The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study.

BACKGROUND: Alopecia areata (AA) is a skin disease characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas, but its aesthetic repercussions can lead to profound changes in patient's psychological status and relationships. AIM: The goal was to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression.
MATERIALS AND METHODS: Fifty patients with AA seen in the Department of Dermatology of Hedi Chaker University Hospital, Sfax were included in this study. Anxiety and depression were evaluated by Hospital Anxiety and Depression scale questionnaire, alexithymia was assessed by Toronto Alexithymia scale 20, and severity of AA was measured by Severity of Alopecia Tool.
RESULTS: Patient's mean age was 32.92 years. 52% of patients were females. Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). Forty-two percent of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).
CONCLUSIONS: Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.

What was known?

Alopecia areata as many other skin diseases can have a severe impact on psychological wellbeing. Several studies have shown a link between alexithymia and alopecia areata.

Introduction

Alopecia areata (AA) is a skin disease of unknown etiology with prevalence of 0.2% in the general population.[1] This disorder occurs in both sexes, at all ages,[2] and is characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas. Various factors, including immunological and endocrine abnormalities,[3] genetic factors,[4] infections,[5] and psychological/psychiatric disturbances have been claimed to play a role in its etiopathogenesis.[6]

As hair is an important component of identity and self-image, even partial hair loss can lead to a variety of psychological difficulties.[78] AA can have psychosocial complications, including depression, low self-esteem, altered self-image, and less frequent and enjoyable social engagements.[910] A link between alexithymia and AA has been suggested by several studies.[1112]

Alexithymia is defined as difficulty being aware of, recognizing, differentiating, and defining emotions, both of self and others.[13] It is hypothesized that alexithymic patients tend to “somatize” emotional problems because they cannot verbalize them.[14] Indeed, it has been reported that alexithymic features are more frequent in some psychosomatic disorders,[13] and AA is also considered a psychosomatic disease.[15]

The objectives of our study were to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression.

Materials and Methods

All new patients diagnosed with AA and who did not have any previous episodes of AA seen in the Department of Dermatology of Hedi Chaker University Hospital Sfax between March 2010 and July 2010 were included in the study. Informed consent was obtained from all enrolled subjects. The diagnosis of AA was made by a qualified dermatologist on a clinical basis. Socio demographic and clinical data including age, sex, family history of AA, site of onset and associated diseases were recorded for all patients. Included patients underwent full clinical examination to determine the number and extension of the sites affected by AA and the severity of the disease. The control group included 50 healthy adults recruited from the hospital staff who did not currently or previously have any psychiatric and dermatological disorders. The controls were age-and gender-matched and did not work in an area related to psychiatry or psychology.

All of the patients and controls were evaluated by a Psychiatrist using the Toronto Alexithymia Scale (TAS) and the Hospital Anxiety and Depression Scale (HADS). Persons who were illiterate, who lacked the ability to communicate, or who had mental retardation were excluded from the study.

The severity of hair loss was assessed by measuring the percentage of the alopecic area on the scalp. Patients with AA were evaluated using Severity of Alopecia Tool (SALT).[16] The SALT score is computed by measuring the percentage of hair loss in each of 4 areas of the scalp (40% vertex, 18% right profile, 18% left profile, 24% posterior) and adding the total to achieve a composite score. Patients were divided according to disease severity: S1-S2: Hair loss below 50%; S3-S4: Hair loss of 50-99%; S5: Total scalp hair loss.

HADS is a self-report scale, which issued to determine the levels of anxiety and depression that a patient is experiencing.[17] It is administered to patients with physical diseases who consult to primary care units. It consists of 14 questions, seven of which measure anxiety, while the other seven measure depression.

TAS-20 is a 20-item self-report scale with a three-factor structure congruent with the alexithymia construct: difficulty in identifying feelings, difficulty in describing feelings, and externally oriented thinking.[18] Each item is rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with five items negatively keyed. The TAS-20 score ranges from 20 to 100; subjects scoring 61 or more have been suggested to be alexithymic.

For statistical analysis, we used the Statistical Package for Social Sciences, version 18. Statistical evaluations performed were student t-test, Chi-square test, and linear regression analysis. A P value less than 0.05 was considered statistically significant.

