ctinicat and Experimentat Dermatology \99V, 16: 114-117.
ADONIS 0307693691000341
Can psychotherapy help patients with psoriasis? M.L.PRICE,* I.MOTTAHEDINf AND P.R.MAYOX Departments of * Dermatology, and f Clinical Psychology, Brighton Health Authority, and XSchool of Cultural and Community Studies, Untversity of Sussex, Brighton, Sussex, UK Accepted for puhlication 28 September 1990
Summary Two groups of people with psoriasis attended a short series of meetings conducted by a clinical psychologist. During these sessions the patients were given the opportunity to discuss between themselves problems created by their skin complaint and they were taught specific relaxation techniques for use whenever they felt under stress. Psychological tests showed that the participants were a noticeably anxious group compared to the general population. However, their levels of anxiety were significantly reduced by the end ofthe study. There was also a modest trend towards physical improvement. No such changes were seen in a matched control group.
Methods
Initially 82 patients, aged between 18 and 65, attending a dermatology clinic for psoriasis were invited to participate. Patients with other significant illness or psoriasis confined to scalp, palms, soles or nails were not approached. Thirty-one of those asked agreed to participate and these, matched for age, sex and severity of disease were randomly assigned to either a series of therapeutic sessions with a clinical psychologist or to a control group. The 15 patients assigned to the clinical psychologist's group were split into two subgroups according to disease severity. Subsequently, three proved to be poor attenders (all were in full-time employment and experienced difficulty in obtaining leave) and one failed to complete all the assessment measures as did four of the controls. All There is ample evidence that psoriasis causes consider- measures are therefore based on 11 patients attending able stress.' ' Furthermore, stressful events may in turn therapy groups {seven men and four w omen) with a mean exacerbate psoriasis.^••' Unfortunately conventional elini- age of 42-82 years, mean duration of psoriasis of 17 years, cal management of psoriasis places little emphasis on and 12 control patients (five men and seven women), with psychological aspects of the disease. Experienced clini- a mean age of 4600 years, and a mean duration of cians are well aware of such problems but often find it psoriasis of 25 years. All participants were assessed clinically and completed difficult to address them in the standard out-patient setting, where time is usually limited and patients are seen the written psychological self-assessment measures (see individually for assessment of their physical treatment. Appendix) on three occasions; prior to the series of group While such privacy is entirely appropriate in this context, sessions (Assessment I), immediately after the groups had it can enhance the patient's sense of isolation as he or she finished (Assessment II) and at follow up 6 months later often remains unaware that many others share the same (Assessment III). The completed documents were scored disorder and concerns. It is possible that strategies aimed blind by an independent rater. The clinical assessment at improving eommunication between patients and was undertaken by the same dermatologist throughout reducing stress could be of value in controlling this the study. The overall severity of disease was measured disorder. Such an approach was first advocated by Dr on a visual-analogue scale by both patient and doctor R.Coles in 1967. He organized open group meetings for taking into account site, area involved, induration, scaling psoriasis patients with a dermatologist as coordinator.'' and erythema. The two groups seen by the clinical We set out to investigate the feasibility and benefits of psychologist met weekly for 8 weeks. The sessions lasted small groups of patients attending a set number of 90 minutes. The number and length ofthe sessions were therapeutic sessions under the guidance of a clinical predetermined by the psychologist. Setting a specific time limit on the number of sessions helps the patients to psychologist. focus on achieving certain goals within a defined period and previous studies on the management of anxiety and depression have shown that significant improvement can Correspondence: M.L.Price, Brighton General Hospital, Elm be gained within such a time frame."''^ Grove, Brighton, E. Sussex BN2 3F.\V, UK. 114
PSYCHOTHERAPY AND PSORIASIS
It was noticeable that members continued talking together immediately after each formal session was officially completed. The major topics raised in various forms were: (a) Shame and/or guilt relating to psoriasis. Many examples of this were raised in the groups, e.g. leaving scale in the bed or at a friend's house. (b) Concern about being ostracized. (c) Feeling sexually unattractive. Only the women members talked about this. Very occasionally, personal sexual problems linked to psoriasis were raised. (d) The details of medical treatment, particularly sharing experiences of different treatments and the comparative advantages and disadvantages of these. (e) Medical personnel encountered during many years of treatment, comments were usually critical, but occasionally complimentary. At the final assessment 10 patients in the clinieal psychologist's groups reported practising the relaxation exercises once a week or more over the past 6 months. The usefulness ofthe groups as a whole on a scale of 0-6 was given a mean rating of 5-64.
