Etiology of psoriasis is still not known and comprises a range of assumptions and very complex etiological and pathogenetic mechanisms. Along with genetical predisposition, mental disorders and stresses might have a key role in the occurrence of this disease. Total number of 70 patients suffering from psoriasis were included in the investigation. Generally accepted structured clinical interview (SCID – The Structured Clinical Interview for DSM-IV) was applied in diagnostics of mental disorders. Various mental disorders were found in as many as 90% of patients suffering from psoriasis. The most frequent mental disorders were depressive disorder (19.2%), the posttraumatic stress disorder (17.8%), alcoholism (16.4%), adaptation disorder (15.1%), anxiety – depressive disorders (13.7%) and generalized anxious disorder (9.6%). The authors have concluded that in patients with psoriasis both various mental disorders and various stress events are frequent. The results have implied that there is a link between psoriasis on the one hand and various mental disorders and various stressors on the other. The investigation implies that there is a need to improve multidisciplinary approach in diagnostics and treatment of psoriasis and multi disciplinary team should consist of dermatologist, psychiatrist and psychologist

Darko Biljan

Davor Laufer

Mirna Šitum

Pavo Filaković

Tomo Brataljenović

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Coll. Antropol. 33 (2009) 3: 889–892Original scientific paperPsoriasis, Mental Disorders and StressDarko Biljan1, Davor Laufer2, Pavo Filakovi}2, Mirna [itum3 and Tomo Brataljenovi}41 Department of Dermatovenerology, University Hospital Center »Osijek«, Osijek, Croatia2 Clinic for Psychiatry, University Hospital Center »Osijek«, Osijek, Croatia3 Clinic for Dermatovenerology, University Hospital »Sestre milosrdnice«, Zagreb, Croatia4 Clinic for Psychiatry, University Hospital Center »Zagreb«, Zagreb, CroatiaA B S T R A C TEtiology of psoriasis is still not known and comprises a range of assumptions and very complex etiological and pathoge-netic mechanisms. Along with genetical predisposition, mental disorders and stresses might have a key role in the occur-rence of this disease. Total number of 70 patients suffering from psoriasis were included in the investigation. Generally ac-cepted structured clinical interview (SCID – The Structured Clinical Interview for DSM-IV) was applied in diagnostics ofmental disorders. Various mental disorders were found in as many as 90% of patients suffering from psoriasis. The mostfrequent mental disorders were depressive disorder (19.2%), the posttraumatic stress disorder (17.8%), alcoholism (16.4%),adaptation disorder (15.1%), anxiety – depressive disorders (13.7%) and generalized anxious disorder (9.6%). The authorshave concluded that in patients with psoriasis both various mental disorders and various stress events are frequent. The re-sults have implied that there is a link between psoriasis on the one hand and various mental disorders and various stress-ors on the other. The investigation implies that there is a need to improve multidisciplinary approach in diagnostics andtreatment of psoriasis and multi disciplinary team should consist of dermatologist, psychiatrist and psychologist.Key words: psoriasis, mental disorders, stressIntroductionEtiology of psoriasis is still not known. It comprises arange of assumptions and very complex etiological andpathogenetic mechanisms. Mental disorders could be oneof the factors which have a significant role in those mech-anisms, but also important effects on the very illness andits forecasts. If that is true, need for multidisciplinary ap-proach in medical treatment of this disease is justified.Even Aristotle suggested that there is a link betweenmood and physical health. During the last few decades,investigators’ interest for establishment of link betweenmental disorders and psoriasis has grown increasingly.For example, in his most recent investigations, Akayosuggested that there is a link between psoriasis anddepression1 and Kirby implied that there is a more fre-quent incidence of depression and anxiety in patientssuffering from psoriasis2. Data of Mazetti et al revealed ahigh prevalence of mental disorders: 71.2% of patientsshowed symptoms which allowed a precise psychiatric di-agnosis based on DSM – III – R criteria, 35% had person-ality disorders, 17.5% were moody, 12.5% were anxiousand 6.25% had a schizophrenic trait. The analysis of thestressful events enabled us to determine the presence ofa specific event in 88.7% of cases3. Devrimci – Ozguvenreported in his investigation that psoriasis patients hadsignificantly higher degrees of depressions and more bodycathexis problems than controls4. According to Szuman-ski, it is evident that depression and anxiety