Divergent Beliefs About Psoriasis Are Associated with Increased Psychological Distress

nal G. Fortune, Stephanie L. P. Chong,w Damon L. Mason,w Siobhan K. T. Helen L. Richards,w Do Sweeney, w Chris J. Main, and Christopher E. M. Grifthsw
Department of Behavioral Medicine and wDermatology Center, University of Manchester School of Medicine, Hope Hospital, Manchester, UK

The psychological adjustment of patients with psoriasis has been studied extensively. By comparison, no research has focused on their partners. We examined illness representations of psoriasis held by patients and their partners, and investigated whether divergent beliefs were associated with psychological distress. Fifty-eight patients with chronic plaque psoriasis and their partners completed a range of psychological assessments including beliefs about the condition, anxiety, depression, and worry. Patients also completed a self-assessment of psoriasis severity. Patients with psoriasis had signicantly higher levels of anxiety, depression, and worry than their partners (ts4 2.53, pso.05). Multiple regression analysis indicated that divergence in patients and partners beliefs about emotional impact of psoriasis and chronicity of timeline accounted for a statistically signicant (21.3%) proportion of the variance in depression for partners. Differences in views on the consequences of having psoriasis and the cyclical nature of the condition were also signicantly associated with increased levels of worry in partners. Dissimilarity in particular aspects of illness representations are associated with increased psychological distress in particular for the partners of patients with psoriasis. The results illustrate the importance of concordance between patients and partners models of illness in relation to adjustment, and highlight the need to consider and collaborate with both patients and their partners in managing this challenging condition.

Key words: anxiety/depression/family/psoriasis/psychological J Invest Dermatol 123:49 56, 2004

There is undeniable evidence that the impact and burden of psoriasis can be substantial (Ginsburg and Link, 1989; Gupta et al, 1993; Finlay and Coles, 1995; Fortune et al, 1997a, 2000, 2002a; Leary et al, 1998; Krueger et al, 2001; Richards et al, 2001). Disability in psoriasis is comparable with that found in patients with cancer, arthritis, hypertension, heart disease, diabetes, and depression (Rapp et al, 1999), and patients with psoriasis report more distress than patients with other forms of skin disease such as vitiligo (Porter et al, 1986) and fungal infections (Fava et al, 1980). Furthermore, patients often feel stigmatized by their condition (Fortune et al, 1997b; Richards et al, 2001), and may have to contend with stigma arising from uninformed public attitudes about their psoriasis, as well as that which may arise from such discrimination. As with all illnesses, psoriasis does not occur in isolation. Given the wide-ranging impact on individual patients lives, it would seem unlikely that the patients families, especially their partners, remain untouched. A partner may nd their social life curtailed, as the patients avoidance and associated disability prevents them from engaging in usually enjoyable activities; they may also be distressed by the fact that their partner is suffering and may have to

Abbreviations: IPQ-R, Illness Perception Questionnaire-Revised; SAPASI, Self-Assessment Psoriasis Area Severity Index

deal with the negative effects that psoriasis can have on the psychological health of the patient. All these problems can be stressful for the well partner and may also place them at risk for psychological and health problems (Kiecolt-Glaser et al, 1995; Vedhara et al, 1999). Indeed, research in chronic illness has found increased levels of depression in partners of those with chronic pain (Flor et al, 1987), rheumatoid arthritis (Walsh et al, 1999), renal disease (Rideout et al, 1990), and heart disease (Croog and Fitzgerald, 1978). In order to account for levels of distress in patients and partners, researchers and clinicians have begun to investigate the common-sense model of disease held by patients and their partners. The main question addressed in this study is whether and to what extent are differences in the commonsense model of psoriasis held by patients and their partners related to psychological outcome for both parties. Empirical literature suggests that in order to understand and respond to the difculties presented by illness, patients construct their own common-sense model of their condition (Leventhal et al, 1980, 1992). These beliefs about a disease are formed around a number of dimensions of the illness experience: (i) illness identity (symptoms associated with the condition); (ii) chronicity or recurrence of the condition; (iii) consequences of the condition; (iv) personal and treatment control; (v) illness coherence (understanding of the condition); (vi) patients emotional response to their condition; and (vii) causes of the condition (Fig 1). These

Copyright r 2004 by The Society for Investigative Dermatology, Inc.

