Eur J Dermatol 2015; 25(4): 329-34
Clinical report 1 ´ Ramón MARTIN-BRUFAU Santiago ROMERO-BRUFAU2 3 ´ Alejandro MARTIN-GORGOJO Carmen BRUFAU REDONDO4,5 Javier CORBALAN1 Jorge ULNIK6 1
Department of Personality, Assessment and Psychological Treatment, University of Murcia, Av. Juan Carlos I, 6, 7◦ H, 30008, Murcia, Spain 2 Mayo Clinic Robert D. and Patricia E. Kern Center, Rochester, MN, United States of America 3 Dermatology Department, Hospital General Universitario Gregorio Mara˜non. Clinica Ruber & Clinica Dermatologica Internacional, Madrid, Spain 4 Service of Dermatology, General Hospital Reina Sofía, Murcia, Spain 5 Department of Dermatology and Venereology, University of Murcia, Spain 6 Faculty of Psychology, Buenos Aires University
Reprints: R. Martín-Brufau
Psoriasis lesions are associated with specific types of emotions. Emotional profile in psoriasis Background: At present there is still controversy about the relationship between emotional stress and psoriasis lesions. Most of the published literature does not include the broad spectrum of emotional response. Objective: The aim of this study was to evaluate the association between skin lesions and emotional state in a large sample of patients with psoriasis. Methods: 823 psoriasis patients were recruited (mean age 45.9 years, 55.7% female) and answered two online questionnaires: lesion severity and current extension were evaluated using a selfadministered psoriasis severity index (SAPASI); emotional state was assessed using the positive and negative affect schedule (PANAS). Second order factors were calculated and correlated with the SAPASI. Results: We found positive associations between the extent and severity of skin lesions and the negative and submissive emotions, a negative correlation with dominance emotions and no association with positive emotions. Conclusion: Our data supports the relationship between emotions and skin lesions. It also allows for discrimination of the associations between psoriasis lesions and the specific type of emotions. Key words: psoriasis, emotions, psychodermatology, PASI, Selfadministered PASI, PANAS
Article accepted on 06/4/2015
doi:10.1684/ejd.2015.2577
P
soriasis is a highly frequent dermatological disease that is especially prevalent in the psychiatric patient population and can significantly decrease the quality of life, causing a great deal of psychological suffering [1, 2]. Psoriasis patients are also at a higher risk of manifesting psychopathological symptoms during childhood and adolescence [3, 4]. It has also been associated with personality alterations [5, 6] and emotional distress in adults beyond what would be expected by the skin lesions alone [7]. Although this higher distress is extensively documented, there is evidence that physicians frequently overlook this emotional suffering and patients are often left with their psychological needs unattended [8]. Research published to date has focused on common psychiatric syndromes, like depression and anxiety [1, 4, 9] or the global stress response [10, 11], but, to our knowledge, very few studies published so far have focused on more specific emotions, which can provide a picture of the specific psychological profile of psoriasis patients, with some exceptions which focused on a narrow spectrum of emotions like anger [12] or shame [13]. Other studies that included a wider range of negative emotions and psychopathology symptoms were limited by a relatively small sample [14]. Only one recent study explored the relationships between emotions and skin lesions in a large sample
EJD, vol. 25, n◦ 4, July-August 2015
of psoriasis patients, using Skindex, but this tool is oriented to the dermatological patient’s quality of life rather than to their emotional profile [15]. To sum up, two of the limitations of the literature about psoriasis and emotions are 1) that the studies often have low sample sizes, and 2) the instruments used are focused on measuring general symptoms of anxiety, depression or psychological distress that do not include a broader spectrum of the possible emotional responses (guilt, embarrassment, sadness, humiliation, but also happiness, hope, joy, etc.). So there is a need to identify the emotional profile of the psoriasis patients in order to better understand their psychological suffering. Also, exploring the relationship between their emotional profile and their skin lesions can be important to understand the mechanisms underlying this psycho-dermatological disease. Different models and classification of emotions have been proposed. Two of the most accepted models are 1) the positive and negative affect schedule model, or PANAS model, also known as the consensual model, based on a distinction between positive and negative emotions [16], and 2) the PAD model of emotions, which uses three dimensions (Pleasure, Activation and Dominance) to classify the human emotions [17]. Following these frequently used classifications of emotions, the aim of this study was to explore the emotional profile of a large
329
To cite this article: Martín-Brufau R, Romero-Brufau S, Martín-Gorgojo A, Brufau Redondo C, Corbalan J, Ulnik J. Psoriasis lesions are associated with specific types of emotions. Emotional profile in psoriasis. Eur J Dermatol 2015; 25(4): 329-34 doi:10.1684/ejd.2015.2577
sample of psoriasis patients and its relationship with the severity and extension of skin lesions measured by the psoriasis area severity index (PASI).
