Toward a better understanding of social anxiety and depression in psoriasis patients: The role of determinants, mediators, and moderators

Highlights

• Self-evaluative salience is related to social anxiety in patients with adult-onset.

• In patients with pre-adult onset, social anxiety is associated with stigmatization.

• Effect of psoriasis on negative body-related emotions is moderated by gender.

• Women had negative body image emotions almost irrespective of the disease severity.

Abstract

Objective

To determine how and under which conditions psoriasis is related to the psychological impairments, in particular, to social anxiety and depression, the current study tested the interplay of selected factors such as gender, age of onset of psoriasis, cognitive and affective elements of body image, experiences of stigmatization, and patients' subjective perceptions of severity of the disease.

Methods

Adult psoriasis patients (N = 193) completed the Appearance Schemas Inventory-Revised, the Stigmatization Scale, the Body Emotions Scale, the Beck Depression Inventory, and the Social Anxiety Questionnaire. The disease severity was defined based on the Body Surface Area (BSA) index.

Results

The effect of psoriasis on social anxiety was moderated by age of onset: higher severity of the disease was associated with higher levels of social anxiety, but only for patients with pre-adult onset psoriasis. Hierarchical multiple regressions revealed that in patients with adult-onset (≥ 18 years of age) the importance of appearance to one's sense of self-worth was the main contributor to social anxiety, while in patients with pre-adult onset, social anxiety was most strongly related to experiences of stigmatization. Moreover, the results indicated that negative body-related emotions mediated the relationship between severity of the disease and depression. Additionally, the relationship between severity of psoriasis and body image emotions was moderated by gender.

Conclusions

Findings significantly extend previous studies by confirming and highlighting the role of age of onset of psoriasis in psychological impairments, and provide more insight into factors that contribute to social anxiety in this group of patients.

Introduction

Psoriasis is a common chronic skin disorder, affecting men and women equally [1]. The disease ranges in severity from a few scattered red scaly plaques to involvement of almost the entire body surface. As with other skin diseases, visible disfigurement can serve as a stressor in itself and, furthermore, can provoke negative reactions in others, resulting in experiences of stigmatization and rejection [2], which jointly may contribute to the development of multitude of psychological impairments. To date, an extensive literature describes the co-occurrence of psoriasis and depression, anxiety, negative self-image, and suicidal ideation [3], [4], [5], [6], [7], [8], [9]. Some studies have suggested that the impact of psoriasis on patients' lives and well-being is often higher than in other skin conditions and chronic diseases [4], [10], [11]. However, it has also been reported that the severity of psoriasis is not or is poorly related to the risk of depression and psychological distress [3], [12], [13], [14]. Thus, the question remains how and under which conditions psoriasis is related to the psychological impairments, in particular, to depression and social anxiety.

Studies show that psoriasis is associated with impaired sense of self-worth, impaired psychological well-being, and inhibition of social interactions [7], [8], [9], [15]. According to Thompson [16] disfigurements caused by skin diseases can have a profound psychological impact upon body image (especially body image emotions), resulting in appearance-related distress and negative mental health outcomes. Therefore, in this study, we investigated whether the effect of psoriasis on depression would be mediated by negative emotional attitude toward the body. Psoriatic lesion may trigger negative body image emotions (e.g., body-related shame) that may become generalized to negative self-perception and intensify negative affective states, and finally results in depressive symptoms. However, some studies suggest that the impact of psoriasis may be different in women than in men, seeing that women with psoriasis experience more psychological distress and depression [12], [13], [17], [18]. We hypothesized that psoriasis can more strongly affect body image in women than in men. Accordingly, we also investigated whether the effect of psoriasis on body-related emotions would be moderated by gender.

Another important objective of our study has been to give prominence to determinants of social anxiety in psoriasis patients, which have been somewhat neglected in previous research. To our knowledge, risk factors of social anxiety in psoriasis have not been specifically investigated before, except for a study of 49 psoriasis outpatients of the dermatologic private practice [19]. Nonetheless, the overview of existing research suggests that pre-adult age of onset has the potential to change substantially the trajectory of patient's life [15], and may be an important risk factor for developing psychiatric disorders [20]. Psoriasis can affect patients during a vulnerable period of social development, because the first appearance of psoriasis can also occur during adolescence [1]. Patients with early negative experiences, including appearance-related teasing and social rejection, may be at greater risk for developing appearance sensitivity and difficulties with social interactions. Therefore, in this study we investigated whether the effect of psoriasis on social anxiety would be moderated by age of onset. However, besides age of onset, it is worthwhile to consider the relative importance of other factors such as experiences of stigmatization, that can range from others staring to more blatant events such as insults or being asked to leave public places [2], [8], [21], and can strongly influence patients' social withdrawal and contribute to their fear of social contact. Moreover, research has also suggested that a maladaptive form of body-image investment, which refers to deriving one's sense of self-worth from physical appearance, is associated with appearance sensitivity and social anxiety, demonstrating the importance of body image to interpersonal functioning [22]. Importantly, two types of appearance investment have been identified in research – motivational salience and self-evaluative salience of appearance [23]. Motivational salience refers to efforts or desires to maintain or improve one's appearance. In contrast, self-evaluative salience refers to the centrality of appearance to self-worth, and is considered a maladaptive form of investment. Accordingly, the importance of physical appearance in one's personal life and its salience to one's self-worth and sense of self may have particular impact on developing and maintaining social anxiety in psoriasis patients. Maladaptive assumptions about appearance may induce body-specific shame proneness, and intensify worries about how people may react to their skin lesions and what they might think of them, which in turn might increase anxiety and discomfort in social situations, and lead to avoid social interaction for fear of being disliked, humiliated, or rejected.

Finally, it is worth mentioning that previous studies have pointed out that the objective severity of psoriasis did not significantly associate with psychological outcome variables [12], [13], [14], [24]. Magin and colleagues [24] reported that self-assessed rather than objective severity is associated with psychological burden of the disease, and multivariate models of association with psychological morbidity in patients with skin disease are likely to be improved by inclusion of self-assessed disease severity. Accordingly, in this study we proposed to include and test the associations between subjective disease severity and negative psychological outcomes, including social anxiety and depression.

Taken together, we attempted to confirm and extend previous findings, therefore, aims of this study were manifold. First, this study aimed to examine whether patients with onset before the age of 18 years differ psychologically from patients with adult-onset psoriasis, regarding depression, social anxiety, experiences of stigmatization, emotional attitude toward the body, and beliefs about the importance and influence of appearance in their life and self-worth. We hypothesized that patients with pre-adult onset would be more socially anxious, depressed, and characterized by greater self-evaluative salience of their appearance and, furthermore, would experience higher levels of negative feelings to the body than patients with adult-onset psoriasis. Second aim of the study was to test whether the effect of psoriasis on social anxiety would be moderated by age of onset. It was presumed that the disease severity would have different predictive strength on social anxiety depending on pre-adult onset (< 18 years of age) and adult-onset psoriasis. Further, third aim of this study was to identify potential determinants of social anxiety. As mentioned above, studies on social anxiety in psoriasis patients are sparse, it is therefore important to understand better what factors contribute to social anxiety in this group of patients. Fourth, this study aimed to investigate whether emotional attitude toward the body mediates the relationship between patients' subjective perceptions of the severity of the disease and depression. Fifth aim of the study was to test whether gender moderates the relation between subjective disease severity and body-related emotions. Based on existing literature [12], [13], [17], [18], it was presumed that the presence of psoriatic lesions would have different predictive strengths on emotional attitude toward the body depending on gender.