Results

Fifty patients were included in this study. Their mean age was 32.92 years (Standard Deviation = 11. 81), with a minimum of 18 years and a maximum of 60. There were 48% males and 52% females, with a male to female ratio of 0.92. As to the level of education, 18% had elementary school education, 40% had secondary school education, and 42% had higher education level. 52% of patients were single, 46% were married and 2% were divorced. As to occupation, 52% were employed, 22% were unemployed, 24% were studying and 2% were retired. Patient's demographic characteristics are summarized in Table 1.

Table 1

Demographic characteristics of patients

At the time of first presentation, 80% had patchy alopecia with less than 50% involvement (S1-S2), 12% had patchy alopecia with 50-99% involvement (S3-S4), and 8% had alopecia total is. The mean duration of hair loss prior to diagnosis was 69.28 days with figures ranging from 1 day to 400 days.

Alexithymia, anxiety and depression in the patient group

The mean score of alexithymia determined by TAS was 56.12 ± 14.42 in the patient group. Forty-two percent of patients scored positive for alexithymia.

The mean score of anxiety and depression was respectively 10.42 ± 3.49 and 8.96 ± 4.43. Anxiety and depression were detected respectively in 62% (N = 31) and in 38% of patients (N = 19).

Alexithymia, anxiety and depression in the control group

The mean score of alexithymia was 54 ± 14.78. The rate of alexithymic control subjects was 38%. The mean score of anxiety was 7.9 ± 3.48 and the mean score of depression was 7.18 ± 3.72. Anxiety was found in 34% of control subjects and depression in 20%.

Comparison between patient and control groups

No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. The patient group had significantly more anxiety and depression than the control group (P = 0.005 and P = 0.047) as shown in Figure 1.

Figure 1

Rate of alexithymia, anxiety and depression in the patient and control group

Factors correlated with alexithymia, anxiety and depression

When the participants with alexithymia and without alexithymia were compared in terms of gender, education or occupation, no statistically significant differences were found between groups. Alexithymia was not correlated to gender, education or occupation, neither in the patient nor in the control group.

In the patient group, the correlation between alexithymia and severity of AA was assessed, and no statistically significant correlation was found. There was no significant difference in depression between alexithymic and non-alexithymic patients. In terms of anxiety, alexithymic patients were more anxious than non-alexithymic patients (P = 0.019). The correlation of the different socio-demographic and clinical factors to alexithymia is summarized in Table 2.

Table 2

Factors correlated with alexithymia

To further assess factors that influence alexithymia, we used stepwise linear regression. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).

Depression was significantly more frequent in women with AA compared to men (odds ratio [OR] =4.433, 95% confidence interval [CI]: 1.269-15.489, P = 0.016). It was found that unmarried patients with higher depression scores had a significantly higher risk for having AA compared to those who had lower depression scores (OR = 3.939, 95% CI: 1.168-13.281, P = 0.024). No relationship was found between the severity of AA and depression.

Discussion

Alexithymia

Alexithymia is defined as a deficit in the awareness and identification of emotional states. It is composed of four major factors: (1) Difficulty in identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal; (2) difficulty in describing feelings to other people; (3) constricted imaginative processes, as evidenced by a paucity of fantasies; and (4) a stimulus-bound, externally-oriented cognitive style.[19] In a review, Arck et al.[20] have found that there is solid evidence for a local neuroendocrine skin axis that operates as an important “brain-skin” connection, and they have established a fully functional peripheral equivalent of the systemic, stress-activated hypothalamic-pituitary-adrenal axis.[2122] Hence, it is not surprising that alexithymic individuals, who fail to cope with stress, are at risk for the development of specific dermatologic diseases.

Few studies have focused on the relationship between AA and alexithymia.[23] Several authors,[1124] have shown that a majority of patients with AA are alexithymic compared with controls. They found that AA tends to be associated with high avoidance in attachment relationships, high alexithymic characteristics, and poor social support. However, in our study, there was no significant difference between AA patients and controls in terms of alexithymia prevalence. Nevertheless, overall alexithymia rate in patients and controls was high: 42% in the patient group and 38% in the control group. Indeed, studies on alexithymia in the Mediterranean region seem to show elevated levels in the general population.[25]

