|Year : 2019 | Volume
| Issue : 2 | Page : 62-67
Association between psychiatric morbidity, coping, and quality of life in psoriasis: A cross-sectional study
Vaditya Lakshmi Momini1, Vikas Menon2, Malathi Munisamy3
1 7th Semester MBBS Student, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||07-Sep-2019|
|Date of Acceptance||14-Sep-2019|
|Date of Web Publication||02-Jan-2020|
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Background: Psychological factors are key determinants of outcomes in psoriasis. Little is known about burden of psychological morbidity, coping styles of patients with psoriasis, and relationship between coping styles, psychiatric morbidity, and quality of life (QoL) in this group. Methods: A cross-sectional, comparative study was carried out on cases with psoriasis and apparently healthy age- and gender-matched controls (n = 72 each). Both groups were compared on depression, anxiety, QoL, and coping preferences using standard measures. Multiple linear regression (MLR) analysis was used to assess predictors of depression and anxiety in psoriasis. Results: Cases with psoriasis had less schooling (P < 0.001) and belonged to lower socioeconomic class (P = 0.005). They also preferentially used emotion-focused coping strategies (P = 0.007) compared to controls and scored higher on depression and anxiety and had poorer QoL across all domains (P < 0.001 for all comparisons). In MLR analysis, female gender (B = 3.04, 95% confidence interval [CI] = 1.22–4.86, P = 0.001), lower QoL (B = −0.06, 95% CI = −0.12–−0.01, P = 0.033), and higher anxiety (B = 0.68, 95% CI = 0.45–0.91, P < 0.001) were the predictors of depression while higher depression (B = 0.57, 95% CI = 0.39–0.76, P < 0.001) predicted anxiety in psoriasis. Conclusion: Significantly, higher psychiatric morbidity, poorer QoL, and maladaptive coping are present in patients with psoriasis when compared with controls. Gender appears to be an important moderator in the relationship between psoriasis and depression.
Keywords: Asia, coping, depression, gender, psoriasis
|How to cite this article:|
Momini VL, Menon V, Munisamy M. Association between psychiatric morbidity, coping, and quality of life in psoriasis: A cross-sectional study. Int J Adv Med Health Res 2019;6:62-7
|How to cite this URL:|
Momini VL, Menon V, Munisamy M. Association between psychiatric morbidity, coping, and quality of life in psoriasis: A cross-sectional study. Int J Adv Med Health Res [serial online] 2019 [cited 2020 Jul 11];6:62-7. Available from: http://www.ijamhrjournal.org/text.asp?2019/6/2/62/274622
| Introduction|| |
Psoriasis is a chronic autoimmune psychocutaneous dermatologic disease, which has a visible deleterious effect on one's physical appearance. Psychiatric and psychological factors may play an important role in a significant percentage of patients with psoriasis. Although psychiatric comorbidity such as depression may be primary or secondary to the disease, growing evidence indicates that in many cases, these comorbidities may robustly predict clinical outcomes and impairments in quality of life (QoL) independent of disease severity., This assertion is further supported by studies that point to stable or deteriorating QoL indices in psoriasis despite clinical improvement., The answer to this may be the psychological distress that is experienced by many patients. This provides strong reasons to study the magnitude and correlates of psychological distress in psoriasis so that clinicians can identify such presentations more efficiently and institute prompt management to optimize clinical outcomes.
Psychiatric factors have been found to influence clinical outcomes in psoriasis, even independent of disease severity. Knowledge about the levels of psychiatric morbidity, QoL and factors influencing the same would inform management strategies aimed at optimizing outcomes. Psychological stress, which has been linked to exacerbations of psoriasis, has also been consistently linked with deficits in personality and coping skills in dermatological and nondermatological clinical populations., Coping refers to a set of cognitive and behavioral strategies employed by patients in response to a stressor and has been shown to influence depression and QoL in psoriasis. Based on this premise, it appears that coping may be a key intermediate variable on the causal pathway between stress and psychological morbidity/QoL in psoriasis. This purported association may be relevant from treatment perspective too as coping strategies can be modified through appropriate therapy. It may also differ across ethnic and cultural settings and merits evaluation.
