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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 1  |  Page : 1-8

Effect of eating and psychopathological traits in psoriatic patients


1 Department of Dermatology and Venereology, Al-Zahraa Hospital, Al-Azhar University for Girls, Cairo, Egypt
2 Department of Psychiatry, Al-Zahraa Hospital, Al-Azhar University for Girls, Cairo, Egypt

Date of Submission28-Jun-2018
Date of Acceptance04-Feb-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Naglaa A Ahmed
Assistant Professor of Dermatology and Venereology, Obour City 11828, Qalyubia Governorate, 11828
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_59_18

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  Abstract 


Background Psoriasis is a chronic inflammatory immune-mediated skin disease. Few studies have investigated the link between psychiatric disorders including eating disorders (EDs) and psoriasis. We hypothesized that EDs and the psychological effect of psoriasis contribute to the development of obesity and metabolic syndrome in psoriatic patients, who are frequently susceptible to psychiatric comorbidity.
Objective The objective of this study was to evaluate the presence of EDs and psychological distress in patients affected by psoriasis compared with a control population and correlate these data with different features of the cutaneous disease and BMI. This was done to suggest the importance of a psychological support that could reduce the occurrence of loss of control over food and help psoriasis improvement.
Patients and methods From September 2014 till February 2015, we enrolled 100 consecutive psoriatic outpatients and a control group of 100 selected nonpsoriatic outpatients, matched by age, sex, and BMI to the study group. The assessment utilities were composed by the Eating Disorder Inventory (EDI), the Symptom Checklist-90-Revised (SCL-90-R), and the Psoriasis Area Severity Index score.
Results Regarding EDI and SCL-90-R subscales, psoriatic patients had higher scores for all EDI and SCL-90-R subscales than nonpsoriatic patients. According to the relation between BMI and SCL-90-R subscales in psoriatic patients, obese and overweight groups showed higher scores in all SCL-90-R subscales than the normal weight group.
Conclusion In patients with psoriasis, EDs and severe psychiatric symptoms seem to be associated with overweight/obesity more frequently than in the general population.

Keywords: eating disorders, obesity, psoriasis, psychiatric symptoms


How to cite this article:
Ahmed NA, El Shafie TM, Abd Alhalim SM. Effect of eating and psychopathological traits in psoriatic patients. Al-Azhar Assiut Med J 2019;17:1-8

How to cite this URL:
Ahmed NA, El Shafie TM, Abd Alhalim SM. Effect of eating and psychopathological traits in psoriatic patients. Al-Azhar Assiut Med J [serial online] 2019 [cited 2019 Oct 20];17:1-8. Available from: http://www.azmj.eg.net/text.asp?2019/17/1/1/266737




  Introduction Top


Psoriasis has a large effect on the lives of patients, and common psychological and social relational problems can be seen in these patients. Psoriasis is associated with a variety of psychological problems, including poor self-esteem, depression, anxiety, sexual dysfunction, and suicidal ideation [1].

A person having psoriasis is viewed as an integral structure of mind and body, a combination of psychological and somatic factors in constant inter-relationship, and thus, we include psoriasis into a category of skin diseases with influences on psychosomatic factors [1].

Eating disorders (EDs) are conditions defined by abnormal eating habits, which may involve either insufficient or excessive food intake. Anorexia nervosa and bulimia nervosa are the most common specific forms. Other types include binge eating disorder (BED) and ED not otherwise specified [2].

EDs especially BED can be considered among the psychopathological cofactors that may be associated with a lifestyle which contributes to the development of obesity and metabolic syndrome in patients with psoriasis, which are also prone to several psychiatric comorbidities, including depression and anxiety [3].

It is necessary to prompt diagnosis of concomitant psychiatric disorders because early detection and appropriate treatment of these comorbid disorders are important in terms of preventing progression to more advanced stages [4].


  Patients and methods Top


This was a case–control observational study carried out at the Department of Psychiatry of Al-Zahraa Hospital, Al-Azhar University for Girls on participants referred to Dermatology and Andrology of Al-Zahraa Hospital, Al-Azhar University for Girls. The study is approved by the ethical committee of Faculty of Medicine for girls, Al-Azhar University, Cairo, Egypt. An informed consent was obtained from each participant. One hundred consecutive and unselected patients affected by psoriasis were enrolled in the study from September 2014 till February 2015. During the same period, we selected a group of one hundred nonpsoriatic patients attending the outpatient clinics of the same departments.

