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Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii
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vol. 38
Original paper

Affective temperament, depressive symptoms and interleukins in patients with psoriasis

Luiza Marek-Józefowicz
Marcin Jaracz
Alina Borkowska

Department of Dermatology and Venerology, Faculty of Medicine, Ludwik Rydygier Medical College in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
Chair of Clinical Neuropsychology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
Adv Dermatol Allergol 2021; XXXVIII (1): 137-143
Online publish date: 2021/03/10
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Psoriasis is a chronic disease significantly impairing psychosocial functioning of patients and is also recognized as a serious psychosomatic disease. Distress related to the disease may lead to a significant decrease in the quality of life, and in extreme cases this may be a cause of depression, or even suicide [1–4]. Psoriasis also co-occurs with mental disorders, depression being the most frequent. The studies carried out in recent years also indicate the possibility of the existence of common etiopathogenetic factors in psoriasis and depression. In the studies of common markers for both disorders, the abnormal function of the stress axis is emphasised, with special significance being attributed to interleukin (especially interleukin-1 (IL-1), interleukin-6 (IL-6)) and cortisol. Several studies have shown that inflammatory-immunological processes play a significant role in the course of depression and it is likely that they are important for hypothalamic-pituitary-adrenal (HPA) axis regulation [5–7]. The function of nervous, immune and endocrine systems is disrupted both in depression and psoriasis [1, 8, 9].
The results of up-to-date studies indicate the existence of specific personality and temperamental traits related to a higher risk of occurrence of psoriasis, which are also significant for its further course and treatment [10–13]. The studies of significance of affective temperament traits in etiopathogenesis and clinical picture of somatic diseases in general, have been undertaken in recent years. The study of a large population of 9937 subjects indicate that individuals with dysphoric, cyclothymic and depressive temperaments and those who adopted displacement, somatization and passive aggression as their predominant defence mechanisms presented high somatic symptom severity [14]. This indicates the plausibility of affective temperament evaluation in patients suffering from various somatic diseases. Stressful life events were more frequently associated with anxious and depressive temperaments in female psoriasis patients [13].


In the present study we hypothesized that affective temperament dimensions measured by the Polish version of Temperament Evaluation of Pisa, Paris and San Diego Autoquestionnaire may be related to the severity of depressive symptoms and the levels of IL-1 and IL-6, which are associated with immune system activity, in patients with psoriasis.

Material and methods

Study subjects

One hundred and ten patients with psoriasis (62 men and 48 women) were enrolled in the present study. The patients’ age ranged from 18 to 60 years (mean: 44.1 ±13.0). The control group consisted of 98 healthy individuals aged 22–65 years (mean: 41.0 ±10.7). The exclusion criteria were: age above 65 and under 18 years, history of head injuries, comorbid severe neurological and autoimmune diseases, addiction to drugs or alcohol, intake of immunosuppressive drugs in the past 3 months. Examination and assessment of severity of dermatological lesions PASI was conducted by one physician.

Psychological assessment

Affective temperament was assessed by means of the Temperament Assessment of Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A). The TEMPS-A is a 110-item yes-or-no self-report autoquestionnaire, designed to assess affective temperament in psychiatric and healthy subjects. It consists of five sub-scales: depressive, cyclothymic, irritable, hyperthymic and anxious. In the present study, we used the Polish version of TEMPS-A.

Beck Depression Inventory

Beck Depression Inventory is a self-rated scale consisting of 21 items relating to the various symptoms of depression. The minimum overall score is 0 points, and maximum is 63 points. The threshold for the recognition of depression was adopted as 12 points.

Dermatological assessment

PASI (Psoriasis Area and Severity Index). The maximum PASI value is 72, and the minimum is 0. Higher scores indicate greater severity of the clinical lesions.

Immunological assessment

In order to determine the cytokine levels in the serum, ELISA method was applied.

Statistical analysis

The normality of distribution of variables was assessed by means of the Shapiro Wilk test. As the distribution of variables did not meet the normality criterion, nonparametric tests were applied. For comparison of the significance of differences between groups, U-Mann Whitney test was applied and an analysis of correlations between variables was performed by means of the Spearman’s rho coefficient. Homogeneity of variance was evaluated using the Levene test. Internal consistency of affective temperament subscales was evaluated with Cronbach-a coefficient. For exploratory factor analysis, the Principal Component Analysis (PCA) with a Varimax rotation was applied.


