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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 161-164

The impact of stress, stigmatization, and psychological morbidity on the quality of life in psoriasis

1 Department of Psychiatry, BKL Walawalkar Rural Medical College, MUHS, Kasarwadi, Maharashtra, India
2 Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim, India
3 Department of Dermatology, BKL Walawalkar Rural Medical College, MUHS, Kasarwadi, Maharashtra, India

Date of Submission11-Jan-2019
Date of Decision09-May-2019
Date of Acceptance27-May-2019
Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Harshavardhan Sampath
Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, 5th Mile, Tadong, Gangtok - 737 102, Sikkim
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_1_19

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Background: Psoriasis is a chronic and disabling dermatological disorder. The quality of life (QoL) in psoriasis is determined not only by clinical factors such as the type and extent of lesions but also by important psychosocial variables such as stressful live events, stigmatization, and psychological morbidity. Aims and Objectives: To assess the clinical and psychosocial determinants of QoL in psoriasis. Methodology: Using a cross-sectional, hospital-based study design, outpatients with psoriasis were administered the psoriasis disability index, psoriasis severity (simplified psoriasis index), psoriasis life stress inventory (PLSI), 6-item stigmatization scale, and 12-item general health questionnaire (GHQ-12). Results: The sample consisted of 39 psoriasis patients with a mean age of 41.77 years (standard deviation 13.15). Psoriasis vulgaris was the most common variant. Multiple regression analysis showed that among the clinical and psychosocial variables, only psychological morbidity (GHQ-12) significantly predicted psoriasis QoL (β = 0.314, t = 2.05, P < 0.049). Conclusion: Psychological factors are pivotal in determining QoL in psoriasis and need to be routinely assessed in dermatological settings.

Keywords: Psoriasis, psychological morbidity, quality of life, stigmatization, stress

How to cite this article:
Mahapatro NK, Sampath H, Mishra A. The impact of stress, stigmatization, and psychological morbidity on the quality of life in psoriasis. Ann Indian Psychiatry 2019;3:161-4

How to cite this URL:
Mahapatro NK, Sampath H, Mishra A. The impact of stress, stigmatization, and psychological morbidity on the quality of life in psoriasis. Ann Indian Psychiatry [serial online] 2019 [cited 2022 May 22];3:161-4. Available from: https://www.anip.co.in/text.asp?2019/3/2/161/262201

  Introduction Top

Psoriasis is a common, chronic, recurrent, and painful autoimmune inflammatory disease that is both disfiguring and disabling.[1] Its prevalence varies between 2.0% and 3.0% among different populations and ethnic groups worldwide.[2] Although psoriasis does not greatly impact mortality, its morbidity is comparable to other life-threatening diseases and is among the most disabling of dermatological conditions.[3] It is commonly assumed that the suffering experienced in psoriasis is due to illness-related biological factors, such as the extent, severity, location of lesions, and clinical type of psoriasis. However, psychosocial factors are increasingly being recognized to contribute to poor quality of life in psoriasis. Stressful life events, stigmatization, and psychological morbidity are important psychosocial variables.

Stressful life events can trigger the onset and recurrences in psoriasis and are associated with increased severity and duration of flare-ups.[4] As psoriasis is a disfiguring illness, it is not surprising that high levels of stigma, shame, rejection, embarrassment, and social avoidance are an integral experience of psoriasis patients which affects the quality of life (QoL).[5] With almost one-third of psoriasis patients experiencing significant psychological problems, studies report that psychological health is a major determinant of disability and poor QoL.[6]

Thus, QoL in psoriasis is best understood in the bio-psycho-social realm. Apart from routine clinical assessment, these psychosocial issues are not systemically explored in routine dermatological practice. Furthermore, research studies that have attempted to study the determinants of QoL in psoriasis have thus far analyzed only two or three of the above variables. Unless all the major contributors of QoL, viz., illness severity, life stress, stigmatization, and psychological morbidity, are simultaneously analyzed, the inferences drawn will be biased. Hence we planned to study the QoL and its determinants in psoriasis.

  Methodology Top

This was a cross-sectional, hospital-based study conducted on outpatients from the dermatology department in a tertiary care teaching hospital. All consecutive adult patients (18–60 years) who gave their written informed consent were screened for psoriasis clinically by two dermatologists. Patients were excluded if they had a mental illness before the onset of psoriasis.

The following rating scales were administered:

The simplified psoriasis index (SPI) is a practical tool for assessing psoriasis in the clinical setting.[7] It provides a simple yet holistic summary of psoriasis severity. Its three components included separate indicators of current severity, psychosocial impact, and historical course. The tool has demonstrated good validity and intra- and inter-rater reliability.[7] For this study, the first component, i.e., current severity (SPI-s), was used to measure the clinical severity of psoriasis.

