Original Research

Medical Journal of Islamic Republic of Iran, Vol. 25, No. 4, Dec. 2011, pp. 200-204

Psychological status in patients with chronic urticaria

Najmosadat Atefi1, Mahboobeh Rahimi2, Shadi Peyghambari3, Shadi Ghourchian4

Department of Dermatology, Rasul-e-Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Received: 7 March 2011 Revised: 12 October 2011 Accepted: 26 October 2011

__________________________________________________________________________________________
Abstract
Background: Chronic urticaria (CU) is a common dermatological disease that induces a substantial burden on
individuals’ life. Also if one’s self-image changes (which usually happen in patients with dermatological diseas-
es), it leads to anxiety or other various symptoms.
We aimed to compare the psychological scales in patients with CU with non-dermatological individuals with
the purpose of early diagnosis and appropriate psychiatric consult.
Methods: In this study, psychological status of 30 patients with the diagnosis of chronic urticaria (lasting for
more than 6 weeks) and 30 controls, chosen among the hospital staff were evaluated. Evaluation was carried out
by using standard General Health Questionnaire (GHQ-28). Psychosomatic disorders, anxiety, depression and
social functions were assessed. Data were analyzed by SPSS v. 16, and the frequency indices and Chi- Square
test.
Results: Although from 30 patients with CU, 63.3% suffered from psychological disorders, this prevalence
was estimated 46.6% in the control group. Altogether, psychological disorders in patients with CU were signifi-
cantly (p=0.007) more prevalent than individuals without dermatological problems. Anxiety was the most com-
mon reported disorder.
Conclusion: In our study, the most prevalent psychiatric disorders included anxiety, psychosomatic disorders,
social dysfunction and depression, sequentially. It seems that depression is the least significant psychiatric dis-
order among patients who suffer from urticaria. Also, anxiety was the most reported disorder among them,
which may be considered as the primary cause of the disease or it may be secondary to the disease process. This
theory clarifies the importance of dermatologists and psychiatrists cooperation.

Keywords: Chronic Urticaria, Psychological problems, Dermatology.

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autoimmunity, infectious, systemic diseases

Introduction and drugs. Although psychiatric disorders
Chronic urticaria (CU) known as wheal, have been expressed as a risk factor, the
hive and nettle rash is a common dermato- pathogenesis has not been identified yet [7-
logical disease that induces a substantial 10]. It seems that the psychological effects
burden on individuals’ life. It is defined as change the quality of life of affected indi-
recurrent spontaneous onset of itchy in- viduals. This theory was proved by Gupta et
flammatory wheals that last more than 6 al in 1999. By their study, the quality of life
months [1-5]. It is estimated that 10-20% of was evaluated by administrating a 22-item
individuals experience 1 episode of this dis- quality-of-life scale to 100 patients with CU
ease during the life [6]. CU can be caused and 96 healthy individuals [11].
due to immunologic or allergic reactions, Moreover, when an ailment progresses det-
__________________________________________________________________________________________________
1. (Corresponding author) Assistant Professor of Dermatology, Rasul-e-Akram Hospital, Tehran University of Medical
Sciences, Tehran, Iran. [email protected]
2. General Practitioner, Tehran University of Medical Sciences, Tehran, Iran. [email protected]
3. Medical student, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Shahid Beheshti University of Medical
Sciences, Tehran, Iran. [email protected]
4. Medical student, Scientific Students' Research (SSRC) Center of Tehran University of Medical Sciences, Tehran Uni-
versity of Medical Sciences, Tehran, Iran. [email protected]
 N. Atefi, et al.

