Angelo Picardi

Stressful Life Events and Skin Diseases: Disentangling Evidence from Myth

The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Clinical wisdom and experience, as well as many anecdotal observations and uncontrolled case series, support this opinion. We reviewed the available evidence on the role of stressful life events in triggering or exacerbating skin diseases. The role of stressful events in vitiligo, lichen planus, acne, pemphigus and seborrhoeic dermatitis was either controversial or insufficiently explored. The role of stressful events in psoriasis, alopecia areata, atopic dermatitis and urticaria was apparently clearer. However, only a few studies met acceptable methodological standards for stress measurement. Also, few studies considered common potential confounding factors (e.g. age, duration of illness, familial factors), and no study controlled adequately for the influence of other crucial factors (e.g. discontinuation of treatment, seasonal effects). Adding that the large majority of studies were retrospective, it seems wise to conclude that only preliminary evidence has been published so far on the role of stressful life events in bringing on or worsening any dermatological disease. Further research is mandatory, either in the form of prospective studies or, more feasibly, of well-designed case-control studies with adequate statistical power. Future studies should also pay more attention to protective as well as vulnerability factors in stressful events. Further, it would be important to investigate other sources of psychological stress, such as chronic stress and everyday stress. Measuring stress appraisal, although difficult, would also be important.

Factors associated with patient satisfaction with care among dermatological outpatients

Background It has been shown that poor patient satisfaction can lead to poor adherence to treatment with consequently poor health outcomes. In order to improve the quality of care perceived by the patient and thus the health outcome, it is important to understand which are the main factors influencing patient satisfaction.

Stability of Alexithymia and Its Relationships with the ‘Big Five’ Factors, Temperament, Character, and Attachment Style

Background: Controversy still exists concerning the stability of the alexithymia construct. Also, although alexithymia has been found to be related in a theoretically meaningful way to other personality constructs such as the ‘Big Five’ factors, few studies have investigated its relationship with influential constructs such as temperament and character, and attachment security. Methods: Two hundred twenty-one undergraduate and graduate students were administered the Toronto Alexithymia Scale (TAS-20), the State-Trait Anxiety Inventory (STAI), the Zung Depression Scale (ZDS), the Temperament and Character Inventory (TCI-125), the Big Five Questionnaire (BFQ), and the Experiences in Close Relationships (ECR) questionnaire. After 1 month, 115 participants completed again the TAS-20, STAI, and ZDS. Results: Alexithymia was only moderately correlated with depression and anxiety. Both the absolute and relative stability of TAS-20 total and subscale scores was high, and a negligible portion of their change over time was accounted for by changes in depression or anxiety. In separate multiple regression models including also gender, age, depression and anxiety, TAS-20 total and subscale scores were correlated with low energy/extraversion, low emotional stability, openness, low friendliness/agreeableness; harm avoidance, low self-directedness, low cooperativeness, low reward dependence; attachment-related avoidance and anxiety. Conclusions: Our findings lend support for both absolute and relative stability of alexithymia, corroborate an association between alexithymia and insecure attachment, and contribute to a coherent placing of alexithymia in the broader theoretical network of personality constructs.

Association between poorer quality of life and psychiatric morbidity in patients with different dermatological conditions

Objective: To determine the relationship between skin-related quality of life and psychiatric morbidity in patients with different skin conditions. Methods: We recruited all adults attending the outpatient clinics of the Dermatological Institute IDI-IRCCS, Rome, Italy, during 14 predetermined days. Eligible patients, who gave their informed consent, completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). We used a stringent cut-off threshold (≥5 on the GHQ-12) for identification of psychiatric morbidity. Skindex-29 scale scores were computed separately for GHQ noncases and GHQ cases. Results: A total of 2,136 patients were included in the analysis. For all skin conditions, GHQ cases had substantially poorer score in all 3 domains of quality of life, Symptoms, Emotions, and Functioning. Most differences remained significant after adjusting for clinical severity, age, sex, and education in multiple regression models. These differences were not as marked in the Symptoms scale for some conditions known to be nearly asymptomatic (eg, alopecia, vitiligo, nevi), suggesting that, although patients with psychiatric morbidity might be more burdened by their symptoms, nevertheless they do not perceive nonexistent symptoms. Conclusion: In most skin conditions we considered, psychiatric morbidity was strongly associated with poorer quality of life. Although the cross-sectional nature of our study does not allow identification of the direction of this association, care for the psychological condition of patients might have an impact on their quality of life.

Further Evidence of the Validity and Reliability of the Skindex-29: An Italian Study on 2,242 Dermatological Outpatients

Background: Quality of life is increasingly recognized as an important measure in dermatology. The Skindex-29 is a self-administered questionnaire recently developed to measure comprehensively the complex effects of skin diseases on patients’ quality of life. Objective: We aimed to provide further evidence of the reliability and validity of the Skindex-29 in a large sample of patients affected by a wide variety of skin diseases. Methods: An Italian version of the Skindex-29 was produced following accepted guidelines for the cross-cultural adaptation of questionnaires. All adult outpatients attending a dermatological hospital on predetermined days were given the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). Results: A total of 2,242 complete questionnaires were analyzed. The internal consistency and test-retest reliability of each scale were high. The factor structure of the Skindex-29 was strikingly similar to the one originally observed in American patients. The pattern of correlation with the GHQ-12 provided evidence of convergent validity of the Skindex-29. Conclusion: The instrument seems to measure three fundamental dimensions of skin health-related quality of life.

