J Health Psychol 2012 Ak 774 81

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DOI: 10.1177/1359105311423863

2012 17: 774 originally published online 21 November 2011J Health PsycholAhmet Akar

Mehmet Ak, Bikem Haciomeroglu, Yilmaz Turan, Nergis Lapsekili, Ali Doruk, Ali Bozkurt andTemperament and character properties of male psoriasis patients

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Journal of Health Psychology

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DOI: 10.1177/1359105311423863

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Introduction

The skin is closely related to mind and it has

been accepted as one of the most importantbody parts that reflects the psychological state

of the person and in the evaluation of tempera-

ment and character. Skin plays an important

role in expressing emotions like anger, fear,

shame and excitement, responding to emotional

stimulus, in the development of self-image and

self-esteem, and in the socialization process

from infancy to adulthood. The relationship

between the skin and the brain begins in the

embryonic period. Skin and brain are originatedfrom ectoderm and some of the hormones and

neurotransmitters can affect both of them

(Koblenzer, 1983; Mercan and Altunay, 2006).Skin disorders such as alopecia and psoria-

sis are accepted as falling within the category

of psychosomatic disorders (Tucker, 2009).

Psoriasis has been explained as a psychoso-

matic disorder for a long time (Griffiths and

Richards, 2001). It is a chronic and disabling

Temperament andcharacter propertiesof male psoriasis patients

Mehmet Ak, Bikem Haciomeroglu,Ylmaz

Turan, Nergis Lapsekili, Ali Doruk,

Ali Bozkurt and Ahmet Akar

Gulhane School of Medicine, Turkey

AbstractPersonality properties have an effect on the onset and triggering of psoriasis. The current study aimed to

examine the personality of psoriasis patients in relation to the severity of the illness. Psoriasis and healthy

participants completed the Beck Depression Inventory, Beck Anxiety Inventory, Maudsley Obsessive

Compulsive Inventory, Temperament and Character Inventory. Severity of psoriasis was evaluated by

the PASI. MANCOVA results revealed significantly higher Novelty Seeking, Harm Avoidance, Reward

Dependence and Self-Transcendence scores for psoriasis group. Severity of PASI was predicted by harm

avoidance and reward dependence. Personality properties should be evaluated while planning therapeuticinterventions for psoriasis patients.

KeywordsCharacter, psoriasis, temperament

Corresponding author:

Mehmet Ak, Department of Dermatology, Gulhane

School of Medicine, Etlik-Ankara 06018, Turkey.

Email: [email protected]

863HPQXXX10.1177/1359105311423863Ak et al.Journal of Health P sychology

Article

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Ak et al. 775

skin disease, which affects up to two percent of

the population. Little is known about the physi-

cal, psychological and social factors related to

the illness (Rapp et al., 1997). It is equally seen

in men and women and it can begin at any age.

Stress and psychosocial factors play an impor-

tant role both in the onset and exacerbation of

the disorder. Some of the studies do not show a

strong correlation between the severity of the

disorder and stress and psychosocial factors

(Griffiths and Barker, 2007; Mercan and

Altunay, 2006). On the other hand, in a study

that examined the relationship between the

severity of psoriasis, different types of psori-

atic treatment and patients quality of life, it

was found that psychological distress can exac-

erbate the illness and, after the treatment, the

quality of life of the patients was significantly

improved (Coimbra et al., 2011). Although

psoriasis is not a life threatening disorder, it has

significant effects on the patients quality of

life. For example, suicidal ideas are signifi-

cantly higher in psoriasis patients compared to

patients with non-psychosomatic skin disor-

ders (Bozta and Polat, 2010). Some of the psy-

chiatric disorders such as major depression,

generalized anxiety disorder, obsessive com-

pulsive disorder and alcohol dependency are

more common in psoriasis patients (Bozta and

Polat, 2010; Nasreen et al., 2008; Taner et al.,

2007;Van Voorhees and Fried, 2009). The rela-

tionship between psoriasis and affective disor-

ders and their treatments are multi-dimensional.