We matched the two groups by age, sex, and BMI. Patients with and without psoriasis had to be at least 18 years old and they passed a psychiatric clinical interview and had to fill in two psychiatric questionnaires: Eating Disorder Inventory (EDI) and Symptom Checklist-90-Revised (SCL-90-R).

All patients with and without psoriasis were evaluated in different clinical aspects, which included weight, height, and morbidity (diabetes, hypertension, dyslipidemia, and metabolic syndrome). BMI was measured as weight and height ratio (kg/m2) [BMI=weight (kg)/height (m2)]. On the basis of BMI, the participants were classified into three groups: normal weight (BMI<25 kg/m2), overweight (BMI 25–29.9 kg/m2), and obese (BMI≥30 kg/m2).

Moreover, we collected data about psoriasis duration and type. The severity of psoriasis is evaluated using the Psoriasis Area Severity Index (PASI) [5].

EDs were examined using EDI. The EDI is a self-report measure of EDs, created by Garner et al. [6] to measure symptoms of variable EDs (anorexia nervosa, bulimia, and BED). It is made up of 64 items grouped into eight subscales. Three of them measure attitudes and behaviors related to eating, weight, and body imaging: drive for thinness (DT), bulimia (B), and body dissatisfaction (BD). The other five subscales explore general clinically relevant psychological traits: ineffectiveness (IN), perfectionism (PE), interpersonal distrust (ID), interoceptive awareness (IA), and maturity fears (MF).

The SCL-90-R is used to measure general psychiatric symptomatology. It is a self-report scale made up of 90 items validated by Derogatis [7]. It includes domains measuring somatization (SOM), obsessive–compulsive (OC), depression (DEP), anxiety (ANX), phobic anxiety (PHOB), hostility (HOS), interpersonal sensitivity (IS), paranoid ideation (PAR), psychoticism (PSY), and sleep disease (SLEEP) or additional items. Each symptom is rated on a five-point scale (0=not at all and 4=extremely), indicating the experience of these symptoms in the last week. We also calculated a Global Severity Index (GSI). It represents the sum of the scores divided by the number of items, and it is designed to measure overall psychological distress; the cutoff score for the GSI used in this study was 0.57, as indicated by the existing literature [8].

Scores equal to or above 0.57 are considered to be indicative of ‘dysfunctional’ patients, who have a high probability of psychiatric disorders. The standard time set given with the SCL-90-R is ‘7 days including the day of test’. The SCL-90-R requires between 10 and 15 min to complete.

Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0 (IBM SPSS Inc., Chicago, US). Qualitative data were described using number and percentage. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Comparison between different groups regarding categorical variables was tested using χ2-test. When more than 20% of the cells have expected count less than 5, correction for chi-square was conducted using Fisher’s exact test. The distributions of quantitative variables were tested for normality using Kolmogorov–Smirnov test, Shapiro–Wilk test, and D’Agstino test, and also Histogram and QQ plot was used for the vision test. If it reveals normal data distribution, parametric tests was applied. If the data were abnormally distributed, nonparametric tests were used. For normally distributed data, the comparison between the two studied groups was done using the independent t-test. The significance of the obtained results was judged at the 5% level [9],[10].


  Results Top


This study included 100 patients with psoriasis [38 (38%) females and 62 (62%) males]. Their age ranged between 19 and 70 years, with mean±SD of 40.46±13.72 years. A total of 100 apparently healthy participants served as control [37 (37%) females and 63 (63%) males], and their age ranged between 19 and 70 years, with mean±SD of 40.47±13.74 years ([Table 1]).
Table 1 Clinical characteristics of the two studied groups

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A comparison was done between patients with psoriasis and control group regarding EDI subscales; patients with psoriasis had higher scores for all EDI subscales.

There were statistically significant differences regarding perfectionism (P) (P=0.003), interoceptive awareness (IA) (P=0.020), maturity fears (MF) (P=0.003), and at least one altered subscale (P=0.006), showing more pathological scores in patients with psoriasis.

In contrast, there were no statistically significant differences between patients with psoriasis and control group regarding drive for thinness (DT) (P=0.495), bulimia (B) (P=0. 415), body dissatisfaction (BD) (P=0.495), ineffectiveness (IN) (P=0.541), and interpersonal distrust (ID) (P=0.273) ([Table 2]).
Table 2 Comparison between the two studied groups according to Eating Disorder Inventory subscales

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A comparison was done between patients with psoriasis and control group regarding SCL-90-R subscales, and patients with psoriasis had higher scores for all SCL-90-R subscales.