People of Mediterranean origin are more likely to use somatizing and to convey emotional information through body language in order to communicate distress.[26] On the contrary, prevalence of alexithymia amongst Northern Europeans is relatively low, between 9.9 and 13.[2728]

This difference might be explained by cultural aspects. Culture can influence the experience and expression of emotion, and because alexithymia is primarily characterized by emotion identification and communication, culture is likely to influence alexithymia severity.[29] A recent study hypothesized that cultural differences in alexithymia may be explained by culturally based variations in the importance placed on emotions.[30]

Anxiety and depression

AA has been associated with an increased prevalence of certain psychiatric disorders, particularly depression and anxiety, varying from 40% to 93%.[3132] The present study confirms these findings: anxiety (62%) and depression (38%) were significantly higher in the patient group in comparison with controls (P = 0.005 and P = 0.047). This implies that the effect of AA on patients is psychologically distressing. Our study supports the fact that AA is a condition of high psychological impact because it alters self-image leading to embarrassment, lack of self-confidence and lower self-esteem.[8]

In our study, unmarried patients showed significantly more signs of depression compared to healthy controls. This finding is consistent with a study from Egypt,[33] which showed that single patients with AA were more likely to develop psychiatric disorders. These results denote that un established social life in unmarried patients makes them worry about their future resulting in more psychological distress and psychiatric morbidity.

In our sample, the female patients are differentiated from males by higher levels of anxiety and depression. This finding is in accordance with previous studies that indicated a higher prevalence of psychiatric morbidity among women with dermatological disease, especially eczema, psoriasis, acne and AA.[3435] Some studies,[3637] have found that hair loss was a traumatic experience for both men and women, but more difficult to support and accept for female patients. Women are more concerned about their physical appearance and hair is an important part of it.[36] Thus, the negative psychological impact of AA may be due to the importance of hair loss and its impact on their appearance. In Tunisia, where Islamic customs prevail women try to cover their hair in case of AA. This observation was also made in Kuwaiti and Egyptian studies.[38]

Some studies,[3339] showed that psychiatric comorbidity was associated with the presence of multiple patches of AA. Patients with limited AA are able to cover the patches with their remaining hair and are therefore less likely to experience psychological problems such as anxiety and depression.[7]

The link between alexithymia, anxiety and depression

Previous studies have reported a connection between alexithymia, anxiety and depressive symptomatology, and it is well known that patients are prone to experiencing alexithymic features.[2740] Our study showed a positive correlation between alexithymia and anxiety. Moreover, our regression showed that anxiety was responsible for 14.7% of variation in alexithymia, suggesting that anxiety may underlie patient's difficulties to identify feelings as other authors have previously noted.[41] Due to the cross sectional design of our study, we cannot answer the question of whether alexithymia leads anxiety symptoms or contrarily anxiety symptoms lead to alexithymia.

Some authors conceptualized alexithymia as a stable personality trait reflecting a deficit in the cognitive processing of emotional information.[42] The differentiation of cases with alexithymia state or trait would be important because cognitive therapies could be more indicated on primary alexithymia as suggested by Jimerson et al.[43] and Sexton et al.[44] Finally, the causal relationship between negative emotional states such as depression and anxiety and AA is still to be determined: (1) Are these negative emotional states due to AA? (2) Might AA be caused or triggered by these psychiatric conditions? (3) Do AA and psychiatric conditions share a common ground of vulnerability?

Limitations of the study

There are some limitations to our study that should be taken into consideration. First, the sample size was relatively small. Secondly, the participants were recruited from a hospital service of general dermatology. Consequently, our patient sample may not be representative of all patients with AA. The strengths of this study are that not only alexithymia but also related psychiatric conditions such as anxiety and depression have been examined. This is the first Tunisian case control study on the subject.

Conclusion

Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. No significant differences have been found in alexithymia prevalence between the patient and the control group, but overall alexithymia prevalence was high. Thus, no definite conclusions can be drawn from our study as to a possible relationship between alexithymia and AA and more studies are needed on this subject, possibly taking into account intercultural differences of alexithymia. However, the high prevalence of anxiety and depressive symptoms suggests that a screening for psychiatric distress in all AA patients might be warranted.

What is new?

In our study, AA patients were not more alexythymic than controls. Prevalence of alexithymia was high in patient and control group, which might be linked to the Mediterranean origin of the population.