Limited data are present on the relationship between disease severity in psoriasis and psychiatric comorbidity patterns, coping strategies employed by patients, and its relationship with psychological morbidity. To answer these questions, we planned the present research with two objectives: (1) to compare psychiatric morbidity, coping, and QoL in psoriasis with an apparently healthy control group and (2) to assess the relationship between psychiatric morbidity, coping, and QoL in psoriasis and identify independent predictors of depression and anxiety in this group.
| Methods|| |
Setting and design
This was a comparative, cross-sectional study carried out in collaboration between departments of psychiatry and dermatology at a tertiary care cum teaching hospital in southern India. The hospital is located in an urban area of Puducherry, southern India, and receives both direct and referred cases in the outpatient department. Data collection was done in the specialty weekly psoriasis clinic of the department of dermatology.
Subjects and methods
We included all consecutive patients with psoriasis in the age group of 18–65 years. Apparently healthy age-matched controls (±5 years) were recruited from voluntary blood donors attending the institute's blood bank. Those who were found to be having any physical morbidity, following the blood bank screening protocol, were excluded. Patients diagnosed with chronic diseases, such as hepatic, cardiac, renal diseases, carcinomas, pregnant, or those who have delivered in the last 1 year were excluded. To rule out psychological morbidity among the controls, we used the Modified MINI Screen instrument.
Sample size calculation
To have 80% power of detecting a difference of 18% in proportion of patients with depression between psoriasis and the control group, assuming a type I error of 5%, we calculated a sample size of 72 in each group.
Baseline sociodemographic details were collected using a semi-structured proforma for both groups. Socioeconomic status was assessed using the modified BG Prasad socioeconomic classification scale (2016). In patients with psoriasis, the disease severity was additionally assessed using psoriasis area severity index (PASI). Subsequently, all subjects were rated on the following instruments:
- Patient health questionnaire-9 (PHQ-9) refers to a 9-item self-administered depression module of larger PHQ, which in turn is derived from the PRIME-MD scale for the assessment of common mental disorders., It is a widely used multipurpose measure to screen for as well as monitor the severity of depression. Scores of 5, 10, and 15 have been recommended by the developers as the cutoff for making a diagnosis of mild, moderate, and severe depression
- Generalized anxiety disorder-7 (GAD-7) is a brief self-reported measure used both as a screening tool and as a severity measure of generalized anxiety symptoms with strong psychometric properties. The scale scores may range from 0 to 21 and the recommended cutoffs for mild, moderate, and severe anxiety are 5, 10, and 15, respectively. This scale has previously been used in nonpsychiatric clinical populations in India
- Coping strategies inventory short form (CSI-SF) is a brief 16-item scale derived from the 78-item CSI., The items are rated on a 5-point Likert scale ranging from 1 to 5 (never, seldom, sometimes, often and almost always). The different forms of self-reported coping responses that are generally used when faced with difficult situations are evaluated through this scale. Coping responses are classified into emotion-focused and problem-focused, each of which is further subclassified as either engagement type or disengagement t
- World Health Organization Quality of Life BREF (WHO-QoL BREF) is a cross-culturally valid and brief version of the WHO QoL-100. It contains 26 items of which two items assess overall QoL and general health and 24 items assess satisfaction in four domains during the past month: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items). Items are scored on a 5-point Likert scale, with responses ranging from 1 to 5. Mean domain scores were transformed into a linear 0–100 scale and used for the present analysis.
The above measures were applied in a single interview carried out by a trained rater. Those found to have any depressive or anxiety symptoms (any positive score on the PHQ-9/GAD-7) were referred to the department of psychiatry for further evaluation and management. The study protocol had prior approval from the institutional ethics committee. Written informed consent was obtained from all the participants of the study.
Both descriptive and inferential statistics were used to analyze the data. Normality of data (age, disease duration, PASI, depression and anxiety scores) was assessed by Kolmogorov–Smirnov test. Normally distributed continuous data were compared by independent student's t-test, and Mann–Whitney “U”-test was used for non-Gaussian data. Categorical data were compared using Chi-square test or Fisher's exact test as applicable. Psychological morbidity was correlated with illness variables, such as PASI scores, using Spearman's correlation test as was the association between coping and psychological morbidity.