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Patients Illness representations (IPQ-R)

e.g. Illness identity, consequences, personal control, treatment control, timeline, emotional representations

Outcomes
e.g. psychological function, psychological distress (HADS, PSWQ), well-being, social functioning

Illness stimuli

Psoriasis
Dissimilarity in illness representations Partners Illness representations (IPQ-R)
e.g. Illness identity, consequences, personal control, treatment control, timeline, emotional representations

Figure 1 Common-sense model of dissimilarity in psoriasis representation held by patients and their partners.

beliefs or illness representations are said to drive attempts to cope with illness and have a signicant impact on adjustment to illnesses (Petrie et al, 1996; Murphy et al, 1999). Within psoriasis, illness representations have been demonstrated to be the most consistent predictor of stress, distress, and disability in patients (Fortune et al, 2002a), and are associated with increased use of outpatient services (Scharloo et al, 2000). Moreover, a growing body of research demonstrates that beliefs about illness held by signicant others in relation to the patient can also have an impact on the well-being of that individual, especially if those beliefs diverge (Heijmans et al, 1999). There exists the potential for spouses of patients with psoriasis to underestimate the consequences of a condition such that the patient feels misunderstood, or to overestimate the consequences and become overprotective and encourage increased dependency by the patient. Furthermore, illness beliefs have been shown to account for more of the distress in carers than objective physical correlates of the partners condition (McClenahan and Weinman, 1998). No research has been conducted, to date, on partners of individuals with psoriasis. Thus we investigated the illness representations of psoriasis held by psoriasis patients and their well partners, and examined how their differences in beliefs about psoriasis may be associated with adaptive outcome in terms of anxiety, depression, and worry.

0.9 to 48.1. At the time of the study, 65% of patients were employed. The mean age of the partners was 47 ( 13) years, 74% were employed, and 51% were male. Using the United Kingdom Ofce of National Statistics Classications (ONS, 2001), patientpartner dyads were consistent with the following socio-economic classes: Social Class 1 8.7%; Social Class 2 37%; Social Class 3 13%; Social Class 4 2.2%; Social Class 5 8.7%; Social Class 6 15.2%; Social Class 7 10.9%; and Social Class 8 4.3%. Patients and partners psychological distress Mean scores were calculated for levels of psychological distress in patients and their partners. Independent t tests indicated that patients had signicantly higher levels of anxiety (t 2.65, po.01), depression (t 2.53. po.05), and pathological worry (t 2.85, po.01) than their partners (Table 1). We also examined the number of patients and partners whose scores placed them in the category of probable mood disorder. Table 2 illustrates these results in comparison with those reported in previous studies. Gender differences Independent t test analysis indicated no difference between males and females on any clinical or

Table 1. Mean scores (standard deviation) for anxiety, depression, and worry in psoriasis patients and well partners
Patient HADS anxiety 7.60 ( 3.98) 4.55 ( 3.53) 47.47 ( 11.90) Partner 5.63 ( 4.00)a 3.02 ( 2.90)b 40.33 ( 14.86)a

Results
Participants Fifty-eight patients with chronic plaque psoriasis and their partners completed a range of questionnaires assessing psychosocial factors. The mean age of the psoriasis population was 44 ( 12) years. The mean age of onset of psoriasis was 26 ( 16) years, and the duration of psoriasis was 18 years ( 11); 49% of patients were male. The mean SAPASI was 12.3 ( 10.5) and ranged from
HADS depression PSWQ
a b

Signicant difference between well partners and patients at po0.01. Signicant difference between well partners and patients at po0.05. HADS, Hospital Anxiety and Depression Scale; PSWQ, Penn State Worry Questionnaire.