The psoriasis life stress inventory (PLSI) is a 15-item questionnaire that provides a measure of the daily hassles and stressors of everyday life, specifically experienced by patients with psoriasis with good reliability and validity.[8] Each scenario is rated on 4-point Likert scale from 0 (not experienced or not at all stressful) to 3 (a great deal stressful) based on how stressful each situation is perceived. A cutoff score of 10 distinguishes between high- and low-stress reactors.

Psoriasis-specific stigma was assessed using the 6-item stigmatization scale. Stigmatizing experiences are scored on a 3-point Likert scale with higher scores indicating greater stigma. The scale has shown to be a valid and reliable tool to measure in stigmatization in psoriasis.[9]

Psychiatric morbidity was assessed using the 12-item general health questionnaire (GHQ-12). It has demonstrated excellent reliability and validity across various settings and populations, correlating with both well-being and distress.[10] Scoring was done using a 3-point Likert scale from 0 to 3, with scores ranging from 0 to 36 with scores over the cutoff point of 12 indicative of cases.[10]

The psoriasis disability index (PDI) is a 15-item scale that specifically addresses self-reported disability in five areas life affected by psoriasis, viz., daily activities, employment, personal relationships, leisure time, and treatment effects over the past 4 weeks.[11] Each question is scored on a 4-point Likert scale ranging from as “not at all” (score 0) to “very much” (score 3). Disability is calculated by summing the score of each of the 15 questions with higher scores indicating greater disability. It is one of the most widely used tools to assess the disability and QoL in psoriasis.

The study design and protocol were approved by the Institutional Ethics Committee. Written informed consent was obtained from all patients. Data analysis was performed using MINITAB 17 statistical software.[12]

  Results Top

Thirty-nine psoriasis patients participated in the study. The mean age of the sample was 41.77 years (standard deviation [SD] 13.15) with 51.3% (n = 20) males. The majority were Hindu by religion (79.5%), Nepali by ethnicity (69.2%), married (74.4%), and lived in a nuclear family (64.1%). Psoriasis vulgaris (n = 28) was the most common variant followed by palmoplantar (n = 9) and scalp psoriasis in two patients. [Table 1] shows the distribution of severity, life stress, stigmatization, psychological morbidity, and disability experienced by patients with psoriasis.
Table 1: Distribution of clinical variables in the sample

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Fifty-nine percent of the sample consisted of high-stress reactors (PLSI scores >10), i.e., they reacted significantly to the stress associated with a life of psoriasis. 58.9% (n = 23) of subjects had psychological morbidity (GHQ-12 scores >12). Scores on the domain of the PDI were as follows: daily activities (mean 3.62, SD 3.24), employment (mean 1.46, SD 2.01), personal relationships (mean 0.26, SD 0.67), leisure time (mean 1.51, SD 2.44), and treatment effects (mean 0.36, SD 0.74).

Multiple regression analysis was performed to assess the relative impact of clinical severity, stress, stigmatization, and psychological morbidity on psoriasis QoL [Table 2]. The results of the regression indicated that four predictor variables (clinical severity of psoriasis, stress, stigma, and psychological morbidity) explained 61.05% of the variance (R-sq [adj] 56.46%, F = 13.32, P = 0.000) in QoL (response variable). Among the clinical and psychosocial variables, only psychological morbidity significantly predicted QoL (β = 0.310, t = 2.04, P < 0.049).
Table 2: Multiple regression analysis of the quality of life versus severity simplified psoriasis index-s life stress, stigma, and psychological morbidity

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  Discussion Top

The interplay of psychosocial factors in determining the outcome, disability, and QoL in psoriasis has been an important area of research in psychodermatology. While most early research had focused on exploring the psychological morbidity in psoriasis, it has neglected QoL issues. Later studies, while having measured QoL, failed to include a multitude of factors such as life stress and stigma that influence QoL in psoriasis. The present study was an attempt to understand the QoL in psoriasis and explore its determinants in the physical, psychological, and social realms.

The clinical severity of psoriasis is an important factor influencing anxiety, social isolation, and poor QoL.[3] In the present study, the sample consisted of patients with milder forms of psoriasis (SPI-s score mean 5.32, SD 8.25). 59% of our sample consisted of high-stress reactors, despite most having a mild severity of psoriasis (SPI-s score mean 5.32, SD 8.25). This underscores the importance of delinking assumptions of a linear relationship between clinical severity and stress experienced. Moreover, a recent study from South India has observed that stress experienced by patients is not proportional to clinical severity.[13] Levels of stigmatization experienced by our sample were comparable to those reported by others.[14] Two-thirds of our sample suffered from psychological distress, which stresses the importance of this variable in predicting QoL in psoriasis.[15],[16]

The domains of disability most affected by psoriasis were daily activities, followed by leisure time activities, employment treatment, and personal relationships in that order. The scores of the PDI (mean 7.26, SD 7.44) indicate an overall lower disability or higher QoL in our sample. This could be a reflection of lesser severity of illness, lower psychological morbidity, or lower levels of stigmatization, or a combination of all three factors. Manjula et al., in their study on QoL in psoriasis in a tertiary care teaching hospital in Kerala, reported a median score of 14.5,[17] and Rakhesh et al. similarly reported a higher mean PDI score of 17.06.[18] Despite these differences, the affected domains in both studies were identical to the present study, i.e., the areas most affected were daily activities and employment while the least affected was relationship.

