JEADV (2004) 18, 27 36

O R I G I NAL ART I C L E

Self-reported stress reactivity and psoriasis-related stress of Nordic

psoriasis sufferers
Blackwell Publishing Ltd.

R Zachariae,* H Zachariae, K Blomqvist, S Davidsson, L Molin, C Mrk, B Sigurgeirsson

Psychooncology Research Unit, Aarhus University Hospital, Denmark, Department of Dermatology, Aarhus University Hospital, Denmark,
Department of Dermatology, Helsinki University Hospital, Finland, Department of Dermatology, University Hospital Reykjavik, Iceland,
Department of Dermatology, rebro Medical Centre Hospital, Sweden, Department of Dermatology, Rikshospitalet University Hospital, Oslo,
Norway, Department of Dermatology, University of Iceland, Reykjavik, Iceland (representing the Faroe Islands). *Corresponding author,
Psychooncology Research Unit, Aarhus University Hospital, Barthsgade 5,3, 8200 rhus N, Denmark, Tel. + 45 89 49 36 55; Fax + 45 89 49 36 60;
E-mail: bzach@akh.aaa.dk

ABSTRAC T
Objectives The purpose of the study was to investigate the perceived influence of stress on psoriasis onset
and disease severity in a large sample of psoriatics and to compare stress reactors and non-reactors with
respect to psoriasis-related stress, disease severity, family history of psoriasis and sociodemographic factors.
Patients/methods A total of 5795 members of the Nordic psoriasis associations and 702 patients recruited
from Nordic dermatologists or university clinics were asked whether their first outbreak of psoriasis
occurred during times of worry and stress. They were also asked to rate the degree to which their psoriasis
was influenced by stress and to complete the Psoriasis Life Stress Index, the Psoriasis Disability Index and a
number of additional questions concerning sociodemographic factors.
Results Seventy-one per cent of the members and 66% of the patients reported that their psoriasis was
exacerbated by stress, and 35% in both groups reported that the onset of their psoriasis occurred during a
time of worry and stress. Stress reactors, scoring above the median on stress reactivity, reported greater disease severity, psoriasis-related stress and impairment of disease-related quality of life. They also reported
more frequent use of tobacco, tranquillizers and antidepressants. More women than men were stress
reactors, and stress reactors were more likely to have a family history of psoriasis.
Conclusion Our findings confirm and extend the results of previous studies and indicate that a subgroup
of psoriatics may be more psychologically reactive to their disease and its influence on everyday life. Whether
this group is also physiologically more reactive to psychosocial stress remains to be investigated.
Key words: family history, psoriasis, quality of life, stress
Received: 12 June 2002, accepted 5 September 2002

Introduction
Psoriasis is a multifactorial disorder with a genetic component
that requires additional factors,1 possibly including psychosocial factors, to be manifested as lesional psoriasis. While a
disfiguring disease like psoriasis may serve as a stressor in
itself and influence the social and psychological well-being of
the patient,2,3 stressful life events have been considered possible
aetiological factors influencing the onset of psoriasis. It has also
been suggested that periods with increased disease activity may
be preceded by increased distress.4
2004 European Academy of Dermatology and Venereology

Several avenues of research have been pursued. Some

researchers have attempted to measure the extent of stressful life
events and correlated the results with outbreaks and/or severity
of psoriasis symptoms, and results of uncontrolled investigations indicate that distress or stressful events may have an impact on psoriasis. Hellgren5 reported that 53% of 163 patients
found that their psoriasis appeared after stressful life situations,
and two studies of 100 and 179 psoriatics by Polenghi et al.6,7
revealed that approximately 70% of the patients reported that
they had experienced a stressful event about 1 month before the
onset of the disease. Others have studied the possible effect of
27