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Table 2. Data from comparable studies on patients and well partners as cases for anxiety, depression, and pathological worrying
Psoriasis patient (n 58) (%) Probable anxiety Probable depression Pathological worry
a b c

Well partner (n 58) (%) 10.3 1.7 10.3

Comparativepsoriasisa,b (n 115a; n 140b) (%) 43a 10a 38b

Comparativecontrolc (n 60) (%) 4c 0c 11c

27.6 10.3 15.5

Richards et al (2001a). Fortune et al (2000). Fortune et al (2003a,b).

demographic variable (ts o.97, ps40.33). Independent t tests indicated that there were no signicant differences between male and female patients in their levels of psychological distress (t o1.03, p40.3). Female partners, however, had signicantly greater levels of anxiety (t 2.74, po0.01) and worry (t 3.55, po0.001) than their male counterparts. General differences between patients and partners beliefs about psoriasis Prior to the examination of dissimilarity in patientpartner dyads, differences in illness representations between patients and partners overall were examined. Multivariate analysis of variance indicated no signicant differences between the beliefs that patients and spouses held (Fso2.03, ps40.16). Thus, overall, patients and partners held very similar beliefs about psoriasis. Table 3 presents the adjusted mean scores and standard deviations for the different dimensions of illness representations for psoriasis patients and their partners. Dissimilarity between illness representations held by patients and partners Beliefs about causes of psoriasis Patients views of causal attributions of psoriasis were used as the criterion, and partners scores were compared against these and coded in terms of agreement, minimization, and maximization for individual cause items. The percentages of patientpartner pairs minimizing and maximizing on each of the individual causes are illustrated in Fig 2. Partners of patients with psoriasis were inclined to maximize etiological roles for stress, poor medical care, and overwork relative to patients and to minimize aging, alcohol, smoking, family problems, accident, patients own behavior, mental attitude, chance, pollution, diet, and germ/ virus as causes of patients psoriasis. Symptoms experienced as part of psoriasis The level of agreement on individual symptoms that patients and partners associated with psoriasis was also examined. In general, there was consensus between patients and their partners on the symptoms associated with psoriasis. Patients and their partners showed least agreement on pain, stiff joints, skin burning, and sleep difculties, with partners tending to maximize all these symptoms with the exception of sleep difculties, which were minimized. Most agreement was in relation to itching, skin aking, and changes in weight (Table 4). Associations between dissimilarity scores and psychological distress Dissimilarity scores were computed for

Table 3. Adjusted mean scores (standard deviation) of patients and partners ratings on different dimensions of illness representations
Dimension
Illness identity Timeline Consequences Personal control Treatment control Illness coherence Timelinecyclical Emotional representation Patient (n 58) 5.43 ( 2.72) 4.13 ( 0.60) 3.34 ( 0.82) 3.20 ( 0.83) 3.55 ( 0.56) 3.26 ( 1.15) 3.43 ( 0.75) 3.19 ( 0.84) Well partner (n 58) 5.63 ( 3.15) 3.90 ( 0.74) 3.30 ( 0.76) 3.04 ( 0.79) 3.43 ( 0.65) 3.57 ( 0.95) 3.41 ( 0.80) 2.85 ( 0.82)

Altered immunity Personality Accident Smoking Alcohol Ageing Emotional state Overwork Family problems Mental attitude Own behaviour Pollution Poor medical care Chance Diet Germ or virus Hereditary Stress or worry 0 10 20 30 40 50 60

Figure 2 Percentage of partners maximizing and minimizing & individual beliefs about causes of psoriasis.

the remaining illness representation categories (Table 5), and in order to examine whether divergent views on the representation of illness could help explain outcome in

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Table 4. Percentage of well partners agreeing, maximizing, and minimizing the symptoms associated with their partners psoriasis
Symptom Pain Stiff joints Skin burning Fatigue Upset stomach Nausea Sleep difculties Headaches Breathlessness Dizziness Wheeziness Loss of strength Sore eyes Sore throat Weight loss Skin itching Skin aking Agreement (%) 68.5 63.6 70.4 76.4 83.6 83.9 73.6 82.5 89.1 89.4 92.9 83.6 91.1 87.5 100 100 98.2 Maximizing (%) 18.5 18.2 16.7 14.5 12.7 12.5 11.3 10.5 7.3 7.1 7.1 5.5 5.3 1.8 0 0 0 Minimizing (%) 13 18.2 13 9.1 3.7 3.6 15.1 7 3.6 3.5 0 10.9 3.6 10.7 0 0 1.8