Although psoriasis is an illness without itch-

ing, depressive psoriasis patients have itching,

and when the severity of depression increases,

the severity of the itching and the risk for sui-

cide also increase. With antidepressant treat-

ments, itching and insomnia complaints

disappear (Mercan and Altunay, 2006; Gupta

and Gupta, 1999; Gupta et al., 1993).

Although a personality structure specific to

psoriasis has not been defined, psoriasis patients

are reported to have more obsessive compulsive,

avoidant, schizoid and passive-aggressive prop-

erties than healthy controls (Kilic et al., 2008;Rubino et al., 1995). A few numbers of studies

that investigated the temperament and character

properties of psoriasis patients have controver-

sial results. Kilic and colleagues (2008) found

higher Harm Avoidance and lower Self-

Directedness scores of psoriasis patients com-

pared to healthy controls. On the other hand,

Guler and colleagues (2007) found that psoria-

sis, vitiligo and neurodermatitis patients were

not different from each other in terms of tem-

perament properties, and for the character prop-

erties they are similar to healthy controls. Doruk

et al. claimed that temperament and character

properties of psoriasis patients were not differ-

ent from healthy controls (Doruk et al., 2009).

Generally most of the studies were based on

Coloningers psychobiological personality the-

ory. This dimensional psychological approach to

the personality model defined that personality

had two fundamental components: temperament

and character. According to this model, person-

ality is a complex system consists of different

psychobiological dimensions of temperament

and character. Temperament refers to automatic

emotions and responses thought to be moder-

ately heritable, therefore largely genetically

based, where as character is largely environ-

mentally derived and responsive to learning and

maturation (Cloninger, 2003). Cloninger and

colleagues identified four temperament dimen-

sions (novelty seeking, harm avoidance, reward

dependence and persistence) and three character

dimensions (self-directedness, cooperativeness

and self-transcendence; Cloninger et al., 1993).

In this study, based on Cloningers psycho-

biological personality model, it was aimed to

compare the temperament and character proper-

ties of psoriasis patients and healthy controls,

and to investigate the relationship between the

temperament and character properties and the

severity of psoriasis.

Method

Participants

Patients diagnosed with psoriasis in a derma-tology clinic were informed about the study

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776 Journal of Health Psychology17(5)

and those who accepted to participate were

referred to a psychiatry clinic. All participants

were male ranging from 20 to 30 years old.

Diagnostic evaluations were made with the

SCID-I, and all participants completed the

Beck Depression Inventory (BDI), Beck

Anxiety Inventory (BAI) and Maudsley

Obsessive Compulsive Inventory (MOCI).

Temperament and character properties of the

participants were evaluated by Temperament

and Character Inventory (TCI). The Psoriasis

Area and Severity Index (PASI) was used by

dermatologists in order to evaluate the severity

of psoriasis. Participants who had any dermato-

logical or systemic disorders other than psoria-

sis (ie, diabetes mellitus, hypertension),

DSM-IV Axis I Disorders (ie, depression, gen-

eralized anxiety disorder) and participants who

had a low education level were excluded from

the study. The control group had no physical or

psychiatric disorder and their demographic

properties (gender, age and education level)

were similar to the patient group. The control

group consisted of voluntary individuals who

accompanied the patients in the hospital.

Seventy-three participants diagnosed with

psoriasis were interviewed with a psychiatrist

and 61 patients were included in the study. Four

patients with obsessive compulsive disorder,

four patients with depressive disorder, two

patients with generalized anxiety disorder, one

patient with panic disorder and one patient with

adjustment disorder were excluded from the

study. The co-morbidity ratio of psychiatric dis-

order with psoriasis was 16 percent. The control

group consisted of 55 healthy participants.

Assessment tools

Temperament and Character Inventory (TCI).

Coloningers Temperament and Character Inven-

tory is a self-assessment tool consists of 240

items rated as true or false. Temperament has

four dimensions, defined as Novelty Seeking

(NS), Harm Avoidance (HA), Reward Depend-

ence (RD) and Persistence (P). Character hasthree dimensions as Self-Directedness (SD),

Cooperativeness (C) and Self-Transcendence

(ST). Kose et al. (2004) and Arkar (2005) con-

ducted Turkish reliability and validity studies of

the scale.

