Literature Review:

Stress Reactance in Psoriatic Patients

w. Michael Hooten , M.D.

Ab stract

The association between stress and psoriasis is well documented. A subgroup if psoriatic
pat ients appear to be high stress reactors who can identify specific psychosocial stresses which
exacerbate their psoriasis. In contrast, low stress reactors report no association between stressand the
exacerbation ifpsoriasis. I n differentiating high versus low stress reactors, a review if the literature
suggests: 1) a neurogen ic mediated disease process; 2) high stress reactors' disease course is not
con.founded by underlying psychopathology and, 3) high stress psoriatics experience more disease
related stress than low stress reactors.

BACKGROUND

The term psori asis origina te d from th e G reek word psorian, mean ing to hav e th e
it ch and was first described by C elsus (25 B.C .-45 A.D. ) in his work De Re Medica ( 1,2).
Many ea rly psoriatics were misdiagnosed as suffe ring fr om leprosy, impeti go, scabies
or pyod erma (1,2) . In 1809, Robe r t Wi llan wa s th e first to parti all y di ffe re nt ia te
pso riasis from o t her skin d iseases and in 184 1, H ebra d escribed psori asis as a
separat e cli nica l e nt ity ( I).
Pso riasis is a papu losq uamous exfolia t ive derm atiti s whi ch pr esent s as dis cr et e
flat -t opped papul es or plaqu es cove re d with thin , whit e, loosely ad herent sca les.
Frequ ently, psoriasis initia lly appears on th e scalp a nd th en sprea ds to involve th e
back , sacr u m, palms, nai ls a nd th e ex te nso r surface of th e ex t re m it ies (3). Th e
prevalen ce of psoriasi s in th e ge ne ra l population vari es fro m 0. 1-2.48% wit h a mean
ag e of ons et of 27.8 ye a rs (4). Psori asi s is a ch ro nic relapsin g disease with 39% of
psoriatics reporting com ple te symptom atic resolution a t least o nce during the cou rse
of th e dis ea se (4,5) .

PATHOPHYSIOLOGY

Th e pathogenesi s of psoriasis has yet to be full y eluc ida te d . An incr ea sed

incid en ce of dis eas e in as socia t ion with ce r tain HLA types sugges ts th at genetic
factors participat e in th e pr edisposition for disease developm ent (6) . Abno rmaliti es
in keratinocyt e proliferation induced by T lymphocyt es, alte rat ions in cell-me d iated

W. Mich ael H oot en , M.D . is a seco nd year psychi atry reside nt at J ohns H opki ns Schoo l of
M edi cin e in Baltimor e.