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anxiety, and depression), predictor variables were entered individually into the regression equation to see if they were independently related to the dependent variable of interest. The variables included in the analysis included: demographic variables of age and gender; clinical history variables of duration of psoriasis and age at onset; physical ndings of SAPASI; and divergence in illness perceptions of illness identity, causes, personal control, treatment control, consequences, illness coherence, emotional representations, timeline chronic, and timeline cyclical. Psoriasis patients From the initial examination of regressions for the above variables as independent predictors of anxiety, depression, worry, and disability, it was found that the independent predictor variables did not account for any signicant proportion of the variance in terms of anxiety, depression, or disability. The demographic variables of age and divergence in beliefs about emotional representations were, however, found to predict a signicant proportion of the variance in worry. At stage 2 only those variables that were signicantly associated with worry from this analysis were retained and entered into the regression analysis. Thus the demographic variable of age was entered in block one and the divergent belief about emotional representations was retained for entry at block 2. The results are presented below in Table 6, and signicant b values are in bold. The results indicate that divergence in illness beliefs did not make a signicant contribution to the variance in worry in psoriasis patients, over and above the age of the patient. Partners The predictor variables (age of partner, gender of partner, severity of patients psoriasis, and divergence in illness beliefs) were individually regressed onto each of the dependent variables for the partner (anxiety, depression, worry). In relation to anxiety, no variables were signicantly associated with anxiety with the exception of gender (F1,54 10.72, po.01). Initial examination of predictor variables in relation to depression indicated that both dissimilarity in emotional representations and timeline (acute/chronic) representations were independently associated with depression. Following the stage 2 analysis, both these variables accounted for 21.3% of the variance in depression and both standardized regression coefcients reached signicance (Table 7). The independent contribution of the predictor variables in relation to worry in partners was examined and indicated that gender, divergence in beliefs about consequences, and in beliefs about the cyclical nature of psoriasis were signicantly associated independently with worry in partners. These statistically signicant variables were moved to stage 2 of the analysis and entered in blocks into the regression equation. The results of this are presented in Table 8. Gender accounted for 17.2% of the variance and divergence in beliefs relating to consequences and cyclical timeline contributed an additional 24.8% of the variance in worry scores, with signicant standardized regression coefcients for gender and consequences. This suggests that for well partners, gender and divergence in beliefs about consequences may be important as risk factors in worry.

Table 5. Percentage of partners maximizing and minimizing on various illness belief dimensions in relation to the patient
Nature of dissimilarity Timeline Consequences Personal control Emotional impact Treatment control Illness coherence Timeline cyclical Illness identity (symptoms) Agreement (%) 70 66 72 59 73 72 70 74 Maximizing (%) 18 19 14 19 17 12 11 4 Minimizing (%) 12 15 14 22 10 16 19 22

psoriasis patients and their partners, a series of hierarchical multiple regression analyses were undertaken, predicting in turn psoriasis-related disability (for patients only), anxiety depression, and worry. The order of entry of the variables into the equations was assigned so as to permit the investigation that divergence in illness representations will account for unique variance in psychological outcome (anxiety, depression, worry, and disability) over and above demographic and physical variables. Firstly, to determine the entry of variables into the nal regression equations, at stage 1 for each of the outcome variables (disability, worry,

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Table 6. Regression analysis testing the signicance of change in explained variance on worry in patients with psoriasis
Variables Demographic Age Illness beliefs Emotional representations Adjusted R2 (%) 16.3 16.7 R2 change (%) 17.9 2.0 F 11.14 1.23 p o0.01 0.27 b 0.37 0.15

Table 7. Regression analysis testing the signicance of change in explained variance on depression in partners of patients with psoriasis
Adjusted R2 (%) 18.0 R2 change (%) 21.3

Variables Illness beliefs Emotional representations Timeline (acute/chronic)

F 6.37

o0.01
0.35 0.30

Table 8. Regression analysis testing the signicance of change in explained variance on worry in partners of patients with psoriasis
Adjusted R2 (%) R2 change (%)

Variables Demographic Gender Illness beliefs Cyclical representations Consequences

