Manifestations and intensity of indirect self-destructiveness in patients with psoriasis vulgaris

Psoriasis significantly impairs the quality of life of people affected by it, and the degree of reduction in quality of life is similar to that of diabetes, cancers or acute myocardial infarction [6-11]. Psoriasis also contribute to the formation of secondary changes in the psyche of a person suffering from this condition, they are responsible for depressed mood, depression, anxiety, the social isolation and withdrawal. Severe itching that often accompanies psoriasis very significantly promotes sleep disorders, especially an insomnia. About 5% of patients with the most severe forms of psoriasis (eg. erythrodermic psoriasis) attempt suicide. Psoriasis also affects social functioning, is primarily the cause of stigmatization of people suffering from this disease, it contributes to worse functioning in the family and at work. It has been proven also that the fact of having psoriasis favors addictions (smoking, drinking, drug use) that may be a mechanism of escape from a difficult situation resulting from the disease. ABSTRACT


INTRODUCTION Psoriasis Vulgaris and its Psychosocial Aspects
Psoriasis is a common chronic inflammatory disease, whose main manifestation are skin lesions such as hyperkeratotic papules and plaques covered with a layer of scales.The disease affects approximately 2-3% of the world's population.In addition to skin psoriasis also affects joints and cardiovascular system [1][2][3][4][5].
Psoriasis significantly impairs the quality of life of people affected by it, and the degree of reduction in quality of life is similar to that of diabetes, cancers or acute myocardial infarction [6][7][8][9][10][11].
Psoriasis also contribute to the formation of secondary changes in the psyche of a person suffering from this condition, they are responsible for depressed mood, depression, anxiety, the social isolation and withdrawal.Severe itching that often accompanies psoriasis very significantly promotes sleep disorders, especially an insomnia.About 5% of patients with the most severe forms of psoriasis (eg.erythrodermic psoriasis) attempt suicide.Psoriasis also affects social functioning, is primarily the cause of stigmatization of people suffering from this disease, it contributes to worse functioning in the family and at work.It has been proven also that the fact of having psoriasis favors addictions (smoking, drinking, drug use) that may be a mechanism of escape from a difficult situation resulting from the disease.
Susceptibility to the development of psoriasis is genetically conditioned, and the inheritance of susceptibility is poligenic.In addition to genes the occurrence or exacerbation of psoriasis is also influenced by environmental factors, among which the most important are stress, addictions (smoking and alcohol abuse) and infections, injuries or certain drugs [1][2][3][4][5].
In this situation stress and addictions are often both one of the causes and main effect of psoriasis.

Indirect Self-Destructiveness-Characteristics of the Concept and its Relationship with Psoriasis
Indirect self-destructiveness, also called chronic, hidden or latent is defined most often as a tendency to engage in behavior that increase the likelihood of negative and reduce the likelihood of positive consequences for the entity [30][31][32][33].
Indirect self-destructiveness is often called "suicidal lifestyle."What differentiates indirect selfdestructiveness from its direct form (which include suicide and self-mutilations) is mainly the result of the action which is unnecessary and away in time.
The main manifestations of indirect self-destructiveness include: intentional suffering and defeat, helplessness, passivity, social and health neglects, addictions, transgression and violation of social norms and heedlessness and inability to plan and succumbing to temptation.According with Suchańska and Kelley we can distinguish 5 classes of indirect self-destructiveness designated A1-A5 (A1-transgression of norms and risk, addictions, A2-poor health maintenance, A3 -personal and social neglect, A4-lack of planfulness and A5 -helplessness and passiveness in the face of the problems).These classes are not separate entities but mutually overlapping, so that it is often difficult to classify the exact manifestation of a particular class [30][31][32][33][34][35][36][37].
After characterization of psoriasis vulgaris and indirect self-destructiveness it is well obvious that although this notions are seemingly quite far apart, they have several common aspects.
Addictions and neglect of health are manifestations of indirect self-destructiveness which are certainly associated with psoriasis, as evidenced by numerous publications devoted to this subject [13,15,17,19].
Indirect self-destructiveness determine unfavorable lifestyle, a lifestyle is according to the paradigm of Lalonde the major determinant of human health, and also the only one for which the subject has any impact thus linking frequent dermatological disease-psoriasis with indirect self-destructiveness, in the absence of any existing so far publications this topic seems to be well reasoned and practical at the same time [38].
The aim of the study was to determine the intensity and major symptoms of indirect self-destructiveness in the population of patients with psoriasis.

