How to cite this article: Torres-Hernández M, López-García S, Pedroza-Escobar D, Escamilla-Tilch M. The role of alexithymia as a psychosomatic factor in psoriasis. Rev Med Inst Mex Seguro Soc. 2015 May-Jun;53(3):268-72.
Received: January 13th 2014
Accepted: October 30th 2014
Marcela Torres-Hernández,a Sonia López-García,b David Pedroza-Escobar,c Mónica Escamilla-Tilchd
aServicio de Psiquiatría, Hospital de Especialidades “Dr. Bernardo Sepúlveda”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
bGenética y Biología Molecular, Centro de Investigación y Estudios Avanzados (CINVESTAV), Instituto Politécnico Nacional
cEscuela Superior de Medicina, Instituto Politécnico Nacional
dGenética y Biología Molecular, Instituto Nacional de Nutrición “Salvador Zubirán”
Communication with: Marcela Torres-Hernández
Telephone: (55) 5627 6900, extensions 21451 y 21515
Background: Alexithymia is the lack of mental representations of emotions leading to limited ability to understand and regulate these and can contribute to the development or maintenance of a psychosomatic illness. The aim of the study was to demonstrate that alexithymia is a feature that occurs more frequently in patients with psoriasis and that the coexistence of alexitimia-psoriasis is associated with high levels of trait anxiety.
Methods: We applied the Toronto Alexithymia Scale -20 (TAS-20), Inventory of state-trait anxiety (STAI) to 16 outpatients with psoriasis of Dermatology Service of Hospital de Especialidades (Centro Médico Nacional Siglo XXI) and the results were compared with 25 control subjects.
Results: 25 % of patients with psoriasis presented alexitimia, while in the control group was 8 % (p = 0.002). Correlation between the scores of the TSA-20 and STAI-trait (r = 0.6957, p < 0.0001) was observed.
Conclusions: The alexitimia occurs more frequently in individuals with psoriasis than in the general population, and levels of trait anxiety in individuals with psoriasis are similar regardless of the presence of alexithymia.
Keywords: Alexithymia; Affective symptoms; PsoriasisM Anxiety; Somatoform disorders
Somatization is the presence of somatic symptoms that cannot be explained by organic etiology.1-3 Patients who somatize have higher levels of physiological arousal and are less likely to adapt to a stressor than control subjects.2,4 Potential etiologies have been proposed to explain the phenomenon of somatization: a biological or genetic component, personality traits, exposure in early childhood to the behavior patterns of the disease, exposure to trauma, and dysfunctional emotional processing. Some patients present each style at different times.2,5,6 Alexithymia may be associated with somatization. This is based on the assumption that individuals with alexithymia lack the mental representations of emotions due to a deficit in their cognitive processing, which leads to limited ability to understand and regulate emotions and an inability to recognize the psychological impact of the generating circumstances and a tendency to shift attention away from these various symptoms.7-9 Some authors have suggested that alexithymia may contribute to the development or maintenance of psychosomatic illness and, consistent with this hypothesis, patients with psychosomatic diseases report higher levels of alexithymia compared to controls.9,10
Alexithymia research in the field of dermatology is still limited and shows mixed results. The current findings suggest important implications for clinical practice for the treatment of specific dermatological disorders, and in addition to treating concomitant problems such as anxiety and depression, it is important to be aware of alexithymia and its possible association with the dermatological condition, since the link seems important, either in the onset of the disease, its development, or its prognosis.11-15
Psoriasis has associations with major psychiatric illnesses such as anxiety, depression, suicide, smoking, and alcohol abuse. It has been found that these have a higher prevalence among patients with psoriasis than other dermatological conditions, and that psoriasis often goes unnoticed and is not treated.15-18 There are few studies regarding the relationship of alexithymia and psoriasis.19 Some results confirm the high prevalence of alexithymia in patients with psoriasis (between 33 and 40%) compared with controls;20,21 the existence of stressors has been reported prior to the onset of psoriasis, but the relationship between the degree of severity or chronicity and alexithymia score is rejected.21,22 It is suggested that alexithymia may increase the exacerbation of psoriasis possibly through impaired emotional regulation, in which stress as an adaptive response, activates the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system affects the immune system and the possible disease states.23 These studies provide very limited data to support the role of alexithymia as a psychosomatic factor in psoriasis.24
Type of study and sample size
A cross-sectional retrospective (baseline survey) study was performed. The universe of the work consisted of 16 adult patients diagnosed with psoriasis who subsequently attended appointments at the Servicio de Dermatología in the Hospital de Especialidades del Centro Médico Nacional Siglo XXI, during the months of April and May 2013, and a control group consisting of 25 healthy subjects. Both groups completed the Toronto Alexithymia Scale-20 (TAS-20) and the state-trait anxiety inventory (STAI). Individuals with other autoimmune, oncological, and endocrine diseases were not included except for diabetes mellitus 2 (DM2), obesity, and dyslipidemia, as well as those who were treated with antidepressants or anxiolytics.
Verification of quality of data capture was done through random check of 10% of all records and exploratory data analysis to verify aberrant results. Univariate description was done through descriptive statistical tests: measures of central tendency, dispersion, and proportions in the package Excel 2010.
Statistical analysis of categorical variables was done by chi squared test and Fisher's exact test. The Mann-Whitney U test was used for ordinal variables. Pearson correlation coefficients were calculated between the scores of the TAS-20, the STAI-state, and STAI-trait. The inferential statistical analysis and graphics were performed using the statistical software GraphPad Prism 5.
