ARTICLE
Psoriasis is a mostly chronic, noninfectious skin disease with polygenic
genetic disposition, characterized by a greatly accelerated rate of epidermal
turnover. The sharply demarcated, erythematous lesions, which indicate
increased vasculature in the subepidermal cutis, are elevated over the
surface of the surrounding uninvolved skin and covered with silvery, loosely
adherent scales. They vary in size and configuration from patient to patient
and in the same individual from time to time. Psoriasis is a lifelong
disorder which may reflect only a few patches (sites of predeliction are
the sacral region, scalp, elbows or knees) or may be extensive with total
skin involvement [1]. In general, psoriatic lesions are not particularly
painful or irritating, yet, they are often disfiguring and may present
a considerable psychological problem for many psoriasis sufferers [2].
Estimates of the occurrence of psoriasis in different countries vary from
0.97-2.8% among all age groups [3].
The influence of psychosocial factors on the etiology and the fluctuating
disease activity has been discussed repeatedly in recent years. A number
of empirical studies have focused on the investigation of psychosocial
aspects of psoriasis, such as stress factors and life events [4-7]. It
is widely accepted that psoriasis and other dermatological diseases (e.g.
chronic urticaria) are caused by several factors, some of which may be
psychosocial. Estimates of the proportion of psoriasis patients whose
disease is influenced by stressful events vary from 40 to 80% [8], depending
on how stress is defined. Evidence for psychosocial variables related
to the onset of psoriasis was found by Seville [4], who reported that
39% of 132 patients recalled specific stress events within one month prior
to the onset of psoriasis, and that those who were able to recall stress
events had a significantly better prognosis than the rest of the psoriatics.
In another study it was found that patients with psoriasis were exposed
significantly more often to stressful life situations and suffered more
frequently from psychological distress than subjects with fungal infections
[5]. In a prospective study Gaston et al. found a positive correlation
between the severity of psoriasis symptoms and psychological distress
and the impact of adverse life events [6]. Gupta et al. observed
even suicidal ideation in psoriasis [9].
Vogel considers psoriasis to be a symptom of suppressed aggression [10].
The rational is that anger is absorbed and deflected into vascular skin
reactions rather than overtly expressed, which results in a dilation of
the arterial and venous skin vessels. This suppression process is assumed
to develop during early childhood. And indeed, there are several physiological
findings which are in line with some of Vogel's hypotheses. For instance,
Mon demonstrated increased capillary dilation and the formation of new
capillaries in psoriatic tissue [11], Baxter et al. found that
vasoproliferation was important for cell growth [12]; psoriatic lesions
lead to abnormally increased temperatures [13, 14]. Graham found hyperemia
in psoriasis patients when they had to speak about personal conflicts
in an interview [15]. Benoit et al. demonstrated the effectiveness
of skin temperature biofeedback on the cellular proliferation of psoriatic
plaques [13].
Aggression inventories have given some support to the applicability
of the repressed aggression theory in the pathogenesis of psoriasis [16].
The present study deals with the issue of aggressive behaviour of persons
suffering from psoriasis. It was investigated whether psoriatics show
less aggressive verbal behaviour than controls in anger-producing situations
as compared to non-anger inducing conditions.
It should be pointed out that this study can not indicate a causal
relationship between psoriasis, stress, and aggressive verbal behaviour.
Method
Subjects
A total of 26 psoriatics and 26 controls participated in the study.
