard deviation, and we could not have conducted a pre-pilot study to determine the standard deviation of our study population. Thus, the sample size could not be calculated. This may be another limitation. In conclusion, we suggest that patients with first onset V have distinct temperament and character profiles independent of their psychiatric comorbidities. However, patients with AA do not have a different personality from the non-affected population. Further studies are needed to emphasize the temperament and character profiles in the etiology, process and treatment of patients who suffer from skin diseases.
CONFLICT OF INTEREST:
The authors have no conflict of
interest.
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28 Alghamdi KM, Kumar A, Taieb A et al. Assessment methods for the evaluation of vitiligo. J Eur Acad Dermatol Venereol 2012; 26: 1463–1471. 29 Manolache L, Petrescu-Seceleanu D. Stress involvement as trigger factor in different skin conditions. World J Dermatol 2013; 2: 16–26. 30 Carrizosa A, Estepa-Zabala B, Fernandez-Abascal B et al. Alopecia areata: a specific personality? Int J Dermatol 2005; 44: 437–438. 31 Alfani S, Antinone V, Mozzetta A et al. Psychological status of patients with alopecia areata. Acta Derm Venereol 2012; 92: 304–306. 32 Annagur B, Bilgic O, Simsek K, Guler O. Temperament-character profiles in patients with alopecia areata. Bull Clin Psychopharmacol 2013; 23: 326–334.
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33 Salzer BA, Schallreuter KU. Investigation of the personality structure in patients with vitiligo and a possible association with impaired catecholamine metabolism. Dermatology 1995; 190: 109–115. 34 Koshevenko I. The psychological characteristics of patients with vitiligo. Vestnik dermatologii i venerologii 1989; 5: 4–6. 35 Cloninger CR. A systematic method for clinical description and classification of personality variants. A proposal. Arch Gen Psychiatry 1987; 44: 573–588. € se S. A psychobiological model of temperament and character 36 Ko TCI. Yeni Symposium. 2003; 41: 86–97. 37 Ghajarzadeh M, Ghiasi M, Kheirkhah S. Associations between skin diseases and quality of life: a comparison of psoriasis, vitiligo, and alopecia areata. Acta Med Iran 2012; 50: 511–515.
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Journal of Dermatology 2014; 41: 709–715
ORIGINAL ARTICLE
Distinct temperament and character profiles in first onset vitiligo but not in alopecia areata Gamze ERFAN,1 Yakup ALBAYRAK,2 M. Emin YANIK,1 Ozden OKSUZ,2 Kaan TASOLAR,1 Birol TOPCU,3 Cuneyt UNSAL2 Departments of 1Dermatology, 2Psychiatry, and 3Biostatistics, Faculty of Medicine, Namık Kemal University, Tekirdag, Turkey
ABSTRACT Alopecia areata (AA) and vitiligo (V) are diseases that are correlated with psychiatric disorders before, during and after diagnosis. The Temperament and Character Inventory (TCI) is a well-established approach for investigating personality traits in various psychosomatic diseases. The aim of this study is to compare and investigate the differences in the TCI between patients with first onset AA, patients with V and healthy controls (HC). Participants in the study included 42 patients with first onset AA, 50 adult patients with V and 60 HC who had no history or diagnoses of psychiatric or dermatological disorders. All participants were assessed with the TCI and the Dermatology Life Quality Index (DLQI). Among the temperament traits, the extravagance, disorderliness and total novelty-seeking scores were lower, and the worry and pessimism scores were higher in patients with V compared with patients with AA and the HC. The mean score of the enlightened second nature and the total selfdirectedness score of the character traits were higher in patients with V compared with patients with AA and the HC group. In the AA group, there was a negative correlation only between the reward dependence total score and the DLQI score. This study suggests that patients with first onset V have a distinct temperament, such as being unenthusiastic and unemotional, and character profiles, such as worry and pessimism, independent of their psychiatric comorbidities, and patients with AA do not have a different personality from the non-affected population.
Key words:
alopecia areata, character, Temperament and Character Inventory, vitiligo.
