|Year : 2019 | Volume
| Issue : 1 | Page : 28-32
Evaluation of anxiety sensitivity in patients with psoriasis
Hilal Kaya Erdogan1, Ali Ercan Altinoz2, Ersoy Acer1, Zeynep Nurhan Saracoglu1, Muzaffer Bilgin3
1 Department of Dermatology, Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir, Turkey
2 Department of Psychiatry, Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir, Turkey
3 Department of Biostatistics, Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir, Turkey
|Date of Submission||09-Feb-2018|
|Date of Acceptance||02-Aug-2018|
|Date of Web Publication||28-Mar-2019|
Hilal Kaya Erdogan
Department of Dermatology, Eskisehir Osmangazi University, Osmangazi University Meselik Campus, Buyukdere District, Eskisehir 26040
Source of Support: None, Conflict of Interest: None
Background/Objectives: Psoriasis is an inflammatory skin disease characterized by erythematous squamous plaques. It has negative physical, psychological, and social effects. Psychiatric comorbidities such as anxiety and depression can accompany to psoriasis. In our study, we aimed to evaluate the anxiety sensitivity (AS) in psoriasis patients. Methods: We included 89 psoriasis patients, 44 controls with nonpsychodermatological disease and 59 healthy volunteers to study. Dermatological examinations were performed, and the Psoriasis Area and Severity Index (PASI) values were calculated. Participants completed a sociodemographic information form, Beck Anxiety Inventory and AS Index-3. Results: Both the psoriasis group and the control group with nonpsychodermatological disease had higher anxiety scores than the healthy control group. Psoriasis patients were found to have higher AS scores than both control group with nonpsychodermatological disease and healthy controls. When the psoriasis group was divided into two groups according to the presence of systemic disease or psoriatic arthritis; there was no difference between the groups in terms of psychometric measurements. Furthermore, there was no significant correlation between PASI scores and disease duration and psychometric evaluations. Conclusion: Our study is the first to show that the AS of psoriasis patients is significantly higher than healthy controls and of those with nonpsychodermatological diseases. It is not clear that high AS in these patients is a predisposing factor to the disease or a consequence of the disease.
Keywords: Anxiety, anxiety sensitivity, psoriasis
|How to cite this article:|
Erdogan HK, Altinoz AE, Acer E, Saracoglu ZN, Bilgin M. Evaluation of anxiety sensitivity in patients with psoriasis. Dermatol Sin 2019;37:28-32
|How to cite this URL:|
Erdogan HK, Altinoz AE, Acer E, Saracoglu ZN, Bilgin M. Evaluation of anxiety sensitivity in patients with psoriasis. Dermatol Sin [serial online] 2019 [cited 2019 Oct 17];37:28-32. Available from: http://www.dermsinica.org/text.asp?2019/37/1/28/255042
| Introduction|| |
Psoriasis is an inflammatory skin disease characterized by erythematous squamous plaques. It is a common disease and affects about 2% of the population. Although the pathogenesis of the disease is not clear; genetic, environmental, and immunological factors are known to play a role in the development of the disease.
Psoriasis is a chronic disease with negative physical, psychological, and social effects. Even if the disease is not severe, patients may complain that their quality of life is negatively affected. Furthermore, many psychiatric comorbidities such as anxiety, depression, sexual disorders, sleep disturbances, and substance abuse related to psoriasis have been reported.
Anxiety sensitivity (AS) was first described by Reiss and McNally in 1985 as an excessive fear of harmful physical and/or social consequences resulting from anxiety-related sensations and symptoms. AS can also be described as “to be afraid of anxiety.” AS index (ASI) measuring AS consists of three subscales (physical, cognitive, and social). Physical subscale (ASIphy) evaluates “fear of physical symptoms” arising from anxiety; cognitive subscale (ASIcog) evaluates “fear of losing cognitive control;” and social subscale (ASIsoc) evaluates the “fear of someone else in the society will be aware of their anxiety symptoms.”
Psychodermatology is a novel and developing subspecialty of dermatology, which connects psychiatry and dermatology. It has become more recognized that multidisciplinary psychodermatology units perform more beneficial consequences for patients with the psychodermatological diseases. Although there is no unique globally accepted classification system of psychodermatological diseases and many of the conditions are overlapped into different categories, the most broadly accepted system is that devised by Lee and Koo.,, A recent study has shown that patients with psychodermatological diseases had higher AS scores than individuals with nonpsychodermatological diseases. In our study, we aimed to evaluate AS in psoriasis patients and to compare with nonpsychodermatological patients and healthy volunteers.
| Methods|| |
We included 89 consecutive patients with psoriasis who admitted to dermatology outpatient clinic of a university hospital between December 2016 and March 2017. While 52 of the psoriasis patients admitted between these dates had the exclusion criteria; 221 of them did not accept to participate in the study. The control group was consisted of 44 consecutive patients with dermatological disease without psychodermatological features (e.g., tinea pedis and herpes labialis) (Control Group 1) and 59 healthy volunteers (Control Group 2). Healthy volunteers who stated that they had no psychiatric and dermatological diseases were selected by snowball technique from the hospital staff. Patients and controls with psychiatric disorders and diseases affecting the central nervous system were excluded from the study.