Predictors of depression and anxiety in psoriasis were identified through independent multiple linear regression (MLR) analyses. Linear regression was preferred over logistic regression as we did not use any diagnostic scales for depression or anxiety, and in such a scenario, classification of patients into depressed and nondepressed categories may have little validity. The independent variables (covariates) for the MLR analysis were selected after examining their significance in the univariate analysis (P < 0.05). All statistical tests were done for two-tailed significance. For the univariate analysis, whenever coping and QoL were examined, the P value for significance was adjusted using Bonferroni correction and set at 0.05/4 (that is 0.0125, due to four related domains being involved), while for the other variables as well as the MLR analysis, a P < 0.05 (two-sided) was considered statistically significant. Test of multicollinearity was performed by checking the value of the variance inflation factor (VIF) in the MLR analysis.
| Results|| |
Baseline sample characteristics
There were equal number of cases and controls (n = 72 each). The mean age of the sample was 35.9 (±10.9) years. Majority of the sample were male (n = 125, 86.8%), married (n = 90, 62.5%), employed (n = 113, 78.5%), educated more than the tenth grade (n = 92, 63.9%), and belonged to lower or middle socioeconomic status (n = 109, 75.7%). The mean duration of illness (psoriasis) was 34.5 (±69.4) months. Cases had a mean PASI score of 3.4 (±1.5). Only 12 (8.3%) cases had any medical comorbidity. Psoriasis vulgaris was the most common subtype of psoriasis (n = 70, 97.2%) while one case each had sebopsoriasis and chronic plaque psoriasis (1.4% each). Most cases were on oral-systemic treatments (n = 68, 94.4%) while four (5.6%) received only topical treatment.
Comparison of demographic and clinical variables between groups
A significantly greater proportion of cases had mild depression (cases 38% [27/71] vs. controls 1.4% [1/68], χ2 = 29.26, df = 1, P < 0.001) and moderate depression (cases 12.7% [9/71] vs. controls 0% [0/69], χ2 = 9.35, df = 1, P = 0.002). Similar differences between groups were noted for proportions of mild anxiety (cases 32.9% [23/70] vs. controls 0% [0/69], χ2 = 27.17, df = 1, P < 0.001) and moderate anxiety (cases 8.6% [6/70] vs. controls 0% [0/69], χ2 = 6.18, df = 1, P = 0.013). As compared to cases, controls were significantly younger, single, had more years of formal schooling, and had greater proportion belonging to upper socioeconomic strata. The other demographic variables did not differ between the groups [Table 1]. Cases had significantly higher scores on depression and anxiety scales and significantly lower QoL scores across all domains. Cases with psoriasis demonstrated a significantly higher preference for emotion-focused disengagement coping style and lower preference for problem-focused coping compared to controls.
|Table 1: Comparison of sociodemographic and clinical variables between cases and controls|
Click here to view
Association between coping styles and psychological morbidity among cases
Problem-focused engagement and disengagement were inversely correlated with depression while correlation between scores on emotion-focused disengagement domain and depression was not significant when P value correction was applied. Similar results were observed for anxiety [Table 2]. In other words, higher depression and anxiety levels were both associated with lower levels of problem-focused coping. Clinical severity of psoriasis (rs = 0.276, P = 0.020) but not disease duration (rs = 0.110, P = 0.359) correlated significantly with levels of depression while both disease severity and duration (rs = 0.353, P = 0.003 and rs = 0.246, P = 0.040, respectively) correlated with levels of anxiety.