INTRODUCTION Skin diseases are usually associated with psychiatric symptomatology. Because skin diseases can be seen by others and this state can create stressful events for the individual, it is difficult to establish whether psychiatric disorders are the causes of the skin disease.1 Alopecia areata (AA) is a clinical condition that presents with a non-scarring hair loss that can be seen on the scalp and hair-covered areas without skin changes.2 The lifetime prevalence of AA is approximately 1.7%. Environmental and genetic factors are suspected in the etiology of AA.3 Emotional stress is an important part of the environmental factors in the etiology of AA.3,4 Evidence has shown that various psychiatric disorders such as anxiety disorders, paranoid disorders and depression are seen in patients who suffer from AA.5–7 The lifetime prevalence of any psychiatric disorder has been estimated at approximately 74%, and major depressive disorder and generalized anxiety were reported as the most common psychiatric disorders among patients with AA.8 In addition to this high percentage of psychiatric comorbidities in patients with AA,
studies have concluded that there is no association between the onset of AA and mood and anxiety disorders.9,10 Furthermore, no association was reported between hair regrowth and psychological well-being in patients with AA in a study conducted by Kose et al.11 The prevalence of vitiligo (V) is estimated at approximately 1–4%.12 It does not cause pain or physical limitations; however, patients with V experience a high degree of social functional impairment.13 Numerous studies have investigated the association between psychiatric disorders or symptoms and V. Patients with V have been reported to have high anxiety scores, depressive disorder, generalized anxiety disorder, social phobia, obsessive symptoms and hypochondria, high rates of alexithymia and avoidant behavior, and high rates of sleep disturbances.14–18 Furthermore, stigmatization may have a strong negative psychosocial impact on patients who suffer from V.19 In addition, a limited number of studies have aimed to identify the temperament and character profiles of patients with V. To our knowledge, only two studies (one in adults and one in a pediatric group) have examined temperament and character traits in patients with V.20,21
Correspondence: Gamze Erfan, M.D., Department of Dermatology, Namık Kemal Universitesi Uygulama ve Arastırma Hastanesi Dermatoloji, Poliklinigi Tunca Cad. 100. Yıl mah, Tekirdag, Turkey. Email: [email protected] Received 25 March 2014; accepted 4 June 2014.
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The Temperament and Character Inventory (TCI) is a wellestablished approach for investigating personality traits in various psychiatric disorders as well as various psychosomatic diseases. The TCI has been proposed as a psychobiological model by Cloninger et al., and increasing evidence has linked some TCI properties to various biological mechanisms.22 To our knowledge, no study has compared personality with the TCI for patients with AA, patients with V and healthy controls (HC). In this study, we aimed to compare temperament and character traits with the TCI between patients with first onset AA, patients with first onset V and HC, and investigate whether there are differences between patients with first onset AA, patients with first onset V and HC in terms of temperament and character traits.
METHODS This was a cross-sectional study. The study was conducted at the Namık Kemal University Medical Faculty, Departments of Dermatology and Psychiatry, between January 2013 and January 2014. Consecutive patients who were admitted to the dermatology outpatient service with a diagnosis of first onset AA and first onset V were included. The definition of first onset and inclusion criteria were set clinically for both patient groups as patients who were admitted as dermatology outpatients, who had been diagnosed with AA and V for the first time, and who had never been diagnosed with a skin disease before the present admission. All patients were referred to a senior psychiatrist for evaluation. Subjects who were younger than 18 years and older than 60 years, who had a history of any psychiatric disorders or who had been diagnosed with a psychiatric disorder after a psychiatric examination, who had another dermatological disease and/or who did not want to participate in the study were excluded. After elimination by exclusion criteria, 42 patients with first onset AA and 50 patients with first onset V were included in the present study. In addition, 60 HC, consisting of hospital staff members and relatives of patients, were recruited. The patients and the HC gave informed consent and agreed to participate in the study. The institutional ethics committee approved the study protocol. The patients and the healthy control group were assessed with the TCI, and the patient groups were also assessed with the Dermatology Life Quality Index (DLQI). The severity of AA was assessed with the Severity of Alopecia Tool (SALT) and the severity of V was assessed with the Rule of Nine.