MATERIALS AND METHODS
The study included 82 adult patients with psoriasis vulgaris hospitalized in the Department of Dermatology, Pediatric Dermatology and Oncology in Lodz in 2013-2014 (27 women and 55 men, mean age 46.6 years).The study excluded patients suffering from other serious chronic diseases, especially neurological and psychiatric diseases.The subjects completed a questionnaire, patients demographic and composed of 52 sentences questionnaire investigating indirect self-destructiveness in adaptation of Suchańska, separate version for men and women.At each of the 52 statements patient chose an option answers -from A (strongly agree) on E (strongly disagree), on the basis of assigned each response scores determined the overall rate of intensity of indirect self-destructiveness (minimum score 52 points, the maximum 260 points) in turn, each related to one of 5 classes of indirect selfdestructiveness, allowing also to define the dominant symptoms of a patient.The study was approved by the Bioethics Committee and participation in the survey was voluntary.
All calculation and graphs were made using Statistica 11PL and Ms Office 2007.

RESULTS
The average score of indirect self-destructiveness in the population studied was 117.61 ± 21.97 (median = 114.5).

DISCUSSION
The average score of indirect self-destructiveness in patients with psoriasis vulgaris was in the lower range of average results.
The most expressed class of indirect self-destructiveness in patients with psoriasis was A5 "Helplessness and passivity" in second place of intensity there were almost simultaneously class A2" Poor health maintenance" and class A4 " Lack of planfulnes".The less expressed class of indirect self-destructiveness was in this population class A1 "Transgression of norms and risk" and its subclass A1a "Addiction".
As we can see passive forms of indirect selfdestructiveness strongly dominate in patients with psoriasis vulgaris over its active forms.
As it turns out, the biggest problem of people with psoriasis is their overwhelming helplessness, passivity and resignation.People with psoriasis, especially with its most severe forms are resigned, don't believe in the therapeutic success, don't believe in success in life are pessimistic for the future, have a great sense of injustice in the world and have feelings of lack of control.
This passivity and helplessness can be a cause of a poor health maintenance, with a predominance of non adherence to medical recommendations and leaving the check-ups.
Thus smoking and drinking alcohol is not a leading problem in population of psoriatic patients and it seems that it can be an ineffective and desperate form of escaping from the psychosocial problems caused by psoriasis.

CONCLUSIONS
The conclusions from this study allow to optimize the approach to a patient with psoriasis.In everyday contact with the patient dermatologist must first activate and motivate a person, strengthen his motivation and educate and explain that it is possible to achieve the remission with the appropriate involvement of the patient and his positive thinking so needed in the therapeutic process.The attitude of forbidding of smoking and drinking alcohol is then ineffective and destroys the therapeutic relationship as well as may contribute to even greater helplessness.Chronic self-destructiveness is a quite enigmatic psychological issue that in dermatology has been  never investigated or reported.Thus, it is the first study integrating chronic self-destructiveness with skin disease.Until now indirect self-destructiveness was studied in field of psychiatry in patients with schizophrenia in people after suicide attempts and in drug addicts [39][40][41].
The relationship of chronic self-destructiveness with psychiatry seems obvious, however, as shown in this work, because of bilateral interaction between the skin and the psyche, the study of indirect selfdestructiveness in psoriasis has its strong justification and practical implications.

Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent
Informed consent was obtained from all patients for being included in the study.

Figure 1 :
Figure 1: Intensity of classes of chronic self-destructiveness in patients with psoriasis.

Table 1 :
Intensity of chronic self-destructiveness in patients with psoriasis -the overall scoreChronic self-destructiveness