There were statistically significant differences regarding obsessive–compulsive (OC) (P=0.006), interpersonal sensitivity IS (P=0.002), paranoid ideation (PAR) (P=0.009), psychoticism (PSY) (P=0.017), and additional items (AI) (P=0.040), showing more pathological scores in patients with psoriasis.

In contrast, there were no statistically significant differences between patients with psoriasis and control group regarding somatization (SOM) (P=0.061), depression (DEP) (P=0. 181), anxiety (ANX) (P=0.537), hostility (HOS) (P=0.621), and phobic anxiety (PHOB) (P=0.103) ([Table 3]).
Table 3 Comparison between the two studied groups according to Symptom Checklist-90-Revised subscales

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According to GSI, patients had higher score than controls in numbers of patients having GSI and in GSI value, with a statistically significant difference (P=0.047) in numbers of patients having GSI ([Table 4]). Therefore, SCL-90-R questionnaire was globally more impaired in patients with psoriasis than in controls.
Table 4 Comparison between the two studied groups according to Global Severity Index

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A comparison was done between patients with psoriasis and controls groups according to EDI subscales in overweight and obese subgroups. Overweight subgroup had higher scores in all EDI subscales in patients group than the controls group, with statistically significant differences in interoceptive awareness (IA) (P=0.007), and obese subgroup had higher scores in all EDI subscales except bulimia (B) in patient group than the control group but with no statistically significant differences ([Table 5]).
Table 5 Comparison between the two studied groups according to Eating Disorder Inventory subscales in overweight and obese subgroups

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A comparison was done between patients with psoriasis and control groups according to SCL-90-R subscales in overweight subgroup. Overweight subgroup had higher scores in all SCL-90-R subscales in patient group than the control group, with statistically significant differences in somatization (SOM) (P=0.036), obsessive–compulsive (OC) (P=0.017), interpersonal sensitivity (IS) (P=0.005), and paranoid ideation PAR (P=0.017) ([Table 6]).
Table 6 Comparison between the two studied groups according to Symptom Checklist-90-Revised subscales in overweight subgroup

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A comparison was done between patients with psoriasis and controls groups according to SCL-90-R subscales in obese subgroup. Obese subgroup had higher scores in all SCL-90-R subscales, except obsessive–compulsive (OC), depression (DEP), additional items (AI), and global severity index value in control group than in patient group, with no statistically significant differences ([Table 7]).
Table 7 Comparison between the two studied groups according to Symptom Checklist-90-Revised subscales in obese subgroup

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According to the relation between PASI score and EDI subscales in patients group, severe disease group showing higher scores in some EDI subscales [bulimia (B), body dissatisfaction (BD), interoceptive awareness (IA), and maturity fears (MF)] than the other two groups (mild–moderate). On the contrary, mild disease group showed higher score in perfectionism (P) than the other two groups (moderate–severe) and showed higher score in drive for thinness (DT) than the severe group only. Moreover, moderate disease group showed higher scores in ineffectiveness (IN) and interpersonal distrust (ID) than the other two groups (severe–mild), with statistically significant differences in ineffectiveness (IN) (P=0.040), interpersonal distrust (ID) (P=0.002), and interoceptive awareness (IA) (P=0.024) ([Table 8]).
Table 8 Relation between Psoriasis Area Severity Index and Eating Disorder Inventory subscales in the patient group

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According to the relation between PASI score and SCL-90-R subscales in patients group, severe disease group showed higher scores in all SCL-90-R subscales than the other two groups (mild–moderate), with statistically significant differences in somatization (SOM) (P=0.013), obsessive–compulsive (OC) (P=0.034) interpersonal sensitivity (IS) (P=0.007), depression (DEP) (P=0. 033), and paranoid ideation (PAR) (P=0.009) ([Table 9]).
Table 9 Relation between Psoriasis Area Severity Index and Symptom Checklist-90-Revised subscales in the patient group

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  Discussion Top


Patients with psoriasis are affected both psychologically and physically and are at increased risk of developing anxiety and depression [11] as well as cardiometabolic and rheumatologic comorbidities, all of which can greatly reduce the quality of life [12].

Our data showed elevated prevalence of psychiatric symptoms and ED in patients with psoriasis compared with those without psoriasis. Regarding the EDI, the scale evaluates the belief that some parts of the body (especially those associated with typical changes of puberty) are too big or too fat. The fat body, grotesque and so distant from the standard, induces shame and discomfort feelings. Patients with psoriasis had higher scores for all EDI subscales than normal populations, with statistically significant alteration in perfectionism (P) (P=0.003), maturity fears (MF) (P=0.003), interoceptive awareness (IA) (P=0.020), and at least one altered subscale (P=0.006). These results are in accordance with a research study that investigated the link between EDs and psoriasis [13].