disorderscan be the cause of psoriasis5. Investigators are makingattempts to clarify this link. One of assumptions wasthat in individuals who are predisposed in terms of ge-netics, various mental disorders which are developed inlifetime or exposure to stress situations might create need-ed »endogenous eruptive pressure« which can induce im-munological mechanism which is responsible for acceler-ated proliferation and differentiation of cheratinocytes.Subjects and MethodsInvestigation was conducted on a group of 70 patientswho suffered from psoriasis in the Osijek and Zagreb re-gion. On average, examinees were 51 years old. The889Received for publication February 08, 2008youngest patient was 23 and the oldest patient was 78years old. Men and women were almost equal in number(36 men and 34 women). Patients with medium and seri-ous psoriasis who asked for treatment were included inthe investigation at the Departments of Dermatologicaland Venerological Diseases at Osijek and Zagreb in theperiod from 2005 to 2007.Examinees were recruited during common medicalevaluation by dermatologist who took anamnesis and re-viewed medical documentation. Patients with mediumand serious psoriasis were asked to take part in the in-vestigation after the objective and plan of the investiga-tion were explained to them. After dermatologist exam-ined them, patients who agreed to take part in theinvestigation were sent to psychiatrist who conductedclinical interview as well as the fulfilling the StructuredClinical Interview for DSM-IV Axis I Disorders (SCID-I)in order to establish the presence of mental disorder, ifany, and to determine the type of mental disorder as well.Structured Clinical Interview for DSM-IV Axis I Disor-ders (SCID-I) is a semi-structured interview for makingmost of the major DSM-IV Axis I psychiatric diagnoses.It assesses thirty-three of the more commonly occurringpsychiatric disorders described in the fourth edition ofthe Diagnostic And Statistical Manual (DSM-IV) of theAmerican Psychiatric Association.ResultsTotal number of 70 examinees took part in the inves-tigation, of which 51% were men (36) and 49% were wo-men (34). On average, the examinees were 51.0 years old(SD 12.6). Psoriasis whose intensity was moderate wasfound in 51.4% of patients (36) (intensity of psoriasisranged from 10 to 29% on the skin) and serious psoriasiswas found in 48.6% of patients (34) (intensity of psoriasison the skin was 30% or more)In the group of examinees, 90% patients (63) who suf-fered from psoriasis had mental disorders which fulfilledthe criteria for various psychiatric diagnoses, only 10% ofpatients (7) did not have any mental disorders. The larg-est number of patients were those who suffered fromanxiety associated with stress and somatophorm disor-ders (45 patients or 61.6%), while affective disorderswere found in 14 patients or 19.2% (Table 1).According to various diagnoses, the most frequentwere: depressive disorders in 14 patients (19.2%), theposttraumatic stress disorder in 13 patients (17.8%), al-coholism in 12 patients (16.4%), adaptation disorders in11 patients (15.1%), anxiety and depressive disorder in10 patients (13.7%) and generalized anxiety disorder in 7patients (9.6%) (Table 2).Also, incidence of neurodevelopmental disorders inchildhood was investigated. Most frequent was extremetimidity (21 patients, respectively in 30%), night fears(12 patients, respectively in 17.1%) and somnabulism (8patients, respectively in 11.4% of patients) (Table 3).Stressful events before onset of psoriasis were foundin 80% of patients. Most frequent were the followingstressful events: death in the family was found in 15 pa-tients (21.4%), accidents were found in 10 patients (14.3%)and disease of family member was found in 9 patients(12.9%). (Table 4).D. Biljan et al.: Psoriasis, Mental Disorders and Stress, Coll. Antropol. 33 (2009) 3: 889–892890TABLE 1FREQUENCY OF MENTAL DISORDERS ACCORDING TO DIAGNOSIS GROUPSDisorder Total %1 Anxiety disorders associated with stress and somatophorm disorders 45 61.6%2 Affective disorders 14 19.2%3 Other disorders classified otherwise (NOS) 14 19.2%TABLE 2FREQUENCY OF SPECIFIC MENTAL DISORDERS ACCORDINGTO DIAGNOSESDisorder Total %Depression – various disorders 14 19.2%Posttraumatic stress disorder 13 17.8%Alcoholism 12 16.4%Adaptation disorder 11 15.1%Anxiety and depression 10 13.7%Generalized anxiety disorder 7 9.6%Social fears 2 2.7%Psychoorganic changes 1 1.4%Schizophrenia 1 1.4%Panic disorder 1 1.4%Anxiety disorder undetermined 1 1.4%Total 73 100%TABLE 3INCIDENCE OF DEVELOPMENTAL DISORDERS IN CHILDHOODDisorders in childhood N %Convulsions 1 1.4%Late control of sphincters 3 4.3%Night fears 12 17.1%Somnabulism 8 11.4%Stammering 1 1.4%Excessive timidity 21 30.0%Total 33 47.1%With 2 or more disorders 11 15.7%More than a half of patients (57.1%) have shown