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Psychosomatics 46:556-564, November-December
doi: 10.1176/appi.psy.46.6.556
© 2005 Academy of Psychosomatic Medicine
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Stress, Social Support, Emotional Regulation, and Exacerbation of Diffuse Plaque Psoriasis

A. Picardi, M.D., E. Mazzotti, Psy.D., P. Gaetano, M.D., M.S. Cattaruzza, M.D., M.Sc., G. Baliva, M.D., C.F. Melchi, M.D., M. Biondi, M.D., and P. Pasquini, M.D., M.P.H.

Received July 6, 2004; revision received Nov. 29, 2004; accepted Feb. 4, 2005. From the Clinical Epidemiology Unit and the Second and Third Dermatological Clinics, Dermatological Institute IDI-IRCCS; and the Department of Psychiatric Sciences and Psychological Medicine and the Public Health Department, La Sapienza University, Rome. Address correspondence and reprints requests to Dr. Picardi, Clinical Epidemiology Unit, Dermatological Institute 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
 
The authors’ aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel’s Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Psoriasis is a chronic inflammatory skin disease characterized by thick, red, scaly lesions that may appear on any part of the body. Pain and itching frequently accompany the lesions. Psoriasis is associated with significant psychological distress and psychiatric morbidity,1–3 experiences of stigmatization,3,4 and decreased health-related quality of life.5 The disability experienced by patients with psoriasis is comparable to that of patients with heart disease, diabetes, cancer, or depression.6 The disease is frequent, with prevalence estimates ranging from 0.3% to 2.5%.7

Several factors, including genetic determinants, racial and regional variation, injury and infection, cigarette smoking, alcohol, and diet,7,8 have been identified as associated either with the causation of psoriasis or with triggering exacerbations of the disease. Psychosomatic factors, particularly emotional stress, are also believed to play a role. However, although many patients believe that stress might cause or exacerbate their psoriasis,9 the hypothesis that stressful events might precipitate the onset or exacerbation of psoriasis has received only preliminary support from studies meeting acceptable methods standards,10 such as a small prospective study11 and some controlled retrospective studies.12–15 Furthermore, one study yielded negative results,16 only one study15 controlled for possible confounding factors, such as alcohol and smoking, and no study explored the role of psychosocial factors that might modulate susceptibility to disease, such as social support,17 attachment security,18 and alexithymia.19

Recently, we performed three case-control studies on the role of stress, social support, attachment security, and alexithymia in patients with psoriasis, vitiligo, and alopecia areata, respectively.20–22 These studies basically shared the same comparison group, consisting of patients affected by skin conditions believed to have a negligible psychosomatic component. Although the studies on vitiligo and alopecia areata suggested a role of psychosomatic factors, especially alexithymia, insecure attachment, and poor social support, the study on psoriasis produced negative results. However, subgroup analysis suggested that psychosomatic factors might play a role in certain clinical subtypes, such as guttate and diffuse plaque psoriasis.20

Investigating the role of psychosomatic factors in selected subtypes of psoriasis rather than in psoriasis as a whole seems a sensible strategy in light of the considerable heterogeneity of psoriasis. Genetic studies suggest that genetic differences might explain the many different ways that psoriasis can appear, such as plaque, guttate, pustular, inverse psoriasis, etc.23 The etiology of psoriasis is likely multifactorial, and patients inherit only a predisposition to the disease. Environmental factor interact with predisposing alleles.8 Therefore, psychosomatic factors might conceivably be more relevant in certain psoriasis subtypes.

Plaque psoriasis is the more common form of the disease,24 and diffuse plaque psoriasis is by far the most common clinical type in patients coming to our institute.25 Based on our previous finding that psychosomatic factors might play a greater role in diffuse plaque psoriasis,20 we planned a case-control study to further investigate the role of recent stressful life events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
All participants were recruited from the inpatient wards of IDI-IRCCS, a large dermatological institution located in Rome. All consecutive admissions for diffuse plaque psoriasis were considered for inclusion in the study, according to the following criteria: ages 18–60 years, at least 8 years of education, a formal diagnosis of diffuse (i.e., involving more than 10% of the body’s surface) plaque psoriasis by two dermatologists, and exacerbation of psoriasis during the last 3 months.