15.3 37.8

17.2 24.8

9.12 8.98

o0.01 o0.001

0.44 0.08 0.41

Discussion
This study examines psychological distress in partners of patients with psoriasis, and shows how areas of dissimilarity between the illness representations held by patients and their partners are associated with psychological outcomes of depression and worry. The study illustrates that when compared as two groups, patients and partners had very similar beliefs about psoriasis. Dissimilarity between patient and partner dyads on psoriasis beliefs, however, was related to psychological distress, in particular, for the partners of patients. There is a substantial body of evidence to suggest that the emotional impact of psoriasis is signicant (Fortune et al, 2000; 2002ac; Richards et al, 2001); however, the results of this study in relation to dissimilarity in illness representations suggest that this is not being recognized by partners and makes a signicant contribution to partner levels of distress. It is well established that patients with psoriasis feel stigmatized by their condition (Ginsburg and Link, 1989; Richards et al, 2001). It may be that in the same way that

individuals with psoriasis may avoid social situations for fear of the negative responses of others (Fortune et al, 1997), they also conceal the emotional impact of their psoriasis from their partners. Indeed, the stigma that accompanies many mental health problems often impedes seeking help. Recognition of such conditions and the difference between views held by patients and their partners can be seen to be congruent with this. Indeed, recent work has shown that patients with psoriasis use social support strategies, such as gaining sympathy or emotional support less frequently than control subjects (Fortune et al, 2002b). This suggests avoidance of engaging in strategies that may be helpful both in terms of coping and enhancing a partners understanding of psoriasis. Further substantiation of this thesis is enhanced by the nding that dissimilarity in emotional representations was independently associated with worrying for psoriasis patients. This has a number of implications. As we have previously reported (Fortune et al, 2003b), psychological distress in the form of excessive worrying is the principal predictor of time taken for photochemotherapy to clear psoriasis. Thus, it may be that a mismatch in beliefs surrounding the emotional impact of the condition and potentially avoiding disclosure of this emotional distress may have an impact on both psychological and clinical outcomes. Although there was no signicant difference between the number of symptoms (illness identity) that patients and their partners associated with psoriasis, there was disagreement over the types of symptoms experienced. This dichotomy was associated with increased depression in patients, a nding that lends credence to the suggestion that patients are not disclosing the physical aspects of the disease to their partners, thereby contributing to the divergence in beliefs. These results suggest that not only do patients feel they need to hide the physical symptoms of psoriasis but also the emotional difculties associated with the condition. Worry in well partners was associated with greater maximization of the consequences associated with having psoriasis. This is perhaps to be expected. If an individuals concerns about negative consequences associated with a condition are not matched by those of their ill partner, it is likely that they will engage in rumination in an attempt to prevent or avoid potential catastrophy related to such consequences. Worrying by partners may thus be viewed as an unhelpful coping strategy to help them manage with the uncertainties associated with the consequences of their partners condition. In this study, partners were found to have signicantly lower levels of psychological distress compared with patients with psoriasis, which is at variance with research in other chronic conditions (Croog and Fitzgerald, 1978; Flor et al, 1987; Walsh et al, 1999; Rideout et al, 1990). This