28 Zachariae et al.

stressful life events on symptom severity. The results so far

are conflicting. Baughman and Sobel8 found significant correlations between life event scores and self-reported psoriasis
severity in 252 patients during the previous 5 years, while
Poikolainen et al.9 did not find an association between life events
and severity in a group of 55 patients. A number of controlled
investigations comparing stress of psoriatics with healthy controls or other patient groups have also found associations between
stress and psoriasis. Seville10 compared 132 psoriasis patients
with 73 patients with skin tumours and 132 patients recruited
from general practice. While 39% of the psoriatics recalled
stressful life events within 1 month before the onset of psoriasis,
the percentages for the other two groups were only 5% and
10%. Fava et al.11 found that 89% of 20 psoriatics reported a
stressful event before disease onset, compared with only 50% of
20 patients with fungal infections. Similar results have been
found in other controlled studies.12,13,14,15 Not all studies have
yielded positive results. Thus Payne et al.16 were unable to find
any association between stress and psoriasis in a study of 16
psoriatics and 16 controls, a result which could be due to the
small sample size.
The majority of studies have relied on retrospective measures
of stress, and only few prospective studies have been conducted.
A time series analysis of stress and disease severity measures
reported by four psoriasis patients once a week over a 20-week
period revealed a modest, but significant, positive association
between psoriasis symptom severity and psychological distress.17
Another recent study of 69 psoriasis patients18 showed that
emotional expression, active coping and seeking social support all factors found to buffer stress19 were associated
with improved mental and physical health 1 year later. That
stress may play a role in the exacerbation of psoriasis has also
received indirect support from both case studies and controlled
investigations, indicating that psychological intervention
techniques may be effective in reducing psoriasis symptoms.
Hypnotherapy, imagery, relaxation and stress management
have thus been reported to help patients suffering from
psoriasis.20,21,22,23,24
Other investigators have studied the role of stress in onset or
relapse of psoriasis using questionnaire surveys of larger samples of patients. In an early questionnaire survey of 2144 psoriatics in the USA, Farber et al.25,26 found that 40% reported that
their psoriasis appeared at times characterized by worry and
that 37% reported worsening of their psoriasis at such times.
In a continuation of this survey including a total of 5600
patients, approximately 33% stated that new patches of psoriasis appeared at times of worry, 33% said that they did not, and
the remaining 33% were uncertain. Subsequent studies with
small samples have confirmed that a substantial number of
psoriatics believe their disease to be influenced by stress27,28,29
and a recent review of the literature indicates that the proportion
of patients believing that stress plays a role in the onset or acts
as an exacerbating factor in psoriasis ranges from 37% to 78%.4

In spite of the relatively large body of literature, only few

investigators have attempted to differentiate stress reactors
from non-reactors. When comparing 64 psoriasis in-patients
characterized as high stress reactors to 63 patients who reported
no significant association between stress and their psoriasis,
Gupta et al.30 found that stress reactors had more severe psoriasis, reported more flare-ups during the 6 months prior to
admission, and experienced more psoriasis-related stress as
measured on the Psoriasis Life Stress Inventory (PLSI). While
Gupta et al. thus found a positive association between stress
reactivity and disease severity, others have found that the beliefs
held by psoriasis patients were unrelated to clinical disease
severity. One would perhaps expect that psoriasis more clearly
associated with a genetic component, e.g. as expressed in the
presence of a family history of psoriasis, would be perceived by
the patients as being less associated with stress than psoriasis in
the absence of a family history. The results from the available
studies, however, are inconsistent. In one study, perceived stress
reactivity was found to be independent of the presence or
absence of a family history of psoriasis. In contrast, the results
of another study indicate an association of both stressful life
events and the presence of a family history with guttate psoriasis
a form associated with streptococcal pharyngitis.
Taken together, a substantial proportion of psoriasis patients
report the onset of their disease to be preceded by stressful
events or to take place during times of worry and that stress
exacerbates their psoriasis. Most studies are based on relatively
small clinical samples, and the only large survey of US psoriatics, which was conducted more than 30 years ago, was limited
to few questions concerning stress. The purpose of the present
study was therefore to investigate the perceived influence of
stress on psoriasis onset and disease activity in a large sample of
psoriatics recruited from several countries and to compare their
reports with those of patients recruited from dermatologists or
university clinics. Furthermore, we wished to compare stress
reactors and non-reactors with respect to several factors,
including psoriasis-related stress, disease severity, family history of psoriasis and sociodemographic factors. The participants in the study took part in a questionnaire-based study of
psoriasis-related quality of life (QoL) of members of the Nordic
psoriasis associations and psoriasis patients recruited from
dermatologists or university clinics. The results of this survey
concerning QoL have been published elsewhere31.

Materials and methods

Patients
A questionnaire package was mailed to randomly selected
members of the psoriasis associations from Denmark, Finland,
Norway and Sweden and to all members of the associations
from Iceland and the Faroe Islands. The numbers were 4000
from Sweden, 2000 from each of the three countries Denmark,

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 27 36

Psoriasis-related stress 29

Norway and Finland, 1127 from Iceland and 173 from the Faroe
Islands. The responders were 1356 (67.8%) from Denmark,
1125 (56.3%) from Finland, 451 (40.0%) from Iceland, 903
(45.2%) from Norway, 1828 (45.7%) from Sweden and 76
(44.0%) from the Faroe Islands, yielding a total of 5739 psoriatics. Dermatologists from all Nordic countries were invited to
participate with up to five consecutive patients each, as was each
university dermatology clinic with 10 consecutive psoriatic
patients from their outpatient clinics and 10 from the wards.
A total of 387 patients recruited by dermatologists and 385
patients recruited at the dermatology departments completed
the questionnaires. To control for possible seasonal variation,
an additional 800 questionnaires were mailed out 6 months
later to randomly selected members of the Danish, Norwegian,
Swedish and Finnish psoriasis associations. A total of 341
(42.6%) psoriatics returned the questionnaires. The total number
of psoriatics who had completed the questionnaire package was
6849 and the average response rate for the total member sample
was 50.2%. Patients were excluded if they were under 18 years
old, and only patients who had their diagnosis of psoriasis made
or confirmed by a dermatologist were included in the study,
resulting in a total sample of 6497 subjects.

