Psychologic factors and psoriasis The influence oj psyclwlngicaljactors on the develnpment afld course oj psorlLlSis E. Sirnonic, M. Kaštelan, L. Čabrijan, A. Štašic and F. Gruber ABSTRACT Background. The purpose of this study has been to explore some psychological factors, which may influence the development and course of psoriasis. Materials and methods. This prospective study includes 150 patients affected with various forms of psoriasis and a control group. AII patients have been polled tor stress by a structured non-standardized questionnaire. Results. The analysis of questionnaires from 150 psoriatic patients has confirmed the existence of psychic stress in 69% of all cases, which represents a statistically significant difference (p< 0.05) compared to the control group in which stress has been tound only in 4% of the cases. Conclusion. The involvement of a liaison psychiatrist in a complete health care of psoriatic patients can be of considerable value tor the patients and for members of their families. Introduction Psoriasis is a multifactorial dermatitis presumed to be determined genetically, but environmental and psy- chological factors can trigger the onset or the exacer- bation ofthe disease. Some authors believe psoriasis to be a psychosomatic disease, i.e. presume that profound acute or chronic emotional stresses can induce or aggravate the course ofthe disease (1-3). Psychosomatics in contemporary medicine con- siders the patient as an integral structure of the mind in the bocly, and at the same tirne emphasizes the constant interaction between somatic and psychic process, and vice versa. The classic etiologic model in medicine is: external cause - tissue damage - functional disorder - body symptoms and signs. On the other hand the psy- chosomatic model supposes the psychic factors to generate a functional disorder thus provoking a tissue damage followed by body symptoms. It is stili unknown how psychic stress affects the first occurrence or the exacerbation of psoriasis. The stress reaction in the patients is probably mediated by the hypothalamic, pituitary adrenal relationship with immunologic effects C 4). The aim of the present study was to assess the mag- C linical st ud y 18 Acta Dermatoven APA Vol 9, 2000, No 1 Clin ical study Table 1. Psychological stress in the etiopathogenesis of psoriasis vulgaris and contact dermatitis No % No % YES 104* 69 2* 4 NO 46 31 48 96 *P<0.05 nitude of psychic factors in the onset and recurrence of psoriasis . Materials and methods The study covered 150 inpatients (98 males and 52 females) w ith psoriasis aclmitted to the Department of Dermatology, Clinical Hospital Center ofRijeka, during the p eriod from Janua1y 1995 to December 1996. In- clusion criteria were: patients with various forms of psoriasis, in which the diagnosis was made clinically, sometimes confirmed by histopathology. Exclusion cri- teria were: psoriasis cases associatecl with other clerma- toses, patients on drugs known to induce psoriasis, age below 17 or above 70, and patients who refused to be interviewed or to complete the questionnaires . Among the psoriatic patients 82. 6% were suffering from psoriasis vulgaris, while 17.3% were afflicted with severe forms: psoriasis erythroclermica, psoriasis arthropathica, or pustulosa. On the basis of history, accurate interview and a non-standardized questionnaire we tried to deter- mine the occurrence of emotional stress or other psy- chological factors in the development or recurrence of the disease . The first part of the questionnaire contains questions about the age, gender, marital status , school education, the employment status and information about the residence. The second part deals with family and personal history, there are questions abou t possible stress situations (death of a loving person, war, problems at work, divorce, matrimonial problems etc.) that occurred before the onset or the aggravation of the illness. The third part of the questionnaire included que- stions concerning the expectation of the patients to be rejected from other people . Additionally the patients w ere asked about their experience of discrimination, isolation, shame, and gu ilt. The control group comprised 50 patients with con- tact dermatitis. The statistical significance of the results was assessed by x2 and