Methods Participants and procedure Participants were psoriasis patients who belonged to the main association of patients with psoriasis in Spain (Acción psoriasis). The inclusion criteria were: having a diagnosis of psoriasis at the moment of the survey, being able to read and write in Spanish and, because of the nature of the survey (online), having access to internet and basic web navigation skills. Regarding exclusion criteria, all patients suffering from another dermatological condition other than psoriasis were excluded from the sample before statistical analysis. In order to generalize the results and have a representative sample of the general psoriasis population, no exclusion was made regarding psychopathology or severity of psoriasis. Informed consent and ethical requirements were approved by the Committee of the Spanish Association of Psoriasis. Data collection was performed in February 2013 (started on the 1st until the 14th ), using online surveys. The Spanish Association of Psoriasis Patients sent an email to the patients containing the link to the online questionnaires and their responses were automatically stored in an online database for subsequent analysis. All patients were informed about the characteristics of the study and asked to sign an online informed consent sheet before they had access to the online questionnaires. Age, sex and marital status of each patient were collected online along with the questionnaires in the survey, which required approximately 15 minutes to complete. Participants were debriefed after the questionnaires were finished and sent. The survey was sent to a total of 1238 patients. This online procedure has been able to obtain large samples of patients in a relatively short period of time. This procedure has not only practical advantages but also methodological ones, as it provides large samples, reduces the risk of maturation of the sample and provides patients from different regional cultural context within the country.
Instruments To evaluate both the emotional and the skin state two frequently used instruments that could be easily responded online were used: The state of the skin
The most commonly used methods to assess the state of the skin in psoriasis are the Psoriasis Area and Severity Index (PASI) and the Body Surface Area (BSA). BSA only measures the percentage of the body surface affected. PASI combines the extension of the affected area of the body and the severity of psoriasis, measured in terms of intensity of redness, scaling and thickness of the psoriatic lesions in each location: head and neck, upper extremities, trunk and lower extremities. In this case the
330
dermatological state of the skin, measured by the severity of the lesion and its current extension, was performed using a web based Self-administered-PASI (SAPASI), registered by the own patient. This has been shown to be equivalent to the PASI evaluated by a dermatologist [6, 18-21]. The emotional state
The current emotional state was measured using the PANAS questionnaire, a questionnaire widely used for emotional assessment, which measures both positive and negative affect. It has 21 Likert-like scales evaluating both positive (interested, excited, strong, enthusiastic, proud, alert, inspired, etc.) and negative emotions (distressed, upset, guilty, scared, hostile, irritable, ashamed, nervous, etc.). It offers two overall scores of positive and negative affect, as well as individual scales for each one of the 21 scales, based on emotions they have felt recently. We decided to use the PANAS questionnaire because it measures the clinical state at the moment, which makes it a good instrument to correlate with the state of the skin. It has been used in clinical and non-clinical populations, showing good psychometric properties [22, 23]. It has also been shown that the negative affect scale is well correlated with other questionnaires used to measure psychopathology [18] so it can be used to compare the results with previous psychopathological studies.