emo-tional suffering due to psoriasis while 38.6% of patientshad difficulties at work. In 37.1% of patients were no-ticed difficulties in private life (Table 5).Attitude towards psoriasis was pessimistic in total of54.3% of patients, in 32.9% of patients it was calm and in12.9% it was optimistic.DiscussionIn examined group, 90% of patients suffering frompsoriasis had mental disorder and it is interesting to notethat only 28.6% of patients were aware of existing mentaldisorders or treated them. The results obtained indicatethat mental disorders, namely exposure to various kindsof stress factors, could be associated with occurrence ofpsoriasis. According to Selye, stress situations are men-tal and physical events which surpass adaptation capa-bilities of human being. Having mental disorder meansthat adaptation skills are extremely low and also com-mon life events can be stressful. According to results ob-tained in this investigation various stressful events be-fore the disease were experienced in 80% of patients. Alarge number of patients (57.1%) experienced emotionalsufferings due to psoriasis. Many authors have investi-gated a link between stress and psoriasis6-16. Severalauthors noticed a high level of anxiety and depression inpatients suffering from psoriasis17–20. Mazetti et al foundin 8 patients suffering from psoriasis even 71.2% of vari-ous mental disorders (personality disorder, depressionand schizophrenic behaviour)3. Folnegovi}-[malc thinksthat patients who suffer from psoriasis and use mecha-nism of regression as defense will develop mental dis-eases, while those patients who use negation and projec-tion as defense mechanisms will not have significantmanifestation of mental disorder21. According to Gupta,patients without adequate skills for getting someoneelse’s attention can draw someone’s attention on the ba-sis of visible skin disease22. Gilbert made attempt to finda common profile of character of psoriatic patients, buthe found only a more frequent depression and variousneurosis in comparison to control group and according tohim, psychotherapy can be advantageous in some of thepatients20. Gupta et al found a connection between pruri-tus in psoriasis and psychosocial factors23. According tosome of the authors, mental factors cause about 1/3 of allskin diseases24. It is deemed that characteristics of per-son, ways to cope with stress event and noticed socialsupport are mediators between stress events and theirpsychological perception. This, along with genetic incli-nation is increasing the probability of becoming ill25.Apart from inheritance, early frustrating or traumaticexperience from the childhood is playing an importantrole (especially until the age of three). Naturally, hereweakened state of defense of organism, allergic predispo-sition, genetically weak points, the effects of micro orga-nisms and other are also important. Surely, more developedand more intensive mental diseases can additionally causedeterioration and spreading of psoriasis and also psoria-sis can additionally have effects on deterioration of men-tal diseases so the cycle of deterioration on both sides be-comes closed.In our investigation, we noticed a high level of variousmental disorders in patients suffering from psoriasis. Ac-cording to mentioned results from other investigations,it is evident that also other investigators have found sim-ilar results, but they did not notice so many various men-tal disorders in such a great percentage. We could explainthis by the fact that in most of the investigations onlycertain mental disorders were investigated such as de-pressive disorder. Advantage of our investigation is in thefact that all groups of mental disorders were included(because the SCID – test was applied), thus this is one ofthe reasons why such a broad spectrum was included andwhy such a high percentage of disorders is obtained. An-other reason might be the war (from 1991 to 1996) as in-dividual psychosocial stressor. People behave in a war ina specific way and numerous defensive systems becometo work as well as numerous pathological mental re-sponses, but also creative and constructive solutions. Be-sides many known consequences, the war brought alsomany less visible effects among which are also psychoso-matic diseases26. It would be interesting to conduct an in-dividual investigation on the link between posttraumaticstress disorder after exposure to the war and psoriasis.The third reason might be the way the investigation wasset. Namely, only those patients who came for treatmentdue to worsening of psoriasis were included in the inves-D. Biljan et al.: Psoriasis, Mental Disorders and Stress, Coll. Antropol. 