t- test. Acta Dermatoven APA Vol 9, 2000, No 1 Psychologic factors and psoriasis Table 2. Time from psychological trauma to the onset of psoriasis < 10 days 3 4,00 10- 30 days 7 9,33 1 - 6 months 16 21,33 > 6 months 49 65,33 Tota! 75 100,00 Results The results showed the existence of psychic stress in 69% of psoriatic patients, which represent a statisti- cally significant difference (p<0,05) compared to the control group where stress has been found only in 4% of the cases (Table 1). The stress was more present among patient~ coming from urban areas (72.7%), than in those of rural provenance ( 47.5%). The time span from exposure to psychological trauma until the onset of the illness in 65.3% lasted longer than 6 months (Table 2). Table 3 shows that in 55.1% male p atients and in 40.38% female patients emotional stress was the most common trigger factor responsible far the onset of psoriasis . Such emotional stresses, either among the patients from urban areas or from rural areas were: death of family members, matrimonial problems ancl dishar- mony or war even ts. The connection between the psy- chic stress and the onset of psoriasis was not establishecl in 27.5 % males and 30.7 % females . Neither was a ge- netic predisposition detectecl in these cases. On the other hancl, the cause of the onset of the disease was also unknown but with a genetic preclisposition in 11.2% males ancl 13.4% females. Infections were connectecl to the first occurrence of psoriasis in only 15.3% females ancl 6.1 % males . An emotional stress was made responsible far the recurrence of the disease in 37.7% male and 38.4% fe- male patients (Table 4). Infections were the second most frequent trigger factor in 20.4% male patients and 28.8% females . The climatic factor was the third most frequent triggering factor for the recurrence of the disease in females (11 .5%). The analysis of the frequency of accompanying cliseases in patients with psoriasis has demonstrated the existence of two or three of them in one patient. The most common were neuropsychiatriČ disorcle rs ancl alcoholism (28.7%) which was especially evident among male patients. In the second p lace were cardiovascular (12.6%) and then gastrointestinal (8.9%) disorders. There was a statistically significant difference between accom- panying disorders in male and female patients (p<0,05). 19 Clinica/ study Psychologic factors and psoriasis Table 3. The influence of trigger factors on the occurrence of psoriasis related to sex of the patients Infection 6 6,12 8 15,39 14 9,33 Emotional stress 54 55,10 21 40,38 75 50,00 Climatic factor o 0,00 o 0,00 o 0,00 Unknown w ith genetic predisposition 11 11,23 7 13,46 18 11,99 Unknown without genetic predisposition 27 27,55 16 30,7 6 43 28,66 Tota! 98 100,00 52 100,00 150 100,00 p>0.05 Table 4. The influence of trigger factors on the recurrence of psoriasis related to sex of the patients Infection 20 Emotional stress 37 Climatic factor 8 Unknown with genetic predisposition 15 Unknown without genetic predisposition 18 Total 98 p > 0.05 Discussion In the present study we investigated certain psy- chological aspects in patients w ith psoriasis. Our study underlined the role of the psychic factors in the onset or recurrence of the disease. The emotional factor was especially present in the urban population. The most frequent causes fo r stress w ere death of a fam ily member, matrimonial problems, and war events. Many authors have confirmed similar data (5-7). The most common factors for the onset of disease are the envi- ronment in which a person has been living and working for a longer period of tirne, and the attitude of a person toward such an environment. The stage of chronic stress may be recognized by psychodynamic approach analy- zing the past ancl present. Chronic stresses , step by step, affect the organism ancl finally lead to the manifestation of disease. Almost all researchers of psychosomatic diseases agree that living with chronic stress is an im- portant factor for the occurrence of psychosomatic clisorclers (8). Psoriasis is associatecl with experiencing emotional reactions of va1ying intensity by the patient. With this 20,41 15 28,85 35 23,33 37,76 20 38,46 57 28,99 8,16 6 11 ,54 14 9,33 15,3 5 9,61 20 13,33 18,37 6 11,54 24 16,00 100,00 52 100,00 150 100,00 illness the patient is not