|Year : 2017 | Volume
| Issue : 1 | Page : 29-33
Study of anxiety in patients with moderate alopecia
Jeet Nadpara, Rahul Tadke, Abhijeet Faye, Sushil Gawande, Sudhir Bhave, Vivek Kirpekar, Milind Borkar
Department of Psychiatry, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
|Date of Web Publication||19-Jun-2017|
Department of Psychiatry, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Digdoh Hills, Hingna Road, Nagpur - 440 019, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Alopecia is known to have an impact on psychosocial health of an individual. Besides depression, anxiety is commonly associated with it and can add significantly to the burden due to it. The present study was carried out in the patients attending dermatology outpatient department, which looked into anxiety symptoms and its correlations with various demographic and clinical factors. Materials and Methods: Thirty consecutive patients diagnosed with moderate alopecia not requiring any major intervention participated in the study. Each patient was individually interviewed using a semi-structured pro forma which included sociodemographic profile, clinical and psychiatric profile, and dermatological diagnosis, and rating scales of Brief Psychiatric Rating Scale (BPRS) and Hamilton Anxiety Rating Scale (HAM-A) were administered. Results and Discussion: Mean age was 30.86 years (standard deviation 11.89), 50% males and majority married with urban background. Many had complaints of uneasiness, excessive worries, and disturbed sleep. The mental status examination in the majority of them revealed anxious mood and preoccupation with worries. None of them satisfied the diagnostic criteria for any anxiety disorder as per Diagnostic and Statistical Manual of Mental Disorders-5. The mean BPRS score was 22.80 with the participants scored significantly on anxiety, tension, and somatic concern and the mean HAM-A score was 10.30 with the majority of participant had score in the range of significant anxiety. Their correlation with factors of gender, marital status, duration, and pattern of alopecia was found to be not significant. Conclusion: Although no diagnosable anxiety disorder was present in patients of moderate alopecia, majority of them had significant anxiety found during the assessment.
Keywords: Anxiety, Hamilton Anxiety Rating Scale, moderate alopecia
|How to cite this article:|
Nadpara J, Tadke R, Faye A, Gawande S, Bhave S, Kirpekar V, Borkar M. Study of anxiety in patients with moderate alopecia. Ann Indian Psychiatry 2017;1:29-33
|How to cite this URL:|
Nadpara J, Tadke R, Faye A, Gawande S, Bhave S, Kirpekar V, Borkar M. Study of anxiety in patients with moderate alopecia. Ann Indian Psychiatry [serial online] 2017 [cited 2019 Jan 22];1:29-33. Available from: http://www.anip.co.in/text.asp?2017/1/1/29/208345
| Introduction|| |
Alopecia is partial or complete absence of hairs from areas of the body where it normally grows and generally used to refer to scalp hairs as it is more visible area of hairs on body. Medically, alopecia is viewed as a relatively mild dermatological condition. It is a common hair loss disease with genetic predisposition among men and women, and it may start at any age after puberty. Alopecia is psychologically disturbing, may cause intense emotional suffering, leading to personal, social, and work-related problems.,, Those suffering from the condition feel that alopecia is a condition with major distress and negative impact on lifestyle and worried about how other people view them as hair is an important component of identity and self-image and successful coping can be a key issue. Early onset alopecia patients may find themselves difficult to adjust in groups, family life or interpersonal relationships and are more likely to show serious psychopathology such as increased rate of the depression or anxiety disorders.
Studies have shown higher lifetime prevalence of psychiatric disorder in patients of alopecia, for example, major depression (39%) and generalized anxiety disorder (39%). In women, general maladjustment in relation to hair loss is quite common and can be seen in up to one-third of them. Satisfactory overall adaptation to mild or moderate forms of alopecia is seen, but adaptation and comorbidity in severe forms (totalis, universalis) are unknown. Patients with alopecia may experience a diminished body image satisfaction. The patients/persons with mild alopecia might not reach or approach a tertiary care center and might opt for alternate or local treatments. Patients with moderate alopecia are usually given local or topical treatments and not any systemic pharmacological agent. Such agents themselves can have anxiety or depressive features as side effects. Apprehension about the progress of alopecia further to severe category may be present in the individual. Furthermore, there are very few studies which have focused on moderate alopecia only.