rimentally and patients must undergo treat- Measurements

ment in a depressed manner, he/she loses the Tow questionnaires were considered for
advantage of the proper utilization of his/her assessing the patients. The first one included
defenses [12]. In the other hand, if one’s demographic questions such as: age, sex,
self-image changes (which usually happen in education, symptoms of urticaria, drug histo-
patients with dermatological diseases) and ry and the treatment. The second one was a
gives rise to undesirable manner, it leads to standard questionnaire known as General
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anxiety, fear and/or other various symptoms. Health Questionnaire (GHQ-28). It consists
Also the quality of life is affected by one’s of 28 questions about psychiatric disorders
self-image [13]. such as depression, anxiety, psychosomatic
According to the absence of previous stud- disorders and social functions. This psycho-
ies about the relationship between CU and logical measurement scale was designed by
psychiatric disorders in Iran, we aimed to Goldberg and Hiller in 1979 and consisted of
compare the psychological scales in patients 4 parts with 7 questions in each part [14]. It
involved in CU with control group. This assesses individuals with somatization, anxi-
may help in early diagnosis and proper psy- ety and insomnia, depression and social
chiatric referral; also it is necessary to man- function.
age psychiatric disorders prior to change the Evaluation scores were based on Likert
life style. method and the answers were scored 1, 2, 3
or 4, sequentially [15]. In this study, the
Methods score of 23 was considered as cut off point
Ethical approval and patients with a score more than 23 were
This was a case-control study which was identified as a psychological patient.
performed in Rasul-e-Akram university hos-
pital. The hospital is a referral dermatology Analysis
center of west, south and east of the capital After gathering the data, the prevalence of
city. Also lots of patients are referred to our psychiatric disorders were calculated in pa-
hospital from other provinces. Verbal clari- tients with CU and the control group. For the
fication about the aim of the study was es- purpose of making the derivation of the sta-
tablished between the authors and the pa- tistics, the results were presented as odds
tients. All researchers respected the Helsinki ratio that is associated with an exposure. For
declaration during all parts of the study. analysis, description and comparison, we
used SPSS software version 16, frequency
Participants indexes were used for description. To com-
During 1 year, all patients referred to our pare the differences, chi-square and inde-
dermatology clinic with the diagnosis of pendent Samples T-test, were used. The p<
urticaria were followed. If the disease lasted 0.05 was considered statistically significant.
more than 6 months, the patients were rec-
ommended to be assessed for mental health Results
by our group. A total of 32 patients aged 16 The patients aged 16 to 79 years old. From
to 79 years participated in this study. Also all patients with CU, 3 of them were male.
30 individuals from hospital staff without The wheals appeared at morning, in the af-
any dermatology diseases were enrolled as ternoon, in the evening and at night in 9, 5,
control group. There was no gender or age 6, and 8 patients, respectively. Two of them
priority for choosing the patients but the cas- suffered from CU for the day and night.
es of control group were matched with the In 19 patients the lesions disappeared with-
patients by considering education, age and in 24 hours. Also the wheals lasted 72 hours
gender. Two out of 32 patients were exclud- in 6 patients and more than 72 hours in the
ed from the study because of migration. remaining (5 patients).

MJIRI, Vol. 25, No. 4, Dec 2011, pp. 200- 204 201
 Psychology and Urticaria
Table 1. Different presentations of CU in the patient group.
The percentage
The time of ap- Morning: 30% Afternoon: Evening : 20% Night: 26.7% All day:
pearance 16.7% 6.7%
The duration of Less than 24 Less than 72 More than 72
wheals h:63.3% h:20% h:16.7%
Recurrence Daily: 60% Weekly:16.7% Monthly: 13.3% Irregular:10%
Distribution (type Ordinary Pressure Angioedema
of urticaria) urticaria:67.7% urticaria: 16.7% :6.7%
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Table 2.The prevalence of psychiatric disorders in the patients with CU and the healthy group.
The prevalence Anxiety scale Psychosomatic Depression Disability in Total
disorders social functions
Case 80% 70% 50% 70% 63.3%
Control 43.3% 40% 16.7% 33.3% 46.65%
p value 0.003 0.02 0.006 0.004 0.007
Odds ratio 4.64 (95% CI: 3.30 (95% CI: 4.30 (95% CI: 4.28 (95%CI : 1.93 (95% CI:
1.67 - 12.87) 1.22 - 8.92) 1.51 - 12.22) 1.59- 11.52) 0.71-5.23)