Instruments TCI. Temperament and character were assessed using the TCI, a 240-question self-evaluated questionnaire.22,23 The TCI was validated in Turkish in healthy and psychiatric Turkish populations.24 According to the Cloninger model, the temperament dimension novelty seeking (NS) is described as a tendency to respond to novelty, impulsiveness, and quick loss of temper and active avoidance of frustration. The second temperament
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dimension, harm avoidance (HA), is bias in inhibiting behaviors, such as pessimistic worry, passive dependent behaviors and rapid fatigability. The third temperament dimension, reward dependence (RD), is a bias toward maintaining habitual behaviors and is shown in social adaptation and dependence on others’ approval. Persistence (P) is defined as a tendency to persevere despite frustration and fatigue. The character dimension, called self-directedness (SD), represents self-determination, self-esteem, and the ability of an individual to control, adapt and regulate behavior to fix the situation according to personal goals and values. The second character dimension, cooperativeness (CO), consists of individual differences in identifying with and accepting other people and measures aspects associated with agreeability, self-centered aggression and hostility. Self-transcendence (ST) refers to spiritual maturity, transpersonal identification and selfforgetfulness. DLQI. The DLQI is an easy, self-administered, 10-item questionnaire. It is the most commonly used questionnaire. It consists of questions that evaluate patients’ perception of the impact of skin diseases on categories including feelings, daily activities, leisure, work and school, and personal relationships, and side-effects of the treatment over the previous week. The total score is 30, and higher scores define greater impairment of quality of life.25,26 SALT. Visually determining the amount of terminal hair loss in each of the four views of the scalp and adding these together with a maximum score of 100% determine this scale. In this score, the right and left temporal regions compose 18%, the occipital region 24%, and the frontal and parietal regions 40% of the scalp.27 Rule of Nine. The Rule of Nine assessment calculates as the head and neck, each arm, leg, and the four trunk quadrants each composing 9% and genitalia 1% of the total body surface area. According to Wood’s lamp examination of the depigmentation of patients with V, the severity of the disease is assessed with the Rule of Nine, which is subjective and based on visual assessments.28
Statistical methods Data were analyzed with the Statistical Package for the Social Sciences, PC version 18.0 (SPSS, Chicago, IL, USA). A confidence interval (CI) of 95% and a two-tailed P-value less than 0.05 were statistically significant for all analyses. The Levene test was used to test the homogeneity of the variance of the variables. All numerical variables were tested with the Kolmogorov–Smirnov test for normality of distribution. Differences between the groups in age, education years, and TCI temperament scores such as NS, HA, RD, S and the subscores, and character scores such as SD, CO and ST and the subscores were tested with a series of one-way ANOVA. Tukey’s honestly significant difference test was applied in a post-hoc analysis for multiple comparisons of the three groups. The DLQI scores were tested with independent sample Student’s t-tests.
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Temperament and character profiles in vitiligo
Differences between the sexes were compared with the v2test. The Pearson correlation test was used to analyze the correlation coefficients between the TCI scores and the DLQI scores.
RESULTS The mean ages were 35.66 9.72, 34.88 4.23 and 34.78 5.21 years in the AA, V and HC groups, respectively. The mean age was similar between the groups (F = 0.91, P = 0.61). The male/female ratio and the mean years of education were similar between groups the (Table 1). Among the temperament traits, the NS3, NS4 and total NS scores were significantly different between the groups (F = 9.912, P < 0.001; F = 5.373 P = 0.006; F = 8.258, P < 0.001, respectively). The post-hoc test revealed that the NS3, NS4 and total NS scores were significantly lower in the V group compared with the AA and HC groups (P < 0.001, P = 0.001; P = 0.005, P = 0.05; P = 0.005, P = 0.001, respectively). Among the HA scores, HA1 was significant between the groups (F = 3.885, P = 0.023). The HA1 score was significantly higher in the V group compared with the HC group (P = 0.031); however, the HA1 score was similar between the AA and HC groups and the AA and V groups (P > 0.05). There were no differences between the groups in terms of the other subscores and the total HA score. The RD subscores and total score and the P score were similar between groups (P > 0.05). The comparisons of the total and subscores of the temperament dimension of the TCI are presented in Table 2. Among character traits, there were significant differences between the groups in terms of the SD5 score and the total SD score (F = 5.469, P = 0.005; F = 3.304, P = 0.039, respectively). The mean SD5 score was significantly higher in the V group compared with the AA and HC groups (P = 0.017; P = 0.015, respectively). The total SD score was higher in the V group compared with the HC group (P = 0.05). The other SD subscores were similar between the groups (P > 0.05). The total CT and ST scores and subscores were also similar between the groups (P > 0.05). Table 3 shows comparisons of the total scores and subscores of the TCI character dimension.