Questionnaires
All subjects received a questionnaire package, which included
questions regarding their perception of the influence of stress
on psoriasis, perceived psoriasis severity and family history of
psoriasis. The subjects also completed the Psoriasis Disability
Index (PDI)32,33 and the PLSI.34

Perceived influence of stress on psoriasis

The subjects were asked to indicate: (1) Does your psoriasis
have a tendency to break out during times of worry and stress?;
(2) Does your psoriasis become worse during times of worry
and stress?; (3) Did you experience your first outbreak of
psoriasis during a period of worry and stress? The response
format was yes, no or not sure. The subjects were also asked to
rate the influence of stress on their psoriasis on an 11-point scale
with end-points representing not at all and to a very high degree.

Psoriasis severity
The respondents were asked to indicate which parts of their
body were afflicted and to rate their subjective experience of
psoriasis severity, including the degree of erythema, scaling,
plaque thickness and itch as well as their general assessment of
severity on 11-point scales with end-points representing not at
all and to a very high degree. They were also asked to rate the
area of their psoriasis on a scale from 0% to 100%. For the 695
psoriatics recruited at dermatology departments and by dermatologists, disease severity was also assessed by dermatologists

using the Psoriasis Area and Severity Index (PASI) scoring

system35, where the area involved together with severity of
erythema, infiltration and desquamation are graded, resulting
in a range of total scores from 0 to 72. A detailed PASI instruction
booklet had been mailed out to all dermatologists to increase
the comparability of the PASI scores across countries, clinics
and departments. A principal components analysis with varimax
rotation was conducted for erythema, scaling, plaque thickness,
itch and afflicted area. All variables loaded on one factor with
factor loadings ranging from 0.90 (scaling) to 0.65 (area). A
continuous total severity scale was therefore computed as the
sum of the first four variables (scoring ranges 010) plus the area
(0100) divided by 5. Total severity is presented as percentage
scores. This total severity scale was significantly correlated with
both self-reported severity (Spearmans R = 0.85; P < 0.01) and
total PASI scores (Pearsons R = 0.40; P < 0.01).

Family history of psoriasis

The subjects were asked whether their father, mother or siblings
had psoriasis. The response format was yes, no or not sure. A
family history of psoriasis score of 0 3 was computed, with 0
representing no relatives with psoriasis and 3 indicating that
father, mother and one or more siblings had psoriasis.

The PDI
The PDI consists of 15 disease-specific items with the total score
reflecting the impact psoriasis has had on the daily life and
activities of the respondent over the previous month. The PDI had
been translated into the Nordic languages using the translationback translation method36 and validated in a preliminary sample.
Total scores and score distributions of the individual items were
similar and internal consistencies were found acceptable with
internal reliability coefficients (Cronbachs ) ranging from
0.80 (Iceland) to 0.92 (Sweden). The total score is calculated as
a percentage score (0%100%).

The PLSI
In contrast to the PDI, which measures the impact of psoriasis
on specific aspects of daily living, the PLSI measures the degree
of subjective stress related to psoriasis experienced by the
respondent within the last month. The PLSI consists of 15
items, covering different aspects of psoriasis-related stress. Two
scores are computed. The PLSI-A score reflects the number of
items experienced by the respondent during the last month,
while the PLSI-B score reflects the degree of stress experienced
by the respondent for each of these items as rated on four-point
Likert scales. The PLSI was translated into the Nordic languages
and tested in a preliminary sample using the same procedure as
described for the PDI. As for the PDI, total scores and score
distributions of the individual items were similar and internal

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 2736

30 Zachariae et al.

consistencies were found acceptable with reliability coefficients

(Cronbachs ) ranging from 0.77 (Iceland) to 0.88 (Norway).
Total PLSI-A scores range from 0 to 15, and total PLSI-B scores
are presented as percentage scores (0%100%).
When conducting a factor analysis of this measure, as previously
done by Fortune and colleagues37, we found that the items
loaded on two separate factors related to (1) stress resulting from
anticipation of other peoples reactions leading to avoidance or
worry (e.g. not going to a public place when you would have
liked to) and (2) stress resulting from actual experiences of
being evaluated by others on the basis of the skin condition (e.g.
people making a conscious effort not to touch you). Two separate subscales, PLSI-avoidance and PLSI-experience, were thus
constructed by excluding items loading on more than one factor
(i.e. with a difference between loadings less than 0.30). Total
scores for both scales are presented as percentage scores.

Additional questions
In a question aimed at determining a value that the respondents place on their skin condition38, the subjects were asked how
much time they would be prepared to spend on treating the skin
each day if there was a daily treatment which could clear their skin
completely. The response categories were 5 min, 10 min, 30 min,
1 h, 2 h and 3 h. The remaining questions concerned diagnosed
comorbidity of arthritis, marital status, educational status, employment, use of tranquillizers, sleep medication, antidepressants,
drinking and smoking habits, and use of alternative treatments.