The wheals recurred daily in 18 patients, control group. Our results were similar to
weekly in 5 patients and monthly in 4 pa- what was revealed previously by most of
tients. The recurrence did not follow a regu- studies. In our study, 90% of patients were
lar pattern in 3 patients. female. It seems that female predominance
The wheals were usually seen ordinarily was not by chance in our study, and in real,
(ordinary urticaria), although the lesions ap- women are more prone to CU, in our de-
peared in specific locations in 7 patients. scent. Also psychiatric disorders especially
Among them, pressure points such as elbow depression and stresses are more prevalent
were involved in 5 patients (pressure among the women in our country.
urticaria) and lips and eyelids were involved In our study, the most prevalent disorders
in 2 patients (angioedema) (Table 2). consisted of anxiety, psychosomatic disor-
After improvement, 10 patients (33.3%) ders, social dysfunction and depression, se-
complained from bruising in the same loca- quentially. It seems that depression is the
tion of the wheals. It seems that the wheals least significant psychiatric disorder among
were associated with vasculitis in them. patients who suffer from urticaria.
Family history for urticaria was positive in Also, previous studies were representative
33.3% of patients. In addition, 36.7% of the for changes of quality of life in these pa-
cases with CU deteriorated by cold or hot tients [16]. Although we did not measure the
weather and pressure. quality of life, the absence of mental health
Although out of 30 patients with CU, can change the quality of life during the
63.3% have been suffered from psychiatric time.
disorders, this prevalence is roughly 46.6% In our study, we did not find any relation-
in the control group. Altogether, psychiatric ship between demographic factors (sex, age,
disorders in patients with CU were signifi- family history, past medical history and dif-
cantly more prevalent than individuals with- ferent clinical presentations of urticaria) and
out dermatological problems (p= 0.007, Ta- psychiatric disorders.
ble 1). If an individual believes that he/she is
worthless due to his/her disease, it reflects
Discussion negative self-image and induces adverse
In our study, it was found that the preva- emotions such as anger and depression. Alt-
lence of psychiatric disorders in patients hough patients with chronic diseases are as-
with CU was significantly more than the sumed to rise to adverse emotions [17,18],

202 MJIRI, Vol. 25, No. 4, Dec 2011, pp. 200- 204
 N. Atefi, et al.

90%
80%
70%
60%
50%
Patients group
40%
Control group
30%
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20%
10%
0%
Anxiety disorders Psychosomatic Depression Disability in social
disorders functions

Fig 1. Distribution of the results of psychological assessment in patients with CU versus the control group.

anxiety and disability in social functions CU [21].

have been more prevalent among patients in By Potocka, et al. in 2009, patients with
this study. visible skin diseases frequently comprehend
Unpleasant physical complaints (e.g., pru- these changes as unattractive. This concep-
ritus, or painful skin), and the requirement of tion causes aversion in others. By their opin-
administrating various drugs such as oint- ion, this alienation affects patients’ self-
ments, result in many changes in the pa- image, self-acceptance, and social functions
tient’s life. All of them give rise to signifi- [13]. In 2009, Młynek, et al. confirmed that
cant mental maladjustment [19, 20]. People sleep and mental health of patients are sig-
with skin problems must deal with their own nificantly affected by German version of CU
emotional reactions at first, and then, get by [22].
restrictions everyday life and manage their In 2010, in Pakistan, the prevalence of de-
social/ familial function [12]. pression was found 66.6% among adult
Since urticaria is not often accompanied by males with CU. Based on their own recom-
cosmetic problems in most of patients, the mendations, patients with dermatological
chief complaints have not been based on diseases should be tested for depression with
their own appearance in this study. This the purpose of early diagnosis and soon psy-
concept rationalizes the low prevalence of chiatric consult [23].
depression among our patients in compari- Recent studies confirmed functional and
son with other mental disorders. Also, since organic relations between peripheral nerve
wheal is defined as pruritic lesions, it can system (PNS) and mast cells. Also local skin
motivate anxiety and social dysfunction productions of mast cells affect neural secre-
among our patients. tions [24]. In 2010, these findings and clini-
In another study in 2006, the prevalence of cal viewpoints in recent studies motivate
anxiety and depression was studied among more investigations about the organic/ men-
Japanese patients by using manifest anxiety tal origination of CU.
scale and self-rating depression scale. The
results showed that psychiatric disorders Conclusion
were more prevalent in patients with CU According to our results, the cooperation
[16]. In another study in Turkey in 2007, by of dermatologists and psychiatrists can im-
using Minnesota multiphasic personality in- prove patients’ health with dermatological
ventory, it was found that the symptoms of disorders. Preventive management and psy-
depression, hysteria, paranoid personality, chological consult should be considered in
schizophrenia and hypochondria was signifi- dermatological patients even in outpatients.
cantly more common among patients with

MJIRI, Vol. 25, No. 4, Dec 2011, pp. 200- 204 203
 Psychology and Urticaria
matic diseases in accordance with threat and chal-
References lenges of civilization in the modern world]. Lódz:
1. Zuberbier T, Bindslev-Jensen C, Canonica W, UL; 1996. p. 143–146.
Grattan CEH, Greaves MW, Henz BM et al. 13. Potocka A, Turczyn-Jabloñska K, Merecz D.
EAACI/GA2LEN/EDF guideline: definition, classifi- Psychological correlates of quality of life in derma-
cation and diagnosis of urticaria. Allergy 2006; tology patients: the role of mental health and self-
61:316–320. acceptance. Acta Dermatoven APA 2009,18:2.
2. Joly P, Buffet PA, Chosidow O, Deschamps B, 14. Goldberg DP, Hillier VF. A scaled version of
D’Incan M, Dumel F et al. Conférence de consensus: the General Health Questionnaire, Psychological
Downloaded from mjiri.iums.ac.ir at 4:03 IRDT on Tuesday June 12th 2018

prise en charge de l’urticaire chronique. Arch Pediatr Medicine, 1979; 9: 139-145.