The comparison subjects were patients with skin conditions believed to have a negligible psychosomatic component. They were consecutively included in the study according to the following criteria: ages 18–60 years, at least 8 years of education, and a formal diagnosis by two dermatologists of a skin condition other than psoriasis, alopecia, acne, atopic dermatitis, vitiligo, urticaria, lichen planus, pruritus, or seborrhoeic dermatitis.

Assessment Instruments
A standardized form was used to collect information regarding gender, age, marital status, education, time of exacerbation of psoriasis, number of cigarettes smoked per day, duration of smoking, daily alcohol intake, and duration of drinking.

Stressful events were assessed with Paykel’s Interview for Recent Life Events,26 a semistructured interview covering 63 clearly defined events, also containing a question about any additional relevant event not specifically included in the schedule. The participants were asked if each event did or did not occur in the last 12 months, and detailed questioning was performed to determine the nature, circumstances, and month of occurrence of each event reported. We used the validated Italian version of the interview.27

Social support was assessed with the Multidimensional Scale of Perceived Social Support,28 a validated29,30 self-report questionnaire measuring the perception of the adequacy of support from family, friends, and significant others. It consists of 12 items, each scored on a 7-point scale, yielding three subscale scores called family support, friends support, and others support. Subscale scores are added to give a total social support score. Higher scores indicate greater perceived support. We used the Italian version of the questionnaire, which has documented reliability.31

Attachment was assessed with the Experiences in Close Relationships questionnaire, a validated self-report instrument32 comprising 36 items, each scored on a 5-point scale. The questionnaire yields scores on two dimensions, namely, anxiety and avoidance, that are regarded as the main dimensions underlying adult attachment styles. We used the validated Italian version of the questionnaire.33

Alexithymia was measured with the 20-item version of the Toronto Alexithymia Scale, a self-report questionnaire of demonstrated reliability and validity.34 It consists of 20 items, each scored on a 5-point scale. We used the validated Italian version of the questionnaire.35

Procedures
The study protocol was reviewed and approved by the institutional ethical committee. The subjects provided written informed consent to participate in the study. Each patient was assigned to a research dermatologist who performed a face-to-face interview in a quiet and comfortable room. The dermatologist collected demographic and clinical information; administered the Interview for Recent Life Events, the Multidimensional Scale of Perceived Social Support, the Experiences in Close Relationships questionnaire, and the Toronto Alexithymia Scale; and then collected the completed questionnaires.

Variables and Statistical Analyses
All stressful events occurring in the 12 months before the interview were included in the analysis, except for events that occurred for patients with psoriasis after the exacerbation. The events were classified as desirable or not and controllable or not. A separate category was devoted to major events, e.g., bereavement. For each participant, the total number of events and the number of events in each category were computed.

The subscale scores on the Multidimensional Scale of Perceived Social Support were obtained by summing scores on relevant items, then the subscale scores were summed to give the total score. Only the latter score was used in the analyses because we were mainly interested in a general construct of perceived social support. A single, higher-order domain of global social support has been supported by a confirmatory factor-analysis study.30

The anxiety and avoidance scores on the Experiences in Close Relationships questionnaire were obtained by summing the relevant items. The Toronto Alexithymia Scale total score was obtained by summing all items. It was used to divide the participants into three categories according to commonly accepted criteria. The participants who scored below 52 were classified as nonalexithymic, those scoring 52 to 60 were considered borderline alexithymic, and those scoring more than 60 were classified alexithymic.

The participants were also classified based on their daily alcohol and nicotine intake. The patients who did not smoke tobacco or smoked only occasionally were classified as nonsmokers, whereas those who smoked on a daily basis were classified as smokers. Similarly, the participants who did not drink alcoholic beverages or had a daily consumption of less than 12 g of ethanol were classified as nondrinkers, whereas those who consumed 12 or more grams of ethanol per day were classified as drinkers.

