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Psychosomatics 44:374-381, October 2003
© 2003 The Academy of Psychosomatic Medicine

Psychosomatic Factors in First-Onset Alopecia Areata

A. Picardi, P. Pasquini, M.S. Cattaruzza, P. Gaetano, G. Baliva, C.F. Melchi, M. Papi, D. Camaioni, A. Tiago, T. Gobello, and M. Biondi

Received June 5, 2002; revision received Nov. 1, 2002; accepted Dec. 2, 2002. From the Clinical Epidemiology Unit and the outpatient clinics of the Istituto Dermopatico dell'Immacolata-Istituto di Ricovero e Cura a Carattere Scientifico (IDI-IRCCS); as well as the Public Health Department and the Department of Psychiatric Sciences and Psychological Medicine, University of Rome "La Sapienza," Rome. Address reprint requests to Dr. Picardi, Clinical Epidemiology Unit, IDI-IRCCS, Via dei Monti di Creta, 104–00167 Rome, Italy; a.picardi{at}idi.it (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Although the onset of alopecia areata has often been anecdotally linked with emotional stress, findings from the few controlled studies have not been univocal. The authors compared outpatients experiencing a recent onset of alopecia areata (N=21) with outpatients affected by skin conditions commonly believed as having a low psychosomatic component (N=102). Participants were administered Paykel's Interview for Recent Life Events, the Experiences in Close Relationships scale, the 20-item Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support. Multiple logistic regression was used to control for age and gender. The total number of recent life events (last 12 months) was not different between the alopecia patients and the comparison subjects. Also, the alopecia patients and the comparison subjects did not differ in terms of the number of undesirable or major events. The comparison subjects even experienced a greater number of uncontrollable events. Alopecia areata tended to be associated with high avoidance in attachment relationships, high alexithymic characteristics, and poor social support. The results suggest that personality characteristics might modulate individual susceptibility to alopecia areata.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Alopecia areata is a relatively frequent nonscarring hair loss condition, with an estimated incidence of 20.2 per 100,000 person-years and a lifetime risk of 1.7%.1 It is characterized by the sudden appearance of one or several circumscribed patches of hair loss, usually on the scalp, beard, eyebrows, or eyelashes. Although complete resolution often occurs, the disorder may also become chronic or progress. Hair loss can have a severe psychosocial impact, and it has been found to be associated with substantial psychological distress2–4 and a high prevalence of psychiatric morbidity.5,6

The pathogenesis of alopecia areata is not fully understood.7 Genes seem to play an important part,8 and recent research also suggests the importance of autoimmune mechanisms.9 A role of infectious factors has been proposed10 but remains controversial.11 Psychosomatic factors such as emotional stress and personality have also been suggested to play a role.12,13

An association between stressful events and the onset of alopecia areata has been suggested by anecdotal reports14,15 and by some uncontrolled retrospective studies.16 Some case-control studies have also reported such an association.17–21 However, another study found only a marginally significant association,22 and another study yielded negative results.23 A further investigation that included patients experiencing an exacerbation had negative results.24

While providing preliminary evidence of a role of stressful events,16 many of these studies used life event checklists rather than interviews or were conducted with patients whose onset dated back many months or even years. Hence, these studies carry a considerable risk of fall-off in event recall and recall bias.25 Also, most studies investigated only the role of life events and neglected other factors potentially modulating susceptibility to disease, such as social support,26,27 attachment security,28 or alexithymia.29 Further, no study controlled for possible confounding factors like alcohol intake or smoking.

In this study, we explored the role of stressful events and all of the aforementioned factors in triggering alopecia areata.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
Participants were recruited at the outpatient clinics of IDI-IRCCS, a large dermatological institution situated in Rome. All consecutive admissions for alopecia areata were considered for enrollment, and the following inclusion criteria were used: age 18–60 years, at least 8 years of education, formal diagnosis of alopecia areata by a dermatologist, and onset dating back no more than 3 months. The comparison group consisted of patients 18–60 years of age with at least 8 years of education who were affected by skin conditions in which psychosomatic factors are believed to play a minor role (e.g., mycosis, dermatitis, insect bites).