2003;10:1121–1129. 15. Likert, R. "A Technique for the Measurement
3. Powell RJ, Du Toit GL, Siddique N, Leech SC, of Attitudes". Archives of Psychology 1932;140: 1–
Dixon TA, Clark AT et al. BSACI guidelines for the 55.
management of chronic urticaria and angio-oedema. 16. Pasaoglu G, Bavbek S, Tugcu H, Abadoglu O,
Clin Exp Allergy 2007;37:631–650. Misirligil Z. Psychological status of patients with
4. Zuberbier T: Urticaria. Allergy 2003, 58:1224- chronic urticaria. Journal of Dermatology 2006; 33:
1234. 765-771.
5. Kaplan AP. Chronic urticaria and angioedema. 17. Koo J, Lebwohl A. Psychodermatology: the
NEJM 2002; 346: 175–179. mind and skin connection. Am Fam Physician
6. Hashiro M, Okumura M. Anxiety, depression, 2001;64:1873–1879.
psychosomatic symptoms and autonomic nervous 18. Papadopoulos L, Walker C, Aitken D, et al. The
function in patients with chronic urticaria. J Dermatol relationship between body location and psychological
Sci. 1990 Oct; 8(2): 129-35. morbidity in individuals with acne vulgaris. Psychol
7. Koblenzer CS. Psychosomatic concepts in der- Health Med 2000;5:431–438.
matology. A dermatologist- psychoanalyst's view- 19. Steuden S, Jankowski K. The application of the
point. Arch Dermatol 1983 Jun;119(6):501-12 quality-of-life questionnaire SKINDEX in patients
8. Hein UR, Henz BM, Haustein UF, Seikowski K, with psoriasis. Przegl Dermatol 2001;88:41–48.
Aberer W, Lautenschlager S, et al. Correlation be- 20. Kadyk DL, McCarter K, et al. Quality of life in
tween chronic urticaria and depression/ somatization patients with allergic contact dermatitis. J Am Acad
disorder. Hautarzt 1996 Jan;47(1):20-3. German. Dermatol. 2003;49:1037–1048.
9. Sheehan-Dare RA, Henderson MJ, Cotterill JA. 21. Ozkan M, Oflaz SB, Kocaman N, Ozseker F,
Anxiety and depression in patients with chronic Gelincik A, Buyukozturk, et.al. Psychiatric morbidity
urticaria and generalized pruritus. Br J Dermatol and quality of life in patients with chronic idiopathic
1990 Dec;123(6):769-74. urticaria. Ann Allergy Asthma Immunol 2007 Jul; 99
10. O'Donnell BF, Lawlor F, Simpson J, Morgan (1):29-33.
M, Greaves MW. The impact of chronic urticaria on 22. Młynek A, Magerl M, Hanna M, Lhachimi S,
the quality of life. Br J Dermatol 1997 Feb; Baiardini I, Canonica GW, et al. The German version
136(2):197-201. of the Chronic Urticaria Quality-of-Life Question-
11. Gupta MA, Gupta AK. Depression modulates naire: factor analysis, validation, and initial clinical
pruritus perception. A study of pruritus in psoriasis, findings. Allergy 2009 Jun; 64(6):927-36.
atopic dermatitis and chronic idiopathic urticaria. Ann 23. Bashir K, Dar NR, Rao SU. Depression in adult
N Y Acad Sci 1999 Oct 20;885:394-5. dermatology out patients. J Coll Physicians Surg Pak
12. Sarwa A, Polak K, Sarna D. [The influence of 2010 Dec; 20(12):811-3.
the patient’s self-image on aetiopathogenesis of 24. Broom BC. A reappraisal of the role of
thedisease]. In: Sklodowski H, editor. [Psychosomatic 'mindbody' factors in chronic urticaria. Postgrad Med
medicine and psychology of patients with psychoso- J 2010 Jun; 86(1016):365-70.

204 MJIRI, Vol. 25, No. 4, Dec 2011, pp. 200- 204