The psoriatics were recruited by mail and by announcements in two Dermatology
Clinics. People in the area of Frankfurt/ Main (FRG) with documented diagnoses
of Psoriasis vulgaris were addressed either as members of the "Deutscher
Psoriasisbund" ("German Psoriasis Association"), a large, nationwide self-help
organisation (n > 9,500), or as patients of the University Dermatology
Clinics in Giessen or Marburg. Only those with chronic or acute nummular
psoriasis (Psoriasis vulgaris) were included, while other forms of psoriasis
such as pustular, exfoliative, and guttate psoriasis were excluded. Diagnoses
were verified by dermatologists. There was no tangible incentive provided
for participation. Each psoriasis volunteer above 18 years of age willing
to participate as a subject was included in the study, provided the dermatological
criteria outlined above were met. A Wilcoxon test showed no differences
between the psoriasis groups in terms of the extent of skin area involved
(5 categories). Each group had six persons with acute and seven with chronic
types of psoriasis. The control group consisted of persons without psychosomatic
or skin diseases. Each quadruple of two psoriatics and two controls was
matched on sex and age (maximum range of 12 months difference within one
quadruple). They were 36 men from 22 to 52 years, and 16 women from 29
to 44 years (mean 35.69; s = 8.66). A Friedmann test indicated no differences
among the four experimental groups (groups x conditions) in terms of their
socioeconomic status (8 categories) and education (7 categories).
Experimental procedure
A 2 x 2 factorial design with two subject populations and experimental
conditions was employed. Psoriatics and controls were assigned to either
an anger-inducing situation or a nonanger-inducing situation. To obtain
comparable subjects across the conditions, two psoriatics and two controls
were first grouped together as matching quadruples (see also above); then
the two psoriatics and the controls of each quadruple were randomly assigned
to either an anger-inducing or an nonanger-inducing situation. The experimental
procedure was a slightly modified version of that employed by Baron in
his research on aggression [17]. On their arrival, the test persons found
a 28-year old male confederate already waiting. Together they entered
the experimental room, where it was explained that they were participating
in a study on social behaviour that involved a scenario of becoming acquainted
with a stranger. Subsequently the subject and the confederate were asked
to sit at a table facing each other and to write brief sketches describing
their own personalities. These sketches were then openly exchanged by
the experimenter. After reading the self descriptions the participants
had to rate their partner in terms of eight characteristics (appearance,
tolerance, friendliness, helpfulness, humor, honesty, intelligence, and
maturity) on five-point scales (1 = not at all, 5 = very much). Finally
these ratings were exchanged. After reading the ratings, the confederate
was instructed to leave the room, presumably for an additional experimental
task. Then the experimenter entered and the subject was asked to complete
the photo hand test (card position A) [18].
The confederate's self-description and partner ratings were standardized.
There were two versions of the ratings (independent variable). One set
of ratings represented negative derogatory feedback and was supposed to
induce anger and aggression in the subject. The confederate rated the
subject as fairly unintelligent, immature, unattractive, etc. The other
ratings consisted of relatively positive, favorable statements with the
purpose to decrease the probability of aggressive behaviour. The confederate's
standard ratings were empirically developed in a pilot study. Both rating
versions were found to be effective in influencing the level of verbal
aggression.
The study was carried out at two different locations under similar environmental
conditions. The carpeted room (5 m x 6 m) was furnished with a table and
two chairs.
The patients were informed afterwards about the true nature of the study.
After the experiment all participants were given the opportunity of reflecting
upon the experimental situation with a psychotherapist.
The photo hand test (PHT)
The PHT is a projective test with special reference to the prediction
of overt aggressive behaviour. It is an extended German version of the
hand test. The PHT has 34 slightly blurred, 9 cm x 12 cm, black and white
photographs of a single hand in different postures on neutral background.
The cards are consecutively presented in a standardized order. The subject
has to respond to each card according to the request, "What does this
hand look like it might be doing" [19]. Only the first answer was used
for the analysis.
Six response categories were employed to code the subjects' responses
in a mutually exclusive fashion: (1) Aggression (dominating, injuring,
attacking, etc.), (2) Directs (leading, conducting, directing, etc.);
categories one and two are expected to correlate with a person's "tendency
to act out in an aggressive way of any kind". (3) Fear (fear of retaliation
or aggression of others). (4) Affection (hand expresses positive emotional
attitudes). (5) Communication (hand is communicating). (6) Dependence
(seeks support or aid of another person); categories three to six are
supposed to contain responses that actively decrease the probability of
aggressive overt behaviour. A non-applicable rest category was added.