Instruments
A standardized form was used to collect information about demographic variables, smoking and drinking habits, clinical type of alopecia areata, and age at onset.

Stressful events were assessed with Paykel's Interview for Recent Life Events,25 a semistructured interview covering 64 events. Of these, 63 are specific and clearly defined, while the last coding is for any additional important event not included elsewhere in the schedule. Participants were asked if each event occurred or did not occur in the preceding 12 months, and detailed questioning was carried out to determine the nature, circumstances, and month of occurrence of each event reported. We used the validated Italian version.30

Social support was measured with the Multidimensional Scale of Perceived Social Support,31 a self-report questionnaire of demonstrated validity and reliability.32–35 It consists of 12 items, each scored on a 7-point Likert scale. Higher scores indicate greater perceived support. This instrument allows the assessment of the subject's perception of the adequacy of support from family, friends, and significant others. The reliable Italian version was used.36

Attachment style was assessed with the Experiences in Close Relationships scale, a self-report questionnaire measure of adult romantic attachment that possesses fine psychometric properties.37 It consists of 36 items, each scored on a 5-point Likert scale. The Experiences in Close Relationships scale gives two scale scores measuring anxiety and avoidance, the two main dimensions underlying adult attachment styles. We used the validated Italian version.38,39

Alexithymia was measured with the 20-item Toronto Alexithymia Scale, a self-report questionnaire of established reliability and validity.40,41 We used the validated Italian version.42

Procedures
The study protocol was approved by the institutional ethical committee. The study was explained to all eligible patients who were then invited to participate. Those who accepted signed an informed consent form and were assigned to a research dermatologist who carried out a face-to-face interview in a quiet and comfortable room. The research dermatologist collected demographic and clinical information, administered the Interview for Recent Life Events, and gave participants the Multidimensional Scale of Perceived Social Support, the Experiences in Close Relationships scale, and the Toronto Alexithymia Scale to complete.

Data Reduction and Statistical Analysis
All stressful events occurring in the preceding 12 months were included in the analysis except for events that occurred to the alopecia patients after disease onset. Events were classified along the dimensions of desirability and controllability, and a separate category was devoted to major events. For each participant, the total number of events and the number of events in each category were computed.

The subscale scores of the Multidimensional Scale of Perceived Social Support were computed and summed to give the total score. Given that subscale correlations were fairly high and that we were interested primarily in a general construct of perceived social support, only the total score was used in the analyses. Participants who scored in the lower quintile were considered as receiving poor social support.

The scores for the Experiences in Close Relationships scale were used to classify participants into attachment categories according to the classical four-category model.43,44 We used age- and sex-stratified norms obtained in the validation study of the Italian version.38,39 Scores within one standard deviation from the norm were considered as normal. Participants scoring above normal on the anxiety scale were classified as preoccupied, those scoring above normal on the avoidance scale were classified as avoidant, those scoring above normal on both scales were classified as fearful. All remaining participants were classified as secure.

Total scores on the Toronto Alexithymia Scale were used to divide participants into three categories, according to commonly accepted criteria. Participants scoring below 52 were classified as nonalexithymic, those scoring 52–60 were considered borderline alexithymic, and those scoring more than 60 were classified as alexithymic.

Participants were divided in two categories according to their daily alcohol and nicotine intake: those who did not smoke or smoked infrequently were classified as nonsmokers, while those who smoked every day were classified as smokers. Similarly, participants who did not drink or consumed less than 12 g of ethanol per day were classified as nondrinkers, while those who consumed 12 g or more of ethanol per day were classified as drinkers.