Sociodemographical and clinical data including age, duration of psoriasis and of its current episode, the PASI score, the BDI score, and the level of interleukins in psoriasis patients (with and without depression) and in healthy controls are presented in Table 1. Healthy subjects were younger than psoriasis patients and scored lower in BDI. The level of interleukins did not differ between patients and healthy subjects. Psoriasis patients with depression showed significantly greater intensity of psoriasis symptoms and shorter duration of the current acute illness episode compared to patients without depression. The prevalence of depression among psoriasis patients was high with more than 50% of patients obtaining results higher than 12 points in BDI.

Results of correlations between subscales of TEMPS-A

in psoriasis patients are displayed in Table 2. Highest positive correlations were obtained between depressive and anxious, and between cyclothymic and irritable domains (correlation coefficients 0.68 and 0.65, respectively). The reliability analysis results based on the Cronbach-a coefficient show high internal consistency of the five subscales measuring five domains of affective temperament (Table 3). These results indicate the usefulness of TEMPS-A autoquestionnaire in the evaluation of affective temperament in psoriasis. The results of TEMPS-A in psoriasis patients with and without depression and in healthy controls are shown in Table 4. Psoriasis patients present significantly higher scores on depressive, cyclothymic, irritable and anxious scales compared to the healthy subjects. No between-group differences were observed with respect to the hyperthymic temperament. Psoriasis patients with depression (BDI ≥ 12) showed higher levels of depressive and anxious temperaments compared to patients without depression. They also scored somewhat lower on the hyperthymic scale, however the difference was not statistically significant.
The results of correlations between duration of illness, duration of the current acute episode, PASI and BDI scores, the level of interleukins in psoriasis patients, and between BDI scores, interleukins in healthy controls are presented in Table 5. Bonferroni correction was applied to all correlations. Severity of psoriasis was positively correlated with BDI score in the whole group of psoriasis patients. Duration of the current acute episode of psoriasis correlated negatively with PASI score in the whole group of psoriasis patients and in patients with depression, while such relationship was not observed in patients without depression. With regard to other parameters evaluated, a significant correlation between levels of IL-6 and the intensity of psoriasis in the whole group of psoriasis patients as well as in patients with depression were noted. Such correlation was not found in patients without depression.
Table 6 presents the correlations between five affective temperaments and the results obtained in PASI, BDI, and the level of interleukins in investigated groups. Bonferroni correction was applied to all correlations. All correlations were corrected. In the whole group of psoriasis patients, the intensity of depressive and anxious temperaments correlated with the intensity of depressive symptoms. Similar results were observed in patients with depression and healthy controls, but not in psoriasis patients without depression. In healthy controls, the level of depressive symptoms was additionally correlated with rates of irritable temperament. No correlations between cytokine levels and scores in TEMPS-A were observed in other groups.