Statistical analyses
Proportions and ordinal data were analysed with 2 tests and
other non-parametric tests. Continuous data were analysed
with t tests for independent samples and univariate and
multiple factorial analyses of variance (ANOVA) with post hoc
pairwise comparisons, controlled for multiple comparisons.
Further analyses were conducted with multiple logistic regression analyses. Due to the large sample, even small differences
may reach statistical significance. To better compare differences
between groups, standardized mean differences (Cohens d)
were calculated for a number of variables39. All significance
levels reported are two-tailed.

Results
Demographic characteristics, disease severity and
duration
No differences (P = 0.17) in mean self-reported severity were
found between members and the seasonal control group and
the two groups were therefore pooled in subsequent analyses.
Unless otherwise indicated, the analyses have been conducted
on the total group of psoriasis association members (member

group) and the group of psoriasis patients recruited at

dermatology departments and by practising dermatologists
(patient group). While there were no differences in the proportions of men to women between the six countries, significant
differences were found between countries for age, with Finnish
members being significantly older than the Swedish members,
who were significantly older than the members from the
remaining four countries (P < 0.05; Scheffe post hoc multiple
comparison tests). A multiple analysis of variance (MANOVA)
revealed significant differences between countries for both total
self-reported severity and duration, but not for afflicted area.
Members had longer disease duration than the patient sample,
and patients had greater severity scores and greater afflicted
area than members (results of the statistical analysis not shown).
The results are shown in Table 1. There were no differences
between countries in PASI total scores and scores for head,
trunk and upper and lower limb, and no differences between the
three groups in the proportion of members (30%) or patients
(30%) who had been diagnosed with arthritis (data not shown).

Perceived influence of stress

Compared to the remaining five countries, more Finnish and
fewer Danish and Swedish members reported that their psoriasis
had a tendency to break out during times of worry and stress
(0.001 < P < 0.05). More Finnish and Norwegian members
and fewer Danish and Swedish members reported that their
psoriasis worsened during times of worry and stress (0.0001
< P < 0.05). More Finnish and fewer Icelandic and Faroe Island
members reported that they had their first outbreak of psoriasis
during a time of worry and stress (0.0001 < P < 0.05) than for
the remaining countries. Norwegian members rated the
influence of stress on an 11-point scale significantly higher than
Swedish members (P < 0.05; Scheffe test). When comparing
patients, differences between countries did not reach statistical
significance for any of the four stress reactivity measures. The
results are shown in Table 1. Significantly more members
reported that their psoriasis had a tendency to break out
(68.7%) and worsen (70.7%) during stress than patients (63.1%
and 66.1%). More patients (24.2% and 21.8%) reported that
they were not sure than members (17.2% and 16.8%) for these
two items. No differences were found between members and
patients for the remaining two items on the influence of stress
on psoriasis. 2 tests showed that more participants with longer
disease duration (median 27 years) were unsure (57%) or
responded no (53%) to the question (P < 0.001). On the other
hand, fewer older participants (median 52 years) were unsure
(48%) or responded no (43%).

Comparing stress reactors and non-reactors

Based on the degree (score 011) to which they believed stress
to influence their psoriasis, the subjects were grouped into stress

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 27 36

5.2 (3.2)
4.2 (3.5)
5.9 (2.9)
5.1 (3.5)
6.0 (3.0)
5.2 (3.0)
5.4 (3.1)
32/27
35/25
44/17
21/26
34/21
36/33
35/25
63/40
52/13
75/10
63/00
71 /09
61 /13
66/12
60/16
52/22
64/10
63/11
70/09
61 /13
63/13
9.21 (8.27)
7.56 (4.96)
10.50 (10.19)
7.52 (4.97)
9.20 (6.43)
9.31 (8.72)
9.34 (8.20)
21.0 (15.2)
17.8 (11.7)
17.5 (11.8)
20.1 (13.8)
21.2 (15.2)
24.4 (16.0)
21.2 (14.9)
by dermatologists and departments
219
32 (26)
46.4 (21.2)
23
37 (23)
49.7 (14.3)
115
34 (29)
46.3 (21.2)
19
25 (24)
40.5 (19.0)
165
36 (26)
53.2 (18.1)
164
36 (27)
48.0 (20.4)
702
34 (27)
48.3 (20.2)
Patients recruited
Denmark (DE)
Faroe Is. (FA)
Finland (FI)
Iceland (IC)
Norway (NO)
Sweden (SW)
Total

(3.2)
(3.1)
(2.8)
(3.1)
(2.9)
(3.1)
(3.0)
5.4
4.9
5.5
5.5
5.7
5.2
5.4
33 /26
25/16
38 /22
24/38
35/25
36 /26
35/26
69/15
66/07
76/11
68/13
74/10
67/13
71 /13
67/17
66/07
72/13
65/16
71 /13
68/13
69/14