The mean SALT score in patients with AA was 12.58 15.07, and according to the Rule of Nine, the mean of the V surface depigmentation area was 5.40 2.47. In the AA group, there was a significant negative correlation only between the total RD score and the DLQI score (r = 0.318, P = 0.045). A significant negative correlation was found between the total SD score and the DLQI score in the V group (r = 0.318, P = 0.001) (Table 4). The power analyses for the NS, HA, RD, P, SD, C and ST between V and AA, HC and AA, V and HC were 88.3%, 5.7% and 96.1%; 20.3%, 9.2% and 51.81%; 5.0%, 9.9% and 11.93%; 7.0%, 11.9% and 16.9%; 5.9%, 47.4% and 67.8%; 5.5%, 43.9% and 43.1%; and 7.7%, 10.3% and 5.3%, respectively.
DISCUSSION The temperament and character traits of patients who suffer from numerous psychiatric disorders as well as several diseases that may be associated with psychiatric diseases have been investigated in recent years. In the present study, we investigated the temperament and character traits of patients with AA and V that are associated with stressful events and several psychiatric disorders.29 Although numerous studies have investigated psychopathology in patients with AA and the effects of psychopathology on the symptom severity of AA, few studies have investigated personality traits in patients with AA. Carrizosa et al.30 reported that patients with AA did not have different personality traits compared with those of patients who had other skin diseases. Alfani et al.31 compared patients with AA and HC in terms of personality traits with the Minnesota Multiphasic Personality Inventory (MMPI-2) and revealed that patients with alopecia appeared to experience more depressive, hysterical and anxiety feelings, have more hypochondriac tendencies, and were more in conflict with their social environment. To our knowledge, only one study investigated personality traits with the TCI in patients with AA. In this recent study, Annagur et al. reported that patients with AA had low NS, RD and ST scores compared with healthy participants. The researchers also found that patients with AA had a higher psychopathology index and higher depression scores than HC.32 Regarding
Table 1. Mean age, sex and mean years of education in alopecia areata, vitiligo and healthy control groups Alopecia (n = 42)
Vitiligo (n = 50)
Healthy control (n = 60)
Statistic
Age (years)
35.66 9.72
34.88 4.23
34.78 5.21
F = 0.91 P = 0.65
Sex Male Female Education (years)
28 (66.7%) 14 (33.3%) 9.61 2.32
21 (42%) 29 (58%) 8.78 3.13
30 (50%) 30 (50%) 9.63 3.26
v2 = 5.71 P = 0.57 F = 1.01 P = 0.69
Severity of disease Rule of Nine Severity of Alopecia Tool
– 12.58 15.07
5.40 2.47 –
– –
– –
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Table 2. Comparisons of total scores and subscores of temperament of Temperament and Character Inventory of subjects Alopecia (n = 42) Novelty seeking Exploration–excitability (NS1)
Vitiligo (n = 50)
Healthy control (n = 60)
5.76 1.85
5.66 2.04
5.86 1.86
Impulsiveness (NS2)
4.33 2.03
3.80 1.84
4.40 2.01
Extravagance (NS3)
4.71 1.91
3.22 1.61
4.58 1.97
Disorderliness (NS4)
4.07 1.95
3.2 1.59
4.28 1.82
18.88 5.01
15.68 4.66
19.13 4.71
Harm avoidance Worry and pessimism (HA1)
5.19 2.22
6.2 2.12
5.15 2.23
Fear of uncertainty (HA2)
4.33 1.69
4.62 1.56
3.95 1.70
Shyness (HA3)
3.28 2.41
3.72 1.94
3.30 2.04
Fatigability (HA4)
4.02 2.44
3.72 2.26
3.65 2.12
16.83 6.71
18.32 5.82
16.05 6.07
Reward dependence Sentimentality (RD1)
7.19 2.07
7.48 1.64
6.75 1.80
Attachment (RD3)
3.97 1.80
3.96 1.64
4.20 1.79
Dependence (RD4)
2.66 1.52
2.34 0.93
2.38 1.31
13.78 3.13
13.79 2.51
13.36 3.40
4.80 1.95
5.30 1.86
5.13 1.79
Total
Total
Total Persistence