The results of the present study revealed a considerable prevalence of depressive symptoms in psoriasis patients. More than 50% of subjects from this group present moderate to severe depression. This clearly indicates that psoriasis and depression may co-occur, and considerable worsening of symptoms of depression in some patients indicates the need for better recognition and desirability of implementation of antidepressant treatment in these patients. These results are concordant with those obtained by other researchers who have observed a greater incidence of depression in dermatological disorders including psoriasis [15–19]. Devrimci-Ozguven et al. in a study covering 50 patients with psoriasis and a 50-subject control group found a much higher severity of depressive symptoms in psoriasis patients than in the control group. In addition, the severity of depressive symptoms in BDI correlated positively with the intensity of the symptoms of psoriasis, while negatively with disease duration, which may be the result of development of adaptive mechanisms in a situation of chronic disease. It was also observed that the risk of occurrence of psoriasis is significantly increased in patients with moderate or severe depression, which may indicate common etiological mechanisms in these two disorders [20]. As indicated by other authors, severity of depression is associated with worse quality of life in dermatological patients. In a study by Gupta and Gupta conducted in a group of 217 patients with psoriasis, 7.2% reported to show the desire to die, and 5.5% had increased suicidal thoughts [21]. It is now believed that psoriasis is a risk factor for depression and anxiety disorders as well as disorders of the sexual domain. On the other hand, depression can contribute to the occurrence of psoriasis [17, 22, 23].
In the present paper, the Polish version of TEMPS-A was used to evaluate the affective temperament [15]. So far, the questionnaire has been used mainly to define the characteristics of affective temperament among patients with bipolar disorder and their relatives, it also proved to be useful in determining these characteristics among the general population [24–29]. As indicated by the results of our study, it is also a very valuable tool in studies of patients with psoriasis. The results indicate greater intensity of depressive and anxious temperaments in patients with psoriasis as compared to the control group. The investigated healthy subjects have obtained results similar to those observed in the population of Polish healthy individuals, various dimensions of affective temperament occurring with similar frequency, although the anxious and irritable temperaments are somewhat more pronounced [15]. This also pertains to the data from other populations (Spanish, Hungarian, Italian), in which similar results were obtained [30–32]. The results may indicate that depressive and anxious temperaments are enduring personality dispositions and are associated with a predisposition to the disease. This is also indicated by no association between the severity of lesions in the PASI scale, duration of illness and duration of the recent worsening and the various dimensions of affective temperament.
The rates of hyperthymic temperament in psoriasis patients were similar to those observed in the control group. An analysis of temperamental profiles in both groups shows these rates to be higher compared to other temperaments, which was also observed in other populations [33]. Hyperthymic traits may be helpful in coping with the disease as they usually involve the sense of a better quality of life, a more optimistic assessment of the current situation and one’s ability to function in that situation, more involvement in the tasks of a “challenge character” and perhaps with greater persistence in goal achievement. An over-representation of hyperthymic traits was demonstrated for example among candidates for pilots and military pilots who work in high-risk conditions [32].
An increasing number of reports support the immune hypothesis of depression, which emphasizes the importance of the immune system in the aetiology of this disease. It indicates the role of cytokines in disruptions of neurotransmission, behaviour and in the observed endocrine changes. The variable course of depressive disorders is explained by the inherent inflammatory mechanisms and immune disorders. Several clinical trials have demonstrated that depression is associated with changes in the concentration of cytokines in plasma [34–36]. Most observations indicate activation of the immune system in depression being an increased synthesis and secretion of acute phase proteins and an increase in the synthesis and concentration of pro-inflammatory cytokines. The receptors for IL-1, IL-2, IL-6 and tumor necrosis factor-a (TNF-a) are present within the thalamus and hippocampus, and IL-1, IL-6 and TNF-a are continuously generated at low concentrations in neurons and glia [7, 36–39].
Somewhat contrary to our expectations, we did not observe differences in cytokine levels between psoriasis patients and controls. This result is best explained by the fact that the skin changes in psoriasis patients occurred many weeks before the admission to hospital. High cytokine rates are observed in the acute phase of the disease and exacerbation of skin changes. Admittedly, the patients from our sample showed elevated skin changes, which was indicated by the PASI score, but the disease process itself was in the chronic phase, which might have accounted for the lack of statistically significant differences in cytokine levels.
We found a significant correlation between the severity of psoriasis in the PASI scale and the level of depressive symptoms measured with the BDI. The level of IL-6 was positively correlated with BDI and PASI scores, however, for the BDI score, it failed to hold significance after the correction for multiple correlations. This observation warrants further research, as Karanikas et al. found a higher concentration of inflammatory markers such as IL-6 in depressed patients compared to patients without depressive disorder [40]. Furthermore, in the study by Kaur et al. [41], a positive correlation was found between the severity of psoriasis measured by the PASI scale and the level of IL-6 in serum, which was also confirmed in studies of other authors [42, 43]. In contrast, Takahashi et al. found a positive correlation between the level of TNF-a, IFN-g, but found no correlation with IL-6 [44]. These differences may result from the presence, in patients with various degrees of psoriasis severity, of many cytokines from different cells, at various concentrations, interacting with each other.


Patients with psoriasis present a greater prevalence of depression, which in about half of patients achieved the severity of clinically expressed depressive syndrome. Patients with psoriasis present a specific profile of affective temperament with elevated depressive, anxious and irritable temperaments. The higher level of IL-6 in patients with psoriasis is related to higher severity of depressive symptoms which in turn is associated with overall greater psoriasis severity. This indicates common mechanisms for both disorders. Specific affective temperament traits may constitute a predisposition to both diseases.

Conflict of interest

The authors declare no conflict of interest.