With this background, the present study was carried out in patients with moderate alopecia presenting in dermatology outpatient department who are not for any major dermatological treatment and procedure like hair transplant. The following were the aims and objectives:
- To study anxiety symptoms in patients with moderate alopecia
- To study the correlation of socio-demographic and clinical profile of patients of moderate alopecia with anxiety.
| Materials and Methods|| |
It was a cross-sectional, single interview study. The study was carried out in dermatology outpatient department of a tertiary care teaching hospital. The study protocol was approved by Institutional Ethics Committee. Thirty consecutive patients diagnosed with moderate alopecia attending the dermatology outpatient department of the hospital, satisfying inclusion and exclusion criteria participated in the study. The patients approaching for treatment to the institute were included in a case series format. The inclusion criteria were patients in the age group of 18–60 years, having moderate alopecia following up in the dermatology clinic willing to participate and give written informed consent. Those not willing, on any major dermatological treatment (including steroids) or hair transplant, having any other major medical, surgical or psychiatric illness (diagnosed depression, psychoses or substance use disorder), and hair loss due to any other medical or surgical cause were excluded from the study. The diagnosis of moderate alopecia as not requiring any major dermatological intervention or oral medications, or Stage II for women on Ludwig's scale or Stage II for males on Hamilton–Norwood scale of grading of hair loss (alopecia) was made by dermatologist.
After written informed consent, each participant was individually interviewed, along semi-structured pro forma prepared for the study which included sociodemographic profile, clinical and psychiatric profile, and dermatological diagnosis. Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria were used for diagnosis of any psychiatric conditions including anxiety disorders. Brief Psychiatric Rating Scale (BPRS) and Hamilton Anxiety Rating Scale (HAM-A) were administered.
BPRS is a widely used instrument for assessing the positive, negative, and affective symptoms of individuals and has proven reliability, particularly valuable for documenting the efficacy of treatment in patients who have moderate to severe disease. It consists of 18 items, where score of 18–32 indicates mildly ill, 33–44 indicates moderately ill, 45–55 indicates markedly ill, and 55–70 indicates severely ill.
HAM-A is one of the first rating scale developed to measure the severity of anxiety symptoms with time-tested reliability and validity. The scale consists of 14 items, each defined by a series of symptoms, and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety). Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where 14–17 indicates mild severity, 18–24 mild to moderate severity, and 25–30 moderate to severe.
Data thus collected was tabulated and analyzed using statistical test of mean, median, percentage, Chi-square test, t-test, ANOVA. A P < 0.05 was considered statistically significant for the correlations.
| Results|| |
The mean age of the participants was 30.86 years (standard deviation [SD] =11.89), majority being males (70%), educated above secondary, residing in urban areas and half of them were married [Table 1]. The dermatological profile shows majority had moderate hair loss of duration more than a month (53.3%), had alopecia areata (63.3%), and androgenic alopecia (36.7%) pattern. Half had a history of alopecia in their family and most (83.3%) of them had never taken treatment for alopecia [Table 2].
Psychiatric complaints were reported by majority (73.5%) of the participants (in form of – anxiety, excessive worry, apprehension and predominantly anxious and occasional depressive and somatic symptoms), of duration predominantly less than a month (56.7%), a few (6.7%) had given a history of psychiatric complaints in past (anxiety and depression) but not on any treatment now, and 16.7% of the participant had given family history of psychiatric illness (schizophrenia, depression).