(15.8)
(15.6)
(12.5)
(13.7)
(14.3)
(15.4)
(14.9)
25.8
25.8
33.9
26.0
27.7
29.6
28.9
41.8 (20.7)
39.2 (18.8)
36.1 (20.0)
35.1 (19.7)
44.8 (18.9)
36.7 (19.1)
39.1 (20.0)
Psoriasis association members
Denmark (DE)
1422
23 (23)
Faroe Is. (FA)
68
26 (24)
Finland (FI)
1136
24 (23)
Iceland (IC)
398
19 (20)
Norway (NO)
960
26 (23)
Sweden (SW)
1811
21 (21)
Total
23 (22)

First outbreak during stress?,

Yes/No (%)
Worse during stress?,
Yes/No (%)
Outbreak during stress?,
Yes/No (%)
PASI, 072
Duration, years
Total severity, %
Area, %

Table 1 Mean (SD) disease severity scores, disease duration and reported influence of stress on psoriasis of Nordic psoriasis association members and patients recruited by dermatologists

Influence of stress, 010

Psoriasis-related stress 31

reactors, defined as subjects scoring above the median (score 6),

and non-reactors (score < 6). Compared to the remaining five
countries, more Finnish and Norwegian and fewer Swedish
subjects were characterized as stress reactors (P < 0.05) (data
not shown). There was no difference in the proportion of stress
reactors and non-reactors between the member and patient
samples. Comparisons corrected for multiple comparisons
between the two groups are shown in Table 2. Stress reactors
also reported significantly greater use of alternative medicine,
other alternative treatments and dietary measures both within
the last week and previously than non-reactors (data not shown).
More women than men used antidepressants (P < 0.01). We
therefore conducted a logistic regression analysis with stress
reactivity entered as the dependent variable, and sex and use of
antidepressants entered as independent variables at the first and
second step. Being female was a significant predictor (B, 0.20;
P < 0.001; odds ratio, 0.81) and continued to be so when controlling for use of antidepressants (B, 0.20; P < 0.001; odds
ratio, 0.82), although use of antidepressants also was significantly related to stress reactivity (B, 0.52; P < 0.001; odds ratio,
1.68). There were no differences in the percentage of stress reactors or the reported use of antidepressants between the seasonal
control and the main sample.
A hierarchical, logistic regression analysis was conducted with
stress reactors versus non-reactors as the dependent variable
and sex, age, family history of psoriasis, educational background
and country recoded as dummy variables, and total self-reported
disease severity and disease duration entered as predictors at
each step. As seen in Table 3, the final model showed that being
characterized as a stress reactor was significantly associated with
being female, younger age, having a family history of psoriasis,
higher educational level, belonging to the Finnish sample versus
belonging to the other country samples, and having higher selfreported disease severity. Self-reported disease severity and age
contributed more to the variability in stress reactivity than the
remaining predictors, which were only very modest predictors
of stress reactivity. To analyse stress reactivity as a predictor of
psoriasis QoL, a multiple linear hierarchical regression was conducted with PDI scores as the dependent variable, stress reactivity entered at the first step, and age, sex, education, disease
severity and duration entered as a block at the second step.
When entered alone, stress reactivity was a significant predictor
of PDI scores ( = 0.24; P < 0.001; R2 = 0.06). When controlling
for the remaining factors previously shown to influence QoL,
stress reactivity continued to be a significant predictor ( =
0.11; P < 0.001). Age, education, severity and duration were also
significant predictors (P < 0.050.001), explaining an additional 28% of the variation.

Visibility and severity

The number of visible areas (head, face, hands, nails) and nonvisible areas (trunk, arms, legs) were computed and correlated

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 2736

32 Zachariae et al.

Table 2 Demographic characteristics, disease severity, quality of life, psoriasis-related stress, number of cigarettes, alcohol consumption, and medication use
of psoriasis sufferers characterized as stress reactors and non-reactors
Variable

Stress reactors

Non-reactors

P<

P < 0.01

Effect size, Cohens d b

Sex (per cent women)

Age (mean (SD))
First outbreak during stress (per cent yes)
Family history of psoriasis (mean number of relatives)
Arthritis diagnosis (per cent yes)
Educational background (high)
Married/living with a partner (per cent yes)
Total self-reported disease severity (mean per cent score (SD))
PASI score (mean score (SD))
Disease duration (mean number of years (SD))
PDI (mean per cent score (SD))
PLSI-A (mean score (SD))
PLSI-B (mean score (SD))
PLSI anticipationavoidance behaviours (mean count (SD))
PLSI actual experience (mean count (SD))
PLSI anticipationavoidance related stress (mean (SD))
PLSI actual experience related stress (mean (SD))
Time willing to spend on treatment (min/day) (mean (SD))
Cigarettes per day (mean (SD))
Glasses of wine per week (mean (SD))
Number of beers per week (mean (SD))
Liquor (2 cL) per week (mean (SD))
Total alcohol consumption per week (mean (SD))
Use of tranquillizers (per cent yes)
Use of sleep medication (per cent yes)
Use of antidepressants (per cent yes)

