Effect of written emotional disclosure interventions in persons with psoriasis undergoing narrow band ultraviolet B phototherapy

ARTICLE

Auteur(s) : Andrea Paradisi¹, Damiano Abeni¹, Enzo Finore¹, Cristina Di Pietro¹, Francesca Sampogna¹, Cinzia Mazzanti², Maria Antonietta Pilla², Stefano Tabolli¹

¹Health Services Research Unit, IDI-IRCCS, Via dei Monti di Creta 104, 00167, Rome, Italy
²Phototherapy Unit, IDI-IRCCS, Rome, Italy

accepté le 27 Avril 2010

Psoriasis is a common inflammatory condition characterized clinically by red, scaly plaques of the skin. In about 15% of patients it is associated with inflammatory arthritis. The disease adversely affects psychological and social functioning of patients, who often are stigmatized [1, 2]. The association between psoriasis and psychological or psychiatric disorders is well documented. Psychological distress frequently develops secondary to the psychosocial impact of psoriasis, but it has also been suggested that it can be a causative or compounding agent, or a factor underpinning disease persistence. As a result, a growing amount of literature suggests that addressing psoriatic patients’ psychological needs may produce both psychological and physical benefits [3]. Emotional writing disclosure (ED) is a short-term psychological intervention that has been successfully used in several controlled studies in a variety of conditions [4, 5]. Recently, Vedhara and coworkers [6] showed that changes in mood following ED predicted improvements in disease severity in patients affected by psoriasis.

The aim of our randomized controlled study was to investigate whether two different techniques of ED affected the outcome of a standardized clinical intervention such as narrow band ultraviolet B (UVB-NB) therapy in psoriatic patients. Psoriasis was chosen for two main reasons. First, because it is a chronic debilitating disease, whose symptoms are often exacerbated by stressful events; any intervention that lessens distress thus has the potential to reduce the risk or severity of flare-ups. Second, psoriasis is an immune-mediated inflammatory skin disease. These data, combined with evidence suggesting that ED can modulate the immune response [7, 8], led us to test whether this intervention could reduce inflammation, hence symptom severity, and eventually result in improved physical and emotional well-being.

Materials and methods

Subjects

One hundred consecutive adult (≥ 18 years old) patients with plaque-type psoriasis and at least 10% of body surface area involvement, who were scheduled for UVB-NB phototherapy at the Phototherapy Unit of IDI-IRCSS, were contacted.

Inclusion criteria were psoriasis involving > 10% of body area, age > 18 years, being able to read, write and appropriately fill in the self-administered instruments (written in Italian). Subjects undergoing psychotherapy or behavioral therapy were excluded. Patients were asked to avoid any systemic treatment for psoriasis for at least 1 month before beginning UVB-NB therapy. Those with pronounced scaling applied 5% salicylic acid ointment for 5 days before the beginning of the study to enhance UVB transmission. Other topical treatments were not allowed for at least 2 weeks before the study.

Patients who fulfilled inclusion/exclusion criteria and gave their written informed consent were randomly assigned to three groups: emotional Pennebaker writing (PW); emotional King writing (KW), and the control non-ED group (CG).

Patients were assigned to the groups according to a randomization list prepared and kept by a member of the unit not involved in patient enrollment, treatment, or assessment. The list was prepared with manual procedures starting from tables of random numbers, using the Moses/Oakford algorithm [9]. The randomization was in blocks of variable numbers, to reduce predictability of future allocation while ensuring that in each recruiting period the ratio between the number of subjects included in the three study groups was near the final expected ratio of 1:1:1.

The investigation involved a baseline assessment (T₀); three consecutive ED sessions (for the emotional Pennebaker writing and emotional King writing groups); UVB-NB phototherapy (2 months), with an assessment midway through therapy (T₁) and one at the end of treatment (T₂); and a follow-up assessment (4 months after ED, T₃).

Experimental conditions

Briefly, the emotional Pennebaker writing method asks patients to describe the worst experience in their lives related to their disease, as follows [10]:

“Over the next 20 minutes, please write about your deepest thoughts and feelings about your experience with psoriasis. If you don't feel you have had a traumatic experience, you can choose to write about major conflicts or problems that you have experienced or are experiencing now. Ideally, we would like you to write about significant experiences or conflicts that you have not discussed in great detail with others. You might tie your personal experiences to other parts of your life. How is it related to your childhood, your parents and/or people you love? Whatever you choose, it is critical that you really delve into your deepest emotions and thoughts. I want you to really let go and explore your very deepest feelings and thoughts”.