Statistical analysis For the demographic characterization of our sample, we compared the demographic characteristics of our sample with a national sample from 123 hospitals across Spain. Student t test and 2 were used to compare the two samples. The results are presented in table 1. PASI (extension and severity of psoriatic lesions) results were obtained along with the BSA (extension) of the skin lesions as two separate variables. Pearson’s ‘r’ was used to assess the degree of correlation between emotional state and skin state and associations between the state of skin lesions and emotional state were considered significant when p800 subjects) reinforces the reliability of the study, and the fact that data was collected from different geographical locations inside the country increases the generalization of the results. Other advantages of the method used in our study are (1) the reduction in the time of data collection, which may reduce the influence of eventual maturation of lesions over time or different environmental influences (season of the year, weekends, vacations) over the lesions and/or the emotional state, (2) the reduction of the probability of typing or coding errors, as patients input their data directly into an electronic database, (3) the reduction of the amount of missing data, as patients are notified automatically if the survey is not fully completed before they can finally send the online questionnaire, and (4) the reduction of the interference caused by the presence of the healthcare provider, allowing for a calm situation for responding and reducing the desirability bias and thus probably improving the quality of the responses.
Final remarks As dermatologists assisting patients with psoriasis, we all have patients in whom the appearance of an outbreak or worsening of preexisting lesions occurs sometime after going through difficult life situations that concern them [39], while in others, this relationship is much less clear. Our results show an association between the negative and submission emotions and the severity of the lesions, in a group of more than 800 subjects, which corroborates this clinical intuition. But the fact that such association is low probably means that the relationship is true only in a proportion of patients and not in others, or that it only occurs on some occasions and not others within the same patient. That is to say, the relationship may not be constant or homogeneous. In this sense, it would be interesting to know what variables influence this relationship, which sometimes occurs and sometimes does not. It could depend on the nature of the stressor or an interaction between the stressor and some individual characteristic. An association has been found between personality traits and early onset of psoriasis, in a study that found that patients with early-onset psoriasis (
Clinical report 1 ´ Ramón MARTIN-BRUFAU Santiago ROMERO-BRUFAU2 3 ´ Alejandro MARTIN-GORGOJO Carmen BRUFAU REDONDO4,5 Javier CORBALAN1 Jorge ULNIK6 1
Department of Personality, Assessment and Psychological Treatment, University of Murcia, Av. Juan Carlos I, 6, 7◦ H, 30008, Murcia, Spain 2 Mayo Clinic Robert D. and Patricia E. Kern Center, Rochester, MN, United States of America 3 Dermatology Department, Hospital General Universitario Gregorio Mara˜non. Clinica Ruber & Clinica Dermatologica Internacional, Madrid, Spain 4 Service of Dermatology, General Hospital Reina Sofía, Murcia, Spain 5 Department of Dermatology and Venereology, University of Murcia, Spain 6 Faculty of Psychology, Buenos Aires University
Reprints: R. Martín-Brufau
Psoriasis lesions are associated with specific types of emotions. Emotional profile in psoriasis Background: At present there is still controversy about the relationship between emotional stress and psoriasis lesions. Most of the published literature does not include the broad spectrum of emotional response. Objective: The aim of this study was to evaluate the association between skin lesions and emotional state in a large sample of patients with psoriasis. Methods: 823 psoriasis patients were recruited (mean age 45.9 years, 55.7% female) and answered two online questionnaires: lesion severity and current extension were evaluated using a selfadministered psoriasis severity index (SAPASI); emotional state was assessed using the positive and negative affect schedule (PANAS). Second order factors were calculated and correlated with the SAPASI. Results: We found positive associations between the extent and severity of skin lesions and the negative and submissive emotions, a negative correlation with dominance emotions and no association with positive emotions. Conclusion: Our data supports the relationship between emotions and skin lesions. It also allows for discrimination of the associations between psoriasis lesions and the specific type of emotions. Key words: psoriasis, emotions, psychodermatology, PASI, Selfadministered PASI, PANAS
Article accepted on 06/4/2015
doi:10.1684/ejd.2015.2577
P
