The contribution of perceptions of stigmatisation to disability in patients with psoriasis

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Abstract

Objective: The aim of the present study was to assess the significance of general and psoriasis specific psychological variables in patients with psoriasis and to examine the relative importance of disease status and these psychological variables in predicting psoriasis-related disability. Method: A total of 115 patients with psoriasis underwent clinical assessment and completed a number of psychological and psoriasis specific questionnaires. Results: High levels of self-reported distress were identified with 43% and 10% of patients scoring as probable cases on the Hospital Anxiety and Depression Scale (HADS) subscales of anxiety (mean 9.3±4.9) and depression (mean 4.8±3.7), respectively. Multiple regression analysis indicated that clinical severity of psoriasis and anatomical area of involvement had no impact on psychological distress and disability. Perceptions of stigmatisation were significantly related to both psychological distress and degree of disability (P's<.001) and accounted for a significant amount of the variance in disability over and above general psychological distress (F change=11.03; P<.001). Conclusion: Psychological factors were much stronger determinants of disability in patients with psoriasis than disease severity, location or duration. This has important implications in relation to the clinical management of psoriasis.

Introduction

Psoriasis is a chronic, inflammatory, currently incurable dermatological condition. It affects 2–3% of the population, has an equal distribution between the sexes and its onset may occur at any age. Studies have indicated that genetic factors have an important role in the onset of psoriasis [1]. Psychological distress and stressful life events have been shown to be important in the onset and exacerbation of the condition [2], [3], [4].

Clinically psoriasis is characterised by red, heavily scaled plaques on the skin [5]. Severity of psoriasis may range from small localised lesions typically on the scalp, elbows and knees to involvement of the entire skin — erythroderma. Patients commonly report frequent ‘skin shedding’ and ‘itching’ in association with their psoriasis [6]. Patterns of clearance and recurrence are impossible to predict. The varied distribution of the condition means the clinical manifestations of psoriasis may or may not be visible to an observer.

There are a wealth of studies that have indicated psoriasis patients to be anxious [7], depressed [8], [9], engage in excessive worrying [10] and be restricted in everyday life as a result of their psoriasis [4], [11], [12], [13], [14]. Reductions in physical functioning have been shown to be comparable to those seen in cancer, arthritis, hypertension and heart disease [15].

In common with many other chronic diseases, the biomedical model has been suggested to be limited in its ability to explain the psychological effects and disability associated with the condition [14], [16]. In view of this, a number of studies have investigated potential cognitive mechanisms relating to the psychosocial impact of psoriasis [7], [17]. One area that has received interest within the literature is that of perceptions of stigma. That patients with psoriasis believe they are stigmatised by their condition is well established and a number of studies have investigated possible factors influencing such perceptions and the consequences of these [7], [13], [18]. Fear of negative evaluation and self-assessed severity have been shown to predict the degree to which patients believed other people stigmatised them, stress surrounding others' reactions and distress resulting from the disease [19]. In line with this, we have previously suggested [14], [20] that anticipation of other people's reactions to their psoriasis contributes to a significant degree of stress and disability.

Clearly the importance of perceptions of stigma should also be considered in relation to the proposed link between stress and psoriasis [21]. Patients' perceptions of being stigmatised and their subsequent avoidance coping responses may be considered to be stressful in their own right [14], [16], potentially influencing the course of the condition. Thus, it is particularly important from both a theoretical and clinical management perspective to examine this concept further. This should highlight the clinical potential of reducing disability and distress by targeting interventions at cognitive factors relating to perceptions of stigmatisation.

The current study aimed to examine the specific contribution of perceptions of stigmatisation to psoriasis-related disability and distress in patients attending a psoriasis speciality clinic. It was hypothesised that perceived stigma would explain more variance than severity of psoriasis in psoriasis-related disability and distress.

Section snippets

Participants

One hundred fifteen patients with a definite diagnosis of psoriasis confirmed by clinical assessment were recruited to the study by means of continuous sampling from those who attended a weekly psoriasis speciality clinic. Participants were excluded from the study if they had any other psychiatric or significant medical condition with the exception of psoriatic arthritis.

Procedure

Patients attending the psoriasis clinic were provided with an explanatory leaflet describing the study. On obtaining verbal

Patient characteristics

Of the 115 patients 54 (47%) were female and 61 (53%) were male. They ranged in age from 18 to 70 years, with a mean age of 41.5 years (S.D. 14.7). Of these participants, 77 were employed and 38 unemployed. A family history of psoriasis was positive in 61 (53%) of patients. The mean age of onset of psoriasis was 22.8 years (S.D. 14.9), and ranged from 2 to 61 years. The mean duration of psoriasis was 18.7 years (S.D. 13.0) and ranged from 0 to 52 years. Compared with other published data [26],

Discussion

The current study investigated the specific contributions of clinical, demographic and psychological variables to psoriasis-related disability. The results suggest that clinical variables such as severity of psoriasis, site of involvement and duration of psoriasis are not directly related to either psychological difficulties or psoriasis-related disability. It would appear that the impact of psoriasis in these patients is not simply reducible to the chronicity, severity or location of disease

Acknowledgements

This study was supported in part by the NHS Executive Research and Development Programme for Physical and Complex Disabilities (Grant No: PCD2/A1/284).

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