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Subjects The subjects consisted of patients with a dermatologistconrmed diagnosis of chronic plaque psoriasis and their partners. All psoriasis patients were recruited either from a psoriasis specialty clinic, general dermatology outpatient clinics, or an inpatient ward setting. Patients were eligible to participate if they agreed to their partner being involved in the study, the couple was living together in a committed relationship, and the partner had no other general medical condition. All patients and partners were English speaking and provided written informed consent. Procedure Psoriasis patients and their partners were instructed to complete the questionnaires independently and return them to the investigator in two separate self-addressed stamped envelopes. These questionnaires assessed various aspects of the patients and partners psychological and social functioning. In addition, demographic data and self-report information on the patients psoriasis were collected. The study was approved by Salford and Trafford Local Research Ethics Committee. Measures The following measures were completed by each patient with psoriasis: (1) Self-Assessment Psoriasis Area Severity Index (SAPASI; Feldman et al, 1996) comprises a single page questionnaire of an anterior and posterior silhouette of a body for the subject to shade areas affected by psoriasis and three visual analogue scales to indicate the degree of redness, scaling, and thickness of an average lesion. This provides an estimate of the physical severity of psoriasis. The SAPASI has been reported to be reliable and valid and correlate with standardized clinicianrated scales (Fleischer et al, 1994, 1996). (2) Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith, 1983) is a 14-item scale providing an assessment of symptoms of anxiety and depression and is suitable for use in medical and surgical patients. Items are rated on a 03 point scale indicating the strength of agreement with each item. A score of X 11 on either the anxiety or depression subscale of the HADS is representative of a high probability of suffering from anxiety or depression. Good reliability and validity coefcients have been reported (Lewis and Wessely, 1990). (3) Penn State Worry Questionnaire (PSWQ) is a 16-item selfreport scale purporting to measure the strength of pathological worry. Scores of above 60 are indicative of pathological worry. It has been demonstrated to be psychometrically sound with good testre-test reliability (r 0.93; Meyer et al, 1990; Davey, 1993) and high internal consistency in psoriasis (Cronbachs a 0.93; Fortune et al, 2000). (4) The Illness Perceptions Questionnaire-Revised (IPQ-R; MossMorris et al, 2002) provides a theoretically based measure of patients beliefs about their condition, which is suitable for use in any patient population. The original questionnaire (IPQ; Weinman et al, 1996) was recently revised to improve the psychometric properties of the original instrument and incorporate a number of previously neglected additional components of a patients implicit model of illness. The IPQ-R includes seven sub-scales (38 items), which attempt to operationalize the components of the common-sense model of illness held by patients. These subscales assess perceptions about how long psoriasis will last (timeline; six items including My psoriasis will last a short time, My psoriasis is likely to be permanent rather than temporary.); beliefs in the consequences associated with the condition (six items including: My psoriasis has had major consequences on my life, My psoriasis causes difculties for those who are close to me); beliefs about personal control (six items including: There is a lot which I can do to control my symptoms; Nothing I do will affect my psoriasis) and treatment control (5 items including: My treatment can control my psoriasis; There is nothing which can help my psoriasis); the individuals understanding of their condition (illness coherence; ve items including: The symptoms of my condition are puzzling to me; I have a clear picture or understanding of my condition); beliefs about the cyclical nature of the condition (four items including My psoriasis is very unpredictable, The symptoms of my psoriasis change a great deal from day to day); and the emotional representations associated with the illness (six items including: I get depressed when I think about my psoriasis;

nding may reect the non-life-threatening nature of psoriasis. Furthermore, if patients are concealing both the symptoms and the distress they experience from their signicant others, this may also contribute to reduced levels of distress in the partner cohort. There are a number of limitations to this study that should be considered. Firstly, as both patient and partner had to consent to participate it may be that only those couples who felt relatively condent in their relationship agreed to participate. Thus it may be that the results presented here are an underestimation of dissimilarities in understanding psoriasis and the distress associated with it for both patients and partners. Secondly, as patients and partners did not complete questionnaires in the presence of the researcher, it is possible that collusion took place in terms of completion of questionnaires and responses to items. But the lack of agreement on the symptoms associated with the condition and emotional representations suggests otherwise. Thirdly, as a cross-sectional study it is not possible to determine directionality or causality denitively. It remains conceivable that depression and worry in patients or their partners may contribute to lack of agreement. Indeed, recent studies have demonstrated the positive impact of group cognitive behavioral therapy on both psychological (anxiety and depression) and physical severity (Psoriasis Area and Severity Index) in the management of psoriasis (Fortune et al, 2002c). Such improvements were also in line with changes in illness representations for patients, particularly those concerning the consequences of their condition, illness identity, and attributions for emotional causes of their condition (Fortune et al, 2004). As such, further longitudinal studies are clearly required to substantiate this hypothesis. One further limitation is the absence of a description of the longevity of the relationship or an estimation of the quality of the relationship. This is potentially an area of importance, and we are currently undertaking an examination of such at present, focusing on the degree of criticism within the relationship, which may be perceived as contributing to everyday stress. Clearly, further research will be well placed, examining the families and partners of individuals with psoriasis. This study offers an insight into the way in which divergence, in terms of the way psoriasis is thought about by patient and partner, may have an impact on psychological and clinical outcome. Furthermore, the potential importance of working with psoriasis patients within their psychosocial environment, that is, including their partner has been highlighted. Indeed, interventions involving partners have proved useful for both patients and partners in other chronic conditions including pain (Keefe et al, 1996), rheumatoid arthritis (Radojevic et al, 1992), and cardiac illness (Daugherty et al, 2002). Moreover, the results illustrate the importance of concordance between patients and partners models of psoriasis in relation to adjustment, and highlight the need to consider and collaborate with both patients and their partners in managing this challenging condition. Methods
Design Cross-sectional study of patients with psoriasis and their partners.

