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COMMENT ON "PERSONALITY DISORDERS AND PSYCHIATRlC SYMPTOMS IN PSORIASIS": A CRITICAL ANALYSIS

Tokyo Institute of Psychiatry

Psychological Reports, 78:1265-1266; 1996.

Summary.-In 1995 Rubino, et al. reported that a cluster analysis provided evidence for four different personalities in patients with psoriasis. Because they did not include controls with other disfiguring chronic dermatologic conditions, did not relate severity of disfigurement or chronicity of the psoriasis with personality dysfunction, and did not assess pre- and post-onset of psoriasis personality structure, we do not think it is prudent at this time to draw conclusions about personality and psoriasis.

Psoriasis is a skin condition which has often been ascribed to stressful situations and emotional disturbances (2, 5). Several psychosomatic studies on the etiology of psoriasis have focused on the role of personality (2, 5, 6); however, no report has addressed the question of a single personality for patients with psoriasis. Rubino, et al. (6) reported four different personality clusters for patients with psoriasis: (a) avoidant, dependent, schizoid, and self-defeating, (b) compulsive, narcissistic, and aggressive, (c) no personality disorder, and (d) borderline, paranoid, and schizotypal, etc.

We think that Rubino, et al.'s statement that "These findings firmly confirm a massive comorbidity of psoriasis with DSM-III-R personality disorders" (p. 552) is premature. Other patients with chronic disfiguring dermatologic conditions are the appropriate controls for this study rather than dental and surgical patients (who usually have acute problems), and both patients and controls would need to be studied before and after the onset of their conditions. Given this, it is not clear whether the personality traits found by Rubino, et al. are long-standing phenomena present well before the onset of the psoriasis or are just state-traits secondary to the illness itself.

In DSM-IV (1) personality disorder is defined as "an enduring pattern of inner experience that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" (p. 629). Consequently, personality traits that may be secondary to the psoriasis or another disfiguring condition may not be enduring, may not have begun in adolescence or early adulthood, and may not be stable over time, i.e., they may be state-related phenomena and not enduring traits.

Patients with psoriasis have considerable stress from disfigurement and any correlation of amount of disfigurement (and also perceived disfigurement) with severity of personality dysfunction should be studied to rule out the effect of this variable on the development of traits that resemble personality disorder. This was not done in the Rubino, et al. study. Many prior reports have noted the difficulty patients with psoriasis have with disfigurement (3, 4).

In summary, because Rubino, et al. did not control for other disfiguring chronic dermatologic conditions, did not relate severity of disfigurement or chronicity of the psoriasis with personality dysfunction, and did not assess pre- and post onset of psoriasis personality structure, i.e., their study was done at one time-point and is therefore cross-sectional, it is prudent to postpone any conclusions about personality and psoriasis at this time.

REFERENCES

1. AMERICAN PSYCHIATRIC ASSOCIATION. (1994) Diagnostic and Statistical Manual of Mental Disorders. (4th ed., Rev.) Washington, DC: American Psychiatric Press.

2. FAVA, G., PERINI, G. I., SANTONASTASO, P., & VELLER FORNASA, C. (1980) Life events and psychological distress in dermatologic disorders: psoriasis, chronic urticaria and fungal infections. British Journal of Medical Psychology, 53, 277-282.

3. GUPTA, M. A., & GUPTA, A. K. (1995) The Psoriasis Life Stress Inventory: a preliminary index of psoriasis-related stress. Acta Dermato Venereologica, 175, 240-243.

4. LASSUS, A., & FORSSTROM, S. A. (1991) Double-blind study comparing oleum horwathiensis with placebo in the treatment of psoriasis. Journal of International Medical Research, 19, 137-146.

5. PANCONESI, E. (1984) Psychosomatic dermatology. In E. Panconesi (Ed.), Stress and skin disease: psychosomatic dermatology. Clinics in Dermatology. Vol, 2, No. 4. Philadelphia, PA: Lippincott. Pp. 125-131.

6. RUBINO, I. A., SONNINO, A., PEZZAROSSA, B., CIANl, N., & BASSI, R. (1995) Personality disorders and psychiatric symptoms in psoriasis. Psychological Reports, 77, 547-553.

Accepted May 3. 1996.