The patients were taught relaxation procedures using a method which included self-hypnosis. The relaxation was presented as a simple, effective means of managing anxiety, controlling both physical and mental responses, and patients were encouraged to practise these procedures at home and use them whenever they felt under stress. In addition to the above, a great deal of time was spent discussing the varied experiences of individual members ofthe group and how they coped with the problems which psoriasis created in their lives. This led to considerations ofthe importance of one's own self-concept, its relation to having psoriasis and how changes in this respect could enhance self-esteem. Again, praetical cognitive techniques to promote such changes were suggested by the therapist. At the 6-month follow-up, patients indicated, on a scale of 0-6, the frequency with which the relaxation exercises had been continued and the benefit derived from these exercises and from the group as a whole. Throughout the study period both active and control patients continued with conventional clinical management by the dermatologist as required. Therapies used included topical treatment, conventional UVB, etretinate and PUVA. Results The psychologist found that the patients rapidly adjusted to the concept of meeting in a group. Attendance levels throughout the study were high apart from the three patients who were unable to obtain sufficient leave from work. These three were excluded from the final analysis.
The scores on the anxiety and neuroticism scales at the initial assessment as shown in Table 1 indicate that the participants in this study could be described as a noticeably anxious group. Thus, the mean neuroticism scores for both groups were two points higher than the general population mean scores for men and women. Moreover, six patients (26%) come within the category of definite cases of anxiety based on the hospital anxiety and depression scale (HAD). The depression scores, in contrast, were low and self-esteem scores relatively high.
Table 1. Mean ( ±s.d.) seores on psychological assessment measures Assessment I
Assessment II
6-month follow-up
Group therapy
Controls
Group therapy
Controls
Group therapy
8-91 + 2-51 4-t)0±2-86 32-27 ±8-50
9-17 + 2-62 4-08 ±2-68 32-08 ±6-83
8-09 ±2-74 3-09 ±2-81 34-l8±9-27
8-83 + 2-04 4-83±2-41 33'25±6-OO
7-00 + 2-10 3-09 ±2-77 35-45 ±5-99
9-00+2-89 4-92±2-94 31-25±7-56
Social adjustment work home social private
1-64+2-29 M8 + 2-14 3-27+ 2-05 0-82 ±160
0 50 + 0-95 0-92+145 2-17±l-27 042±l-00
l-36±]-36 1-09+1-45 2-45 ±1-69 0-82±l-08
1-67+1-58 142±l-73 2-83 ±1-80 0-67 ±0-98
1-09+1-64 O'91±l-38 2-64±l-36 0-45 ±0-82
1 30+1-49 1-58±1-16 2-75+1-82 l'00±]-13
neuroticism extraversion
7'82±3-63 7-64±3-26
7-50+2-68 7-67 ±3-26
7-45 + 3-30
7-67 + 2-57
6-27 ±3-55 7-36±3-78
7-58±2'84 742 ± 3-06
HAD anxiety depression Self-esteem
115
Controls [n=l2)
116 Those patients who took part in the group-therapy sessions showed a fall in anxiety scores on the H A D after the group sessions and at 6 months' follow-up. T h e controls, in contrast, showed little change in anxiety and testing for linear trend over time gave a significant interaction effect {F^2i^2-89, i*
ADONIS 0307693691000341
Can psychotherapy help patients with psoriasis? M.L.PRICE,* I.MOTTAHEDINf AND P.R.MAYOX Departments of * Dermatology, and f Clinical Psychology, Brighton Health Authority, and XSchool of Cultural and Community Studies, Untversity of Sussex, Brighton, Sussex, UK Accepted for puhlication 28 September 1990
Summary Two groups of people with psoriasis attended a short series of meetings conducted by a clinical psychologist. During these sessions the patients were given the opportunity to discuss between themselves problems created by their skin complaint and they were taught specific relaxation techniques for use whenever they felt under stress. Psychological tests showed that the participants were a noticeably anxious group compared to the general population. However, their levels of anxiety were significantly reduced by the end ofthe study. There was also a modest trend towards physical improvement. No such changes were seen in a matched control group.