56.4%
49.2 (13.2)
47.2%
0.70
31.7%
46.3%
50.2%
44.4 (19.7)
9.9 (8.5)
26.9 (14.3)
15.8 (15.3)
4.5 (3.4)
17.0 (16.8)
2.2 (2.0)
0.9 (1.3)
24.1 (24.4)
7.0 (12.8)
78.6 (57.4)
5.0 (8.1)
1.9 (3.6)
2.0 (4.5)
1.2 (3.5)
5.1 (7.5)
10.6%
13.0%
8.0%

51.3%
53.7 (14.6)
23.9%
0.63
28.7%
41.5%
49.8%
35.8 (19.7)
8.5 (7.8)
29.0 (15.4)
10.1 (12.4)
3.0 (3.0)
9.7 (12.8)
1.5 (1.8)
0.5 (1.0)
14.4 (19.5)
3.2 (8.3)
65.9 (53.8)
4.3 (7.7)
2.0 (3.8)
2.1 (4.6)
1.4 (4.2)
5.4 (8.4)
6.9%
11.7%
4.8%

0.0001
0.0001
0.0001
0.0001
0.01
0.0001
NS
0.0001
0.05
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
NS
NS
0.05
NS
0.0001
NS
0.0001

0.11
0.32
0.58
0.11
0.08
0.11
0.01
0.44
0.17
0.14
0.42
0.47
0.49
0.37
0.35
0.44
0.35
0.23
0.09
0.03
0.02
0.05
0.04
0.26
0.07
0.30

a
a
a

NS
a

NS
a

NS
a
a
a
a
a
a
a
a
a
a

NS
NS
NS
NS
a

NS
a

aCorrected
bEffect

for multiple comparisons.

size conventions: 0.2 (small); 0.5 (medium); 0.8 (large).

Independent variable

SE

Significance

Odds ratio

Sex (male / female)

Age (year)
Family history of psoriasis (yes/ no)
Educational background (high / basic)
Finnish nationality (Finland vs other countries)
Self-reported severity (0%100%)

0.19
0.02
0.12
0.18
0.71
0.02

0.05
0.00
0.05
0.06
0.27
0.00

0.001
0.001
0.05
0.001
0.01
0.001

0.82
0.98
1.12
1.21
2.03
1.02

with the number of avoidance behaviours, actual experiences of

being evaluated, and the reported distress associated with
avoidance and experiences. Significant correlations (R = 0.15
0.35; P < 0.0001) were found for numbers of both visible and
non-visible areas. The correlation between number of visible
areas and distress related to being evaluated (R = 0.21) was
significantly greater (P < 0.001) than the correlation between
number of non-visible areas and distress related to being
evaluated (z = 3.14; R = 0.15). The correlations between distress
related to avoidance behaviours and the number of visible
(0.29) and non-visible (0.30) areas did not differ statistically
(z = 1.02; P = 0.30).
To assess whether stress reactivity was associated with certain
aspects of psoriasis severity, the non-parametric correlations

Table 3 Significant predictors of self-reported

stress reactivity in a sample of 6497 Nordic
psoriasis sufferers results of a hierachical,
logistic regression

between self-reported stress reactivity and the self-reported

scores on the degree of itching, scaling, erythema, thickness of
plaque (scores: 010) and afflicted body area in per cent were
calculated. All aspects were positively correlated (P < 0.0001)
with the degree of stress reactivity, with moderate to small correlations ranging from 0.22 (itching) to 0.20 (thickness of plaque). The correlation with the calculated total severity scores was
0.25 (P < 0.0001).

Discussion
In the first survey of Farber et al.25, 37% of the participants
reported that their psoriasis became worse during times of
worry, while 22% answered that it did not. When asked

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 27 36

Psoriasis-related stress 33

whether worry was associated with the appearance of psoriasis,

40% responded that their psoriasis broke out during such times
and 21% said that it did not. Of the total sample in our study,
71% of the psoriasis association members and 66% of the
patients recruited by dermatologists or university clinics
reported that their psoriasis worsened during times of worry
and stress, and only 13% and 12% responded negatively. The
percentages in our sample are considerably higher than the
percentages found among US psoriatics in the late 1960s. Since
it is not likely that the disease of psoriasis has become more
susceptible to stress, this difference may be due to either cultural
differences between the USA and the Nordic countries or
more likely changes in illness perception of psoriasis patients.
Today, psoriatics may have become more familiar with the
concept of stress and the possible influence of psychological
factors on physiological disease. The smaller number of psoriatics, in comparison to the study by Farber et al.,25 answering
that stress and worry did not affect their psoriasis only partially
explains the difference, which is also due to fewer participants
answering that they are unsure.
When asked whether their first outbreak occurred during
times of worry and stress, 35% of both members and patients
responded affirmatively. This number is considerably smaller
than the number of psoriatics responding that their psoriasis
flare-ups were associated with stress. This could be due to difficulties remembering the time when their psoriasis first
appeared. This was confirmed by our finding that psoriatics
with longer disease duration were significantly more likely to
be unsure than psoriatics with shorter disease duration. Since
younger psoriatics were more likely than older to disagree that
their first outbreak occurred during times of worry and stress,
this suggests that the question whether the first outbreak was
associated with stress may be more subject to memory difficulties and memory bias than to generational differences, and
illustrates the methodological difficulties associated with retrospective studies40. It is also possible, however, that the more positive answers to this question obtained from older participants are
due to the increased tendency to respond in a socially desirable
way among older subjects41,42. Although the differences found
between the Nordic countries reached statistical significance
due to the large sample, the differences were small, suggesting
only moderate effects of cross-cultural differences. The percentage responding yes to whether their first outbreak of psoriasis
was associated with stress is also considerably smaller than the
60% of the participants in the study of Fortune et al.29 who
responded that stress was the primary cause of psoriasis. Taken
together with the small differences found between countries in
our study, this illustrates that the way the questions are phrased
is likely to influence the responses, and may explain the large
differences found between studies. This is also illustrated by our
finding that, although fewer patients (66%) than members
(71%) reported that their psoriasis worsened during times of
worry and stress, there were no differences between the two