1. Koo J, Marangell LB, Nakamura M, et al. Depression and suicidality in psoriasis: review of the literature including the cytokine theory of depression. J Eur Acad Dermatol Venereol 2017; 31: 1999-2009.
2. Wilson PB, Bohjanen KA, Ingraham SJ, et al. Psoriasis and physician activity: a review. J Eur Acad Dermatol Venereol 2012; 26: 1345-53.
3. Kleyn CE, Talbot PS, Mehta NN, et al. Psoriasis and mental health workshop report: exploring the links between psychosocial factors, psoriasis, neuroinflammation and cardiovascular disease risk. Acta Derm Venereol 2020; 100: adv00020.
4. Kim YK, Na KS, Myint AM, et al. The role of pro-inflammatory cytokines in neuroinflammation, neurogenesis and the neuroendocrine system in major depression. Prog Neuropsychopharmacol Biol Psychiatry 2016; 64: 277-84.
5. Hughes M, Connor T, Harkin A. Stress-related immune markers in depression: implications for treatment. Int J Neuropsychopharmacol 2016; 19: pyw001.
6. Becher B, Spath S, Goverman J. Cytokine networks in neuroinflammation. Nat Rev Immunol 2017; 17: 49-59.
7. Miná VA, Lacerda-Pinheiro SF, Maia LC. Influence of inflammatory cytokines in physiopathology of suicidal behavior. J Affect Disord 2015; 172: 219-30.
8. Hall J, Cruser A, Podawiltz A, Mummert D. Psychological stress and the cutaneous immune response: role of the HPA axis and the sympathetic ervous system in atopic dermatitis and psoriasis. Dermatol Res Practice 2012; 2012: 403908.
9. Peters EM. Stressed skin? A molecular psychosomatic update on stress-causes and effects in dermatologic diseases. J Dtsch Dermatol Ges 2016; 14: 233-52.
10. Amanat M, Salehi M, Rezaei N. Neurological and psychiatric disorders in psoriasis. Rev Neurosci 2018; 29: 805-13.
11. Kilic A, Gulec MY, Gul U, et al. Temperament and character profile of patients with psoriasis. J Eur Acad Dermatol Venereol 2008; 22: 537-42.
12. Takahashi H, Tsuji H, Honma M, et al. Japanese patients with psoriasis and atopic dermatitis show distinct personality profiles. J Dermatol 2013; 40: 370-3.
13. Litaiem N, Youssef S, Jabeur K, et al. Affective temperament profile in psoriasis patients in Tunisia using TEMPS-A. J Affect Disord 2013; 151: 321-4.
14. Hyphantis TN, Taunay TC, Macedo DS, et al. Affective temperaments and ego defense mechanisms associated with somatic symptom severity in a large sample. J Affect Disord 2015; 150: 481-9.
15. Borkowska A, Rybakowski JK, Drozdz W, et al. Polish validation of the TEMPS-A: the profile of affective temperaments in a college student population. J Affect Disord 2010; 123: 36-41.
16. Galpour M, Hosseini S, Khademloo M, et al. Depression and anxiety disorders among patients with psoriasis: a hospital based case-control study. Dermatol Res Practice 2012; 2012: 381905.
17. Offidani E, Del Basso D, Prignago F, et al. Discriminating the presence of psychological distress in patients suffering from psoriasis: an application of the clinimetric approach in dermatology. Acta Derm Venereol 2016; 96: 69-73.
18. Cohen BE, Martires KJ, Ho RS. Psoriasis and the risk of depression in the US population: National Health and Nutrition Examination Survey 2009-2012. JAMA Dermatol 2016; 152: 73-9.
19. Tee SI, Lim ZV, Theng CT, Chan KL. A prospective cross-sectional study of anxiety and depression in patients with psoriasis in Singapore. J Eur Acad Dermatol Venereol 2016; 30: 1159-64.
20. Devrimci-Ozguven H, Kundaci N, Kumbasar H, et al. The depression, anxiety, life satisfaction and affective expression levels in psoriasis patients. J Eur Acad Derm Venereol 2000; 14: 167-271.
21. Gupta M, Gupta A. Depresion and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998; 139: 846-50.
22. Schmitt J, Ford DE. Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis – a structural equations modeling approach. Gen Hosp Psychiatry 2007; 29: 134-40.
23. Esposito M, Saraceno R, Giunta A, et al. An Italian study on psoriasis and depression. Dermatology 2006; 212: 123-7.