Methods
Initially 82 patients, aged between 18 and 65, attending a dermatology clinic for psoriasis were invited to participate. Patients with other significant illness or psoriasis confined to scalp, palms, soles or nails were not approached. Thirty-one of those asked agreed to participate and these, matched for age, sex and severity of disease were randomly assigned to either a series of therapeutic sessions with a clinical psychologist or to a control group. The 15 patients assigned to the clinical psychologist's group were split into two subgroups according to disease severity. Subsequently, three proved to be poor attenders (all were in full-time employment and experienced difficulty in obtaining leave) and one failed to complete all the assessment measures as did four of the controls. All There is ample evidence that psoriasis causes consider- measures are therefore based on 11 patients attending able stress.' ' Furthermore, stressful events may in turn therapy groups {seven men and four w omen) with a mean exacerbate psoriasis.^••' Unfortunately conventional elini- age of 42-82 years, mean duration of psoriasis of 17 years, cal management of psoriasis places little emphasis on and 12 control patients (five men and seven women), with psychological aspects of the disease. Experienced clini- a mean age of 4600 years, and a mean duration of cians are well aware of such problems but often find it psoriasis of 25 years. All participants were assessed clinically and completed difficult to address them in the standard out-patient setting, where time is usually limited and patients are seen the written psychological self-assessment measures (see individually for assessment of their physical treatment. Appendix) on three occasions; prior to the series of group While such privacy is entirely appropriate in this context, sessions (Assessment I), immediately after the groups had it can enhance the patient's sense of isolation as he or she finished (Assessment II) and at follow up 6 months later often remains unaware that many others share the same (Assessment III). The completed documents were scored disorder and concerns. It is possible that strategies aimed blind by an independent rater. The clinical assessment at improving eommunication between patients and was undertaken by the same dermatologist throughout reducing stress could be of value in controlling this the study. The overall severity of disease was measured disorder. Such an approach was first advocated by Dr on a visual-analogue scale by both patient and doctor R.Coles in 1967. He organized open group meetings for taking into account site, area involved, induration, scaling psoriasis patients with a dermatologist as coordinator.'' and erythema. The two groups seen by the clinical We set out to investigate the feasibility and benefits of psychologist met weekly for 8 weeks. The sessions lasted small groups of patients attending a set number of 90 minutes. The number and length ofthe sessions were therapeutic sessions under the guidance of a clinical predetermined by the psychologist. Setting a specific time limit on the number of sessions helps the patients to psychologist. focus on achieving certain goals within a defined period and previous studies on the management of anxiety and depression have shown that significant improvement can Correspondence: M.L.Price, Brighton General Hospital, Elm be gained within such a time frame."''^ Grove, Brighton, E. Sussex BN2 3F.\V, UK. 114
PSYCHOTHERAPY AND PSORIASIS
It was noticeable that members continued talking together immediately after each formal session was officially completed. The major topics raised in various forms were: (a) Shame and/or guilt relating to psoriasis. Many examples of this were raised in the groups, e.g. leaving scale in the bed or at a friend's house. (b) Concern about being ostracized. (c) Feeling sexually unattractive. Only the women members talked about this. Very occasionally, personal sexual problems linked to psoriasis were raised. (d) The details of medical treatment, particularly sharing experiences of different treatments and the comparative advantages and disadvantages of these. (e) Medical personnel encountered during many years of treatment, comments were usually critical, but occasionally complimentary. At the final assessment 10 patients in the clinieal psychologist's groups reported practising the relaxation exercises once a week or more over the past 6 months. The usefulness ofthe groups as a whole on a scale of 0-6 was given a mean rating of 5-64.