Assessment tools and procedure
Forms containing sociodemographic and clinical information (age and gender) and medical history (psychiatric and dermatologic diseases and medications) were filled. Dermatological examinations were performed, and the Psoriasis Area and Severity Index (PASI) values were calculated by the same dermatology specialist.
Beck Anxiety Inventory (BAI) was used to evaluate anxiety of the volunteers. BAI was developed by Beck et al. and Ulusoy et al. validated BAI for the Turkish population. It has 21 items and items are rated between 0 and 3. Total score of BAI range between 0–36. Higher scores of BAI indicate higher anxiety levels.
AS of the volunteers was assessed by ASI-3. The ASI-3 has 18 items and items are rated between 0 and 4. Total score of ASI-3 range between 0–72. Higher ADI-3 scores indicate higher AS. Mantar et al. developed and validated the Turkish version of ASI-3.
Ethic committee approved the study protocol. Patients and volunteers were informed, and informed consent form was signed before being admitted to the study.
All the assessments including medical and psychometric evaluations were executed in a single session.
Continuous data were expressed as mean ± standard deviation and median (Q1-Q3). Categorical data were defined as frequency and percentage. Normality was analyzed by Shapiro–Wilk test. The Kruskal–Wallis H-test was used to determine the differences between the BAI and ASI-3 scale scores of the three groups. The Spearman correlation test was used to determine the direction and magnitude of the relationship between the scale scores. P < 0.05 was considered as statistically significant. Analyzes were performed using IBM SPSS Statistics 21.0 software (SPSS Inc., Chicago, IL, USA).
| Results|| |
The study included 89 psoriasis patients, 44 patients in control Group-1 and 59 healthy volunteers in control Group-2. The mean age of the psoriasis patients was 41.15 ± 10.99, 39.09 ± 11.10 of the patients in control Group-1 and 40.05 ± 10.83 of the volunteers in control Group-2, respectively. There was no significant difference between the groups in terms of mean ages (P = 0.58). Forty of the psoriasis patients were male, 49 were female; 20 of the patients in control Group-1 were male, 24 were female and 25 of the volunteers in control Group-2 were male and 34 were female. The groups were similar in terms of gender (P = 0.94) [Table 1].
The dermatological diseases that were in the control Group-2 were acute urticaria (18%), verruca vulgaris (16%), contact dermatitis (14%), folliculitis (12%), tinea pedis and onychomycosis (12%), melanocytic nevi (4%), seborrheic keratosis (4%), acute telogen effluvium (4%), postinflammatory hyperpigmentation (2%), striae (2%), cellulitis (2%), acrochordon (2%), melasma (2%), geographic tongue (2%), lipoma (2%), and herpes labialis (2%).
Mean disease duration in psoriasis group was 12.50 ± 10.18 years. Seventy-three of the patients (82%) had psoriasis vulgaris and 16 (18%) had palmoplantar psoriasis. The mean PASI score of 73 patients with psoriasis was 6.76 ± 10.07. Psoriatic arthritis was present in 13 (14.6%) of the patients. The systemic disease was present in 27 patients (30.3%). Accompanying systemic diseases were diabetes mellitus, hypertension, coronary artery disease, hyperlipidemia, migraine, iron deficiency anemia, cholelithiasis, hypothyroidism, and asthma.
The mean scores of BAI were found 12.98 ± 8.94 in the psoriasis group, 13.91 ± 11.38 in the control Group-1 and 5.73 ± 5.70 in control Group-2. When the groups were compared in terms of BAI scores; both the psoriasis group and the control Group-1 had significantly higher scores than the control group-2 (P < 0.00) [Table 2].
Mean ASI-3 scores were 22.16 ± 14.69 in the psoriasis group, 13.68 ± 7.63 in the control Group-1 and 11.36 ± 10.00 in the control Group-2. When groups were compared in terms of ASs; psoriasis patients were found more sensitive than both control Group 1 and 2 (P < 0.00) [Table 2].
When the psoriasis group was divided into two groups according to the presence of systemic disease or psoriatic arthritis; there was no significant difference between the groups in terms of psychometric measurements (P > 0.05 for all parameters).