Data were first analyzed with univariate statistics. The chi-square test (with Yates's correction for two-by-two tables) or Fischer's exact test were used as appropriate to analyze differences between groups in categorical variables. The t test was used to study differences in continuous variables. Then, multiple logistic regression analyses were used to control for the possible confounding effects of age and gender. Each regression model included as independent variables age, gender, and the risk factor under study. The dependent variable was subject status (alopecia patient versus comparison subject). Odds ratios were estimated from the regression coefficients. All analyses were run under SPSS, version 8.0 for Windows.45


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 21 patients with alopecia areata and 102 comparison subjects were included in the study. Only one patient with alopecia areata and eight comparison subjects refused to participate. The characteristics of alopecia patients and comparison subjects are summarized in Table 1. In most cases (71%), the onset of alopecia areata dated back to no more than 6 weeks. Alopecia patients and comparison subjects did not differ in terms of age, marital status, educational level, or tobacco or alcohol consumption. However, gender distribution was uneven, with a higher percentage of male subjects among alopecia patients ({chi}2=5.43, df=1, p<0.05). Table 2 reports the comparisons between alopecia patients and comparison subjects with regard to stressful events, social support, attachment style, and alexithymia.


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TABLE 1. Demographic and Clinical Characteristics of Patients With Alopecia Areata and a Comparison Group of Patients With Skin Conditions of Lower Psychosomatic Concern




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TABLE 2. Putative Psychosomatic Risk Factors Among Patients With Alopecia Areata and a Comparison Group of Patients With Skin Conditions of Lower Psychosomatic Concern



There were no significant differences between alopecia patients and comparison subjects in the total number of stressful events and in the number of undesirable or major events. Comparison subjects experienced a greater number of uncontrollable events. Multiple logistic regression analysis confirmed this result.

We found no significant differences between alopecia patients and comparison subjects in total scores on the Multidimensional Scale of Perceived Social Support. As seen in Table 2, both univariate analysis and multiple logistic regression analysis showed a tendency for alopecia areata to be associated with poor social support (odds ratio=2.4, 95% confidence interval [CI]=0.8–7.3).

There were no substantial differences between alopecia patients and comparison subjects in mean scores on the anxious attachment subscale of the Experiences in Close Relationships scale, whereas alopecia patients tended to have higher scores on the scale measuring avoidant attachment (Table 2). Similarly, alopecia patients were more likely than comparison subjects to score above normal on this scale. For the distribution of attachment categories, alopecia patients exhibited an increased frequency of avoidant attachment and fearful attachment. Multiple logistic regression analysis confirmed a tendency for alopecia areata to be associated with high avoidance in attachment relationships (odds ratio=2.9, 95% CI=0.9–9.7).

Alopecia patients had higher mean Toronto Alexithymia Scale scores and were classified more often as having high alexithymic traits. However, the differences were not significant in univariate analyses. The logistic model showed a tendency for alopecia areata to be associated with high alexithymic traits (odds ratio=2.3, 95% CI=0.8–6.2).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This study suggests that personality and social factors, such as avoidant attachment, alexithymia, and poor social support, might play an etiological role in alopecia areata. However, a direct role of stressful events is not supported.

The mean number of recent life events did not differ between a group of patients with alopecia areata and a comparison group of patients with other skin conditions considered to lack psychosomatic factors. Also, there were no differences between alopecia patients and comparison subjects in the mean number of undesirable or major events. Comparison subjects even reported a greater number of uncontrollable events. Although alopecia patients had a slightly shorter period of time under study because of the exclusion of events occurring after alopecia onset, the results were not actually influenced because no such event was reported.

Our study differs from most other investigations because we included only patients with a very recent onset of alopecia areata. Other studies yielding positive results included patients for whom the onset was not specified17,19 or occurred up to 6 months,18,21 1 year,22 or even 3 years20 earlier. The reliability of the recall of events occurring up to 12 months before onset might have been low. Also, given that stress is often offered as an explanation for alopecia areata, many patients might have tended to locate more events in the distant period preceding onset in an effort to find an explanation for their disease. Only one study included patients with newly diagnosed alopecia areata;23 it is interesting to note that it gave negative results.