In the modified protocol developed by King [11] participants are asked to write about their best possible future self- and life-goals, as follows:

“Think about your life in the future. Imagine that everything has gone as well as it possibly could, and the desires related to the psoriasis have been realized. You have worked hard and succeeded at accomplishing all of your life goals. Think of this as the realization of all of your life dreams. Now, over the next 20 minutes, write about what you imagined.”

In each ED session, held at IDI-IRCCS, participants were free to write about the same or different events. After each writing session patients were directed to phototherapy.

Narrow-band UVB irradiation (311 nm) was used. The minimal erythema dose (MED) was assessed before the beginning of treatment to determine the starting dose. MED was tested by exposing each of 6 uninvolved and untanned skin templates measuring 2 cm² to incremental doses of 0.1, 0.2, 0.4, 0.6, 0.8 and 1 J/cm². MED was rated visually and defined as the dose producing barely detectable erythema with sharp borders 24 h after irradiation. The starting dose was 70% of MED (visit 1). Then the dose was increased by 20% of MED until visit 8, and thereafter by 10%. If erythema developed, the dose was adjusted depending on erythema severity. Patients were treated 3 times a week until complete remission, or for a maximum of 8 weeks (24 sessions). Patients were free to use an emollient on treatment-free-days. All systemic treatments for psoriasis were withdrawn throughout the study.

Median values and range were calculated for all scores (PASI, SAPASI, Skindex-29, and GHQ-12). The Wilcoxon test for paired samples was used to evaluate differences over time within each group, The χ² test was applied to compare frequencies between groups for categorical variables. A p-value < 0.05 was considered significant.

All statistical analyses were performed with the STATA statistical software, (release 9.0; Stata Corporation, College Station, TX, USA).

Outcome measures

The Self-Administered Psoriasis Area and Severity Index (SAPASI), a patient-rated psoriasis specific outcome measure, is a widely validated instrument that provides an objective measure of disease severity [13], and has been effectively used in previous studies [14].

The Skindex-29 has been shown to be a valuable tool for measuring health-related Quality of Life (QoL) in dermatological patients [15]. Its Italian version has been developed following guidelines for the cross-cultural adaptation of health-related QoL measures and validated in a previous survey [16].

The General Health Questionnaire-12 (GHQ-12), a useful and reliable instrument for detecting current non-psychotic psychiatric disorders both in general practice settings and in the community, has recently been used and validated in a dermatological setting [17]. The GHQ-12 can be scored with two different methods. The binary method (0-0-1-1) yields dichotomous scores and is used to screen for psychiatric disorders, whereas the Likert method (0-1-2-3) yields ordinal scores and is used to measure psychological distress.

PASI, SAPASI, Skindex-29, and GHQ-12 scores were obtained at baseline and then halfway through and at the end of UVB-NB treatment. Participants were mailed the follow-up questionnaires (SAPASI, Skindex-29, and GHQ-12) two months after the end of phototherapy and returned them by mail.

Results

A highly significant decrease in PASI scores from the beginning (T0) to the end of phototherapy (T2) was observed in all groups (p = 0.013, p = 0.003, and p = 0.003 in emotional Pennebaker writing, emotional King writing and control non-ED patients, respectively), indicating disease remission.

The SAPASI scores also fell sharply. In fact, the comparison of SAPASI scores at the 4 time points (figure 2) showed that 2 months after the ED sessions all groups had similar responses to phototherapy, with complete or almost complete remission of psoriasis. However, in the interval between the end of therapy and the final assessment the SAPASI scores rose significantly in emotional King writing and control non-ED patients (control non-ED group, p < 0.05; emotional King writing p = 0.07); in the emotional Pennebaker writing group such differences were minimal and not significant.

A significant difference (p < 0.05) between baseline and final SAPASI scores was also found in the emotional Pennebaker writing group, while in the other groups the difference between T₀ and T₃ was not significant.

Baseline (T₀) and final (T₃) Skindex-29 scores (table 2) were not significantly different in any patient group; however in the time between the end of UVB-NB therapy and the final assessment, the Skindex-29 scores of emotional King writing patients increased significantly in the emotions (p: 0.01) and symptoms (p: 0.01) scales and in control non-ED patients in the emotions (p: 0.01) and functioning (p: 0.04) scales, while emotional Pennebaker writing patients did not experience a significant increase in any of the Skindex-29 scales.