[Table 3] and [Table 4] mean total BPRS score of the participants was 22.80 (SD = 3.97). Item wise split score on BPRS shows that anxiety had maximum mean score of 2.5 (SD = 1.17). Participants had moderate scores on items of tension 1.9 (SD = 0.81) and somatic concern 1.9 (SD = 0.94) and depressive mood mean score 1.8 (SD = 1.01). Mild mean scores were noted for guilt feelings 1.3 (SD = 0.54), emotional withdrawal 1.1 (SD = 0.39), motor retardation 1.1 (SD = 0.30), blunt affect 1.1 (SD = 0.24), and excitement 1.03 (SD = 0.17).
|Table 3: Split score on Brief Psychiatric Rating Scale and Hamilton Anxiety Rating Scale|
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The mean total HAM-A score of the participants was 10.30 (SD = 6.396). Item wise split score on HAM-A shows that the item anxious mood had maximum mean score of 2.0 (SD = 1.19). Participants had moderate score on items cardiovascular symptoms 1.7 (SD = 1.18), tension 1.6 (SD = 1.01), and mild score on items insomnia 1.1 (SD = 0.94) and depressed mood 1.1 (SD = 1.09). Categorization shows half (50.0%) had scores in the range of mild anxiety (score 14–17) and 6.7% had moderate anxiety (score 18–24).
Gender wise comparison using t-test BPRS score of the participants did not show any statistically significant difference (P = 0.30). Furthermore, no significant difference was noted for marital status (P = 0.53) and pattern of alopecia group (P = 0.38). The HAM-A score of the participants was not statistically different for gender (P = 0.42), marital status (P = 0.92), and pattern of alopecia group (P = 0.56). ANOVA test was used to analyze the BPRS and HAM-A scores across the total duration of dermatological complaints [Table 5] and no statistically significant difference noted across the groups [Table 6].
|Table 5: Correlation of Brief Psychiatric Rating Scale and Hamilton Anxiety Rating Scale with gender, marital status and pattern of alopecia|
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|Table 6: Duration of alopecia with mean total Brief Psychiatric Rating Scale and Hamilton Anxiety Rating Scale score on ANOVA|
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| Discussion|| |
The age group of 25–34 is when most of the image wise important events take place in once life, such as marriage, job interviews, promotions, and other social events and this can make the individual seek early medical help for alopecia and the higher education and urban background enhance the awareness about any health problem let it be otherwise minor one like alopecia.
The chronic skin conditions such as psoriasis, severe alopecia, skin manifestations of autoimmune diseases, and other major skin disorders usually have depression as a common psychiatric comorbidity which adds to the burden and disabilities due to the disease. Alopecia in severe form can be equally cosmetically challenging and distressing to the individual and has depression as comorbidity associated with it and many requiring active psychiatric management. For the mild to moderate form of alopecia along with depression, anxiety has been increasingly being considered important.,,
In this study, the participants were individuals with moderate alopecia not requiring any major dermatological intervention such as oral medications or hair transplant. The majority of them revealed anxiety symptoms (including preoccupation and worries related to hair loss) in the clinical interview when specifically asked. Although none of them satisfied the diagnostic criteria for any major anxiety disorder as per DSM-5 criteria, the majority had significant scores on the HAM-A and anxiety questions of BPRS, suggesting that significant anxiety was present in them. The split HAM-A score had higher score on factors anxious mood and cardiovascular symptoms. In this study, half of the participants did fall in the category of mild anxiety on HAM-A and a few (6.7%) had scores in the range of moderate anxiety.
The factors of gender, marital status, and pattern of alopecia were not found to have any correlation with the severity of anxiety present in the participants. The significance of anxiety and its impact on the lifestyle of individual and burden due to it has been discussed in the literature from time to time.,,,,, The presence of alopecia in moderate form could be equally distressing to the people. Hair is cosmetically important because of the present social structure and facing and adapting to the alopecia could be psychologically difficult to the individual and could be the forerunner of generation of anxiety in them. As against the severe form of alopecia in which the acceptance for advanced form of treatment could be inevitable and the individual is prepared for it.
Furthermore, the duration of alopecia did not have any significant impact on the presence and severity of anxiety in the participants. The anxiety did not increase with the increase in the duration of alopecia. Do the individual personality factors play any role? Need to be evaluated in depth using the personality assessment tools.