vitally endangered but is, be- cause of the importance of the skin, put into the situation of not being able to enjoy many pleasures of the claily lite. Therefore psoriatic patients mostly suffer from clepression, anxiety, neurosis ancl alcoholism. (9-11). Without protessional treatment ancl assistance the patient can harclly escape from this closecl magic circle. The Italian dermatologists demonstrated an increase in muscles tension in psoriatics and by means of biofeedback relaxation treatment obtainecl a improvement irt 64% of the patients (12). Our stucly, which was carried out on the basis of an accurate histo1y ancl a questionnaire, inclicate that stress is one of the most important factors in the onset of psoriasis . Further st:uclies are necessaiy to better understancl the stress events by tli.e Paykel's scale, which has been used by some authors (12-14). The complete health care of psoriatic patients shoulcl inclucle a psychiatrist as well as a clermatologist trainecl in the fielcl of psychosomatics ancl psychotherapy (15- 18). Acta Dermatoven APA Vo l 9, 2000, No 1 21 Psychologic factors and psoriasis Conclusion Prelimina1y results of this study demonstrated that the psycbic factor is of paramount importance for the development and aggravation of psoriasis. The deve- lopment of liaison psychiatry would enable tbe treat- ment of psychological prohlems of the patients, the cooperation with the patient's family and an additional education of ali members of the medica! team. Rt ..., -r;• r;, n ·v T•-f (' L' s; . .i:l..1 r .1::.i .r.l. .r.:J ., ~ . ..J .r..J „J AUTHORS' ADDRESSES l. Farber EM, Neli L. Psoriasis: a stress related disease. Cutis 1993; 51: 322-6. 2. Gupta MA, Gupta AK, Ellis CN, Voorheese JJ. Some psychosomatic aspects of psoriasis Adv Dermatol 1990; 5: 21-31. 3. Kantor SD. Stress and psoriasis. Cutis 1990; 46: 321-2 4. Farber EM, Lonigan SW, Rein G. The role of psychoneuroimmunology in the pathogenesis of psoriasis. Cutis 1990; 46: 314-6. 5. Barišic-Druško V,Jukic Z, Dešic-Brkic A, Biljan D. Značaj psihičkih faktora u nastanku iti jeku psoriasis vulgaris. Acta Derm lug 1990; 17: 119-25. 6. Al Abadil MS, Senior HJ, Bluhen SS. The relationship between stress and the onset and exacerbation of psoriasis and other skin conditions. Br J Dermatol 1994; 130: 199-203. 7. Duran V, Jovanovic M, Misic-Pavkov G, Poljacki M. Utjecaj stresa i strukture ličnosti na početak i težinu kliničke slike psorijaze. Med Pregl 1993; 46: 120-3 8. Adamovic V. Osnivači psihosomatskog pokreta .In : Emocije i tjelesne bolesti. Beograd, Nalit 1983: 49-66. 9. Farber EM, Mali L. Psoriasis and alcoholism. Cutis 1994; 53: 21-7. 1 O. Ramsey B, O Reagan M. A survey of the social and psychological effects of psoriasis. Br J Dermatol 1988; 118: 195-201. 11. Root S, Keut G, Al-Abadie MSK. The relationship between disease severity, disability and psychological distress in patients undergoing PUVA treatment for psoriasis. Dermatology 1994; 189: 234-7. 12. Finzi AF, Polenghi MM, Guzzi R, Rebecchi I. Psychosomatic dermatology: the Milan experience. Ann Ital Dermatol Ciin Sper 1993; 47: 7-11. 13. Invernizzi G, Gala C, Bovio L, Conte G, Manca G, Polenghi M, Russo R. Onset of psoriasis:the role of life events. Med Sci Res 1988; 16: 143-4. 14. Polenghi MM, Gala C, Citeri A, Russo R, Pigatto PD, Altomare GF. Psoriasi ed eventi stressanti.G It Derm Vener 1987; 122: 167-70. 15. Folnegovic Šmalc V. Uloga psihijatra u liječenju psorijaze. Psoriasis 1987; 23/24: 18-20. 16. Price ML, Mottahedin J Mayo PR. Can psychotherapy help patients with psoriasis. Ciin Exp Dermatol 1991; 16: 114-7. 17. Koblenzer CS. Psychotherapy for intractable intlammatory dermatoses. J Am Acad dermatol 1995; 32: 609-12. 18.Troskot N, Dešic- Brkic A, Kanižaj-Suttar I, Del Toso Depeder Z. Naša iskustva u grupnom liječenju psorijatičara metodam DUO-Formula. Acta derm lug. 1990; 17: 79-83. Edita Simonič MD, dermatovenereologist, Dept. Dermatovenereolo!!,y, ClinicalHospital Centre, J(rešimirova 42, 51000 Rijeka, Croatia Marija Kaštelan MD, dermatovenereologist, same address Leo ČabrijanMD, dermatovenereologist, same address Adalbert ŠtašičMD, dermatovenereologist, same address Franjo Gruber MD, PhD, projessor and chairman, Dept. Dermatovenereology, same address, corresponding author Clini cal study 22 Acta Dermatoven APA Vol 9, 2000, No 1