It should be emphasized that our findings do not imply that psychological stress has no role in alopecia areata because we assessed only discrete life events and did not investigate other important sources of stress that may adversely affect health, such as chronic stress situations and minor daily hassles.46

A relationship between attachment security and health has been suggested by many studies that have shown that attachment security might modulate the susceptibility to stressful events28 and the psychoendocrine and cardiovascular responses to a variety of stressors.47–49

Our findings suggest that insecure attachment, in particular avoidant attachment, might increase vulnerability to alopecia areata. An association between insecure attachment and alopecia areata was also found in another case-control study performed on a large sample of dermatological patients, most of whom with newly diagnosed alopecia areata.23

Avoidant attachment is characterized by a tendency to inhibit the display of negative emotions. Hence, it predisposes to an emotionally suppressive coping style and to avoidance of support seeking, which might in turn adversely affect health.50 Indeed, a relationship between emotional suppression, denial and avoidance, physiological reactivity, and ill-health has long been hypothesized51 and received support from several lines of research, such as psychophysiological studies.52

Alexithymia is a cognitive-affective disturbance classically believed to be frequent among patients affected by diseases with a substantial psychosomatic component.53,54 Alexithymic individuals are characterized by considerably reduced symbolic thinking, poor fantasy life, and limited ability to identify and verbally express emotions.29,53,54 In our study, the presence of high alexithymic characteristics emerged as a possible risk factor, although the association was only marginally significant. Our findings corroborate the common opinion that alexithymia is a general risk factor that might increase susceptibility to disease.55 According to a classical hypothesis, alexithymia might lead to an inaccurate self-perception of stress states, which might in turn increase the frequency of exposure to stressful stimuli, reduce an individual's coping ability, and hence lengthen the exposure to stress.56 Indeed, some studies showed that alexithymia might bias stress perception and lead to a decoupling between subjective and physiological responses to stress.57–59

The finding of both high alexithymic characteristics and avoidant attachment in patients with alopecia areata suggests also the presence of deficits in emotion regulation. Such deficits might be linked to altered physiological self-regulation and possibly to psychosomatic illness,60 even in the absence of stressful events.

Many studies documented that social support is a protective factor for psychological and physical health.61 No firm conclusion can be drawn from our study because we observed only a slight trend toward an association between poor social support and alopecia areata. Unfortunately, we could not investigate a possible "stress buffering" effect,62,63 since our study had insufficient statistical power to test for an interaction between social support and stress.

There might be a complex interplay between insecure attachment, alexithymia, and poor social support in increasing the risk of alopecia areata.

First, the reduced level of perceived social support observed in the alopecia patients might partly result from the presence of insecure attachment. Several studies have documented a relationship between attachment security and perceived support availability.64–68 Individuals with a secure attachment think that their partner can be counted on to fulfill important needs, and they expect that their partner will provide support when necessary. Conversely, insecure attachment may inhibit the request of support and hamper its expression and reception in close relationships.

Second, the lower perceived support observed in the alopecia patients might also result from alexithymia-related deficiencies in social skills. A study reported that the alexithymic difficulty in identifying and communicating feelings is related to less perceived support, fewer close relationships, and less social skills.69

Third, early attachment processes might play a role in the development of alexithymic characteristics.70 A recent twin study suggested that the alexithymic difficulty in identifying and communicating feelings is largely influenced by shared environmental factors.71 Also, some studies showed an association between alexithymia and insecure attachment.72,73

In conclusion, our findings corroborate the opinion that psychosomatic factors play a role in triggering alopecia areata, possibly through psychoneuroendocrine or psychoneuroimmune mechanisms.74–76

Despite the small study group size, we found that the onset of alopecia areata tended to be associated with avoidant attachment, high alexithymic characteristics, and poor social support. Our results do not support the hypothesis that stressful events directly increase vulnerability to alopecia areata. Rather, our findings suggest that personality characteristics might modulate individual susceptibility to alopecia areata, possibly through deficits in emotion regulation or reduced ability to cope effectively with stress.

Given that most associations only approached significance, our study provides only preliminary evidence of an etiological role of avoidant attachment, alexithymia, and poor social support in alopecia areata. It needs confirmation by further studies, which should investigate chronic and daily stressors in addition to life events and should be performed with large samples in order to detect possible interactions between personality and stress. Studying the possible role of anxiety and depression as predisposing factors might also be expedient.


  ACKNOWLEDGMENTS

 
Supported by funding from the Progetto Ricerca Corrente of the Italian Ministry of Health. The authors thank Simone Bolli and Elisabetta Luchetti for their help in data input.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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