51
52 J EFFERSO N J O URNAL OF PSYCHIATRY

rea ctivity a nd a co m ple men t-me d ia te d reac tio n local ized to t he st ra t u m co rne um
hav e a ll be en implicat ed in the pathog en sis of psoria sis (7-9).
In a se ries o f report s, Farber propos ed a neu ropeptide-ind uced neurog en ic
inflammatory m ech anism (10-14). This th eory sugges ts th at th e rel ea se of subs ta nce
P by local or syst emic fa ctors from se nso ry nerves in th e skin ca us es local inflamm a -
tory responses th at tri gger psoriasis. The skin is innervat ed by unm yel inat ed se ns ory
fibers a nd su bsta nce P has be en localized in th e fre e nerv e e nd ings loca t ed in th e
d ermal papilla e a nd e pide r m is of healthy human skin ( 15, 16). Subst ance P is rel ea sed
by a n a n t id ro m ic m ech anism foll owing sti m u lat ion of noc iceptors resu lting in a whea l
(plas ma prot ein ex t ravasa t ion) a nd flare (vasod ila t ion) ( 17) . By wa y of a ffe re n t C
fibe rs to the s pinal cord, asce nd ing ne rve tract fibers transm it se ns ory inform at ion to
th e th al amus a nd higher co r tical ce n te rs . D ecending pa thways th en relay inform a-
tion back to the s pinal co rd .
Although local rel ea se of neuropeptid es fr om se nsory nerves in th e skin ha s not
been m e asured in response to stressful stim u li, the ac t iva t io n o f high e r cortical a reas
during st ress result s in a lte re d rel eas e of s ubs ta nce P fr om th e a d re na l gla nd by
d es cending a u tono m ic fibers ( 18). So me of th ese d escending a u tonomic fibers
in ne rva te opio id int ern euron s in the dorsal horn whi ch syna ps e wit h subst ance
P-containing nerves in th e s pinal co rd ( 19). In resp onse to st ress, Fa rb er proposed
that d escending a u to no m ic nerves t r igge r a n t idro m ic rel ea se of s ubsta nce P in t he
skin whi ch would pa rtly ex pla in the effec ts o f e m o t iona l stress on skin ph ysiology
( 14). Experiment al d at a site d by Fa rb er in su ppo rt of t his hypo th esis includ es the
d ecrea sed r esponse of d orsal-horn neurons to noxi ou s st im u li following activation o f
hi gh er co r t ica l ce n te rs a nd th e exace rba t io n o f a dj uva n t-ind uced arthri ti s
(13,14,20 ,21). In th e case s of surgicall y induced se nso ry a nes t hes ia , a slow r ecu rr e nce
of psoriasis parall els th e return of cu taneou s se nsa t ion (12). In rel at ed anim al
studi es , su bstance P-cont aining nerve fibers regen e rat e during burn wou nd heali ng
(22) . This sugges ts th at the r ecurren ce of psoria sis foll owin g surgica lly ind uced
a nes t hesia co u ld r esult from the regeneration of su bst a nce- P co ntaini ng ne rve fibe rs.
Further evid e nce includ es the s uccessful use of topi cal ca psaicin in t he treatm ent of
m od era t e t o seve re psoria sis (23). The ben eficial e ffects o f ca psa icin a re mo st lik el y
r el at ed to th e d epleti on of su bs ta nce P fr om local se nsory ne rve ter m inals (24,25) .

STRESS

Th ere is a large body of lit erature ass oc ia t ing st ress a nd th e d evel op m e n t or

exace r ba tio n of psoriatic lesions (26-40). From th e lit eratu re , it is possib le to ident ify
a su bg ro u p of ps oriatic patient s wh o a p pear t o be hi gh st ress react ors. Th ese pati ent s
report th at psych osocial s t ress exac e rba tes th eir psori a sis. In con t ras t, low st ress
react ors rep ort no a ssocia t ion bet ween st ress a nd t he exace r ba t io n of psori a sis. In a
s u rvey involvin g 2 144 psoriatic pati ents, 40% ind ica ted th at pso ria tic lesion s a p-
peared at " t imes o f worry" (5) . In a no t he r s u rv ey involvin g 5600 pso ria t ic pati en ts,
33% r esp onded that "new patch es" of psoria sis a p peared du ri ng periods of " wo rry"
(4 ) . In a n att empt to furth er char ac te rize pati ent s wh o r ep ort a n increa se in psora tic
LITERAT URE REVIEW 53