Beck Depression Inventory (BDI). BDI consists

of 21 self-assessment items exploring the symp-

toms of depression scored from 03. Hisli

(1988) conducted the reliability and validity

study of Turkish version of the scale.

Beck Anxiety Inventory (BAI). The level of anxi-

ety of participants was assessed by BAI devel-

oped by Beck and colleagues (Beck et al.,

1988). Likert type scale consists of 21 self-

assessment items ranging from 03. Ulusoy

and colleagues conducted the reliability and

validity study of Turkish version of the scale

(Ulusoy et al., 1998).

Maudsley Obsessive Compulsive Inventory (MOCI).

A self-assessment scale developed by Hodgson

and Rachman (1977) evaluates the type and

severity of obsessive compulsive symptoms.

Thirty-seven items are rated as true or false.

Turkish reliability and validity study of the

scale was conducted by Erol and Savasir (1988).

Statistical analysis

Multiple regression analyses were conducted

in order to see whether temperament and char-

acter properties could be predicted from

depression, anxiety, obsessive-compulsive and

PASI scores in the psoriasis group. In order to

examine the differences between the psoriasisand control groups in terms of temperament

and character properties, one-way Multivariate

Analysis of Covariance (MANCOVA) was

conducted after controlling for BDI, BAI and

MOCI scores.

Results

The psoriasis group and healthy control groups

were compared in terms of age, BDI, BAI andMOCI scores. The mean age of the psoriasis

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Ak et al. 777

group (23.68 4.38l) was not significantly dif-

ferent from the mean age of the control group

(26.11 6.15). In terms of BDI scores, there

was a significant difference between psoriasis

(M =16.04 12.52) and control groups (M =5.75 8.41), (t =4.64, p


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inheritable, manifest in infancy and similar in

different cultures (Kose, 2003; Sadock, 2004).

These properties are important determinants of

the individuals response to stressors and cop-

ing mechanisms. Different findings have been

presented for psoriasis patients in terms of tem-

perament properties. For example, in their

study, Kilic et al. (2008) found high HA andRD scores in psoriasis patients. Guler et al.

(2007) reported low harm avoidance scores yet

high novelty seeking, especially impulsiveness

scores in psoriasis patients. In the current study,

HA, RD and NS scores were found to be higher

than in controls. These results lead us to con-

sider that the previous conflicting results might

actually be due to not controlling for clinical

variables. However, it should be taken intoaccount that this study includes only male

Table 2. Comparison of psoriasis and control groups in terms of temperament and character propertiesafter controlled for Depression, Anxiety and OC Symptoms

TCI Psoriasis GroupN= 61(Mean SD)

Control GroupN= 55(Mean SD)

F

Exploratory excitability (NS1) 6.57 1.69 5.64 1.95 0.43Impulsiveness (NS2) 6.70 2.09 5.57 2.13 0.85

Extravagance (NS3) 3.96 1.61 2.98 1.67 4.17*

Disorderliness (NS4) 5.91 1.91 4.45 2.37 3.66*

Novelty Seeking (NS) 23.13 4.71 18.63 6.58 3.90*

Anticipatory worry (HA1) 5.87 1.93 4.25 2.25 7.18**

Fear of uncertainty (HA2) 4.09 1.89 2.90 1.93 0.35

Shyness with strangers (HA3) 4.47 1.48 3.59 1.61 4.58*

Fatigability and asthenia (HA4) 5.40 2.14 4.00 2.14 3.86*

Harm Avoidance (HA) 19.83 5.37 14.75 6.50 5.93*

Sentimentality (RD1) 6.87 1.82 5.68 2.22 2.98Attachment (RD2) 5.06 1.30 4.34 1.66 0.96