these studies, Annagur et al.’s study had the most similar methodology to our study for discussing our results. In contrast to their findings, we did not find any differences in the TCI main scores and subscores in patients with AA compared with patients with V and the HC. These differences may be associated with including first onset patients and excluding patients who had been diagnosed with psychiatric disorders. The personality traits of patients with AA do not differ from the nonaffected population, and our results are in line with those of Carrizosa et al., who reported similar personality traits in patients with AA and patients who suffered from other skin diseases. Similar to AA, a limited number of studies have investigated the relation between personality and V. Salzer and Schallreuter33 investigated impaired catecholamine metabolism and its association with personality in patients with V and reported no specific personality in patients with V compared with HC. A study that investigated psychological characteristics in patients with V by using MMPI revealed that patients with common V had impaired social adaptation.34 To our knowledge, only one study has investigated temperament and character traits in
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Statistic F = 0.158 P = 0.854 F = 1.437 P = 0.241 F = 9.912 P = 0.000 F = 5.373 P = 0.006 F = 8.258 P = 0.000 F = 3.885 P = 0.023 F = 2.270 P = 0.107 F = 0.676 P = 0.510 F = 0.359 P = 0.699 F = 1.865 P = 0.159 F = 2.209 P = 0.113 F = 0.323 P = 0.724 F = 0.880 P = 0.417 F = 0.336 P = 0.715 F = 0.807 P = 0.448
€ler et al.21 compared adult patients with V. In this study, Gu personality traits between patients with psoriasis, neurodermatitis and V, and HC by TCI and revealed that patients with V had lower NS2 scores (impulsiveness) compared with patients €ler et al.’s study, we found with psoriasis and HC. Similar to Gu significantly lower NS3 (extravagance), NS4 (disorderliness) and total NS scores in patients with V compared with patients with AA and HC. Individuals who have low total NS scores were slow, unenthusiastic, unemotional, reflective, reserved, tolerant of monotony, systematic and orderly.35 Reserved, controlled or restrained individuals have low extravagance subscale (NS3) scores. They can delay gratification when they are frustrated longer than most people. These individuals do not waste their money, energy and feelings. However, they can give the impression of being ungenerous or frugal because of their unwillingness to spend or acquire things.22,35 People who scored low on the NS4 subscale tend to be organized, orderly, methodical and systematic. They often prefer activities with strict rules and regulations.34,35 In addition, variation in the dopamine transporter gene affects the expression of NS. Our results may identify why patients with V are socially isolated
© 2014 Japanese Dermatological Association
Temperament and character profiles in vitiligo
Table 3. Comparisons of total and subscores of character dimension of Temperament and Character Inventory of subjects Alopecia (n = 42)
Vitiligo (n = 50)
4.28 2.23
4.40 2.26
4.20 2.08
Purposefulness (SD2)
5.38 2.29
5.74 1.72
5.01 2.09
Resourcefulness (SD3)
3.19 1.08
3.22 1.26
3.11 1.31
Self-acceptance (SD4)
6.28 2.50
6.28 2.59
5.25 2.52
Enlightened second nature (SD5)
7.76 1.77
8.72 1.67
7.65 2.32
27.95 7.22
28.36 6.57
25.23 7.02
5.92 1.68
5.92 1.63
5.45 1.64
Empathy (C2)
4.50 1.48
4.22 1.25
4.21 1.48
Helpfulness (C3)
4.83 1.46
4.74 1.35
4.40 1.49
Compassion (C4)
7.07 2.67
6.80 2.77
6.28 2.55
Integrated conscience (C5)
6.59 1.59
7.06 1.13
6.38 1.61
29.000 6.34
28.74 5.71
26.73 6.12
6.26 2.52
5.78 2.31
6.08 2.01
Transpersonal identification (ST2)
5.40 2.01
5.08 2.20
4.88 2.19
Spiritual acceptance (ST3)
7.02 2.93
7.22 2.32
6.91 2.43
18.69 5.84
18.12 5.25
17.95 4.97
Self-directedness Responsibility (SD1)
Total Cooperativeness Social acceptance (C1)
Total Self-transcendence Self-forgetfulness (ST1)
Total
Healthy control (n = 60) F = 0.114 P = 0.892 F = 1.718 P = 0.183 F = 0.102 P = 0.903 F = 2.993 P = 0.053 F = 5.469 P = 0.005 F = 3.304 P = 0.039 F = 1.499 P = 0.227 F = 0.605 P = 0.547 F = 1.326 P = 0.269 F = 1.169 P = 0.314 F = 2.962 P = 0.055 F = 2.258 P = 0.108 F = 0.542 P = 0.583 F = 0.729 P = 0.484 F = 0.195 P = 0.823 F = 0.250 P = 0.779
Table 4. Correlations between DLQI and total score of RD and SD
DLQI (AA) DLQI (V)
Novelty seeking
Harm avoidance
Reward dependence
Persistence
Selfdirectedness
Cooperativeness
Selftranscendence
0.162 P = 0.318 0.234 P = 0.103
0.06 P = 0.971 0.301 P = 0.059
0.318 P = 0.045 0.151 P = 0.296