A correlation analysis was performed between psychometric measurements and the disease duration and PASI scores. There was no significant correlation between PASI scores and disease duration and psychometric evaluations (P > 0.05 for all parameters) [Table 3].
|Table 3: Correlation between psychometric measurements and the disease duration and PASI scores|
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| Discussion|| |
The skin and nervous system differentiate from the common embryologic root. They also have several common hormones, neurotransmitters, and receptors. Skin plays roles in expressing feelings, responding to emotional stimuli, providing body sensation, self-respect, and socializing.,
Psychiatric and psychosocial factors play important roles in many dermatological diseases. As a result, psychodermatology area was born based on the relationship and interaction between psychiatry and dermatology., In the classification of psychodermatological diseases developed by Koo and Lee; psoriasis falls in the group of psychophysiological diseases such as atopic dermatitis, rosacea, and urticaria.
Psoriasis is a common, chronic inflammatory skin disease. In addition to systemic diseases such as cardiovascular diseases, obesity, and hypertension; many psychiatric diseases also attract attention among comorbidities. In a study, 84% of psoriasis patients were found to have psychiatric disorders. Although most frequently accompanied by depression and anxiety; psoriasis can also be associated with other psychiatric disorders such as eating disorders, personality disorders, sexual disorders, sleep disorders, substance abuse, and mood disorders such as bipolar disorder.,
There is a bidirectional relation between anxiety and psoriasis. It is known that anxiety triggers the formation and deterioration of psoriasis by distribution of epidermal barrier due to stress, changes in the sympathetic nervous system, stress-induced increase of natural killer cells and cutaneous lymphocyte-related antigens, increase in serotonin carrier protein expression, dendritic epidermal serotonin, dysregulation of hypothalamus–pituitary–adrenal axis and increase in neuropeptides and cytokines. On the other hand, psoriasis also increases anxiety due to chronic itching and stigmatization.
Psychiatric diseases and psoriasis may have common inflammatory pathways. Cytokines such as interleukin (IL)-1 and IL-6 were found higher in both psoriasis and depression. It was also shown that tumor necrosis factor-α inhibitors ameliorate depression and anxiety by decreasing inflammation in chronic physical diseases such as rheumatoid arthritis, ankylosing spondylitis, and psoriasis.,
There are studies in the literature investigating depression and anxiety in psoriasis patients. In a study conducted in Turkey, it was found that depression and anxiety levels were higher in psoriasis patients than healthy controls and there was a relationship between psoriasis severity and anxiety. Golpour et al. found the anxiety rate in psoriasis patients as 45% which is statistically higher than the control group. Lamb et al. determined the anxiety among patients with psoriasis as 13.1%. They reported that there was a higher anxiety risk in females, patients with severe disease, patients with psoriatic arthritis, patients receiving only topical treatment, patients with Asians origin and in patients with previous anxiety. We did not find any relationship between the severity, duration of the disease, and presence of psoriatic arthritis and the anxiety and AS.
AS is the fear of anxiety symptoms due to their negative consequences (social, cognitive, and physical). Psychological stress is known to play a role in the onset and worsening of various dermatologic diseases. High AS may also increase the anxiety response and increase the severity of dermatological diseases. The first and only study investigating AS in dermatology patients was conducted by Dixon et al. They found higher AS among patients with psychodermatological diseases like eczema than the patients without psychodermatological diseases. They suggested that combining cognitive-behavioral psychotherapies may contribute to the treatment of psychodermatological patients by reducing AS.
The higher anxiety scores of both psoriasis and nonpsychodermatological patients than healthy volunteers may be related to having a skin disorder. Nevertheless, AS scores of psoriasis patients were higher than nonpsychodermatological patients and healthy volunteers. These results may mean that AS is specific to psoriasis or psychodermatologic diseases.
The strength of this study is that psoriasis is not only compared with healthy controls in terms of AS but also compared with a nondermatological disease to assess whether AS in psoriasis is specific or not. There are several important consequences of this study. First of all, to our knowledge, this is the first study in the literature showing AS in psoriasis patients. Moreover, our findings are valuable in that they demonstrate that a multidisciplinary approach to psoriasis treatment may be beneficial.
