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Disease Severity, Quality of Life, and Psychiatric Morbidity in Patients With Psoriasis With Reference to Sociodemographic, Lifestyle, and Clinical Variables: A Prospective, Cross-Sectional Study From Lahore, Pakistan

Abdul Rahman Khawaja, MB, MPH, MPhil; Syed Muhammad Azam Bokhari, MB, FCPS; Tariq Rasheed, MB, FCPS; Atif Shahzad, MB, FCPS; Muhammad Hanif, PhD; Faisal Qadeer, PhD; and Mohammad Jafferany, MD

Published: June 25, 2015

Disease Severity, Quality of Life, and Psychiatric
Morbidity in Patients With Psoriasis With Reference to Sociodemographic, Lifestyle, and Clinical Variables:

A Prospective, Cross-Sectional Study From Lahore, Pakistan


Background: Psoriasis is an immune-mediated, chronic disease with a genetic background that involves skin, nails, and joints. The incidence of psoriasis varies from 2.0% to 4.0% depending on the geographical location, ethnic background, and environmental conditions. Recent research has proved that psoriasis is a systemic inflammatory disease with extensive systemic implications. Objectives of the study were to explore the severity of psoriasis, dermatology-related quality of life, and psychiatric health of the patients with reference to sociodemographic, lifestyle, and clinical characteristics.

Method: Consecutive patients with psoriasis (ICD-10 criteria) from skin outpatient clinics of 3 tertiary care hospitals in Lahore, Pakistan, between November 1, 2012, and December 31, 2012, were assessed in this prospective cross-sectional study. The final sample includes 87 patients who were evaluated for severity of psoriasis (Psoriasis Area Severity Index [PASI]), dermatology-related quality of life (Dermatology Life Quality Index [DLQI]), and psychiatric morbidity (12-item General Health Questionnaire [GHQ-12]) and were assessed on 23 sociodemographic, lifestyle, and clinical variables.

Results: Of the 23 variables, the PASI was significantly associated with education and habit of drinking alcohol (P < .05), the DLQI was significantly associated with disturbed eating (P < .05), and the GHQ-12 score was significantly associated with hair disease (P < .05), current income (P < .05), and disturbed eating and sleeping (P < .01). The PASI, DLQI, and GHQ-12 were not usually affected by sociodemographic, lifestyle, and clinical factors, except for some variables such as education of the patient, alcohol intake, eating and sleeping disturbance, and income status. A statistically significant correlation (P < .01) was found between all 3 scores (ie, PASI, DLQI, and GHQ-12). The correlation coefficients of the PASI with the DLQI and GHQ-12 are 0.345 and 0.460, respectively, and that of the DLQI with the GHQ-12 is 0.635. A moderating effect of the DLQI score was found on the relationship between the PASI and GHQ-12 scores.

Conclusions: Psoriasis has an immense impact on the life of patients and common comorbidities in psoriasis including coronary heart disease, depression, cerebrovascular disease, and metabolic syndrome. Screening for these comorbidities in psoriasis patients is essential. Impaired quality of life negatively affects the psyche of patients and initiates coping mechanisms, which may lead to depression and anxiety, social dysfunction, and loss of confidence, and the psychosocial burden of the disease may become more than the physical burden. The dermatologist usually manages physical disease and fails to address the social, emotional, and psychological aspects. Quality of life improves if these psychological aspects are also properly dealt with.

Prim Care Companion CNS Disord 2015;17(3):doi:10.4088/PCC.14m01629

Submitted: January 19, 2014; accepted November 11, 2014.

Published online: June 25, 2015.