Table 2 shows the trend in median GHQ scores for the three groups. Baseline scores were lower (although not significantly so, p = 0.34) in emotional Pennebaker writing than in control non-ED subjects. The difference between T₀ and T₃ nearly achieved statistical significance for the emotional Pennebaker writing group (0.056), while in the control non-ED group the p-value was 0.670.
Table 1 Baseline characteristics of experimental emotional (Pennebaker writing and emotional King writing) and control (control non-ED group) psoriatic patients

Discussion

Written ED is a short-term psychological intervention with proven health benefits in a variety of populations. Most studies concern healthy adults [18-20]. A meta-analysis concluded that the procedure reliably improved health outcomes [21]. Application to individuals with medical illness yielded less consistently positive outcomes. Although ED usually involves an immediate increase in negative mood, it eventually leads to reduced stress and physical symptoms and better health care utilization [22]. It is well recognized that writing about traumatic experiences can carry benefits for both healthy individuals and those with chronic diseases, including asthma, rheumatoid arthritis, and HIV infection [23-25]. A study of patients with early-stage breast cancer showed a reduction in physical symptoms and fewer medical appointments for cancer-related morbidities in women randomized to written ED than in controls [26].

Various mechanisms have been proposed to explain the effects of ED. Cognitive processing of the traumatic memory seems to transduce it into a linguistic structure that promotes assimilation and understanding of the event [10]. However, changes in mood may be the mechanism by which it influences the course of psoriasis [6].

ED also produces changes in immune functioning, like increased proliferation of T-helper cells in response to blastogenic stimulation [27], reduction in titers of serum antibody to Epstein-Barr virus [28], and improved responses to hepatitis B vaccination [29].

Psoriasis is a chronic, immuno-mediated skin disease where distress affects QoL [30], disease severity [31] and treatment efficacy [32]. Moreover, some stress-induced effects on circulating lymphocytes have recently been demonstrated, with implications for the cutaneous inflammation in psoriasis [33]. This has suggested the usefulness of biopsychosocial interventions. Tausk et al. [34] evaluated the effect of hypnosis as a treatment modality in psoriasis, suggesting that it can be useful in highly hypnotizable subjects, although a very small number of patients was studied. Fortune et al. [35] demonstrated in a case-control study that an adjunctive cognitive-behavioral symptom management program delivered by medical, psychology and nursing staff is beneficial in these patients. Kabat-Zinn et al. [36] have provided indirect evidence that stress may impair the efficacy of systemic treatments. Psoriasis patients who received audio-taped stress management instructions while undergoing UVB therapy or photo-chemotherapy (PUVA) had a significantly shorter time to clearance than those receiving standard treatment. In addition, psychological factors in the form of pathological worrying have a significant influence on PUVA effectiveness, so much so that low worriers are twice as likely to achieve clearance than their high-worry counterparts [37]. In the only study [6] of ED on 59 patients with psoriasis, changes in mood following ED predicted improvement in disease severity, even though the degree of improvement did not differ between ED and control subjects. However, in that study the control group also received a writing intervention, on a supposedly neutral topic.

ED may provide therapeutic benefit due to the additional care received by patients or the non-specific beneficial effects that result from writing per se [38], thus also modifying outcomes in control patients.

Although writing about life-goals and positive experiences (emotional King writing protocol) also has salutary effects on physical health [11, 39], we found a consistent benefit only in emotional Pennebaker writing patients, that involved both clinical outcome and the Skindex-29 QoL parameters. This is probably related to the fact that psoriatic patients suffer much greater stress than the general population, and the positive writing technique (emotional King writing) is unlikely to achieve the expected results in individuals experiencing “too much stress” [40].

The significant increase previously observed in subjective well-being due to emotional King writing could depend on the fact that it was generally studied in young healthy individuals [11], who may be more optimistic about their future (and benefit more) than individuals in less advantaged situations and with chronic diseases.

The improvement of emotional Pennebaker writing patients at 4 months was in line with that reported in most studies, which documented greater psychological well-being and health variables not earlier than 3-4 months [24, 41]. However in some disorders, such as asthma, benefits seem to be rapid, within two weeks of ED [24]. Different mechanisms, possibly related to the immune response, may be hypothesized in different conditions.

Despite the interest of these preliminary data, the adoption of ED as supplemental therapy for psoriasis requires thorough evaluation. First, our small sample does not support powerful statistics. Given the low response rate and the high proportion of patients lost to follow-up, our data cannot be generalized to all the patients with psoriasis, and it also stresses the difficulties encountered with this intervention. Patients must be clearly motivated and convinced that they should have an active role in the therapeutic process. They also must agree to interrupt any other systemic and topical psoriasis treatment, except emollients on treatment-free-days, to remove any factors that may affect the main outcome measure.