The acting-out score (AOS) is a composite score which is supposed to
predict overt aggressive behaviour, i.e., behaviour that may eventually
bring a person to the attention of school authorities, the police, or
the court. The rationale behind the AOS is that the probability of overt
aggressive behaviour increases as aggressive and domineering tendencies
increase and cooperative attitudes decrease. The score is obtained as
the sum of the responses in the last four categories subtracted from the
sum of the scores in the first two categories; i.e., sum (agg +
dir) sum (fear + affection + communication + dependence). The PHT
was item analyzed (N = 65); mean interitem correlation (PA) = 0.27; mean
item/ total score correlation r = 0.21. Reliability (test-retest, parallel
test), criterion validity, objectivity, transparency of the test purpose,
and ambiguity were assessed for a variety of populations with satisfactory
results overall [18, 19].
The subjects' responses were tape-recorded and the first response to
each card was transcribed. The written protocols were then categorized
by two independent and well trained raters, who were blind regarding the
subject population, the purpose and the design of the study. A week after
the first rating the primary rater categorized the responses of 20 randomly
chosen protocols a second time.
Results and discussion
Inter- and intra-rater agreement were estimated for each of the 34 items
across the six response categories using Cohen's Kappa (k): mean inter-rater
k = 0.86 (n = 52); mean intra-rater agreement k = 0.94 (n = 20) [20].
Two response measures were separately analyzed by means of 2 x 2 analysis
of variance with repeated measures on both factors. The aggression score
(S1 = sum(agg + dir)) as a fairly simple and direct measure of verbal
responses with aggressive content represented the primary dependent variable
for testing the stated hypothesis. The second response measure analyzed
was the AOS.
Analyses of variance of the aggression scores showed two significant
main effects and a significant interaction. Psoriatics responded less
aggressively in verbal responses than controls. On the other hand, anger
induction results in more aggressive verbal responses.
Looking at the interaction effect one can see that three subgroups have
similar mean values. Only the control group under the anger-induced situation
shows more aggressive verbal responses.
This can be emphasized by the AOS. Angered persons respond in a more
overt aggressive form to anger-inducing situations. However, no significant
differences were found in the mean values between controls and psoriatics.
Again, the interaction effect is significant. While psoriatics do not
show differences in the mean values of the AOS depending on induction
of anger, the control group reacts according to the kind of anger induction
(Table I).
Figure 1 presents the
mean number of aggressive verbal responses of the four groups. It points
out the interaction-effect.
Figure 1 and the statistical
results indicate that the psoriatics, aggressive verbal responses differed
from the controls' responses, in particular under anger-inducing circumstances
but not in nonanger-inducing situations.
This supports the hypothesis that psoriatics tend to respond in anger-inducing
situations of social stress with less aggressive verbal behaviour than
the average person. It also corroborates the position of those who consider
psoriasis to be partly influenced by psychosocial variables. The possible
link between aggression and skin immune response might be neuropeptides,
as shown by Farber et al. [21]. It should be pointed out, however,
that the data do not indicate a causal relationship among psoriasis, stress,
and aggressive verbal behaviour. The reduced tendency towards aggressive
verbal responses in anger-inducing situations may just as well be a secondary
phenomenon to psoriasis, typical disfiguring diseases, and may have nothing
to do with etiological variables. Further, it must be taken into consideration
that only those psoriatics, who were particularly "nice" or "helpful"
people, who react differently to aggression-induction from the total population
of psoriatics, agreed participate at the study.
The relevance of the presented results lies in experimentally established
evidence that persons with psoriasis may indeed show reduced verbal behaviour
in anger-inducing situations. These results should be treated with caution,
however, until they are replicated and supported by studies that use psychophysiological
and observational data.