33 (2009) 3: 889–892891TABLE 4INCIDENCE OF STRESS SITUATIONSStress situations N %Death in family 15 21.4%Accident 10 14.3%Misunderstanding with husband / wife 4 5.7%Divorce 3 4.3%Problems at work 5 7.1%Cease of employment 5 7.1%Death of person whom one used to love 4 5.7%Own disease 2 2.9%Disease of family member 9 12.9%Other problems 32 45.7%Total 56 80.0%Patients with two or more stress situations 21 30.0%TABLE 5INCIDENCE OF DIFFICULTIES AND EMOTIONAL SUFFERINGSCAUSED BY PSORIASISYES NON % N %Difficulties at work 27 38.6% 43 61.4%Difficulties privately 26 37.1% 44 62.9%Emotional suffering 40 57.1% 30 42.9%tigation, but patients with moderate stationary type werenot. This investigation implies that in any case a multi-disciplinary approach should be improved both in the in-vestigation and treatment of psoriasis. Such a multi dis-ciplinary approach, besides dermatologist also requires acooperation of psychologist and psychiatrist.ConclusionIn almost 90% of patients suffering from psoriasis,various mental disorders have been found. Only 28.6% ofpatients were subjected to treatment or knew that theyhad mental disorder. The most frequent disorders werethose from the group of anxiety associated with stressand somatophorm disorders (61.6%) and from the groupof affective disorders (19.2%). According to the diagno-ses, the most frequent were various depressive disorders(19.2%), post traumatic stress disorder (17.8%), alcohol-ism (16.4%), adaptation disorder (15.1%); anxiety anddepressive disorder (13.7%) and generalized anxiety dis-order (9.6%). According to the results of the investiga-tion, various stressors can also contribute to the inci-dence, namely exacerbation of psoriasis. The resultsobtained also imply that there might be a link betweenpsoriasis and various mental disorders.R E F E R E N C E S1. AKAY A, PEKCANLAR A, BOZDAGKE, ALTINTAS L, KARAMANA, J Eur Acad Dermatol Venereol, 16 (2002) 347. — 2. KIRBY B, RICH-ARDS HL, WOO P, HINDLE E, MAIN CJ, GRIFFITHS CE, J Am AcadDermatol, 45 (2001) 72. — 3. MAZZETTI M, MOZZETTA A, SOAVI GC,ANDREOLI E, FOGLIO BONDA PH, PUDDU P, DECAMINADA F, ActaDerm Venereol Suppl (Stockh), 186 (1994) 62. — 4. DEVRIMCI-OZGU-VEN H, KUNDAKCI TN, KUMBASAR H, BOYVAT A, J Eur Acad Der-matol Venereol, 14 (2000) 267. — 5. SZUMASKI J, KOKOSZKA A, Psy-chiatr Pol, 35 (2001) 831. — 6. GUPTAMA, GUPTA AK, Acta Derm Vene-reol (Stockh), 75 (1995) 240. — 7. KANTOR SD, Cutis, 46 (1990) 321. —8. FARBER EM, NELL L, Cutis, 51 (1993) 322. — 9. AL’ABADIE MS,KENT GG, GAWKRODGER DJ, Br J Dermatol, 130 (1994) 199. — 10.GASTON L, LASSONDE M, BERNIER-BUZZANGA J, HODGINS S,CROMBEZ JC, J Am Acad Dermatol, 17 (1987) 82. — 11. PALJAND, Pso-riasis and Stress. MS Thesis. In Croat (School of Medicine, University ofZagreb, Zagreb, 1985). — 12. DURAN V, JOVANOVI] M, MISI]-PAV-KOV G, POLJACKI M, NOVOVI] Z, MILOSCIN S, GOLUB R, Med Pregl,46 (1993) 120. — 13. GASTON L, CRAMBEZ JC, LASSONDE M, BER-NIER J, HODGINS S, Acta Derm Venereol Suppl (Stockh), 156 (1991) 37.— 14. SEVILLE RH, Br J Dermatol, 97 (1977) 297. — 15. KOTRULJA L,Povezanost stresa i psiholo{kih karakteristika bolesnika s tijekom pso-rijaze. MS Thesis. In Croat (School of Medicine, University of Zagreb, Za-greb, 2003). — 16. HARVIMA RJ, VIINAMAKI H, HARVIMA IR, ActaDerm Venereol, 76 (1996) 467. — 17. GOLDSMITH LA, FISHER M,WACKS J, Arch Dermatol, 100 (1969) 674. — 18. BENNET P, THOMASB, GAWKRODGER D, The Practitioner, 237 (1993) 539. — 19. HARDYGE, COTTERILL JA, Br J Psychiatry, 140 (1982) 19. — 20. GILBERTAR, RODGERS D, ROENIKGHH JR, Cleveland Clin Q, 40 (1973) 147. —21. FOLNEGOVI]-[MALC V, Psoriasis, 41 (1998) 11. — 22. GUPTA M,VOORHEES JJ, Arch Dermatol, 126 (1990) 90. — 23. GUPTA MA,GUPTA AK, KIRKBY S, WEINER HK, MACE TM, SCHORK NJ, ArchDermatol, 124 (1988) 1052. — 24. KLEIN GF, FRITSCH PO, Hautarzt,42 (1991) 57. — 25. KLAIN E, Pona{anje ljudi u ratu. In: KLAIN E (Ed)Ratna psihologija i psihijatrija (Glavni sanitetski sto`er Republike Hrvat-ske, Zagreb, 1992). — 26. SARAJLI] N, Stres i akutna psihosomatskareakcija u ratu. In: KLAIN E (Ed) Uvod u ratnu psihologiju i psihijatriju(Glavni sanitetski sto`er Republike Hrvatske, Zagreb, 1991).D. BiljanDepartment of Dermatovenerology, University Hospital Center »Osijek«, Hutllerova 4, Osijek, Croatiae-mail: Darko.biljan@os.t-com.hrPSORIJAZA, PSIHI^KE BOLESTI I STRESS A @ E T A KEtiologija psorijaze jo{ je uvijek nepoznata, vjerojatno zbog veoma kompleksne etiopatogeneze u kojoj sudjeluju broj-ni ~imbenici. Uz genetsku predispoziciju, psihi~ki poreme}aji i stresovi bi mogli imati klju~nu ulogu u nastanku te bolesti.U istra`ivanju je sudjelovalo 70 bolesnika sa psorijazom. U dijagnostici psihi~kih poreme}aja je primijenjen op}eprihva-}eni strukturirani klini~ki intervju (SCID – The Structured Clinical Interview for DSM-IV). Razli~iti psihi~ki poreme-}aji dijagnosticirani su kod ~ak 90% oboljelih od psorijaze. Naj~e{}i psihi~ki poreme}aji bili su: depresivni poreme}aji(19,2%) PTSP (17,8%), alkoholizam (16,4%), poreme}aji prilagodbe (15,1%), anksiozno-depresivni poreme}aji (13,7%) igeneralizirani anksiozni poreme}aj (9,6%). Autori zaklju~uju kako su kod bolesnika sa psorijazom u~estali i razli~itipsihi~ki poreme}aji i razli~iti stresni doga|aji. Rezultati ukazuju na povezanost izme|u psorijaze s jedne strane, terazli~itih psihi~kih poreme}aja i razli~itih stresora, s druge strane. Istra`ivanje upu}uje na potrebu pobolj{anja multi-disciplinarnog pristupa u dijagnostici i lije~enju psorijaze, a multidisciplinarni tim bi se trebao sastojati od dermatologa,psihijatra i psihologa.D. Biljan et al.: Psoriasis, Mental Disorders and Stress, Coll. Antropol. 33 (2009) 3: 889–892892