24. Rieder E, Tausk F. Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments. Int J Dermatol 2012; 51: 12-26.
25. Park CI, An SK, Kim HW, et al. Relationships between chronotypes and affective temperaments in healthy young adults. J Affect Disord 2015; 175: 256-9.
26. Dolenc B, Dernovšek MZ, Sprah L, et al. Relationship between affective temperaments and aggression in euthymic patients with bipolar mood disorder and major depressive disorder. J Affect Disord 2015; 174: 13-8.
27. Perugi G, Toni C, Maremmani I, et al. The influence of affective temperaments and psychopatological traits on the definition of bipolar dis order subtypes: a study on bipolar I Italian national sample. J Affect Disord 2010; 136: e41-9.
28. Vazquez GH, Kahn C, Schiavo CE, et al. Bipolar disorders and affective temperaments: a national family study testing the “endophenotype” and “subaffective” these using the TEMPS-A Buenos Aires. J Affect Disord 2008; 108: 25-32.
29. Solmi M, Zaninotto L, Toffanin T, et al. A comparative meta-analysis of TEMPS scores across mood disorder patients, their first-degree relatives, healthy controls, and other psychiatric disorders. J Affect Disord 2016; 196: 32-46.
30. Jiménez E, Bonnín CDM, Solé B, et al. Spanish validation of the Barcelona TEMPS-A questionnaire in patients with bipolar disorder and general population. J Affect Disord 2019; 249: 199-207.
31. Wilson PB, Bohjanen KA, Ingraham SJ, et al. Psoriasis and physician activity: a review. J Eur Acad Dermatol Venereol 2012; 26: 1345-53.
32. Rózsa S, Rihmer Z, Gonda X, et al. A study of affective temperaments in Hungary: internal consistency and concurrent validity of the TEMPS-A against the TCI and NEO-PI-R.
33. J Affect Disord 2008; 106: 45-53.
34. Maremmani I, Dell’Osso L, Rovai L, et al. TEMPS-A temperament profile related to professional choice. A study in 1548 applicants to become a cadet officer in the Italian air force. J Affct Disord 2010; 124: 314-8.
35. Karam EG, Mneimneh Z, Salamoun M, et al. Psychometric properties of the Lebanese-Arabic TEMPS-A: a national epidemiologic study. J Affect Disord 2005; 87: 169-83.
36. Gulyaeva NV. Biochemical mechanisms and translational relevance of hippocampal vulnerability to distant focal brain injury: the price of stress response. Biochemistry 2019; 1: 1306-28.
37. Kubera M, Kenis G, Bosmans E, et al. Plasma levels of interleukin-6, interleukin-10, and interleukin-1 receptor antagonist in depression: comparison between the acute state and after remission. Pol J Pharmacol 2000; 52: 237-41.
38. Kubera M, Kenis G, Bosmans E, et al. Stimulatory effect of antidepressants on the production of IL-6. Int Immunopharmacol 2004; 4: 185-92.
39. Hopkins SJ, Rothwell NJ. Cytokines and the nervous system. I. Expression recognition. Trends Neurosc 1995; 18: 83-8.
40. Shabab T, Khanabdali R, Moghadamtousi SZ. Neuroinflammation pathways: a general review. Int J Neurosci 2017; 127: 624-33.
41. Karanikas E, Harsoulis F, Giouzepas I, et al. Neuroendocrine stimulatory tests of hypothalamus pituitary-adrenal axis in psoriasis and correlative implications with psychopatological and immune parameters. J Dermatol 2009; 36: 35-44.
42. Kaur S, Zilmer K, Leping V, et al. Comparative study of systemic inflammatory responses in psoriasis vulgaris and mild to moderate allergic contact dermatitis. Dermatology 2012; 225: 54-61.
43. Coimbra S, Figueiredo A, Castro E, et al. The roles of cells and cytokines in the pathogenesis of psoriasis. Int J Dermatol 2012; 51: 389-95.
44. Pietrzak A, Chabros P, Grywalska E, et al. Serum concentration of interleukin 6 is related to inflammation and dyslipidemia in patients with psoriasis. Adv Dermatol Allergol 2020; 37: 41-5.
45. Takahashi H, Tsuji H, Hashimoto Y, et al. Serum cytokines and growth factor levels in Japanese patients with psoriasis. Clin Exp Dermatol 2010; 35: 645-9.
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