groups in the mean perceived influence of stress (5.4) scored on

an 11-point scale.
When we divided the sample into stress reactors and nonreactors using the median split, the median found in our study
(7) was comparable to the median (7) found previously by
Gupta et al.30 As seen in Table 2, stress reactors were found to
differ significantly from non-reactors for several variables, even
when controlled for multiple comparisons. First, stress reactors
reported significantly greater total disease severity than nonreactors. The associations between self-reported severity and
stress reactivity were similar for all aspects of severity, including
itching, thickness of plaque, erythema, area etc. When we compared severity as rated by a dermatologist, i.e. PASI scores, of
patient stress reactors and non-reactors, the small difference
found did not reach statistical significance when controlling for
multiple comparisons. As seen by the larger effect size found for
self-reported severity (d = 0.44) compared to PASI scores
(d = 0.17), this difference is not merely a result of the smaller
number of patients compared to members. Our finding is in
agreement with the results of Gupta et al. showing that stress
reactors and non-reactors did not differ with respect to the
usual dermatological criteria of psoriasis severity, e.g. percentage of total body surface affected, thickness of plaque etc. Gupta
et al., however, found that stress reactors did have greater psoriasis severity of emotionally charged areas such as the scalp,
face, neck, forearms, hands and genital region. Similarly, when
we compared the number of affected visible and non-visible
areas, the differences between stress reactors and non-reactors
were larger for visible than for non-visible areas. Taken together,
stress reactors had greater self-reported severity, especially
more afflicted visible areas, than non-reactors, while the traditional dermatologist-rated severity measures (PASI) were not
associated with self-reported stress reactivity. Disease duration,
on the other hand, was inversely associated with stress reactivity. The difference between groups was small, however, as
revealed by the very small correlation between stress reactivity and duration (r = 0.07), a correlation which was further
reduced when controlling for age (r = 0.03).
When comparing the PLSI scores, we found that stress
reactors reported significantly more psoriasis-related stressful
experiences and rated these as more distressing than nonreactors. The association between distress and stress reactivity was
diminished, however, when controlling for the number of
actual experiences. Our findings are in concordance with the
results of Gupta et al.30 who found that stress reactors experienced more psoriasis-related stress. When we distinguished
between PLSI items describing stress resulting from anticipation of other peoples reactions leading to avoidance or worry
(anticipationavoidance) and items concerning stress resulting
from actual experiences of being evaluated by others on the
basis of the skin condition (actual experiences), stress reactors
exhibited higher scores than non-reactors on both subscales.
The difference between the two groups, however, was somewhat

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 2736

34 Zachariae et al.

higher for anticipationavoidance (Cohens d = 0.44) than for

actual experiences (d = 0.35), suggesting that stress reactors
may be especially likely to anticipate stressful experiences. This
result should be seen in the light of previous findings that stress
from anticipating other peoples reactions to their psoriasis
contributed more to disability in everyday life than any other
medical or health status variables investigated37.
More women than men were characterized as stress reactors,
which is in concordance with the findings of Farber et al.25
that more women than men reported their psoriasis to be influenced by worry. We have no ready explanation for this gender
difference. On the one hand, it is theoretically possible that
women with psoriasis are physiologically more reactive to stress
than men. On the other hand, it is also possible that women are
more attentive towards psychological and bodily symptoms,
including stress43. Since women also have a higher incidence of
depression than men44, and since depression has been linked to
somatization45, it is also possible that the higher proportion of
stress reactors among women could be explained by a higher
incidence of depression in this group. When we analysed the
association between gender and stress reactivity while controlling for the use of antidepressants, both factors independently
of each other remained highly significant predictors. As many
cases of depression remain undiagnosed and go untreated, selfreported use of antidepressants is, of course, only an indirect
indicator of depression. It should be noted that, although the
difference found between men and women is statistically significant due to the large sample in our study, the effect size was
small (d = 0.11), which may explain why gender differences
have generally not been found in previous studies.
Stress reactors were younger than non-reactors with a mean
age difference of 4.5 years. This could be due to a generational
difference, and the contrast to the difference between older and
younger participants noted above could reflect that stress
reactivity scored on a scale from 0 to 10 is less susceptible to
social desirability than a dichotomized question. That more
self-reported stress reactors had a higher education than nonreactors could be due to higher education being associated with
greater familiarity with the concept of stress and its potential
influence in health and disease. A multiple logistic regression
analysis revealed that, while controlling for the remaining factors,
sex, age, family history of psoriasis, educational background
and disease severity all continued to be significant predictors
of stress reactivity. In addition, belonging to the Finnish
sample was significantly associated with greater stress reactivity.
Since we controlled for factors differing between countries,
we have no clear explanation as to why Finnish psoriatics
perceived themselves as more stress reactive.
When comparing disability in everyday life associated with
psoriasis as measured by the PDI, stress reactors showed considerably more impairment of QoL than non-reactors, a result
supported by our findings of more frequent smoking and use of
tranquillizers and antidepressants among stress reactors than