Psoriasis, Mental Disorders and Stress

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Coll. Antropol. 33 (2009) 3: 889–892Original scientific paperPsoriasis, Mental Disorders and StressDarko Biljan1, Davor Laufer2, Pavo Filakovi}2, Mirna [itum3 and Tomo Brataljenovi}41 Department of Dermatovenerology, University Hospital Center »Osijek«, Osijek, Croatia2 Clinic for Psychiatry, University Hospital Center »Osijek«, Osijek, Croatia3 Clinic for Dermatovenerology, University Hospital »Sestre milosrdnice«, Zagreb, Croatia4 Clinic for Psychiatry, University Hospital Center »Zagreb«, Zagreb, CroatiaA B S T R A C TEtiology of psoriasis is still not known and comprises a range of assumptions and very complex etiological and pathoge-netic mechanisms. Along with genetical predisposition, mental disorders and stresses might have a key role in the occur-rence of this disease. Total number of 70 patients suffering from psoriasis were included in the investigation. Generally ac-cepted structured clinical interview (SCID – The Structured Clinical Interview for DSM-IV) was applied in diagnostics ofmental disorders. Various mental disorders were found in as many as 90% of patients suffering from psoriasis. The mostfrequent mental disorders were depressive disorder (19.2%), the posttraumatic stress disorder (17.8%), alcoholism (16.4%),adaptation disorder (15.1%), anxiety – depressive disorders (13.7%) and generalized anxious disorder (9.6%). The authorshave concluded that in patients with psoriasis both various mental disorders and various stress events are frequent. The re-sults have implied that there is a link between psoriasis on the one hand and various mental disorders and various stress-ors on the other. The investigation implies that there is a need to improve multidisciplinary approach in diagnostics andtreatment of psoriasis and multi disciplinary team should consist of dermatologist, psychiatrist and psychologist.Key words: psoriasis, mental disorders, stressIntroductionEtiology of psoriasis is still not known. It comprises arange of assumptions and very complex etiological andpathogenetic mechanisms. Mental disorders could be oneof the factors which have a significant role in those mech-anisms, but also important effects on the very illness andits forecasts. If that is true, need for multidisciplinary ap-proach in medical treatment of this disease is justified.Even Aristotle suggested that there is a link betweenmood and physical health. During the last few decades,investigators’ interest for establishment of link betweenmental disorders and psoriasis has grown increasingly.For example, in his most recent investigations, Akayosuggested that there is a link between psoriasis anddepression1 and Kirby implied that there is a more fre-quent incidence of depression and anxiety in patientssuffering from psoriasis2. Data of Mazetti et al revealed ahigh prevalence of mental disorders: 71.2% of patientsshowed symptoms which allowed a precise psychiatric di-agnosis based on DSM – III – R criteria, 35% had person-ality disorders, 17.5% were moody, 12.5% were anxiousand 6.25% had a schizophrenic trait. The analysis of thestressful events enabled us to determine the presence ofa specific event in 88.7% of cases3. Devrimci – Ozguvenreported in his investigation that psoriasis patients hadsignificantly higher degrees of depressions and more bodycathexis problems than controls4. According to Szuman-ski, it is evident that depression and anxiety disorderscan be the cause of psoriasis5. Investigators are makingattempts to clarify this link. One of assumptions wasthat in individuals who are predisposed in terms of ge-netics, various mental disorders which are developed inlifetime or exposure to stress situations might create need-ed »endogenous eruptive pressure« which can induce im-munological mechanism which is responsible for acceler-ated proliferation and differentiation of cheratinocytes.Subjects and MethodsInvestigation was conducted on a group of 70 patientswho suffered from psoriasis in the Osijek and Zagreb re-gion. On average, examinees were 51 years old. The889Received for publication February 08, 2008youngest patient was 23 and the