Multiple regression analysis showed that these clinical and psychosocial variables explained 60.74% of the variance in QoL. In other words, approximately 60% of psoriasis QoL can be predicted by knowing the clinical severity of illness, stress, stigma, and psychological morbidity. Among these biopsychosocial predictor variables, however, only psychological morbidity significantly predicted QoL (β = 0.314, t = 2.05, P < 0.049).

Three Indian studies have attempted to study QoL in psoriasis. Manjula et al., in a study on QoL in psoriasis (n = 32), reported correlations with age and gender on QoL. Since the study did not include any clinical or psychosocial variables, we could not draw any support from the study.[17] A study by Rakhesh et al. found significant correlations between psoriasis stress (PLSI), severity (PASI), and QoL (PDI). However, the authors did not attempt to perform a multiple regression analysis to assess the simultaneous impact of the variables on QoL.[18] Singh et al. also reported significant correlations between stress, QoL, and severity in psoriasis. However, stigma and psychological morbidity were not assessed.[19]

Thus, our study has validated the findings of previous research wherein individual psychosocial factors, viz., stress and stigma, and psychological factors, have been shown to significantly correlate with QoL in psoriasis. Moreover, using regression analysis, we were able to quantify the relative impact of these variables on QoL. By finding psychological morbidity as the single most significant contributor and predictor of QoL, we have reiterated the importance of psychological factors in dermatology. The study is limited in its cross-sectional design where correlation does not necessarily imply causation. The small sample size also limits the power of the study.

  Conclusion Top

The uniqueness of our study lies in the fact that we holistically included all relevant biopsychosocial factors that impacted the QoL in psoriasis. The importance of psychosocial factors, especially psychological morbidity, in determining QoL is underscored.


We would like to acknowledge Dr. Indralal Sharma, Associate Professor (Psychiatry), Dr. Rukmalal Sharma, Professor and HOD (Dermatology), Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number SMIMS/IES/2014-076 obtained on 28th October 2014.

Declaration of Patient Consent

Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Griffiths CE, Barker JN. Pathogenesis and clinical features of psoriasis. Lancet 2007;370:263-71.  Back to cited text no. 1
Christophers E. Psoriasis – Epidemiology and clinical spectrum. Clin Exp Dermatol 2001;26:314-20.  Back to cited text no. 2
Kouris A, Christodoulou C, Stefanaki C, Livaditis M, Tsatovidou R, Kouskoukis C, et al. Quality of life and psychosocial aspects in Greek patients with psoriasis: A cross-sectional study. An Bras Dermatol 2015;90:841-5.  Back to cited text no. 3
Verhoeven EW, Kraaimaat FW, Jong EM, Schalkwijk J, van de Kerkhof PC, Evers AW. Effect of daily stressors on psoriasis: A prospective study. J Invest Dermatol 2009;129:2075-7.  Back to cited text no. 4
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Chularojanamontri L, Griffiths CE, Chalmers RJ. The simplified psoriasis index (SPI): A practical tool for assessing psoriasis. J Invest Dermatol 2013;133:1956-62.  Back to cited text no. 7
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Minitab 17 Statistical Software (2010). [Computer software]. State College, Pennsylvania. USA: Minitab, Inc. (www.minitab.com).  Back to cited text no. 12
Das K, Rao TS. Psychosomatic interface: Psychological distress and perceived stress in psoriasis patients in a tertiary care hospital in South India. Open J Psychiatry Allied Sci 2018;9:123-9.  Back to cited text no. 13
Jankowiak B, Kowalewska B, Fiodaravich Khvorik D, Krajewska-Kułak E, Niczyporuk W. The level of stigmatization and depression of patients with psoriasis. Iran J Public Health 2016;45:690-2.  Back to cited text no. 14
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Woodruff PW, Higgins EM, du Vivier AW, Wessely S. Psychiatric illness in patients referred to a dermatology-psychiatry clinic. Gen Hosp Psychiatry 1997;19:29-35.  Back to cited text no. 16
Manjula VD, Sreekiran S, Saril PS, Sreekanth MP. A study of psoriasis and quality of life in a tertiary care teaching hospital of Kottayam, Kerala. Indian J Dermatol 2011;56:403-6.  Back to cited text no. 17
[PUBMED]  [Full text]  
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  [Table 1], [Table 2]


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