Stressful Life events, social support, attachment security and alexithymia in vitiligo: A case-control study

Background: It has often been suggested that stress might trigger vitiligo. However, only one study supported this hypothesis, and no study explored the role of other personality or social factors. Methods: Out-patients experiencing a recent onset or exacerbation of vitiligo (n = 31) were compared with out-patients with skin conditions in which psychosomatic factors are commonly were regarded as negligible (n = 116). Stressful events during the last 12 months were assessed with Paykel’s Interview for Recent Life Events. Attachment style, alexithymia and social support were assessed with the ‘Experiences in Close Relationships’ questionnaire, the Toronto Alexithymia Scale (TAS-20), and the Multidimensional Scale of Perceived Social Support, respectively. Results: Cases and controls did not differ regarding the total number of events and the number of undesirable, uncontrollable or major events. Three or more uncontrollable events had occurred more frequently among cases than controls. Perceived social support was lower in cases than in controls. Cases scored higher than controls on anxious attachment, tended towards higher scores on avoidant attachment and were classified more often as insecure. Cases scored higher than controls on the TAS-20 and were classified more often as alexithymic or borderline alexithymic. The occurrence of many uncontrollable events, alexithymia and anxious attachment were associated with vitiligo also in multiple logistic regression analysis. Conclusions: These findings suggest that vulnerability to vitiligo is not increased by stressful events, except for many uncontrollable events. Alexithymia, insecure attachment and poor social support appear to increase susceptibility to vitiligo, possibly through deficits in emotion regulation or reduced ability to cope effectively with stress.

Assessing psychological distress in patients with skin diseases: reliability, validity and factor structure of the GHQ-12.

We studied reliability, validity and factor structure of the 12‐item General Health Questionnaire (GHQ‐12) in dermatological patients.

The current state of mental health care in Italy: problems, perspectives, and lessons to learn

After legislative changes in 1978, Italian psychiatry underwent a thorough overhaul, with the gradual closure of all Mental Hospitals. A nation-wide network of Departments of Mental Health now deliver outpatient and inpatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10,000 inhabitants). Hospital care is delivered through small psychiatric units (with no more than 15 beds). There are also many private inpatient facilities operating in Italy, and the number of private inpatient beds per 10,000 inhabitants exceeds the number of public beds; overall there are 1.7 acute beds per 10,000 inhabitants—one of Europe’s currently lowest numbers. There is marked quanti- and qualitative variation in the provision of out- and inpatient care throughout the country, and service utilization patterns are similarly uneven. Studies examining quality of life report a fairly high degree of patient satisfaction, whereas patients’ families frequently bear a heavy burden. In conclusion, the Italian reform law led to the establishment of a broad network of facilities to meet diverse care needs. Further efforts are required to improve quality of care and to develop a more effectively integrated system. Greater attention must be paid to topics such as quality of care and outcomes, public and private sector balance, and the coordination of various resources and agencies.

Relevance of Anger and Irritability in Outpatients with Major Depressive Disorder

Introduction: Current psychiatric classification systems underestimate the part played by anger and aggressiveness in unipolar depression. This study was designed to assess the relevance of anger, irritability, aggressiveness, hostility, and psychomotor activation in major depressive disorder. Methods: A total of 222 newly admitted consecutive outpatients with major depressive disorder (mean age 48.9 years, 64.4% females) were enrolled in the study. They had no comorbid axis I or II DSM-IV disorder, and they received no treatment with antidepressants in the preceding 2 months. They were assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. Principal component analysis was performed on SVARAD items. Results: We obtained a three-factor solution accounting for 47.4% of total variance. The factors were interpreted as ‘anger/irritability’, ‘depression’, and ‘anxiety’, respectively. The anger/irritability dimension was clinically relevant in 23% of patients. Anger/aggressiveness was especially frequent (21.6%), whereas psychomotor activation was infrequent (0.9%). Discussion: In depressive disorders, there are psychopathological dimensions other than depressed mood and anxiety that deserve greater clinical recognition and research. Our study suggests that one of these symptom clusters includes anger, irritability, aggressiveness, and hostility. The relevance of this dimension was not related to concurrent pharmacological treatment. Misdiagnosis of bipolar II disorder is also unlikely to explain our findings. Possibly, personality factors might at least partly explain the occurrence of anger and aggressiveness in several depressed patients. Attachment theory suggests that anger might also be conceived as part of the protest-despair-detachment reaction to a loss, either actual or symbolic.

Psychosomatic Assessment of Skin Diseases in Clinical Practice

Background: Psychiatric disorders are frequent in dermatology patients, and many studies pointed out complex, mutual relationships between psyche and skin. Our aim was to provide a systematic psychosocial evaluation of a large and heterogeneous population of patients with skin diseases, including assessments of quality of life, psychiatric status according to the DSM-IV and psychological conditions with psychosomatic relevance according to established criteria (Diagnostic Criteria for Psychosomatic Research, DCPR). Methods: We studied 545 dermatological inpatients aged 18–65 years, free from dementia and cognitive impairment. They completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12) and were administered the SCID-I and the Structured Interview for Psychological Conditions of Psychosomatic Relevance by a trained mental health professional blinded to questionnaire scores. Results: Overall, 38% of patients received a DSM-IV diagnosis. The most common diagnoses were mood (20%) and anxiety disorders (16%); 48% of patients also received a DCPR diagnosis. The most common were demoralisation, irritable mood, type A behaviour and various forms of abnormal illness behaviour. Adjusting for gender, age, and education, the presence of DSM-IV or DCPR diagnoses was significantly associated with high scores on the GHQ-12 and on the Functioning and Emotions scales of the Skindex-29. Also, DCPR diagnoses were significantly associated with high scores on the Symptoms scale of the Skindex-29. Conclusions: These findings highlight the high frequency of psychosocial problems in patients with skin disease and suggest that the joint use of DSM-IV and DCPR criteria may help identify those patients in whom psychiatric issues are worthy of increased clinical attention.