Corresponding author: Mohammad Jafferany, MD, FAPA, Psychiatry and Behavioral Sciences, Central Michigan University College of Medicine, 3215 Hallmark Ct, Saginaw, MI 48603 (

Psoriasis is an immune-mediated chronic inflammatory skin disease with an unpredictable course and unknown cause.1–3 It is estimated that 1%–3% of the world population have psoriasis.4,5 Psoriasis waxes and wanes in the form of episodes.6 Triggers/exacerbating factors or alleviating factors may be identified.7 Psoriasis affects nails and skin and may affect joints.8,9 Race, geographic location, and ethnic backgrounds are some of the important factors influencing the prevalence of psoriasis.10 Onset of the disease may be sudden or gradual.11 Psoriasis can start at any age11–13; however, the late teens and late fifth decade may be the most common ages at onset.13 Psoriasis may require lifelong management.14,15

Social rejection and alienation are forms of discrimination that patients with psoriasis experience and may result in their feeling stigmatized.16,17 Visible disfigurement impairs the self-image of the patient, which influences all aspects of his/her life,18 and is accompanied by embarrassment, shame, guilt, and anger.19–21 These patients abhor public parks, sports, and social gatherings, and they become the center of attention when they try to hide their skin with inappropriate clothing. They also may avoid intimate relationships.22,23 Reduced opportunities at work, school, or university are the direct result of damaged self-image and reduced self-confidence.24–26 Social interplay between the patient and society is very complex and multifaceted24; it is not unidirectional and leads to initiation of many coping mechanisms, which include anticipation of discrimination and fear of social rejection. This fear causes isolation, social anxiety, and social disability.17,27 Issues of maladjustment arise when people stare and pity, particularly if they think the disease is infectious.28 Intimacy seems impossible, and close relationships become complicated.22,23

Psoriasis is experienced over the course of a patient’s lifetime, as there is no cure and it is not life threatening.29, The patient may develop coping strategies to meet the demands of everyday life and try to adapt to the new paradigm.26,31–33 For the patient, it is an effort to cope on cognitive and behavioral levels to solve personal and social problems by neutralizing conflict and reducing stress.29,30,34 Positive and optimistic self-management can help inner anxieties and outer strains. When these demands exceed the capacity and resources of the patient, coping mechanisms fail, and he/she experiences stress.18,35–37

Social support, attention, confiding relationships, companionship, comprehension of the whole situation, easily understandable explanations, thought sharing, and self-management are strategies used in different forms of psychotherapy.38–40 These nonpharmacologic strategies may be beneficial when incorporated into treatment regimens for patients with psoriasis. If patients change their behavior and attitudes, they can reduce stress and improve quality of life.41,42 Salutogenesis is a term used to explain this phenomenon.43 When patients with psoriasis are the victims of adverse situations, several personal factors help them to develop a sense of coherence and view the situation more realistically. Hope and a sense of wellness fill the mind, and the patient faces all types of stress readily and confidently.43,44 Joy, intimacy, love, relaxation, and a sense of safety can defeat stress, disgust, fear, anger, and anguish in the thoughts of psoriasis patients.38,45

Kurd and colleagues46 found a higher frequency of anxiety and depression in patients with psoriasis in a population-based cohort study in the United Kingdom. Psychiatric morbidity has an association with psoriasis; depression and anxiety are the main psychiatric disorders in these patients.47–49 Depression has a 3-pronged response: autonomic, neuroendocrine, and immunologic; so, effects of depression may be 3-fold if it occurs as a comorbidity in psoriasis.50

Emotional agony takes the shape of anger, which may become unpredictable.51 A holistic approach to treatment has been recommended for patients with skin diseases.52,53 Quality of life includes subjective emotional, intellectual, and physical facets of a person.54 Life at work along with family and friends cannot be ignored.54,55 Intelligent physicians actively listen to their patients and consider their concerns about treatment and prognosis. Thus, periodic assessment of “health-related” quality of life is needed (Figure 1).55,56 Quality of life has a very important role in the activities of daily living and social survival of psoriasis patients.57,58 Finlay and Coles59 conducted a survey to identify handicaps faced by psoriasis patients and resultant impairment. Results showed loss of workdays in working patients. Those who did not work said that it was due to psoriasis.59 The impairment results in disability, with the patient consequently unable to perform a role or activity. This disability changes the status of a person in society.60–63