The patients were taught relaxation procedures using a method which included self-hypnosis. The relaxation was presented as a simple, effective means of managing anxiety, controlling both physical and mental responses, and patients were encouraged to practise these procedures at home and use them whenever they felt under stress. In addition to the above, a great deal of time was spent discussing the varied experiences of individual members ofthe group and how they coped with the problems which psoriasis created in their lives. This led to considerations ofthe importance of one's own self-concept, its relation to having psoriasis and how changes in this respect could enhance self-esteem. Again, praetical cognitive techniques to promote such changes were suggested by the therapist. At the 6-month follow-up, patients indicated, on a scale of 0-6, the frequency with which the relaxation exercises had been continued and the benefit derived from these exercises and from the group as a whole. Throughout the study period both active and control patients continued with conventional clinical management by the dermatologist as required. Therapies used included topical treatment, conventional UVB, etretinate and PUVA. Results The psychologist found that the patients rapidly adjusted to the concept of meeting in a group. Attendance levels throughout the study were high apart from the three patients who were unable to obtain sufficient leave from work. These three were excluded from the final analysis.
The scores on the anxiety and neuroticism scales at the initial assessment as shown in Table 1 indicate that the participants in this study could be described as a noticeably anxious group. Thus, the mean neuroticism scores for both groups were two points higher than the general population mean scores for men and women. Moreover, six patients (26%) come within the category of definite cases of anxiety based on the hospital anxiety and depression scale (HAD). The depression scores, in contrast, were low and self-esteem scores relatively high.
Table 1. Mean ( ±s.d.) seores on psychological assessment measures Assessment I
Assessment II
6-month follow-up
Group therapy
Controls
Group therapy
Controls
Group therapy
8-91 + 2-51 4-t)0±2-86 32-27 ±8-50
9-17 + 2-62 4-08 ±2-68 32-08 ±6-83
8-09 ±2-74 3-09 ±2-81 34-l8±9-27
8-83 + 2-04 4-83±2-41 33'25±6-OO
7-00 + 2-10 3-09 ±2-77 35-45 ±5-99
9-00+2-89 4-92±2-94 31-25±7-56
Social adjustment work home social private
1-64+2-29 M8 + 2-14 3-27+ 2-05 0-82 ±160
0 50 + 0-95 0-92+145 2-17±l-27 042±l-00
l-36±]-36 1-09+1-45 2-45 ±1-69 0-82±l-08
1-67+1-58 142±l-73 2-83 ±1-80 0-67 ±0-98
1-09+1-64 O'91±l-38 2-64±l-36 0-45 ±0-82
1 30+1-49 1-58±1-16 2-75+1-82 l'00±]-13
neuroticism extraversion
7'82±3-63 7-64±3-26
7-50+2-68 7-67 ±3-26
7-45 + 3-30
7-67 + 2-57
6-27 ±3-55 7-36±3-78
7-58±2'84 742 ± 3-06
HAD anxiety depression Self-esteem
115
Controls [n=l2)
116 Those patients who took part in the group-therapy sessions showed a fall in anxiety scores on the H A D after the group sessions and at 6 months' follow-up. T h e controls, in contrast, showed little change in anxiety and testing for linear trend over time gave a significant interaction effect {F^2i^2-89, i*