oldest patient was 78years old. Men and women were almost equal in number(36 men and 34 women). Patients with medium and seri-ous psoriasis who asked for treatment were included inthe investigation at the Departments of Dermatologicaland Venerological Diseases at Osijek and Zagreb in theperiod from 2005 to 2007.Examinees were recruited during common medicalevaluation by dermatologist who took anamnesis and re-viewed medical documentation. Patients with mediumand serious psoriasis were asked to take part in the in-vestigation after the objective and plan of the investiga-tion were explained to them. After dermatologist exam-ined them, patients who agreed to take part in theinvestigation were sent to psychiatrist who conductedclinical interview as well as the fulfilling the StructuredClinical Interview for DSM-IV Axis I Disorders (SCID-I)in order to establish the presence of mental disorder, ifany, and to determine the type of mental disorder as well.Structured Clinical Interview for DSM-IV Axis I Disor-ders (SCID-I) is a semi-structured interview for makingmost of the major DSM-IV Axis I psychiatric diagnoses.It assesses thirty-three of the more commonly occurringpsychiatric disorders described in the fourth edition ofthe Diagnostic And Statistical Manual (DSM-IV) of theAmerican Psychiatric Association.ResultsTotal number of 70 examinees took part in the inves-tigation, of which 51% were men (36) and 49% were wo-men (34). On average, the examinees were 51.0 years old(SD 12.6). Psoriasis whose intensity was moderate wasfound in 51.4% of patients (36) (intensity of psoriasisranged from 10 to 29% on the skin) and serious psoriasiswas found in 48.6% of patients (34) (intensity of psoriasison the skin was 30% or more)In the group of examinees, 90% patients (63) who suf-fered from psoriasis had mental disorders which fulfilledthe criteria for various psychiatric diagnoses, only 10% ofpatients (7) did not have any mental disorders. The larg-est number of patients were those who suffered fromanxiety associated with stress and somatophorm disor-ders (45 patients or 61.6%), while affective disorderswere found in 14 patients or 19.2% (Table 1).According to various diagnoses, the most frequentwere: depressive disorders in 14 patients (19.2%), theposttraumatic stress disorder in 13 patients (17.8%), al-coholism in 12 patients (16.4%), adaptation disorders in11 patients (15.1%), anxiety and depressive disorder in10 patients (13.7%) and generalized anxiety disorder in 7patients (9.6%) (Table 2).Also, incidence of neurodevelopmental disorders inchildhood was investigated. Most frequent was extremetimidity (21 patients, respectively in 30%), night fears(12 patients, respectively in 17.1%) and somnabulism (8patients, respectively in 11.4% of patients) (Table 3).Stressful events before onset of psoriasis were foundin 80% of patients. Most frequent were the followingstressful events: death in the family was found in 15 pa-tients (21.4%), accidents were found in 10 patients (14.3%)and disease of family member was found in 9 patients(12.9%). (Table 4).D. Biljan et al.: Psoriasis, Mental Disorders and Stress, Coll. Antropol. 33 (2009) 3: 889–892890TABLE 1FREQUENCY OF MENTAL DISORDERS ACCORDING TO DIAGNOSIS GROUPSDisorder Total %1 Anxiety disorders associated with stress and somatophorm disorders 45 61.6%2 Affective disorders 14 19.2%3 Other disorders classified otherwise (NOS) 14 19.2%TABLE 2FREQUENCY OF SPECIFIC MENTAL DISORDERS ACCORDINGTO DIAGNOSESDisorder Total %Depression – various disorders 14 19.2%Posttraumatic stress disorder 13 17.8%Alcoholism 12 16.4%Adaptation disorder 11 15.1%Anxiety and depression 10 13.7%Generalized anxiety disorder 7 9.6%Social fears 2 2.7%Psychoorganic changes 1 1.4%Schizophrenia 1 1.4%Panic disorder 1 1.4%Anxiety disorder undetermined 1 1.4%Total 73 100%TABLE 3INCIDENCE OF DEVELOPMENTAL DISORDERS IN CHILDHOODDisorders in childhood N %Convulsions 1 1.4%Late control of sphincters 3 4.3%Night fears 12 17.1%Somnabulism 8 11.4%Stammering 1 1.4%Excessive timidity 21 30.0%Total 33 47.1%With 2 or more disorders 11 15.7%More than a half of patients (57.1%) have shown emo-tional suffering due to psoriasis while 38.6% of patientshad difficulties at work. In 37.1% of patients were no-ticed difficulties in private life (Table 5).Attitude towards psoriasis was pessimistic in total of54.3% of patients, in 32.9% of patients it was calm and in12.9% it was optimistic.DiscussionIn examined group, 90% of patients suffering frompsoriasis had mental disorder and it is interesting to notethat only 28.6% of patients were aware of existing mentaldisorders or treated them. The results obtained indicatethat mental disorders, namely exposure to various kindsof stress factors, could be associated with occurrence ofpsoriasis. According to Selye, stress situations are men-tal and