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My psoriasis does not worry me). An adjusted mean score (sum of the scale items divided by the number of items) is calculated for each of the sub-scales outlined above, with a possible maximum of 5 for each sub-scale. Illness identity or symptoms experienced since the onset of the condition is assessed by 17 items, including pain, stiff joints, skin burning, skin itching, and skin aking. Individuals are required to respond afrmatively or not to the existence of such symptoms in relation to their condition. The nal scale of the IPQ-R measures personal ideas about the cause of psoriasis. The scale requires patients to identify what they believe is responsible for onset or exacerbations of their condition. Items are assumed to be independent and as such are not summed to form a total score. Eighteen causes of the illness are identied, including stress or worry, hereditary, my immunity, my personality, and aging, and these are scored on a ve-point scale from 1 (strongly disagree) to 5 (strongly agree). The spouse or partner was required to complete the same psychometric assessments as the patient with psoriasis with the exception of the SAPASI. They also completed a spouse/partner version of the IPQ-R. The partner version of the IPQ and IPQ-R has been used in a number of studies (Heijmans et al, 1999; Barrowclough, Lobban, Hatton & Quinn, 2001), whereby items are phrased to ascertain the partners perception of their spouses psoriasis, for example, My partners psoriasis is very unpredictable; My partners actions will have no affect on the outcome of their psoriasis. Calculation of dissimilarity scores Dissimilarity scores (Heijmans et al, 1999) were calculated for each of the illness perceptions dimensions. For the seven subscales of the IPQ-R, these were achieved by subtracting partners scale scores from psoriasis patients scale scores, thereby creating a continuous variable representing the direction of difference from the patients belief. Subsequently, for each of the subscales, the mean and standard deviation (SD) in dissimilarity scores were calculated. In order to account for normal variability between patients and partners scores, those scoring within 1 SD either side of the mean for that scale were classied as congruent, those less than 1 SD as minimizing, and more than 1 SD maximizing for that particular scale. In relation to the illness-identity scale (symptoms associated with psoriasis), agreement on the number of symptoms experienced as well as agreement on which particular symptoms were experienced was calculated. For the cause subscale, scores relating to agreement, minimization, or maximization were calculated for individual causal items. Thus overall, partners scores that were less than those of the patients on particular representations were termed minimizing (i.e., the partner did not believe that particular aspect to be as signicant as the patient reported) and partners scores that were greater were termed maximizing (i.e., the partner believed the impact to be greater than the patient reported). All correlations were calculated using these dissimilarity scores. Statistical analysis Data were analyzed using SPSS. Independent t test models were used to examine the differences between psychological distress variables in patients and their partners. Multivariate analysis of variance was used to examine differences in illness beliefs between patients and partners. Kendalls tau (t) correlation coefcient was used to examine associations between dissimilarity in illness beliefs between patients and partners and their association with psychological distress. Values are presented as mean SD.

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Address correspondence to: Dr Helen L. Richards, Department of Behavioral Medicine, University of Manchester Clinical Sciences Building, Hope Hospital, Salford, Manchester M6 8HD, United Kingdom. Email: hrichard@fs1.ho.man.ac.uk

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This study was supported in part by a grant from the Psoriasis Support Trust, London, UK. DOI: 10.1111/j.0022-202X.2004.22703.x Manuscript received May 27, 2003; revised January 12, 2004; accepted for publication February 4, 2004

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