non-reactors. The same pattern emerged when indirectly

assessing QoL using a utility measure of how much time the
respondents were willing to spend daily on a hypothetical, effective treatment. When controlling for other factors associated
with both stress reactivity and QoL, including age, gender, education, disease severity and duration, stress reactivity continued
to be a significant predictor of QoL, a finding which is in agreement with the results of a previous study37. A number of factors,
including the presence of arthritis, marital status, and alcohol
consumption, were not associated with stress reactivity.
If stress reactivity is to be viewed purely as a subjective belief,
unassociated with any physiological influence of stress on psoriasis activity, one would expect that a family history of psoriasis
would either be inversely associated with or unrelated to perceived stress reactivity. We did, however, find a small (Cohens
d = 0.14), but significant, association between stress reactivity
and the presence of a family history of psoriasis. This finding is
in disagreement with the results of Fortune et al.37 who found
that patients with a family history of psoriasis were more likely
to believe that their psoriasis was caused by genetic factors.
Naldi et al.,15 on the other hand, found an association of stressful life events as well as the presence of a family history with
guttate psoriasis. A family history of psoriasis, indicating
the genetic influence on psoriasis, does not necessarily exclude the
possibility that stress influences both onset and exacerbation of
psoriasis. Social learning could be yet another possible explanation. Having family members with psoriasis may have primed
subjects to be subjectively more responsive to psoriasis-related
stress.
The hypothesis that psoriasis onset and severity may be influenced by psychosocial stress finds support from the results of
several investigations showing that cutaneous immune and
inflammatory processes are susceptible to stress46,47. The possible
influence of stress on skin function has previously been demonstrated in studies showing that psychological stress influences
epidermal permeability barrier homeostasis48 and dermal flare
activity49 in healthy subjects, and that psoriatics show greater
galvanic skin responses6 as well as increased cathecholamine
and growth hormone secretion during stress50,51.
Taken together, our results confirm and extend previous
findings that a substantial number of psoriatics experience
stress as influencing onset, flare-ups and exacerbation of psoriasis. Our results also confirm that psoriatics characterized as
high stress reactors report greater disease severity and psoriasisrelated stress. We also found that more stress reactors than nonreactors reported a family history of psoriasis, and that a family
history thus does not exclude perceived stress reactivity. As is
the case with the large majority of the available studies, the correlational and retrospective nature of our measurements does
not allow us to draw any conclusions regarding the causal relationship between stress and psoriasis. Also, since the stress
measures used were self-report measures, we are only measuring what the subjects are consciously aware of and willing to

2004 European Academy of Dermatology and Venereology JEADV (2004) 18, 27 36

Psoriasis-related stress 35

reveal. While the anonymity of the respondents may reduce the

confounding influence of impression management52, the possible role of defensiveness and self-deception cannot be ruled out.
One approach in future surveys could be to include measures of
defensiveness, e.g. the MarloweCrowne Social Desirability
Scale53. Nonetheless, our results could indicate that some psoriatics are psychologically more reactive and attentive to their
disease, its symptoms and its consequences for their everyday
life. Whether the skin of this subgroup of psoriatics is also
particularly physiologically reactive to psychosocial stress
remains to be investigated.

Acknowledgements
This study was initiated and supported by the Nordic Psoriasis
Associations (NORDPSO) and a grant from Leo Pharmaceutical Products Ltd, Ballerup, Denmark. The authors wish to
thank all the members and the staff of the Nordic Psoriasis
Associations, who either participated in or assisted practically
in carrying out the survey, the members of the staff of Leo Pharmaceutical Products, who offered us practical support, and all
departments and physicians engaged in the study. We in particular thank Jan Monsbakken, NORDPSO, and Anette Heymann,
Strategic Marketing, Leo Phamaceutical Products Ltd. We also
thank Novartis Pharma AG for supplying the booklet Psoriasis
Area and Severity Index (PASI) by M. Thompson and G. Feutren,
Clinical Research Department, Sandoz Pharma Ltd, Basel, 1997,
to all departments and physicians engaged in the study.

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