physical events which surpass adaptation capa-bilities of human being. Having mental disorder meansthat adaptation skills are extremely low and also com-mon life events can be stressful. According to results ob-tained in this investigation various stressful events be-fore the disease were experienced in 80% of patients. Alarge number of patients (57.1%) experienced emotionalsufferings due to psoriasis. Many authors have investi-gated a link between stress and psoriasis6-16. Severalauthors noticed a high level of anxiety and depression inpatients suffering from psoriasis17–20. Mazetti et al foundin 8 patients suffering from psoriasis even 71.2% of vari-ous mental disorders (personality disorder, depressionand schizophrenic behaviour)3. Folnegovi}-[malc thinksthat patients who suffer from psoriasis and use mecha-nism of regression as defense will develop mental dis-eases, while those patients who use negation and projec-tion as defense mechanisms will not have significantmanifestation of mental disorder21. According to Gupta,patients without adequate skills for getting someoneelse’s attention can draw someone’s attention on the ba-sis of visible skin disease22. Gilbert made attempt to finda common profile of character of psoriatic patients, buthe found only a more frequent depression and variousneurosis in comparison to control group and according tohim, psychotherapy can be advantageous in some of thepatients20. Gupta et al found a connection between pruri-tus in psoriasis and psychosocial factors23. According tosome of the authors, mental factors cause about 1/3 of allskin diseases24. It is deemed that characteristics of per-son, ways to cope with stress event and noticed socialsupport are mediators between stress events and theirpsychological perception. This, along with genetic incli-nation is increasing the probability of becoming ill25.Apart from inheritance, early frustrating or traumaticexperience from the childhood is playing an importantrole (especially until the age of three). Naturally, hereweakened state of defense of organism, allergic predispo-sition, genetically weak points, the effects of micro orga-nisms and other are also important. Surely, more developedand more intensive mental diseases can additionally causedeterioration and spreading of psoriasis and also psoria-sis can additionally have effects on deterioration of men-tal diseases so the cycle of deterioration on both sides be-comes closed.In our investigation, we noticed a high level of variousmental disorders in patients suffering from psoriasis. Ac-cording to mentioned results from other investigations,it is evident that also other investigators have found sim-ilar results, but they did not notice so many various men-tal disorders in such a great percentage. We could explainthis by the fact that in most of the investigations onlycertain mental disorders were investigated such as de-pressive disorder. Advantage of our investigation is in thefact that all groups of mental disorders were included(because the SCID – test was applied), thus this is one ofthe reasons why such a broad spectrum was included andwhy such a high percentage of disorders is obtained. An-other reason might be the war (from 1991 to 1996) as in-dividual psychosocial stressor. People behave in a war ina specific way and numerous defensive systems becometo work as well as numerous pathological mental re-sponses, but also creative and constructive solutions. Be-sides many known consequences, the war brought alsomany less visible effects among which are also psychoso-matic diseases26. It would be interesting to conduct an in-dividual investigation on the link between posttraumaticstress disorder after exposure to the war and psoriasis.The third reason might be the way the investigation wasset. Namely, only those patients who came for treatmentdue to worsening of psoriasis were included in the inves-D. Biljan et al.: Psoriasis, Mental Disorders and Stress, Coll. Antropol. 33 (2009) 3: 889–892891TABLE 4INCIDENCE OF STRESS SITUATIONSStress situations N %Death in family 15 21.4%Accident 10 14.3%Misunderstanding with husband / wife 4 5.7%Divorce 3 4.3%Problems at work 5 7.1%Cease of employment 5 7.1%Death of person whom one used to love 4 5.7%Own disease 2 2.9%Disease of family member 9 12.9%Other problems 32 45.7%Total 56 80.0%Patients with two or more stress situations 21 30.0%TABLE 5INCIDENCE OF DIFFICULTIES AND EMOTIONAL SUFFERINGSCAUSED BY PSORIASISYES NON % N %Difficulties at work 27 38.6% 43 61.4%Difficulties privately 26 37.1% 44 62.9%Emotional suffering 40 57.1% 30 42.9%tigation, but patients with moderate stationary type werenot. This investigation implies that in any case a multi-disciplinary approach should be improved both in the in-vestigation and treatment of psoriasis. Such a multi dis-ciplinary approach, besides