soriasis is a highly frequent dermatological disease that is especially prevalent in the psychiatric patient population and can significantly decrease the quality of life, causing a great deal of psychological suffering [1, 2]. Psoriasis patients are also at a higher risk of manifesting psychopathological symptoms during childhood and adolescence [3, 4]. It has also been associated with personality alterations [5, 6] and emotional distress in adults beyond what would be expected by the skin lesions alone [7]. Although this higher distress is extensively documented, there is evidence that physicians frequently overlook this emotional suffering and patients are often left with their psychological needs unattended [8]. Research published to date has focused on common psychiatric syndromes, like depression and anxiety [1, 4, 9] or the global stress response [10, 11], but, to our knowledge, very few studies published so far have focused on more specific emotions, which can provide a picture of the specific psychological profile of psoriasis patients, with some exceptions which focused on a narrow spectrum of emotions like anger [12] or shame [13]. Other studies that included a wider range of negative emotions and psychopathology symptoms were limited by a relatively small sample [14]. Only one recent study explored the relationships between emotions and skin lesions in a large sample
EJD, vol. 25, n◦ 4, July-August 2015
of psoriasis patients, using Skindex, but this tool is oriented to the dermatological patient’s quality of life rather than to their emotional profile [15]. To sum up, two of the limitations of the literature about psoriasis and emotions are 1) that the studies often have low sample sizes, and 2) the instruments used are focused on measuring general symptoms of anxiety, depression or psychological distress that do not include a broader spectrum of the possible emotional responses (guilt, embarrassment, sadness, humiliation, but also happiness, hope, joy, etc.). So there is a need to identify the emotional profile of the psoriasis patients in order to better understand their psychological suffering. Also, exploring the relationship between their emotional profile and their skin lesions can be important to understand the mechanisms underlying this psycho-dermatological disease. Different models and classification of emotions have been proposed. Two of the most accepted models are 1) the positive and negative affect schedule model, or PANAS model, also known as the consensual model, based on a distinction between positive and negative emotions [16], and 2) the PAD model of emotions, which uses three dimensions (Pleasure, Activation and Dominance) to classify the human emotions [17]. Following these frequently used classifications of emotions, the aim of this study was to explore the emotional profile of a large
329
To cite this article: Martín-Brufau R, Romero-Brufau S, Martín-Gorgojo A, Brufau Redondo C, Corbalan J, Ulnik J. Psoriasis lesions are associated with specific types of emotions. Emotional profile in psoriasis. Eur J Dermatol 2015; 25(4): 329-34 doi:10.1684/ejd.2015.2577
sample of psoriasis patients and its relationship with the severity and extension of skin lesions measured by the psoriasis area severity index (PASI).
Methods Participants and procedure Participants were psoriasis patients who belonged to the main association of patients with psoriasis in Spain (Acción psoriasis). The inclusion criteria were: having a diagnosis of psoriasis at the moment of the survey, being able to read and write in Spanish and, because of the nature of the survey (online), having access to internet and basic web navigation skills. Regarding exclusion criteria, all patients suffering from another dermatological condition other than psoriasis were excluded from the sample before statistical analysis. In order to generalize the results and have a representative sample of the general psoriasis population, no exclusion was made regarding psychopathology or severity of psoriasis. Informed consent and ethical requirements were approved by the Committee of the Spanish Association of Psoriasis. Data collection was performed in February 2013 (started on the 1st until the 14th ), using online surveys. The Spanish Association of Psoriasis Patients sent an email to the patients containing the link to the online questionnaires and their responses were automatically stored in an online database for subsequent analysis. All patients were informed about the characteristics of the study and asked to sign an online informed consent sheet before they had access to the online questionnaires. Age, sex and marital status of each patient were collected online along with the questionnaires in the survey, which required approximately 15 minutes to complete. Participants were debriefed after the questionnaires were finished and sent. The survey was sent to a total of 1238 patients. This online procedure has been able to obtain large samples of patients in a relatively short period of time. This procedure has not only practical advantages but also methodological ones, as it provides large samples, reduces the risk of maturation of the sample and provides patients from different regional cultural context within the country.