The severity of psoriasis frequently changes, as does the psychiatric and clinical profile of the patient, and both may affect quality of life.24,27,57 Demographic characteristics and lifestyle have a definite bearing on the manner in which the disease behaves and its treatment and prognosis.64 Therefore, we undertook this study to investigate results of the Psoriasis Area Severity Index (PASI), Dermatology Life Quality Index (DLQI), and 12-item General Health Questionnaire (GHQ-12) in various groups of psoriasis patients, with reference to sociodemographic, lifestyle, and clinical characteristics. The interrelationship between the PASI, DLQI, and GHQ-12 were also studied, as well as the moderating effect of the DLQI on the relationship between the PASI and GHQ-12.


This study uses a cross-sectional, prospective and observational design. The setting was the dermatology departments of 3 tertiary care hospitals in Lahore, Pakistan. Eligible patients were informed about the study and its objectives. After signing the consent forms, they were asked about sociodemographic details, and the first part of the questionnaire was completed by the researcher or other trained colleagues. Afterward, history of psoriasis and clinical information were taken by a qualified dermatologist. Family history, associated complaints, treatment history, and comorbidities were also included in the second part of the questionnaire. The questionnaire was followed by a detailed dermatologic examination, during which severity of disease was documented by using the PASI.


The sampling technique was nonprobability, convenient, and purposive. Consecutive psoriasis patients from skin outpatient clinics of 3 tertiary care hospitals in Lahore between November 1, 2012, and December 31, 2012, were included in the sample. Patients with plaque psoriasis (ICD-10 criteria) aged ≥ 14 years were included in the study. Patients were excluded from the study if they had non–plaque variety psoriasis, had severe systemic disease, were receiving systemic steroids or methotrexate, and were aged < 14 years.

Data and Instruments

The 7 sociodemographic variables in this study included gender, employment status, residence, age, marriage years, current income, and education level. The 3 lifestyle-related variables included hobby or sport, smoking, and drinking alcohol. The 13 clinical profile variables included onset of disease, any incident (like death of a close relative or divorce) associated with disease, hair disease, nail disease, other skin disease, psoriasis in first-degree relatives, psoriasis in second-degree relatives, psoriasis in other family members, hypertension, diabetes, other disease, eating disturbance, and sleeping disturbance.

Three scores, the PASI, DLQI and GHQ-12, were used to measure demographic, lifestyle, and clinical characteristics. The severity and extent of psoriasis was measured using the PASI.65 Researchers use this tool to gauge the severity of psoriasis in the form of a score. The whole body is divided into 4 regions: head (10% of the person’s skin), upper limbs (20% of the person’s skin), trunk (30% of the person’s skin), and lower limbs (40% of the person’s skin). Erythema, scaling, and thickness are 3 important clinically discernible features easily visible to and assessable by the clinician. Each feature is observed by the clinician, and a number is assigned that ranges between 0 and 4, with 4 being the worst. Erythema means redness, scaling means desquamation, and thickness means in duration. The sum of the erythema, scaling, and thickness scores constitutes the summary measure of severity of psoriasis for each region. Regional scores were then added to calculate a single score for overall patient severity.

Dermatology-specific and health-related quality of life was measured by the DLQI, which includes fitness, efficiency, illness, self-image, self-esteem, anxiety and depression, work, leisure time, rejection, social support, and stigma.16,66–69 The Urdu version of the DLQI was used to assess the dermatology-specific life quality index.70

The GHQ-12 was chosen as an instrument to gauge depression, anxiety, psychological distress, loss of confidence, and social dysfunction.70–72 It is used as a unitary measure.71 The GHQ-12 has been used in primary care and nonpsychiatric settings worldwide.73 This 12-item questionnaire is easy to understand, uncomplicated, and short and requires very little time to be completed.74 The Urdu version of the GHQ-12 is a validated tool for detection of psychiatric illness in the Pakistani population.70,72 The GHQ-12 was administered by a psychologist at the end of the interview.