dermatologist also requires acooperation of psychologist and psychiatrist.ConclusionIn almost 90% of patients suffering from psoriasis,various mental disorders have been found. Only 28.6% ofpatients were subjected to treatment or knew that theyhad mental disorder. The most frequent disorders werethose from the group of anxiety associated with stressand somatophorm disorders (61.6%) and from the groupof affective disorders (19.2%). According to the diagno-ses, the most frequent were various depressive disorders(19.2%), post traumatic stress disorder (17.8%), alcohol-ism (16.4%), adaptation disorder (15.1%); anxiety anddepressive disorder (13.7%) and generalized anxiety dis-order (9.6%). According to the results of the investiga-tion, various stressors can also contribute to the inci-dence, namely exacerbation of psoriasis. The resultsobtained also imply that there might be a link betweenpsoriasis and various mental disorders.R E F E R E N C E S1. AKAY A, PEKCANLAR A, BOZDAG KE, ALTINTAS L, KARAMANA, J Eur Acad Dermatol Venereol, 16 (2002) 347. — 2. KIRBY B, RICH-ARDS HL, WOO P, HINDLE E, MAIN CJ, GRIFFITHS CE, J Am AcadDermatol, 45 (2001) 72. — 3. MAZZETTI M, MOZZETTA A, SOAVI GC,ANDREOLI E, FOGLIO BONDA PH, PUDDU P, DECAMINADA F, ActaDerm Venereol Suppl (Stockh), 186 (1994) 62. — 4. DEVRIMCI-OZGU-VEN H, KUNDAKCI TN, KUMBASAR H, BOYVAT A, J Eur Acad Der-matol Venereol, 14 (2000) 267. — 5. SZUMASKI J, KOKOSZKA A, Psy-chiatr Pol, 35 (2001) 831. — 6. GUPTA MA, GUPTA AK, Acta Derm Vene-reol (Stockh), 75 (1995) 240. — 7. KANTOR SD, Cutis, 46 (1990) 321. —8. FARBER EM, NELL L, Cutis, 51 (1993) 322. — 9. AL’ABADIE MS,KENT GG, GAWKRODGER DJ, Br J Dermatol, 130 (1994) 199. — 10.GASTON L, LASSONDE M, BERNIER-BUZZANGA J, HODGINS S,CROMBEZ JC, J Am Acad Dermatol, 17 (1987) 82. — 11. PALJAN D, Pso-riasis and Stress. MS Thesis. In Croat (School of Medicine, University ofZagreb, Zagreb, 1985). — 12. DURAN V, JOVANOVI] M, MISI]-PAV-KOV G, POLJACKI M, NOVOVI] Z, MILOSCIN S, GOLUB R, Med Pregl,46 (1993) 120. — 13. GASTON L, CRAMBEZ JC, LASSONDE M, BER-NIER J, HODGINS S, Acta Derm Venereol Suppl (Stockh), 156 (1991) 37.— 14. SEVILLE RH, Br J Dermatol, 97 (1977) 297. — 15. KOTRULJA L,Povezanost stresa i psiholo{kih karakteristika bolesnika s tijekom pso-rijaze. MS Thesis. In Croat (School of Medicine, University of Zagreb, Za-greb, 2003). — 16. HARVIMA RJ, VIINAMAKI H, HARVIMA IR, ActaDerm Venereol, 76 (1996) 467. — 17. GOLDSMITH LA, FISHER M,WACKS J, Arch Dermatol, 100 (1969) 674. — 18. BENNET P, THOMASB, GAWKRODGER D, The Practitioner, 237 (1993) 539. — 19. HARDYGE, COTTERILL JA, Br J Psychiatry, 140 (1982) 19. — 20. GILBERTAR, RODGERS D, ROENIKG HH JR, Cleveland Clin Q, 40 (1973) 147. —21. FOLNEGOVI]-[MALC V, Psoriasis, 41 (1998) 11. — 22. GUPTA M,VOORHEES JJ, Arch Dermatol, 126 (1990) 90. — 23. GUPTA MA,GUPTA AK, KIRKBY S, WEINER HK, MACE TM, SCHORK NJ, ArchDermatol, 124 (1988) 1052. — 24. KLEIN GF, FRITSCH PO, Hautarzt,42 (1991) 57. — 25. KLAIN E, Pona{anje ljudi u ratu. In: KLAIN E (Ed)Ratna psihologija i psihijatrija (Glavni sanitetski sto`er Republike Hrvat-ske, Zagreb, 1992). — 26. SARAJLI] N, Stres i akutna psihosomatskareakcija u ratu. In: KLAIN E (Ed) Uvod u ratnu psihologiju i psihijatriju(Glavni sanitetski sto`er Republike Hrvatske, Zagreb, 1991).D. BiljanDepartment of Dermatovenerology, University Hospital Center »Osijek«, Hutllerova 4, Osijek, Croatiae-mail: Darko.biljan@os.t-com.hrPSORIJAZA, PSIHI^KE BOLESTI I STRESS A @ E T A KEtiologija psorijaze jo{ je uvijek nepoznata, vjerojatno zbog veoma kompleksne etiopatogeneze u kojoj sudjeluju broj-ni ~imbenici. Uz genetsku predispoziciju, psihi~ki poreme}aji i stresovi bi mogli imati klju~nu ulogu u nastanku te bolesti.U istra`ivanju je sudjelovalo 70 bolesnika sa psorijazom. U dijagnostici psihi~kih poreme}aja je primijenjen op}eprihva-}eni strukturirani klini~ki intervju (SCID – The Structured Clinical Interview for DSM-IV). Razli~iti psihi~ki poreme-}aji dijagnosticirani su kod ~ak 90% oboljelih od psorijaze. Naj~e{}i psihi~ki poreme}aji bili su: depresivni poreme}aji(19,2%) PTSP (17,8%), alkoholizam (16,4%), poreme}aji prilagodbe (15,1%), anksiozno-depresivni poreme}aji (13,7%) igeneralizirani anksiozni poreme}aj (9,6%). Autori zaklju~uju kako su kod bolesnika sa psorijazom u~estali i razli~itipsihi~ki poreme}aji i razli~iti stresni doga|aji. Rezultati ukazuju na povezanost izme|u psorijaze s jedne strane, terazli~itih psihi~kih poreme}aja i razli~itih stresora, s druge strane. Istra`ivanje upu}uje na potrebu pobolj{anja multi-disciplinarnog pristupa u dijagnostici i lije~enju psorijaze, a multidisciplinarni tim bi se trebao sastojati od dermatologa,psihijatra i psihologa.D. Biljan et al.: Psoriasis, Mental Disorders and Stress, Coll. Antropol. 33 (2009) 3: 889–892892

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