|Table 2: Correlation of coping with levels of depression and anxiety among cases (n=72)|
Click here to view
Predictors of psychological morbidity in psoriasis
An MLR model was developed to evaluate predictors of depression [Table 3]. The covariates entered into the final MLR model were age, gender, educational status, anxiety scores (GAD-7), QoL (physical domain) scores, coping (problem-focused engagement) scores, and severity of psoriasis (PASI score). Tests of multicollinearity indicated very low levels of multicollinearity with VIF ranging between 1.12 and 1.58 for the covariates in the model. Female gender, lower QoL, and higher anxiety emerged as independent predictors of depression among cases [Table 3]. The adjusted R2 of the model was 0.602, indicating that these variables put together explained about 60% of the variance in depression.
|Table 3: Summary of linear regression model to identify predictors of depression among cases with psoriasis (n=72)|
Click here to view
A similar MLR model, with all the aforementioned covariates, was also constructed to evaluate predictors of anxiety. In addition, duration of illness was also included in this model as it correlated significantly with anxiety scores in the univariate analysis. Minimal multicollinearity was observed with VIF ranging between 1.15 and 1.82 for the covariates in the model. Higher depression alone was a predictor for anxiety. The adjusted R2 of the model was 0.571, indicating that the selected covariates explained about 57% of the variance in anxiety.
| Discussion|| |
Our findings show that cases with psoriasis had significantly higher levels of depression and anxiety and lower QoL than controls. Emotion-focused coping was more common in patients with psoriasis. Anxiety, QoL, and female gender were significant predictors of depression in psoriasis, while only depression emerged as a predictor of anxiety among cases. Interestingly, illness variables such as duration and severity were not associated with psychological morbidity.
Convergent with our findings, prior Indian,,, and international studies across cultures,, have demonstrated high levels of comorbid depression, anxiety and lower QoL,, in psoriasis. Of the Indian studies, two, did not have a control group and hence clear conclusions cannot be drawn from them. Nevertheless, depression and anxiety are prevalent in psoriasis, and the relationship appears to be bidirectional. This psychodermatological link may have its basis in the bidirectional immune-inflammatory and neurochemical processes common to both depression and psoriasis. While we observed an association between disease severity (PASI) and both depression and anxiety, evidence from extant Indian, and Western literature in this regard is inconsistent.
Interestingly, we noted that female gender was associated with depression in psoriasis after controlling for potential confounders. Our findings are echoed by two large prospective studies, which found that the relationship between gender and psoriasis remained after adjustment for confounders. These findings raise the question of gender being a possible moderator in the relationship between depression and psoriasis. Psoriasis is a disfiguring condition that can be profoundly stigmatizing and isolating, and our findings suggest that women may be more vulnerable to these consequences. Further studies, using case–control designs, are required to examine this hypothesis.
Lesser use of problem-focused coping strategies was observed among patients compared to controls. Although this relationship did not hold good after controlling for other variables, it merits further examination. Problem-focused coping refers to strategies that aim to directly tackle the problem or stressful situations, such as problem-solving approach and time management, and have been linked to better health outcomes in general. Planning, acceptance, and active coping were found to be the most common coping strategies in psoriasis in a prospective single-group study. Our findings resonate with a controlled study which indicated significantly less use of active coping strategies in psoriasis when compared with normal controls. Our findings assume significance when juxtaposed with literature, suggesting that coping predicts a range of health outcomes such as distress, psychological morbidity, and QoL in psoriasis. Maladaptive coping may explain the persistence of psychological distress in a subset of patients with psoriasis. As such, management must include an assessment and therapy for suitable modification of coping styles, the impact of which need to be examined using randomized controlled designs.
The study findings should be interpreted in the context of its limitations. This was a hospital-based study carried out at a tertiary care center and the results may not generalize to other settings. The cross-sectional design of the study precludes any inference regarding causality of association between psychological morbidity and factors such as coping and QoL. The screening instruments used do not allow the determination of syndromal psychiatric morbidity. Cases and controls differed on their socioeconomic and educational background as well as marital status. This may be related to the study design as mostly controls were self-selected voluntary blood donors. Nevertheless, the study was adequately powered to check associations of interest. The use of statistical correction lends greater credibility to the findings while the use of a matched control group adds to the rigor. Few studies have systematically examined coping styles of patients with psoriasis in the Indian setting, and our study adds to the literature in this regard.