Instruments To evaluate both the emotional and the skin state two frequently used instruments that could be easily responded online were used: The state of the skin
The most commonly used methods to assess the state of the skin in psoriasis are the Psoriasis Area and Severity Index (PASI) and the Body Surface Area (BSA). BSA only measures the percentage of the body surface affected. PASI combines the extension of the affected area of the body and the severity of psoriasis, measured in terms of intensity of redness, scaling and thickness of the psoriatic lesions in each location: head and neck, upper extremities, trunk and lower extremities. In this case the
330
dermatological state of the skin, measured by the severity of the lesion and its current extension, was performed using a web based Self-administered-PASI (SAPASI), registered by the own patient. This has been shown to be equivalent to the PASI evaluated by a dermatologist [6, 18-21]. The emotional state
The current emotional state was measured using the PANAS questionnaire, a questionnaire widely used for emotional assessment, which measures both positive and negative affect. It has 21 Likert-like scales evaluating both positive (interested, excited, strong, enthusiastic, proud, alert, inspired, etc.) and negative emotions (distressed, upset, guilty, scared, hostile, irritable, ashamed, nervous, etc.). It offers two overall scores of positive and negative affect, as well as individual scales for each one of the 21 scales, based on emotions they have felt recently. We decided to use the PANAS questionnaire because it measures the clinical state at the moment, which makes it a good instrument to correlate with the state of the skin. It has been used in clinical and non-clinical populations, showing good psychometric properties [22, 23]. It has also been shown that the negative affect scale is well correlated with other questionnaires used to measure psychopathology [18] so it can be used to compare the results with previous psychopathological studies.
Statistical analysis For the demographic characterization of our sample, we compared the demographic characteristics of our sample with a national sample from 123 hospitals across Spain. Student t test and 2 were used to compare the two samples. The results are presented in table 1. PASI (extension and severity of psoriatic lesions) results were obtained along with the BSA (extension) of the skin lesions as two separate variables. Pearson’s ‘r’ was used to assess the degree of correlation between emotional state and skin state and associations between the state of skin lesions and emotional state were considered significant when p800 subjects) reinforces the reliability of the study, and the fact that data was collected from different geographical locations inside the country increases the generalization of the results. Other advantages of the method used in our study are (1) the reduction in the time of data collection, which may reduce the influence of eventual maturation of lesions over time or different environmental influences (season of the year, weekends, vacations) over the lesions and/or the emotional state, (2) the reduction of the probability of typing or coding errors, as patients input their data directly into an electronic database, (3) the reduction of the amount of missing data, as patients are notified automatically if the survey is not fully completed before they can finally send the online questionnaire, and (4) the reduction of the interference caused by the presence of the healthcare provider, allowing for a calm situation for responding and reducing the desirability bias and thus probably improving the quality of the responses.
Final remarks As dermatologists assisting patients with psoriasis, we all have patients in whom the appearance of an outbreak or worsening of preexisting lesions occurs sometime after going through difficult life situations that concern them [39], while in others, this relationship is much less clear. Our results show an association between the negative and submission emotions and the severity of the lesions, in a group of more than 800 subjects, which corroborates this clinical intuition. But the fact that such association is low probably means that the relationship is true only in a proportion of patients and not in others, or that it only occurs on some occasions and not others within the same patient. That is to say, the relationship may not be constant or homogeneous. In this sense, it would be interesting to know what variables influence this relationship, which sometimes occurs and sometimes does not. It could depend on the nature of the stressor or an interaction between the stressor and some individual characteristic. An association has been found between personality traits and early onset of psoriasis, in a study that found that patients with early-onset psoriasis (