Thus, the individuals with moderate alopecia are susceptible for significant anxiety and need to be addressed in the clinical evaluation of patients.
| Conclusion|| |
In this study, no diagnosable anxiety disorder was found in patients with moderate alopecia. Fifty percent had mild anxiety, and 6.7% had moderate anxiety on HAM-A.
This study has limitations like it was a cross-sectional study of case series in nature with smaller sample size and was carried out at single center.
Alopecia could be a major source of uncertainty and stress for people adding burden on the patients, can decrease their quality of life and may have a negative effect on their day to day living. As applicable to depression it is also important to screen anxiety in patients with alopecia of moderate grade. Early detection of anxiety can significantly reduce further morbidity or reduce the apprehension usually present in this group.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Cash TF. The psychological effects of androgenetic alopecia in men. J Am Acad Dermatol 1992;26:926-31.
Lee KH, Lee HJ, Lee CH. A psychiatric characteristics of the alopecia occured during childhood and adolescence. J Korean Neuropsychiatr Assoc 2001;40:301-16.
Hunt N, McHale S. The psychological impact of alopecia. BMJ 2005;331:951-3.
Hunt N, McHale S. Reported experiences of persons with alopecia areata. J Loss Trauma 2005;10:33-50.
Colón EA, Popkin MK, Callies AL, Dessert NJ, Hordinsky MK. Lifetime prevalence of psychiatric disorders in patients with alopecia areata. Compr Psychiatry 1991;32:245-51.
Van Der Donk J, Hunfeld JA, Passchier J, Knegt-Junk KJ, Nieboer C. Quality of life and maladjustment associated with hair loss in women with alopecia androgenetica. Soc Sci Med 1994;38:159-63.
Ruiz-Doblado S, Carrizosa A, García-Hernández MJ. Alopecia areata: Psychiatric comorbidity and adjustment to illness. Int J Dermatol 2003;42:434-7.
Cash TF. The psychosocial consequences of androgenetic alopecia: A review of the research literature. Br J Dermatol 1999;141:398-405.
Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep 1962;10:799-812.
Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50-5.
Karia SB, De Sousa A, Shah N, Sonavane S, Bharati A. Psychiatric morbidity and quality of life in skin diseases: A comparison of alopecia areata and psoriasis. Ind Psychiatry J 2015;24:125-8.
] [Full text]
Bilgiç Ö, Bilgiç A, Bahali K, Bahali AG, Gürkan A, Yilmaz S. Psychiatric symptomatology and health-related quality of life in children and adolescents with alopecia areata. J Eur Acad Dermatol Venereol 2014;28:1463-8.
Alfani S, Antinone V, Mozzetta A, Di Pietro C, Mazzanti C, Stella P, et al.
Psychological status of patients with alopecia areata. Acta Derm Venereol 2012;92:304-6.
Baghestani S, Zare S, Seddigh SH. Severity of depression and anxiety in patients with alopecia areata in Bandar Abbas, Iran. Dermatol Reports 2015;7:6063.
Sellami R, Masmoudi J, Ouali U, Mnif L, Amouri M, Turki H, et al.
The relationship between alopecia areata and alexithymia, anxiety and depression: A case-control study. Indian J Dermatol 2014;59:421.
] [Full text]
Chu SY, Chen YJ, Tseng WC, Lin MW, Chen TJ, Hwang CY, et al.
Psychiatric comorbidities in patients with alopecia areata in Taiwan: A case-control study. Br J Dermatol 2012;166:525-31.
Rencz F, Gulácsi L, Péntek M, Wikonkál N, Baji P, Brodszky V, et al.
Alopecia areata and health-related quality of life: A systematic review and meta-analysis. Br J Dermatol 2016;175:561-71.
Aghaei S, Saki N, Daneshmand E, Kardeh B. Prevalence of psychological disorders in patients with alopecia areata in comparison with normal subjects. ISRN Dermatol 2014;2014:304370.
Tsintsadze N, Beridze L, Tsintsadze N, Krichun Y, Tsivadze N, Tsintsadze M. Psychosomatic aspects in patients with dermatologic diseases. Georgian Med News 2015;(243):70-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]