Descriptive and clinical statistics were first calculated. The association of these variables with the PASI, DLQI, and GHQ-12 was examined using the Student t test, analysis of variance, Kruskal-Wallis, and Mann-Whitney test. Interrelation between the 3 scores was also studied, and a correlation matrix was deduced. The moderating role of the DLQI in the relationship between the PASI and GHQ-12 was calculated through hierarchical regression analysis. The data were analyzed using SPSS version 20 (SPSS Inc, Chicago, Illinois).


The sample consisted of 87 patients. Age was distributed in 3 groups: ≤ 25 = 21 (25.3%), 26–45 = 37 (44.6%), and ≥ 46 = 25 (30.1%). The sample included 56 males (64.4%) and 31 females (35.6%). The majority of patients (n = 52) had an urban background (61.9%), and 32 had a rural background (38.1%); 38 of the patients were employed (54.3%), and 32 were unemployed (45.7%). The majority of the patients (n = 53) had gradual onset of disease (63.1%), and only 31 had a sudden onset (36.9%). Fifty-six patients had no hobby or sport (64.4%), whereas 31 had a hobby or sport (35%).

Psoriasis Severity and Clinical Impact

The PASI, DLQI, and GHQ-12 scores were studied with respect to sociodemographic, lifestyle, and clinical variables. The mean score of the PASI for males was 10.1 and for females was 6.6; the standard deviation was 10.0 for males and 7.1 for females. The mean score of the GHQ-12 for males was 15.2 and for females was 13.7; the standard deviation was 8.5 for males and 7.6 for females. The mean score of the DLQI for males was 10.6 and for females was 8.4; the standard deviation was 7.7 for males and 6.6 for females.

Group comparisons of the PASI score showed a significant difference with respect to education level (P = .041) and use of alcohol (P = .038). The other 21 variables showed no significant difference (Table 1). Group comparisons of the DLQI score showed a significant difference with respect to disturbed eating (P = .004). The other 22 variables showed no significant difference (Table 2). Group comparisons of the GHQ-12 score showed a significant difference with respect to current income (P = .030), hair disease (P = .030), disturbed eating (P = .007), and disturbed sleeping (P = .002). The other 19 variables showed no significant difference (Table 3).

Relationships Between Scales

The DLQI score was correlated with the PASI score (0.345, P < .01). Similarly, a positive correlation (0.635, P < .01) between the DLQI score and GHQ-12 score was found. The PASI score was also correlated with the GHQ-12 score (0.460, P < .01) (Table 4).

The relationships between all 3 scales were evaluated using 3 regression models. In Table 5, model 1 examines the primary effect of the PASI on the GHQ-12. Results show that the PASI score has a significant and positive influence on the GHQ-12 score (0.37, P < .01). Model 2 further includes the DLQI as the moderator in the model. The β value of the moderator is also significant (0.53, P < .01). Model 2 shows an increase in R2 by about 26%. In model 3, the intersection term (ie, PASI í DLQI) is also added in the model. The regression for the intersection term is also significant. This result confirms the moderating effect of the DLQI on the relationship between the PASI and GHQ-12 (Figure 2).


We found that at one point in time, severity of psoriasis and dermatologic and health-related quality of life and depression, anxiety, and psychological distress interact and influence each other. In addition, a number of patient characteristics influence disease severity, quality of life, and psychological status. In our study, educational background was associated with severity of disease; higher education helped the patients and they had less impairment of quality of life, a finding shared by others.16,75 As we found, alcohol may make psoriasis worse; and others have reported its association with psoriasis that is more severe and refractory to treatment.76 While we found no significant relationship, others have reported that income has a modest influence on severity of disease.77