After a descriptive analysis, univariate analyses were performed. The chi-square test (with Yates’s correction for 2x2 tables) and the t test were used to analyze differences between groups by categorical and continuous variables, respectively. Then multiple logistic regression analysis was used to remove the effect of confounding factors. A regression model was built for each of the risk factors studied, i.e., stressful events, attachment security, social support, and alexithymia. Each model included case/comparison status as a dependent variable and age, gender, education, marital status, alcohol consumption, and the risk factor under study as independent variables. Odds ratios were estimated from the regression coefficients. All analyses were performed with SPSS, version 8.0 for Windows (SPSS, Chicago).

Because we performed several regression analyses, we considered the possibility of employing some kind of correction to control the potential increase in the rate of type I errors. Given that we had well-defined hypotheses and our study was clearly "explorative" in nature, we reasoned that adjustments would have done more harm than good. Indeed, renowned biostatisticians hold that not making adjustments for multiple comparisons is preferable because it leads to fewer errors of interpretation when the data under evaluation are not random numbers but actual observations of nature.36


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Thirty-three patients with diffuse plaque psoriasis and 73 comparison subjects participated in the study. The most represented diagnostic groups among the comparison subjects were contact dermatitis (N=8), other forms of dermatitis (N=12), bacterial infections (N=6), skin tumors (N=6), connective tissue disease (N=6), prurigo (N=5), ichthyosis (N=5), and skin ulcers (N=4).

The characteristics of the patients with diffuse plaque psoriasis and the comparison subjects are summarized in Table 1. The groups did not differ significantly by gender, marital status, or tobacco or alcohol consumption. However, the patients with psoriasis were older and less educated than the comparison subjects. Also, sizable although nonsignificant differences between the patients with psoriasis and the comparison subjects were apparent for gender, marital status, and alcohol consumption. Hence, all of these variables except tobacco use were deemed as possible confounding factors to be controlled for and were included in multivariate analysis.


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TABLE 1. Demographic and Clinical Characteristics of Patients With Diffuse Plaque Psoriasis and Comparison Subjects



Table 2 summarizes the results of the comparison of the patients with diffuse plaque psoriasis and the comparison subjects and reports for each factor the results of multiple logistic regression analysis.


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TABLE 2. Comparison of Putative Psychosomatic Risk Factors Between Patients With Diffuse Plaque Psoriasis and Comparison Subjects



All logistic models were significant (p≤0.01) compared with the constant-only model and explained more than 20% of the variance, as measured by Nagelkerke’s R2. In relation to the comparison subjects, the patients with a recent exacerbation of diffuse plaque psoriasis had lower total scores on the Multidimensional Scale of Perceived Social Support and higher scores on the Experiences in Close Relationships avoidance scale. Also, they tended to have higher scores on the Toronto Alexithymia Scale, and they were significantly more likely to be classified as having high alexithymic characteristics, with an odds ratio of 3.7 (95% CI [confidence interval]=1.3–10.7). There were no significant differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, in the total number of stressful events, and in the number of undesirable, uncontrollable, and major adverse events.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
Although it is widely held, the belief that stressful events might precipitate psoriasis has received only preliminary support,10 and some studies have reported negative results.16,20 This study corroborates our previous findings20 because we found no excess of stressful events in our inpatients with a recent exacerbation of diffuse plaque psoriasis. Although they had a slightly shorter period of time under study than the comparison subjects because of the exclusion of events that occurred after the exacerbation of psoriasis, this did not substantially influence the results because only four events (i.e., 0.12 events per participant) were excluded from the analysis. Only two other studies explicitly enrolled patients with a recent exacerbation of psoriasis,16,20 and, of interest, both gave negative results.

Our findings did not rule out an association between stress and psoriasis. The life-event paradigm investigates only a portion of environmental stress, and we did not measure other important sources of stress, such as chronic stressful situations or daily hassles.37 Also, given the genetic heterogeneity of psoriasis,8 the possibility exists that other clinical types, e.g., guttate psoriasis,15,20 might be more susceptible to stress. Furthermore, our comparison group consisted of patients with putatively nonpsychosomatic dermatological conditions. Although this enabled us to control for nonspecific factors related to having a skin disease, we could not exclude an excess of life events in psoriatic patients in relation to healthy comparison subjects.