This project was in line with international and institutional ethical standards, and the Ley General de Salud in research on humans.
Both groups had a predominance of males (over 70%). The mean age was 54 ± 12. 68% of the individuals in the control group had no disease, while in the group with psoriasis, diabetes mellitus was found in 47% of patients, followed by systemic arterial hypertension and dyslipidemia, with 25% each. The percentage of tobacco consumption was more frequent in the group with psoriasis (31%), while alcohol was more common in the control group (40%). The presence of a history of mental disorder diagnosis and/or treatment with psychotropic drugs was greater in the group with psoriasis: 31 and 37%, respectively, with a significant difference when compared with the control group (p = 0.0261 and p = 0.0094).
The average development time of psoriasis in patients was 19 (± 11) years. The most common systemic treatment was with methotrexate (31%).
Only 25% of patients had not been subject to systemic treatment, and 40% had received treatment for more than a year.
The average TAS-20 score in the group with psoriasis was 36.8 (± 21.19) and in the control group it was 36.6 (± 18.63). The percentage of individuals with alexithymia in the psoriasis group was 25%, while in the control group it was 8%; when comparing both groups a significant difference (p = 0.002) was found. In STAI-state, the average score of the psoriasis group was 33.18 (± 8.47) and the control group it was 35.28 (± 9.74); The results in both groups were very similar: over 80% had low or very low levels of state anxiety. Regarding STAI-trait, the average score for the psoriasis group was 37.31 (± 12.47) and 36.56 for the control group (9.99 ±); in both groups, over 70% were within the levels of very low and low, only 12.5% of the psoriasis group showed high levels of trait anxiety, and 4% of the control group; there was no statistically significant difference when comparing them (Table I).
|Table I Alexithymia scale scores and anxiety|
|With alexithymia *||4||25||2||8|
|very low 20-31||6||37.5||9||36|
|very high 68-80||0||0||0||0|
|very low 20-31||8||50||10||40|
|very high 68-80||0||0||0||0|
*Statistical significance ofp0.002
TAS-20 = 20-Toronto alexithymia scale;STAI-state = state anxiety inventory; STAI-trait = trait anxiety inventory
Individuals with alexithymia in both psoriasis and control groups predominantly showed levels of state anxiety between very low, low, or medium. Moreover, 50% of the psoriasis group had high levels of trait anxiety, while 100% of the control group had average levels of anxiety. When comparing these, the differences were not statistically significant (Table II).
|Table II Anxiety levels in individuals with alexithymia|
|very low 20-31||1||25||0||0|
|very low 20-31||0||0||0||0|
|STAI-state = state anxiety inventory; STAI-trait = trait anxiety inventory|
Pearson correlation coefficients were calculated between the TAS-20 scores, STAI-state and STAI-trait; a statistically significant correlation between the alexithymia score and trait anxiety (r = 0.6957, p < 0.0001) was found, but not with the state anxiety score.
This is the only study to be done in Mexico and Latin America that compares the levels of alexithymia in patients with psoriasis with those of a control group, and that also tries to relate this with the presence of high levels of chronic anxiety as a personality trait in such individuals.
The percentage of alexithymia observed in the group with psoriasis (25%) was higher than the control group (8%), with a statistically significant difference. This result is consistent with that described in other studies regarding the high frequency; however, there is variation in the percentages reported as the range is set between 33 and 39%.20
Few studies have linked chronic anxiety with the clinical course of psoriasis and there are none that have also related it with alexitimia.25 Higher scores of STAI-trait were expected in patients with psoriasis and alexithymia. Even though a small difference was observed, this was not statistically significant when compared with the control group. Moreover we found a statistically significant correlation between alexithymia score and anxiety levels as a personality trait. This observation supports the points made by various authors regarding the role played by alexithymia in the course of psoriasis, as individuals with alexithymia are characterized by low capacity for adequate adaptation to various environmental stressors, including the dermatological condition itself, which promotes changes in the activity of various systems such as the nervous, sympathetic, endocrine, and immune systems, which trigger or exacerbate psoriasis.8,23,26 These results could be extended to other diseases (asthma, functional dyspepsia, irritable bowel syndrome, fibromyalgia, etc.) with a clear psychosomatic influence.10
We found that patients with psoriasis when compared with the control group presented a higher proportion of history of diagnosis of mental disorders and/or psychopharmacological treatment. This feature is widely described in the literature, and high prevalence of anxiety disorders, depression, substance use, and suicide are reported.15,17,25
It was predicted that the consumption of alcohol and tobacco would be more frequent in people with psoriasis than in the control group, as has been reported in earlier studies,17 but in this study it was not so; conversely, the higher frequency was seen in the control group. This could be associated with the absence of differences between the groups in terms of anxiety levels.
Results from this study should be interpreted with caution, as the main limitation was small sample size, so its power is not what we wished.
Although our study failed to show that levels of anxiety, as a personality trait, are higher in those with alexithymia and psoriasis, given the above limitations we cannot rule out that possibility. Larger studies are needed to make such conclusions.
The influence of stress in psoriasis is fully proven;15,21,27 however, as in many other diseases, the etiology is multifactorial, so the study, therapeutic approach, and prevention are complex. In the future, the influence and specific relations of stress could be demonstrated as a precipitating or triggering environmental factor, within a certain genetic background which leads to a specific disease like psoriasis.28
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.