Dependence (RD3) 3.89 1.40 2.86 1.32 6.33**

Reward Dependence (RD) 15.81 2.88 12.89 4.01 6.20**

Persistence (P) 4.49 1.51 3.52 1.88 1.55

Responsibility (SD1) 4.55 1.94 2.77 2.12 1.86

Purposefulness (SD2) 4.91 1.45 4.11 1.51 0.32

Resourcefulness (SD3) 2.17 1.36 1.43 1.24 1.42

Self-Acceptance (SD4) 9.11 2.18 4.94 2.66 0.28

Congruent second nature (SD5) 6.91 2.33 6.32 2.58 0.004

Self-Directedness (SD) 24.64 6.75 19.57 8.66 0.76

Acceptance (C1) 4.92 1.35 4.07 1.37 2.18Empathy (C2) 4.72 1.39 4.11 1.65 0.24

Helpfulness (C3) 4.53 1.28 4.09 1.41 0.04

Compassion vs. revenge (C4) 4.96 1.66 4.59 1.87 0.22

Intergraded conscience (C5) 5.17 1.59 4.61 1.54 0.98

Cooperativeness (C) 24.30 4.53 21.48 6.31 0.39

Self-Forgetfulness (ST1) 7.21 2.46 4.59 2.80 5.81*

Transpersonal identification (ST2) 5.43 2.31 3.77 2.32 4.87*

Spiritual acceptance (ST3) 8.06 2.64 5.90 2.77 5.91*Self-Transcendence (ST) 20.70 5.84 14.27 6.95 8.38**

*p


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Ak et al. 779

participants. It can be said that male psoriasis

patients have temperament properties such as

impulsiveness, fatigability, worrying and

dependency. These properties, which are herit-

able, might be effective in the onset, course and

treatment stages of the disorder. Many studies

showed that higher HA scores leads to prone-

ness to depression. Elovainio et al. (2004)

reported that shyness with strangers and fatiga-

bility was important in the development of

depressive symptoms. High levels of co-

morbidity of psoriasis and depression might be

linked to temperament properties (Gupta and

Gupta, 1998; Taner et al., 2007; Van Voorhees

and Fried, 2009).

Character is largely environmentally derived

and responsive to learning and maturation.

Character can be defined as psychologically

self-directedness including rule making, execu-

tive and judgmental functioning. In this study

Self-Transcendence scores of psoriasis patients

were found to be higher than in controls. High

self-transcendent individuals are generally

more fair, considerate, religious and decent.

This property is adaptively advantageous for

people who face death or illnesses that are inev-

itable with age (Sadock and Sadock, 2004).

Contrary to the temperament properties that

might be related to co-morbid psychiatric

symptoms, the balance might be kept with this

protective and adaptive character property.

Additionally, in this study, it was aimed to

investigate PASI as a predictor of temperament

and character properties. In psoriasis patients,

the severity of PASI scores was positively

related to HA and RD scores. However no rela-

tionship was obtained with NS. Similarly, there

was no significant relationship between any of

the character properties and PASI. In the light

of these findings it can be said that dependent,

sentimental and avoidant persons have more

severe psoriasis symptoms.

In conclusion, male patients with psoriasis

differed from healthy controls in terms of tem-

perament dimensions including high NS, HA

and RD. Among these properties high HA and

RD can be predicted by the severity of PASI.

Psychosocial support for psoriasis patients is

important for the prognosis of the disorder and

the previously mentioned temperament and

character properties should be taken into con-

sideration while planning therapeutic interven-

tions for psoriasis patients.

In order to eliminate the possible effect of

age and gender on temperament and character

properties, only male patients ranging from 20

to 30 years old were included in the study.

However, this is also an important limitation.

Since it is a cross-sectional design we cannot

talk about causal relationships between psoria-

sis and temperament and character dimensions.

Table 3.Temperament and character properties ofpsoriasis patients

Temperamentand characterdimension

Description ofhighness

Possiblebiological factor

High NS Quicktempered,enthusiastic,easily bored,impulsive,extravagantand disorderly

Dopamine

High HA Anxious,pessimistic,fatigue and

shy, passiveavoidancefrom problemsand threats,anticipatoryworry

Serotonin

High RD Sentimental,sociallysensitive,dependent,relies on socialapproval

Norepinephrine

High ST Fair,considerate,religious,decent

Undefined



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Future studies should examine the effects of

the relationship between psoriasis and temper-

ament and character properties on the treat-

ment response in longitudinal designs, and

should include larger number of participants in

terms of age and gender.

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