sym p to ms in r esponse to stress , Gupta es ta blishe d a broad psych ocu ta neo us profi le of
pati ent s wh o were se lf r ep ort ed hi gh st ress re act o rs ve rs us th ose who were low stress
rea ctors (27). Th e pati ents were ask ed to se lf-ra te th e ex te n t to wh ich stressful
sit ua t io ns mad e thei r psoria sis worse. They were as ke d to res pond to the following
sta te me n t : " St re ssfu l sit ua t ions fr equ ently m ak e my psoria sis worse." The pati ents
were ask ed to r ecord their r esp onses on a lO-point sca le with I d en ot in g "not a t a ll"
a nd 10 " ve ry markedly." The m edian sco re wa s 7. Pati en ts wi th scores of 7 or higher
we r e ca tego r ize d as " hig h st ress r eact ors" a nd t hose wi t h ra tings of I to 6 as " low
st ress r eactors." In a s t udy of 127 consecu t ive psoriati c pati en ts, hi gh stress reactors
ex hibite d more co sme t ica lly di sfiguring di sea se in co ns picuo us areas (i.e., scalp, face,
neck , forearms, hands, ge nital region ) (27) . H oweve r , th e ove rall severity of psori atic
lesions a s m easured by the percentage of tot al body surface a rea affected and the
d egre e of plaqu e thi ckness, sca ling a nd eryt he ma did not di ffer significant ly from low
st ress r eact ors. By wa y of the H a ssles Scal e , a se lf-ra te d IO-poi nt sca le measuring the
d egree of d aily st ress r esulting directly from psoria sis, a nd the Psor iasis Life Stress
In ventory (P LSI), a 4 1 it em in strum ent d esi gn ed to m eas ure st ress res ult ing from th e
impact of psoria sis upon th e quality of life , G u p ta showed th at high stress reactors
r eport ed more dis ease-relat ed st ress (27). Am on g hi gh s t ress react ors, disease-
rel at ed st ress sco res (Hassles sco re) co r re la te d directl y wit h psoriasis sev erity in
cos me t ica lly co ns picuo us body r egion s (scalp, face, neck , forearm s, ha nds and genital
region). Similarly, in a 5 year retrospective st udy, Bau ghm an a nd So bel found a
g rea te r st ress r ea ct ance a mo ng patient s with m od erat el y severe psoriasis (35). When
sim ila r a nalysis wa s perform ed to d et ermine if th e a mo u nt of st ress ex pe rienced over
th e 5 ye a r st udy period influe nced th e d egree of st ress react ance , no suc h in flue nce
wa s found. Althou gh Bau ghman a nd Sob el did not co mment on the causal relation-
ship bet we en th e d egree o f st ress r eact ance a nd psori asis seve rity, Gu pta postulat ed
th at th e a m ou n t of dis ea se-rel at ed st ress ex pe r ie nce d by high st ress reactors wa s a
res u lt o f cos me t ic di sfigu r em e nt , wh ich a dversely impa ct ed appearance and sexual-
ity.
When co m pa re d with scores from th e Social Readju stm ent Rati ng Sca le (SRRS),
whi ch m easu red st ress resu lt ing fro m m aj or life eve n ts d uri ng t he 6 months prior to
the st udy, hi gh st ress r eact ors ex pe r ie nce d more di sease-r el at ed st ress in contrast to
st ress resulting from m aj or life eve n ts (27). Bau ghman and Sobel postu lated that
pso r ias is accou nts for the variat ion in stress a nd th a t a person suffering with psoria sis
is m ore pron e t o int erpret life as st ress fu l whe n co m pa re d to a n indi vid ual who do es
not have t he di sea se (35 ) .
Th e progn osti c sign ifica nce of a high vers us low stress reactor in terms of relapse
has not be en fir m ly es t a blis he d. In a se r ies o f 183 co nsecu t ive psori a tic pati ents
foll owed ove r a thre e year period , those wh o r ecall ed the occ urrance of a sp ecific
st ress within one m onth prior to th e first pso ri atic a ttack were less lik e ly to relapse
(37). The in cubation tim e for specific in cid ent s of st ress a nd th e d evelo pm e n t of
psori at ic plaqu es was 2 d ays to 4 we ek s in 96% of pa ti ent s. These resu lts were
int erpret ed by Seville in te r m s of insig ht, where insigh t was d e fined as " se lf-
kn owl ed ge res ult ing in a n underst anding in d epth with full ac ce p ta nce " (38 ,39).
54 J EFFERSON J O URNA L OF PSYCH IATRY

Those patient s wh o were a ble to recall a specific st ressor were deem ed more
insightful a nd thus less lik ely to re la pse as opposed to t hose who could not recall a
st resso r. Gupta found that high st ress reactors expe rie nce d a g reat e r number of
flare-ups 6 mon th s pri or to adm ission (p < 0. 05) (27) . Sevi ll's obs ervations su ggest
th at t he ac kno wledgeme n t of previous stresso rs cou ld hel p redu ce relapse but
Gupt a 's more recent e m pirica l findin gs reveal th at high stress reactors are pr on e to
relapse.