In this case, the question now to be asked is whether the interventions on AS will contribute to the treatment of psoriasis patients or not? When mindfulness added as an adjunct therapy to the usual treatment of psoriasis, patients with psoriasis reported a significant improvement in both psoriasis severity and quality of life. Our findings on the presence of AS in psoriasis may explain why mindfulness techniques helped these patients, besides other cognitive-behavioral techniques for coping with stress and anxiety may also reduce psoriasis severity and quality of life.
| Conclusion|| |
To the best of our knowledge, our study is the first to show that the AS of psoriasis patients is significantly higher than healthy controls and of those with nonpsychodermatological diseases. It is not clear that high AS in these patients is a predisposing factor to the disease or a consequence of the disease. Further studies are needed to clarify the relationship between AS and psoriasis and to investigate any treatment techniques that will provide reducing AS and improving therapeutic benefit in psoriasis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Christophers E. Psoriasis – Epidemiology and clinical spectrum. Clin Exp Dermatol 2001;26:314-20.
Mermin D, Boursault L, Milpied B, Taieb A, Ezzedine K, Seneschal J, et al.
DLQI as a major criterion for introduction of systemic agents in patients with mild psoriasis. J Eur Acad Dermatol Venereol 2016;30:1961-4.
Ferreira BI, Abreu JL, Reis JP, Figueiredo AM. Psoriasis and associated psychiatric disorders: A systematic review on etiopathogenesis and clinical correlation. J Clin Aesthet Dermatol 2016;9:36-43.
Mantar A, Yemez B, Alkın T. Anxiety sensitivity and its importance in psychiatric disorders. Turk Psikiyatri Derg 2011;22:187-93.
Marshall C, Taylor R, Bewley A. Psychodermatology in clinical practice: Main principles. Acta Derm Venereol 2016;96:30-4.
Jafferany M. Psychodermatology: A guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry 2007;9:203-13.
Lee CS, Koo JY. General Approach to Evaluating Psychodermatological Disorders. Psychocutaneous Medicine. Boca Raton: CRC Press; 2003. p. 17-26.
Dixon LJ, Lee AA, Viana AG, McCowan NK, Brodell RT, Tull MT, et al.
Anxiety sensitivity in dermatological patients. Psychosomatics 2016;57:498-504.
Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol 1988;56:893-7.
Ulusoy M, Sahin NH, Erkmen H. Turkish version of the beck anxiety ınventory: Psychometric properties. J Cogn Psychother 1998;12:163-72.
Taylor S, Zvolensky MJ, Cox BJ, Deacon B, Heimberg RG, Ledley DR, et al.
Robust dimensions of anxiety sensitivity: Development and initial validation of the anxiety sensitivity index-3. Psychol Assess 2007;19:176-88.
Mantar A, Yemez B, Alkın T. The validity and reliability of the Turkish version of the anxiety sensitivity index-3. Turk Psikiyatri Derg 2010;21:225-34.
Kumar S, Kachhawha D, Das Koolwal G, Gehlot S, Awasthi A. Psychiatric morbidity in psoriasis patients: A pilot study. Indian J Dermatol Venereol Leprol 2011;77:625.
] [Full text]
Mercan S, Kivanç Altunay I. Psychodermatology: A collaboration between psychiatry and dermatology. Turk Psikiyatri Derg 2006;17:305-13.
Uzun SK, Erturan I. Primary psychocutaneous diseases. Turk J Dermatol 2014;1:1-6.
Ni C, Chiu MW. Psoriasis and comorbidities: Links and risks. Clin Cosmet Investig Dermatol 2014;7:119-32.
Abbott R, Whear R, Nikolaou V, Bethel A, Coon JT, Stein K, et al.
Tumour necrosis factor-α inhibitor therapy in chronic physical illness: A systematic review and meta-analysis of the effect on depression and anxiety. J Psychosom Res 2015;79:175-84.
Bayramgürler D, Karson A, Ozer C, Utkan T. Effects of long-term etanercept treatment on anxiety- and depression-like neurobehaviors in rats. Physiol Behav 2013;119:145-8.
Köşger F, Bilgili ME, Genek M, Yıldız B, Saraçoǧlu N, Eşsizoǧlu A. The relationship between disease severity and depression, anxiety and quality of life in psoriasis patients. J Mood Disord 2014;4:157-62.
Golpour M, Hosseini SH, Khademloo M, Ghasemi M, Ebadi A, Koohkan F, et al.
Depression and anxiety disorders among patients with psoriasis: A hospital-based case-control study. Dermatol Res Pract 2012;2012:381905.
Lamb RC, Matcham F, Turner MA, Rayner L, Simpson A, Hotopf M, et al.
Screening for anxiety and depression in people with psoriasis: A cross-sectional study in a tertiary referral setting. Br J Dermatol 2017;176:1028-34.
Fordham B, Griffiths CE, Bundy C. A pilot study examining mindfulness-based cognitive therapy in psoriasis. Psychol Health Med 2015;20:121-7.
[Table 1], [Table 2], [Table 3]