Disturbed eating was shown to significantly alter quality of life as measured by the DLQI in this research. Sleep and appetite are affected in patients with psoriasis depending on the location of the lesions on exposed parts of the skin.78 In a study by Gaikwad et al,79 more than half of the patients complained of loss of sleep. This loss of sleep may be very disturbing. Loss of sleep is due to physical symptoms and discomfort but affects quality of life to a great extent.80 Disturbed sleep, disturbed eating, income of the patient, and involvement of hair were significantly related to the GHQ-12 in this research. Quality of sleep may also be reported due to subjective emotional experience.81,82 Dietary intake and sleep are disturbed in older patients with psoriasis. These changes may cause worsening of the disease.83 Pruritis has been shown to cause disturbed sleep.83,84 Suicidal contemplation may also be associated with sleep disturbance.82,85

We found significant positive correlation between the DLQI and PASI scores (0.345, P < .01). Mattei et al86 previously reported a positive correlation between severity of disease and quality of life; in their study, psychological symptoms were also improved by clearing of psoriatic skin lesions (75%), especially in patients treated with biologics. We found significant positive correlation between the DLQI and GHQ-12 scores (0.635, P < .01). Impaired quality of life negatively affects the psyche of patients and initiates coping mechanisms, which have long-lasting implications on the psyche of patients.87 Impaired quality of life may lead to depression and anxiety, social dysfunction, and loss of confidence. These indicators are measured by the GHQ-12.21,88,89

Depression, anxiety, social dysfunction, and loss of confidence are all psychiatric and psychological disorders, which can be treated only if they are identified and evaluated by a clinician who knows about them. If they go unidentified and untreated, the life of the psoriasis patient may be miserable, and the psychosocial burden of the disease may become more than the physical burden.90–92 The skin, neuroendocrine system, and immune system are interconnected and communicative.93–95 Psoriasis patients mostly visit dermatologists, who diagnose and treat patients with psoriasis. As dermatologists have limited knowledge of psychiatry, related needs of these patients go unmet. Medical needs may be met, but functioning and disability are not addressed. Physical needs are partially addressed, ignoring functioning and disability, whereas psychosocial needs are not addressed at all. It can be deduced that only 10% of the patients’ needs are addressed, whereas 90% of the needs of patients are unmet.56,96 Psychological stress affects epidermal permeability barrier homeostasis and may aggravate psoriasis.97,98 Patients with psychocutaneous disorders often do not like to be referred to psychiatrists, so liaison among primary care physicians, psychiatrists, and dermatologists may be very beneficial.90,92,99–101


This study has limitations. The study design was cross-sectional and, therefore, while associations may be identified, the results do not imply causality. Temporal associations were not evaluated. Selection bias is also possible, as sampling was time based and was not a probability sampling. Due to smaller sample size, sampling method, and the tertiary clinic setting of the study, generalizations to other groups of patients are unwarranted. Only plaque psoriasis was included in this study; other varieties of psoriasis may have different clinical and psychiatric correlates.


After patients with psoriasis are examined and treated by dermatologists, they should be screened for psychiatric, cardiac, and metabolic comorbidities. Health-related quality of life should also be estimated in all psoriasis patients. Liaison clinics should be set up in all dermatology departments. Dermatologists should be made aware of the psychiatric complications of psoriasis during their training. A system of active integrated management of psoriasis and comorbidities, both medical and psychiatric, should be developed and evaluated.

Author affiliations: AIMC Research Cell, Allama Iqbal Medical College, Jinnah Hospital, Lahore (Dr Khawaja); Department of Dermatology Services, Institute of Medical Sciences Services Hospital, Lahore (Dr Bokhari); Department of Dermatology, Fatima Jinnah Medical College, Sir Ganga Ram Hospital, Lahore (Dr Rasheed); Department of Dermatology, Postgraduate Medical Institute, Lahore General Hospital, Lahore (Dr Shahzad); Department of Statistics, National College of Business Administration and Economics, Lahore (Dr Hanif); Lahore Business School, The University of Lahore, Lahore (Dr Qadeer), Pakistan; and Department of Psychiatry, College of Medicine, Central Michigan University, East Campus, Saginaw (Dr Jafferany).

Potential conflicts of interest: None reported.

Funding/support: None reported.


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