Based on our findings, we hypothesize that coping and gender are key determinants in the relationship between psoriasis, psychological morbidity, and QoL. Management of psoriasis must be multidisciplinary and psychological interventions should be targeted at four groups of clients: females, those with poor QoL, and those with low problem-focused coping (problem-solving skills, time management, etc.) apart from those with proven psychological morbidity.
Our findings have key treatment and research implications. Although our cross-sectional design cannot confirm a causal relationship between coping style and psychiatric morbidity in psoriasis, it provides an empirical basis for further better-designed research to test this causal hypothesis. From a treatment standpoint, given the malleable nature of coping, therapy directed at enhancing coping styles merit further investigation for its potential benefits on psychiatric morbidity and QoL in patients with psoriasis.
| Conclusion|| |
The results of the study suggest that psychiatric morbidity, such as depression and anxiety, are higher in patients with psoriasis compared to controls, while patients also have lower QoL and employ different coping strategies compared to general population. Gender and QoL predict depression in psoriasis. Future studies should assess the causal impact of coping on psychiatric comorbidity in psoriasis using longitudinal designs, the long-term impact of psychological morbidity in psoriasis, as well as the effectiveness of psychological therapy aimed at modifying coping styles aimed at disease course and outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta MA, Gupta AK. Current concepts in psychodermatology. Curr Psychiatry Rep 2014;16:449.
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.
Jin W, Zhang S, Duan Y. Depression symptoms predict worse clinical response to etanercept treatment in psoriasis patients. Dermatology 2019;235:55-64.
Lebwohl M, Christophers E, Langley R, Ortonne JP, Roberts J, Griffiths CE, et al.
An international, randomized, double-blind, placebo-controlled phase 3 trial of intramuscular alefacept in patients with chronic plaque psoriasis. Arch Dermatol 2003;139:719-27.
Salek MS, Finlay AY, Lewis JJ, Sumner MI. Quality of life improvement in treatment of psoriasis with intermittent short course cyclosporin (Neoral). Qual Life Res 2004;13:91-5.
Hunter HJ, Griffiths CE, Kleyn CE. Does psychosocial stress play a role in the exacerbation of psoriasis? Br J Dermatol 2013;169:965-74.
Menon V, Shanmuganathan B, Thamizh JS, Arun AB, Kuppili PP, Sarkar S. Personality traits such as neuroticism and disability predict psychological distress in medically unexplained symptoms: A three-year experience from a single centre. Personal Ment Health 2018;12:145-54.
Lazarus R, Folkman S. Stress, Appraisal, and Coping. New York: Springer; 1984.
Howells L, Chisholm A, Cotterill S, Chinoy H, Warren RB, Bundy C. Impact of disease severity, illness beliefs, and coping strategies on outcomes in psoriatic arthritis. Arthritis Care Res (Hoboken) 2018;70:295-302.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.
The mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
Karia SB, De Sousa A, Shah N, Sonavane S, Bharati A. Psychiatric morbidity and quality of life in skin diseases: A comparison of alopecia areata and psoriasis. Ind Psychiatry J 2015;24:125-8.
] [Full text]
Sharma R. Online Interactive Calculator for Realtime Update of Prasad's Social Classification. Available from: http//www.prasadscaleupdateweebly
. [Last accessed on 2018 Aug 10].
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999;282:1737-44.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
Jordan P, Shedden-Mora MC, Löwe B. Psychometric analysis of the generalized anxiety disorder scale (GAD-7) in primary care using modern item response theory. PLoS One 2017;12:e0182162.
Menon V, Shanmuganathan B, Thamizh JS, Arun AB, Sarkar S. Efficacy of adjunctive single session counseling for medically unexplained symptoms: A Randomized controlled trial. Indian J Psychol Med 2017;39:641-7.
] [Full text]
Addison CC, Campbell-Jenkins BW, Sarpong DF, Kibler J, Singh M, Dubbert P, et al.
Psychometric evaluation of a coping strategies inventory short-form (CSI-SF) in the Jackson heart study cohort. Int J Environ Res Public Health 2007;4:289-95.