The logistics of ED, involving activities on three consecutive days, may yield greater participation in places with less traffic and/or better transportation than Rome. These considerations also demonstrate that ED requires an ad hoc organization.

Although more patients who are, or think they are more “susceptible” to this kind of intervention may have accepted to participate in and completed the study while others left it, randomization should have ensured internal validity.

As regards the main outcome measure, although the SAPASI scale is admittedly patient-centered (and thus subjective), its close relation to PASI scores has nonetheless been consistently documented [42-44].

Another limitation of the study is the short follow-up. Even though the emotional Pennebaker writing protocol was the more effective in maintaining the clinical benefits of UVB-NB, follow-up period after treatment was 2 months. It is impossible to say whether the effects of emotional Pennebaker writing would have persisted beyond that period, but it cannot be excluded that if the different trends had been maintained the difference between the groups would have grown.

Finally, even though groups differed at T₀ for SAPASI values, mainly due to patients lost at follow-up, the highest SAPASI score was that of the emotional Pennebaker writing group, and at T₃ they showed the lowest SAPASI score. This strengthens our conclusions on the positive effect of emotional Pennebaker writing on clinical severity.

These data, while stressing the need for a carefully planned intervention in a conducing environment with dedicated personnel, warrant further research on the value of structured ED in psoriasis treatment.

Acknowledgments

Conflict of interest: none.

References

2 Vardy D, Besser A, Amir M, Gesthalter B, Biton A, Buskila D. Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients. Br J Dermatol 2002; 147: 736-42.

3 Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders – epidemiology and management. Am J Clin Dermatol 2003; 4: 833-42.

4 Fawzy I, Fawzy N, Hyun C, et al. Malignant melanoma: effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 1993; 50: 681-9.

5 Spiegel D, Bloom J, Kraemer H, Gottheil E. Effects of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989; 2: 888-91.

6 Vedhara K, Morris RM, Booth R, Horgan M, Lawrence M, Birchall N. Changes in mood predict disease activity and quality of life in patients with psoriasis following emotional disclosure. J Psychosom Res 2007; 62: 611-9.

7 Booth RJ, Petrie KJ, Pennebaker JW. Changes in circulating lymphocyte numbers following emotional disclosure: evidence of buffering. Stress Med 1997; 13: 23-9.

8 Knapp PH, Levy EM, Giorgi RG, Black PH, Fox BH, Heeran TC. Short-term immunological effects of induced emotion. Psychosom Med 1992; 54: 133-48.

9 Moses LE, Oakford RY. Tables of Random Permutations. Stanford, Calif: Stanford University Press, 1963.

10 Pennebaker JW. Writing about emotional experiences as a therapeutic process. Psychol Sci 1997; 8: 162-6.

11 King LA. The health benefits of writing about life goals. Pers Soc Psychol Bull 2001; 27: 798-807.

12 Carlin CS, Feldman SR, Krueger JG, Menter A, Krueger GG. A 50% reduction in the Psoriasis Area and Severity Index (PASI50) is a clinically significant endpoint in the assessment of psoriasis. J Am Acad Dermatol 2004; 50: 859-66.

13 Feldman SR, Fleischer Jr AB, Reboussin DM, et al. The self-administered psoriasis area and severity index is valid and reliable. J Invest Dermatol 1996; 106: 183-6.

14 Sampogna F, Sera F, Mazzotti E, Pasquini P, Picardi A, Abeni D, IDI Multipurpose Psoriasis Reasearch on Vital Experiences (IMPROVE) Study Group. Performance of the self-administered psoriasis area and severity index in evaluating clinical and sociodemographic subgroups of patients with psoriasis. Arch Dermatol 2003; 139: 353-8.

15 Chren M, Lasek RJ, Flocke SA, Zyzanski SJ. Improved discriminative and evaluative capability of a refined version of Skindex, a quality-of-life instrument for patients with skin diseases. Arch Dermatol 1997; 133: 1433-40.

16 Abeni D, Picardi A, Pasquini P, Melchi CF, Chren MM. Further evidence of the validity and reliability of the Skindex-29: an Italian study on 2,242 dermatological outpatients. Dermatology 2002; 204: 43-9.

17 Picardi A, Abeni D, Melchi CF, Puddu P, Pasquini P. Psychiatric morbidity in dermatological outpatients: an issue to be recognised. Br J Dermatol 2000; 143: 983-91.

18 Ullrich PM, Lutgendorf SK. Journaling about stressful events: effects of cognitive processing and emotional expression. Ann Behav Med 2002; 24: 244-50.