Although an association was not found between stressful events and the exacerbation of psoriasis, our study supports the hypothesis that this disease has a psychosomatic component because the exacerbation of psoriasis was associated with alexithymia, avoidance of emotional closeness and intimacy in attachment relationships, and poor perceived social support.

Alexithymia is characterized by reduced symbolic thinking, a poor fantasy life, and a limited ability to identify and verbally express emotions. These characteristics are believed to be common among patients affected by diseases with a substantial psychosomatic component.38,39 In this study, the prevalence of alexithymia among psoriatic patients was more than twofold in relation to the comparison subjects. In our previous study, the prevalence of alexithymia among patients with diffuse plaque psoriasis was comparably high, and in relation to the comparison subjects, it approached significance, despite the low statistical power. Other studies of alexithymia in psoriasis13,40 could not be directly compared with ours because they were not performed specifically on patients with diffuse plaque psoriasis.

Attachment style is conceptualized as a disposition toward certain perceptions of others, certain perceptions of self, and certain preferred strategies when we face the presence of a perceived threat. There are several pathways by which insecure attachment could influence health and affect the course of physical disease.41 Attachment insecurity might affect stress regulation in that it may increase perceived stress, it may affect the intensity or duration of the physiological stress response, and it may determine the success of social support in buffering stress. We found a strong association between attachment-related avoidance and the exacerbation of diffuse plaque psoriasis. This finding is consistent with studies suggesting that insecure attachment might increase the susceptibility to several skin diseases.21,22,42 Although the influence of insecure attachment on health might also be mediated by elevated use of external regulators of affect, such as smoking or drinking,41 in our study, the association of the exacerbation of psoriasis with insecure attachment was independent of alcohol and tobacco use.

Social support is classically conceived as a protective factor for health,17,43 whereas perceived social isolation is a major risk factor for morbidity and mortality.44 We found that the patients with a recent exacerbation of diffuse plaque psoriasis perceived significantly less support from their social network than the comparison subjects. This finding is consistent with recent studies on other skin diseases21,22 and with a large body of literature documenting that good social relations are associated with health.

Recent theoretical formulations have emphasized that social support is a process that arises through interactions between people. There are relationship characteristics that shape actual support interactions, as well as partners’ perceptions of and expectations about those interactions.45 Recent findings have suggested that perceived social support, especially intimate support, is largely a byproduct of attachment style.46 Indeed, attachment theory might help explain the complexities of the relationship between social support and health. First, relationships that provide a feeling of security might be more effective in buffering stress. Second, secure attachment is likely associated with a greater willingness to seek support and a related expectation that support would be available and effective if needed.41 Consistently, avoidant attachment correlated with ineffective support seeking,47 and many studies found an association between attachment security and the perceived availability of support.45

Overall, our results were consistent with theories emphasizing that stress is inherent neither to the environment nor to the person alone but that it results from their interplay.48 Models that assume causality to flow from stress as a stimulus to the stress reaction as an outcome are simplistic. An individual’s emotions, thoughts, and behaviors contribute to the genesis of stress. Personality influences the stress process in many aspects. It can affect representations of the descriptive situation, the appraisal of stress situations, and coping processes. It is also crucial in the selection and shaping of stress situations.49

Also, the increased levels of alexithymia and insecure attachment in our inpatients with diffuse plaque psoriasis suggested the presence of impaired emotional regulation. Attachment-related avoidance is associated with the frequent use of suppression as an emotional regulation strategy, which in turn is related to reduced social sharing of emotion, lesser social support, and lower well-being.50 Alexithymia is also negatively correlated with the social sharing of emotion elicited by negative events.51 The rare occurrence of emotional sharing among individuals with high alexithymia and avoidant attachment is important because the social sharing of emotion is consistently associated with positive feelings, subjective benefits, and improvement in immune function and physical and psychological health.52 Emotional events may undermine the delicate symbolic architecture that individuals construct to make the flow of their experience more consistent with the continuity of their appraisal of themselves and the world.53 Emotional sharing after a stressful event might help complete the mental working-through process aimed at either the restoration of beliefs or at finding meaning in the event.54 Searching for and finding positive meaning is an underlying common theme of the coping processes that are associated with positive psychological states, even under severe stress.55 Of interest, expressing emotions and seeking social support correlated with better psychological and physical adjustment in patients with psoriasis,56 whereas alexithymia correlated with increased life stress resulting from psoriasis.57