Tobin DL, Holroyd KA, Reynolds RV, Wigal JK. The hierarchical factor structure of the coping strategies inventory. Cognit Ther Res 1989;13:343-61.
Saxena S, Carlson D, Billington R; WHOQOL Group. World Health Organization Quality Of Life. The WHO quality of life assessment instrument (WHOQOL-bref): The importance of its items for cross-cultural research. Qual Life Res 2001;10:711-21.
Skevington SM, Tucker C. Designing response scales for cross-cultural use in health care: Data from the development of the UK WHOQOL. Br J Med Psychol 1999;72(Pt 1):51-61.
Lakshmy S, Balasundaram S, Sarkar S, Audhya M, Subramaniam E. A cross-sectional study of prevalence and implications of depression and anxiety in psoriasis. Indian J Psychol Med 2015;37:434-40.
] [Full text]
Goyal S, Pisharody R, Nath S. Psychiatric morbidity in psoriasis: A case-control study. J Mar Med Soc 2017;19:18. [Full text]
Kashyap S, Kumar A, Kumar R, Shanker V. Psychiatric morbidity in psoriasis: A study in Himachal Pradesh, India. Int J Res Med Sci 2016;4:2524-7.
Tsai TF, Wang TS, Hung ST, Tsai PI, Schenkel B, Zhang M, et al.
Epidemiology and comorbidities of psoriasis patients in a national database in Taiwan. J Dermatol Sci 2011;63:40-6.
Menegon DB, Pereira AG, Camerin AC, Cestari T. Psoriasis and comorbidities in a Southern Brazilian population: A case-control study. Int J Dermatol 2014;53:e518-25.
Han C, Lofland JH, Zhao N, Schenkel B. Increased prevalence of psychiatric disorders and health care-associated costs among patients with moderate-to-severe psoriasis. J Drugs Dermatol 2011;10:843-50.
Amer AA, Gao XH, Li JH, Qi R, Zhang YJ, Chen HD, et al.
Coping strategies and quality of life among patients with chronic psoriasis and eczema/dermatitis. Indian J Dermatol Venereol Leprol 2017;83:699-701.
] [Full text]
Mukhtar R, Choi J, Koo JY. Quality-of-life issues in psoriasis. Dermatol Clin 2004;22:389-95.
Ferreira BI, Abreu JL, Reis JP, Figueiredo AM. Psoriasis and associated psychiatric disorders: A systematic review on etiopathogenesis and clinical correlation. J Clin Aesthet Dermatol 2016;9:36-43.
Tohid H, Aleem D, Jackson C. Major depression and psoriasis: A Psychodermatological phenomenon. Skin Pharmacol Physiol 2016;29:220-30.
Finzi A, Colombo D, Caputo A, Andreassi L, Chimenti S, Vena G, et al.
Psychological distress and coping strategies in patients with psoriasis: The PSYCHAE study. J Eur Acad Dermatol Venereol 2007;21:1161-9.
Dommasch ED, Li T, Okereke OI, Li Y, Qureshi AA, Cho E. Risk of depression in women with psoriasis: A cohort study. Br J Dermatol 2015;173:975-80.
Ginsburg IH, Link BG. Psychosocial consequences of rejection and stigma feelings in psoriasis patients. Int J Dermatol 1993;32:587-91.
Penley JA, Tomaka J, Wiebe JS. The association of coping to physical and psychological health outcomes: A meta-analytic review. J Behav Med 2002;25:551-603.
Fortune DG, Richards HL, Main CJ, Griffiths CE. Patients' strategies for coping with psoriasis. Clin Exp Dermatol 2002;27:177-84.
Fortune DG, Richards HL, Griffiths CE, Main CJ. Psychological stress, distress and disability in patients with psoriasis: Consensus and variation in the contribution of illness perceptions, coping and alexithymia. Br J Clin Psychol 2002;41:157-74.
Ograczyk A, Miniszewska J, Kępska A, Zalewska-Janowska A. Itch, disease coping strategies and quality of life in psoriasis patients. Postepy Dermatol Alergol 2014;31:299-304.
[Table 1], [Table 2], [Table 3]