Furthermore, we found that psoriatic patients reported more somatization, depression, anxiety, obsessive–compulsive, phobic anxiety, hostility, interpersonal sensitivity, additional items, psychoticism, and paranoid ideation symptoms, as showed on the relative subscales of SCL-90-R, with statistically significant differences regarding obsessive–compulsive (OC) (P=0.006), interpersonal sensitivity (IS) (P=0.002), paranoid ideation (PAR) (P=0.009), psychoticism (PSY) (P=0.017), and additional items (AI) (P=0.040). In addition, they had greater symptom severity of psychological distress than normal populations, as shown by GSI total score on the SCL-90-R.

These data are in accordance with several studies that reported the association between depression and psoriasis, with different opinions regarding the cause–effect relationship. In particular, recent studies define the major depressive disorder such as an inflammatory condition with elevated levels of proinflammatory cytokines [13], as well as various autoimmune diseases, such as psoriasis.

Moreover, these results are in disagreement with a previous cross-sectional, randomized, controlled trial which evaluated the eating behaviors in 100 psoriatic patients by the Eating Attitude Test, Beck Depression Inventory and Beck Anxiety Inventory, and a psychiatric interview [14]. The authors found a higher prevalence of ED in patients with psoriasis and metabolic syndrome compared with the group of patients with psoriasis and without metabolic syndrome.

This study concerned with the relationship between BMI and results of EDI and SCL-90-R in psoriatic people and in controls. With increasing weight, both psoriatic group and control group showed worsening of ED symptoms, assessed by the EDI subscales, and these were more frequently seen in patients group than control group. So we may deduce that obesity and overweight psoriatic patients are more frequently associated with an ED than in general population. This may be owing to that psoriatic patients who gain weight are often affected by negative comments from others and by their changing appearance. This may cause some people to take dieting too far, leading to an ED.

Our study confirmed this hypothesis also by the comparison of patient and control obese/overweight subgroups, which showed, in patients with psoriasis, a higher prevalence of altered subscales in EDI. Moreover, with increasing weight also both groups (patients–controls) showed a worsening of psychiatric symptoms, assessed by the SCL-90-R subscales, and these were more severe in patients group than controls group. This may be owing to preoccupation of obese and overweight patients with people’s perception of them and avoiding physical contact with others to prevent social rejection.

This was assessed in our study by the comparison of total score of GSI of patients (2.34) and controls (2.20) obese subgroups and comparison of total score of GSI of patients (2.33) and controls (2.23) overweight subgroups.

This study reported also a higher prevalence of diabetes, dyslipidemia and metabolic syndrome in patients with psoriasis compared with those without psoriasis, and these results are confirmed by previous researches that assessed comorbidity of psoriasis [14].

Finally, our data indicate that there is no correlation between the severity of somatic disease, assessed by PASI, and ED symptoms, indicated by EDI subscales, as there were mild to moderate cases showing higher scores in EDI subscales. In contrast, with increasing somatic disease severity, assessed by PASI, there was increasing in psychopathological symptoms, assessed by the SCL-90-R subscales and indicating by total scores of GSI in SCL-90-R, with statistically significant differences in somatization (SOM) (P=0.013), obsessive–compulsive (OC) (P=0.034), interpersonal sensitivity (IS) (P=0.007), depression (DEP) (P=0.033), and paranoid ideation (PAR) (0.009).


  Conclusion Top


Psychiatric symptoms and ED symptoms in patients with psoriasis are increase compared to those without psoriasis.

There is an interesting consideration that emerged from our study to suggest the presence of an ED and psychological problems in overweight/obese patients with psoriasis. Therefore, food control may help to lose weight and to increase response to therapy. Moreover, improvement in psychological problems will increase the response toward therapies for psoriasis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Armstrong AW, Schupp C, Wu J, Bebo B. Quality of life and work productivity impairment among psoriasis patients: findings from the National Psoriasis Foundation survey data 2003–2011. PLoS ONE 2012; 7:e52935.  Back to cited text no. 12
    
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Elomaa AP, Niskanen L, Herzig KH, Vinamaki H, Hintikka J, koivumaa- Honkanen H et al. Elevated levels of serum IL-5 are associated with an increased likelihood of major depressive disorder. BMC Psychiatry 2012; 9:12.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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