PSYCHOPATHOLOGY

There have been many un su ccessful a t te m pts to iden ti fy spe cific personalit y
traits whi ch characte rize psoria t ics (32 ,33 ,35,40-46) . T wo st ud ies were identi fied
whi ch co m pare d personalit y profiles of high a nd low st ress reactors (27 ,35). Gupt a
administ ered th e In te r pe rsona l Depend en cy In ventory Subscale to a series of high
a nd low st ress react or s (27). S t ress react an ce wa s d et ermined by way of a IO-point se lf
ra t ed scale as describ ed a bove . Hi g h st ress react ors were mo re int erperson all y
depend ent a nd t ended to rely more up on th e a pproval of others. Additionally, high
s t re ss reactors were less lik ely to report a nger in associa tio n wit h t heir dis ease a nd
fea red g reate r soc ia l d isapproval. In co nt ras t, low st ress react ors ass ert ed angry
feelings in reacti on to th eir di sease. In a 5 year re t rosp ect ive study of 252 psoria tics,
low, m edium a nd high st ress react ors we re id entifi ed by th e severity of stress (Socia l
Readj ust m e n t Scale ) and psori asis (Psoriasis Seve rity Scale) (35). Following delinea-
tion of stress react ance, a tte mp ts to ide n tify associat ed person ality t rai ts proved
unsu ccessful. Co ns ide r ing psori a tics in ge ne ra l, t here have been reports of incr eas ed
psyc has t he nia, hyst eri a , d epression , a nx ie ty, obs essionality and a distrust of socia l
sit uations (33 ,4 1-44) . It is import ant to not e th at th e pr esen ce of t he above disord ers
were es tablishe d by way of qu estionnaires a nd were not t he res u lt of a psychi atric
eva lua tion.
Th ere is conflict ing evide nce conce rn ing t he us e of alcohol among psori atic
patien ts. A gro up of 99 patients co nsecu tively ad m it ted for inpat ient treatm ent of
pso rias is a nd a m at ch ed cont ro l g ro up hospi t ali zed for o t her d ermatologic disord ers
were eva lua te d for alco ho lism using th e criteria est a blishe d by th e National Co uncil
of Alco ho lism and by sco res on th e Se lf-Adm inistered Alcoholism Scr eening Test
(47) . Alcoh oli sm was di a gn osed in II psoriat ic pa t ie nt s and 3 co n t ro l pati ent s
(0.05 < p < 0. 10). T en of II psoriatic pa ti e nts compare d wit h 1 01'3 con t ro l pati ent s
were male (p < 0.05) . In a 5 year retrospective study of se lf-re po r te d a lco ho l
co nsu m p tio n grea ter t han 50 gm per day, 5.3% of 639 ind ivid ua ls wh o rep o rt ed
drin king greater th an 50 gm per day had psoriasis compared to 0.7 % of 1348 wh o
drank less t han 50 gm (p < 0.0 0 1) (48) . T wo previou s st ud ies uti lizin g crite ria
established by t he Na t ional Counci l on Alcoho lism's Expert C ommitt ee a nd a n
unspecified q uestionnaire found no association between psoriasis a nd alco hol ism
(49,50). T he prevale nce of alco ho lism among pso riatics is inco nclusive, but th e da ta
suggest psoriat ics could be a t high e r ris k for d evelopin g alcoholism .
LIT ERATUR E REVIEW 55

C ONC LUS ION

Wh en co m pare d to low st ress reactors, h igh stress reactors have more evidence
of cos me t ica lly di sfiguring di sease, ex pe r ie nce more disease rela ted st ress a nd are
more prone to rel ap se. However, no personality t rai ts or associa te d psychi a tri c
di sorders have been identifi ed whi ch di ffe ren tiat e stress rea ctance. Fu rther eluc ida-
tion of th e pathogen esis of psori asis could pot entiall y allow stress react an ce to be
differentiat ed biologicall y. More st udy is need ed to d et ermine if th e course of
psoriasis cou ld be alt ered in high stress react ors by mo difying t he a bove di stinguish-
ing cha rac te ristics.

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LITERATURE REVIEW 57

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