19 Cameron LD, Nicholls G. Expression of stressful experiences through writing: effects of a self-regulation manipulation for pessimists and optimists. Health Psychol 1998; 17: 84-92.

20 Klein K, Boals A. Expressive writing can increase working memory capacity. J Exp Psychol Gen 2001; 130: 520-33.

21 Smyth JM. Written emotional expression: effect sizes, outcome types, and moderating variables. J Consult Clin Psychol 1998; 66 :174-84.4

22 Sloan DM, Marx BP. A closer examination of the structured written disclosure procedure. J Consult Clin Psychol 2004; 72: 165-75.

23 Kelley JE, Lumley MA, Leisen JCC. Health effects of emotional disclosure in rheumatoid arthritis patients. Health Psychol 1997; 16: 331-40.

24 Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA 1999; 281: 1304-9.

25 Petrie KJ, Fontanilla I, Thomas MG, Booth RJ, Pennebaker JW. Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: a randomized trial. Psychosom Med 2004; 66: 272-5.

26 Stanton AL, Danoff-Burg S, Sworosky LA, et al. Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients. J Clin Oncol 2002; 20: 4160-8.

27 Pennebaker JW, Kiecolt-Glaser JK, Glaser R. Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clin Psychol 1988; 56: 239-45.

28 Esterling B, Antoni M, Fletcher M, Marguiles S, Schneiderman N. Emotional disclosure through writing or speaking modulates Epstein-Barr virus antibody titres. J Consult Clin Psychol 1994; 10: 334-50.

29 Petrie KJ, Booth RJ, Pennebaker JW, Davison KP, Thomas MG. Disclosure of trauma and immune response to a hepatitis B vaccination program. J Consult Clin Psychol 1995; 63: 787-92.

30 O'Leary CJ, Creamer D, Higgins E, Weinman J. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res 2004; 57: 465-71.

31 Picardi A, Abeni D. Stressful life events and skin diseases: disentangling evidence from myth. Psychoter Psychosom 2001; 70: 118-36.

32 Fortune DG, Richards HL, Kirby B, et al. Psychological distress impairs clearance of psoriasis in patients treated with photochemotherapy. Arch Dermatol 2003; 139: 752-6.

33 Schmid-Ott G, Jaeger B, Boehm T, et al. Acute psychological stress induces different phenotypic changes in circulating lymphocyte populations in psoriasis patients compared to healthy controls. Brit J Dermatol 2009; 160: 782-5.

34 Tausk F, Whitmore SE. A pilot study of hypnosis in the treatment of patients with psoriasis. Psychother Psychosom 1999; 68: 221-5.

35 Fortune DG, Richards HL, Kirby B, Bowcock S, Main CJ, Griffiths CE. A cognitive behavioural symptom management programme as an adjunct in psoriasis therapy. Br J Dermatol 2002; 146: 458-65.

36 Kabat-Zinn J, Wheeler E, Light T, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med 1998; 60: 625-32.

37 Kirby B, Richards HL, McElhone K, et al. Psychological distress affects the efficacy of PUVA in patients with psoriasis. Br J Dermatol 2000; 143 (Suppl.57): 15-6.

38 Wetherell M, Byrne-Davis L, Dieppe P, Byron M, Horne R, Weinman J, et al. The effects of emotional disclosure on psychological and physiological outcomes in patients with rheumatoid arthritis: an exploratory home-based study. J Health Psychol 2005; 10: 277-85.

39 Burton CM, King LA. The health benefits of writing about intensely positive experiences. J Res Pers 2004; 38: 150-63.

40 Biswas-Diener R, Dean B. “Positive Psychology Coaching”, 2007, ed. John Wiley & Sons, Inc.

41 Broderick JE, Junghaenel DU, Schwartz JE. Written emotional expression produces health benefits in fibromyalgia patients. Psychosom Med 2005; 67: 326-34.

42 Sampogna F, Sera F, Abeni D, IDI Multipurpose Psoriasis Research on Vital Experiences (IMPROVE) Investigators. Measure of clinical severity, quality of life, and psychological distress in patients with psoriasis: a cluster analysis. J Invest Dermatol 2004; 122: 602-7.

43 Sampogna F, Tabolli S, Abeni D, IDI Multipurpose Psoriasis Research on Vital Experiences (IMPROVE) Investigators. The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study. Br J Dermatol 2007; 157: 508-13.

44 Henseler T, Schmitt-Rau K. A comparison between BSA, PASI, PLASI and SAPASI as measures of disease severity and improvement by therapy in patients with psoriasis. Int J Dermatol 2008; 47: 1019-23.