0.256 P = 0.106 0.224 P = 0.118
0.259 P = 0.063 0.447 P = 0.001
0.064 P = 0.694 0.113 P = 0.434
0.112 P = 0.491 0.210 P = 0.143
Bolded values indicate statistical significance. AA, alopecia areata; DLQI, Dermatological Life Quality Index; RD, reward dependence; SD, selfdirectedness; V, vitiligo.
and participate in limited activities, and provide a direction for further research in dopamine transporters in patients with V. The HA1 (worry and pessimism) score was higher in patients with V compared with the HC in our study. The H1 score is associated with two distinctive behavioral tendencies. First, these individuals are pessimistic worriers who tend to avoid harm and failure. Second, they have difficulties getting over
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injurious and dishonorable experiences; these individuals tend to ruminate about these experiences for long periods of time.36 To our knowledge, we are the first to report higher HA1 scores in patients with V. As a result, patients with V may be more pessimistic and may do more ruminating compared with HC. Among the character traits, we found that SD5 (enlightened second nature subscore) was higher in the V group compared
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with the other groups. Furthermore, the total SD score was €ler et al. higher in the V group compared with the HC group. Gu reported that there was no significant difference among character profiles between patients with psoriasis, neurodermatitis and V and HC.36 Individuals who score high on this subscale have developed a spectrum of goal-oriented, good behaviors; thus, their behaviors automatically shape according to their long-term values and goals. These behaviors become second nature by time. A high SD score means the individual is being mature, responsible, strong, self-sufficient, realistic, goal targeted, constructive, and well associated. However, these individuals might be seen as problematic in a hierarchic cycle.36 To our knowledge, the present study is the first to demonstrate different character profiles in patients with V. Regarding these characteristics, individuals with V may be identified as goaldirected, rigid, responsible and sometimes problematic. In a study that compared depression and quality of life in patients with psoriasis, V and AA, Ghajarzadeh et al. showed that the DLQI scores were significantly higher in patients with psoriasis compared to patients with V and AA. The scores for patients with V and AA were also similar.37 The DLQI findings of the present study were also similar to this study. Our study has several limitations. First, the numbers of participants who were included in the present study may not be sufficient for making a general conclusion in terms of the temperament and character profile. Regarding Cloninger et al.’s psychobiological approach, these results should be supported or associated with biological parameters; however, this should be an interest of further study for researchers. Although all participants were evaluated by a senior psychiatrist and participants who were considered to have a psychiatric diagnosis were excluded from this study, we could not provide data about this issue; this may be another limitation. Our study is the first to compare temperament and character traits between patients with V and AA and HC. We did not have an opportunity to learn the standard deviation, and we could not have conducted a pre-pilot study to determine the standard deviation of our study population. Thus, the sample size could not be calculated. This may be another limitation. In conclusion, we suggest that patients with first onset V have distinct temperament and character profiles independent of their psychiatric comorbidities. However, patients with AA do not have a different personality from the non-affected population. Further studies are needed to emphasize the temperament and character profiles in the etiology, process and treatment of patients who suffer from skin diseases.
CONFLICT OF INTEREST:
The authors have no conflict of
interest.
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