REFERENCES
1. Camp RDR. In: Champion RH, Burton JL, Ebling FJL, eds. Textbook
of Dermatology. 5th edn., Vol. 2. Oxford: Blackwell Scientific publications,
1992: 1391-457.
2. Ramsay B, O´Reagan M. A survey of the social and psychological
effects of psoriasis. Br J Dermatol 1988; 118: 195-201.
3. Christophers E, Sterry W. Epidermis: Disorders of Cell Kinetics and
Differentiation. In: Fitzpatrick TB, ed. Dermatology in General Medicine.
4th ed., 1993: 489-514.
4. Seville OH. Psoriasis and stress. Br J Dermatol 1977; 97:
297-302.
5. Fava GA, Perini GI, Santonastaso P, Fornasa CV. Life events and psychological
distress in dermatological disorders: Psoriasis, chronic urticaria, and
fungal infections. Br J Med Psychol 1980: 53: 277-82.
6. Gaston L, Lassonde M, Bernier-Buzzanga J, Sheilagh H, Crombez JC.
Psoriasis and stress: a prospective study. J Am Acad Dermatol 1987;
17: 82-6.
7. Al´ Abadie MS, Kent GG, Gawkrodger DJ. The relationship between
stress and the onset and exacerbation of psoriasis and other skin conditions.
Br J Dermatol 1994; 130: 199-203.
8. Gupta MA, Gupta AK, Kirkby S, Schork NJ, Gorr SK, Ellis CN, Voorhees
JJ. A psychocutaneous profile of psoriasis patients who stress reactors:
a study of 127 patients. Gen Hosp Psychiat 1989; 11: 166-173.
9. Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN. Suicidal ideation
in psoriasis. Int J Dermatol 1993; 32: 188-90.
10. Vogel PG. Psychosomatische Aspekte der Psoriasis (Psychosomatic
aspects of psoriasis). Z Psychosom Psychoanal 1976; 22: 177-89.
11. Mon AM. Dermal connective tissue and vessels in psoriasis. In: Fraber
EM, Cox AJ, eds. Psoriasis Proceedings of the International Symposium
at Stanford University 1972. Stanford, CA: Stanford University Press,
1971.
12. Baxter DL, Stoughton RB. Mitotic index of psoriasis lesions treated
with anthralin, alucorticosteroid and occlusion. J Invest Dermatology
1970; 54: 410-8.
13. Benoit LJ, Harrel EH. Biofeedback and control of skin cell proliferation
in psoriasis. Psychol Rep 1980; 46: 831-9.
14. Herndon R. Medical complications of psoriasis. Medical Grand Rounds,
Parkland Memorial Hospital, July 17, 1975.
15. Graham DT. The reaction of psoriasis to attitude and to vascular
reactions of the human skin. J Invest Dermatol 1945; 22: 79.
16. Lyketsos GC, Stratigos J, Tawil G, Psaras M, Lyketsos CG. Hostile
personality characteristics, dystymic states and neurotic symptoms in
urticaria, psoriasis and alopecia. Psychother Psychosom 1985; 44:
122-31.
17. Baron R. Aggression-inhibiting influence of sexual humor. J Pers
Soc Psychol 1978; 2: 189-97.
18. Belschner W, Lischke G, Selg H. Der Foto-Hand Test zur Erfassung
der Aggressivität (The Photo Hand Test for the assessment of aggression),
Freiburg: K. Alber, 1971.
19. Bricklin B, Piotrowsky AZ, Wagner EE. In: The Hand Test.
2nd edn., Springfiled, IL: Thomas, 1970.
20. Cohen L. A coefficient of agreement of nominal scales. Educat
Psychol Measure 1960; 1: 37-46.
21. Farber EM, Nickologoff BJ, Recht B, Fraki JE. Stress, symmetry,
and psoriasis: Possible role of neuropeptides. J Am Acad Derm 1986;
14: 305-11.
|
Printable version
