Assessing the risk of anxiety in patients with pemphigus vulgaris using Beck Anxiety Inventory

To the Editor, Pemphigus vulgaris (PV) is a chronic disabling mucocutaneous disorder which could lead to various psychiatric disorders including depression and anxiety.1,2 Here, we assessed demographic, socioeconomic, clinical, and serologic profile of 83 Iranian patients suffered from PV, as well as their psychological profile using the Persian version of Beck Anxiety Inventory (BAI)3 in a crosssectional study from October 2019 to April 2020. A total of 83 patients were studied which their demographic, clinical, and sociodemographic characteristics is given in Table 1. Beck score ranged from 0 to 36 (mean: 7.15 ± 5.67) which was considered as none or minor anxiety level. In regard to gender of patients, 36% of females versus 24% of males showed a variable degree of anxiety (p value: 0.117). A stratified analysis by age, education level, and career status revealed that the association of PV and anxiety was more eminent in younger patients, those with lower level of education and unemployed ones (Table 2). Moreover, disease duration, corticosteroid dosage, and PDAI in patients showed a significant positive correlation with anxiety level (p value: 0.001, 0.016, and 0.008, respectively) (Table 2). No significant association was otherwise noted. There are numerous reports have been published on the depression level and QoL in patients with PV; however, the anxiety level has rarely been investigated by highly reliable and qualified tools.4 To the best of our knowledge, this study was the first one employing the BAI in patients with PV and also the first study on Iranian patients in this regard. Based on our results, 32% of patients with PV experienced some degree of anxiety which was compatible with the results of the only study we found in this regard on 105 Indian patients using Hamilton Depression Scale which showed an anxiety rate of 32% (30% mild and 2% moderate).4 In the present study, 27%, 3%, and 2% of patients had mild, moderate, and severe anxiety level, respectively. In the present study, there was a positive correlation between PDAI and anxiety. This can be interpreted in two directions; either clinical deterioration and extension of disease leads to anxiety, which seems quit logical when considering patients' concerns about their appearance, more severe symptoms and the higher possibility of poorer therapeutic response, or anxiety leads to clinical

considered as none or minor anxiety level. In regard to gender of patients, 36% of females versus 24% of males showed a variable degree of anxiety (p value: 0.117).
A stratified analysis by age, education level, and career status revealed that the association of PV and anxiety was more eminent in younger patients, those with lower level of education and unemployed ones ( Table 2).
Moreover, disease duration, corticosteroid dosage, and PDAI in patients showed a significant positive correlation with anxiety level (p value: 0.001, 0.016, and 0.008, respectively) ( Table 2). No significant association was otherwise noted.
There are numerous reports have been published on the depression level and QoL in patients with PV; however, the anxiety level has rarely been investigated by highly reliable and qualified tools. 4 To the best of our knowledge, this study was the first one employing the BAI in patients with PV and also the first study on Iranian patients in this regard.
Based on our results, 32% of patients with PV experienced some degree of anxiety which was compatible with the results of the only study we found in this regard on 105 Indian patients using Hamilton Depression Scale which showed an anxiety rate of 32% (30% mild and 2% moderate). 4 In the present study, 27%, 3%, and 2% of patients had mild, moderate, and severe anxiety level, respectively.
In the present study, there was a positive correlation between PDAI and anxiety. This can be interpreted in two directions; either clinical deterioration and extension of disease leads to anxiety,  deterioration which is also logical based on the assumption that many of chronic dermatologic disorders, especially those with an autoimmune basis are better to considered as psychocutaneous interrelated disorders. 5 Another important finding in present study was a positive correlation between anxiety and disease duration which means that patients with long-lasting disease were more likely to be anxious.
It is opposite to the result of a previously published study about the correlation of QoL and disease duration in PV. 6 In fact, clinical improvement over the time, learning about various aspects of disease, getting familiar with different therapeutic options and overall, adaptation to their situation are possible explanation for a better QoL in patients with long-lasting disease. 5 Conversely, the anxiety seems to get worse over time, reflecting that the abovementioned mechanisms are not efficient enough to let patients with the long-term disorder cope with the disease.

ACK N OWLED G M ENTS
The authors would like to thank Razi Hospital Clinical Research

Development Center and Autoimmune Bullous Diseases Research
Center for their technical and editorial assistance.

FU N D I N G I N FO R M ATI O N
We received no funding for this project.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interest regarding the publication of this article.

E TH I C A L A PPROVA L
The study protocol was approved by local ethics committee and signed written informed consent was obtained from each patient.