Regarding possible physiological mechanisms mediating the interplay between stress, personality, and psoriasis, there is a complex neuro-immuno-cutaneous-endocrine network that may account for a mind-body connection in the skin.58 In vulnerable individuals, stress-induced release of neuroimmune substances, including neuropeptides,59 might adversely affect cutaneous homeostasis through activation of inflammatory processes in deeper skin layers.58,60 Stress can also alter the epidermal permeability barrier,61 and a barrier abnormality might facilitate the development or persistence of inflammatory skin diseases through activation of an epidermal-initiated cytokine cascade.62 Furthermore, continuous stress can compromise the skin’s wound-healing response.63

Although it is still debated whether the primary defect in psoriasis arises in keratinocytes or in the immune system, the abnormal differentiation and hyperproliferation of keratinocytes and the infiltration of inflammatory components into the skin are the major pathogenic abnormalities.8 Of interest, findings suggest an altered stress-induced increase in CD8+ T (an antigenic marker on suppressor/cytotoxic T cells) lymphocytes among psoriatic patients.64 Personality is also likely to play a role in these pathophysiological processes because personality traits can influence the immune system’s response to stress, possibly by influencing the perception and appraisal of stress situations and thereby the physiological reaction.65 For instance, high levels of hostility correlated with higher cortisol and norepinephrine responses to stress66 and with greater increases in the number and activity of natural killer cells.67,68 Of interest, hostility shares some resemblance with avoidant attachment because it is characterized by a negative attitude toward other people and the belief that others are not to be trusted.

This study has some limitations. First, only inpatients were involved, and this limited its generalizability to some extent. However, our results could probably be generalized to outpatients in other health care systems where hospitalization for psoriasis is less common because many patients with mild or moderate severity who come from more disadvantaged Italian areas are admitted as inpatients to our institute for diagnostic assessments and treatments not easily available in their regions. Despite this, our findings need further confirmation on outpatients. Second, the two groups were moderately unbalanced on some sociodemographic variables. Given that in case-control studies there are both practical and conceptual problems with matching,69 we decided against it and consecutively enrolled all eligible comparison subjects. Although this strategy has advantages, it might also result in unbalanced groups if the group size is relatively small, as in our case. However, possible confounding by sociodemographic variables was minimized with multivariate analysis. Third, we studied patients with a recent exacerbation rather than a recent onset of psoriasis. A potentially disabling disease such as psoriasis might influence the probability of experiencing certain life events, even in patients with quiescent disease. It might also induce an increase in attachment insecurity and possibly also in alexithymia. However, this explanation of the results is unlikely for several reasons: attachment style and alexithymia are fairly stable over time;70,71 of the two attachment dimensions, only avoidance was elevated; and we included patients with skin diseases, rather than healthy subjects, as comparison subjects.

In conclusion, this study confirms the relevance of psychosocial factors in psoriasis72 and underscores the need for a biopsychosocial approach to the management of psoriasis. Psychological distress correlated with increased time to clearance of psoriasis in patients treated with photochemotherapy,73 whereas a meditation-based stress-reduction approach reduced time to clearance in patients undergoing phototherapy or photochemotherapy.74 Cognitive-behavior stress-management techniques delivered in group format may improve the clinical severity of psoriasis,75 whereas collaborating with patients’ partners might also be helpful.76 Our study suggests that psychological interventions aimed at increasing emotional awareness, fostering the security felt in close interpersonal relationships, and increasing social support might help reduce exacerbations of psoriasis or possibly ameliorate their course.


  ACKNOWLEDGMENTS

 
The authors thank Drs. Diana Camaioni and Albertina Tiago for administering the assessment instruments and Simone Bolli, Elisabetta Luchetti, Nidia Melo Salcedo, and Valentina Salvatori for help with the data.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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