**3. And if so, how do they differ from the normal population?**

Individuals with psoriasis have a tendency towards complying with the wishes of other individuals as a motivating style. This tendency is reinforced by the fact that their selfmotivation or self-drive is low.

Regarding thinking styles, psoriasis patients had lower scores on the intuition scale than the healthy population, suggesting that they are more oriented toward practical thinking rather than abstract thinking. In addition, they had a tendency not to employ innovative or creative ways of thinking.

In relation to behaving styles, psoriasis patients are more conventional than the reference group. They were less dominating and more acquiescent. Overall, they tend to seek cooperation and agreement and avoid disagreement as a way of bonding with others. They may be dependent, submissive, and lack initiative or their own opinion. In general, the results indicate a personality profile which is not well adjusted, and this has been associated

Personality in Patients with Psoriasis 217

their relationship with others. It has been found that these patients present attentional bias and are more responsive to subtle signs of rejection (Fortune et al., 2003). The tendency to avoid rejection is compatible with other findings which suggest that the only association with decreased quality of life in psoriasis patients was due to the fear of being rejected rather than to the physical characteristics of the lesions, their localization, or severity

The available data also shows that psoriasis patients have lower scores in self-directedness, which reinforces the tendency to be non-dominant and suggests that they are dependent, sociable and easily influenced, as reported by other authors (Kilic et al., 2008). However, our results indicate that individuals with psoriasis do not have a greater tendency to avoid pain, unlike the findings of Kilic who reported that psoriasis patients had higher scores on the harm-avoidance item. The high vulnerability to stress found in these patients (Valverde et al., 2005) may reinforce their tendency to avoid conflict with others, and may be related to the avoidance behavior reported in other studies (da Silva et al., 2006; Magin, Adams, et al., 2009). Some authors have explained these differences as being a way to compensate for poorly regulated emotions that may modulate outbreaks of psoriasis plaques (Picardi et al., 2005) and which has been confirmed by other studies (Richards, Fortune, et al., 2005). These personality traits suggest that, regardless of stressful events or lesion severity, psoriasis may

Concerning the clinical index, psoriasis patients as a group have lower scores than the healthy population. This decreased level of adjustment has also been found in other studies (Dooley & Finlay, 1990). Given that a low clinical index has been associated with lower life satisfaction in general (Díaz Morales & Sánchez López, 2002), this could indicate why psoriasis patients have less quality of life than the healthy population (Van Voorhees & Fried, 2009), as well as accounting for the psychological disturbances, such as anxiety, depression and sexual problems, that have been reported in other studies (eg, Mercan, 2008). The foregoing suggests that the personality variables measured by MIPS are poorly adjusted in the psoriasis population, which probably underlies the psychiatric vulnerability reported by other studies (Mastrolonardo et al., 2007; Picardi et al., 2005; Richards, Ray, et al., 2005; Valverde et al., 2005). Therefore, as suggested by other authors (Gieler, Niemeier, Brosig, & Kupfer, 2002; Melamed & Yosipovitch, 2004), psychological variables should be assessed in these patients, who should be referred to mental health specialists (Ginsburg, Prystowsky, Kornfeld, & Wolland, 1993; Schneider et al., 2006; Woodruff et al., 1997;

No consensus exists on the personality of dermatological patients. Buske-Kirschbaum suggests that these patients have a common psychological profile (Buske-Kirschbaum et al., 2004). Despite the existence of features found in such patients, other authors do not accept the existence of a profile that differentiates them from the healthy population (Verhoeven et al., 2008). Similarly, research on personality variables in a Spanish dermatological population (Antuña-Bernardo, 2000), who were assessed using the Eysenck Personality Questionnaire, found that there were no differences between the healthy population and patients with various skin diseases, including psoriasis. However, they were found to have

(Fortune, Main, O'Sullivan, & Griffiths, 1997).

be negatively affected by difficulties in managing emotions.

lower quality of life and above-average neuroticism scores.

Yosipovitch & Samuel, 2008).

**4. Controversy** 

with lower satisfaction with life (Díaz Morales & Sánchez López, 2002). The graph in Figure 1 depicts these differences.

Fig. 1. Graphical representation of psoriasis (red) and non-dermatological (blue) profiles. \*p> .05; \*\* p>.01; \*\*\*p>.000.

The results of our study indicate that individuals with psoriasis tend to avoid distancing themselves from others or disagreeing with them. This is suggested by their high scores on acquiescence, low dissatisfaction and low dominance, which could be interpreted as a protective mechanism used by psoriasis patients due to their fear of being rejected or discriminated against (Ulnik, 2007; Ginsburg & Link, 1989; Lu, Duller, van der Valk, & Evers, 2003; Schmid-Ott et al., 2005). This is reflected in an increased tendency to be externally focussed, as shown by other studies: psoriasis patients have low scores on narcissistic traits, are more altruistic and more orientated towards others, and are less aggressive in the face of criticism (Bahmer, 2007). Whereas Matussek et al. (Matussek et al., 1985) found that psoriasis patients presented greater aggressivity toward others compared to the healthy population, the findings in our study are compatible with later studies which reported a decreased ability to express anger toward others (Ginsburg & Link, 1993) and a greater tendency among psoriasis patients who were more sensitive to stress to seek approval, to avoid expressing negative emotions and to avoid being rejected (Gupta et al., 1989). Other studies have also reported that these patients show difficulties in expressing feelings of anger and being assertive, which may be a factor making them vulnerable to stress (Devrimci Ozguven et al., 2000), and could explain the higher level of acquiescence observed in the psoriasis sample. The most relevant aspect of this is that, in contrast to the healthy population, individuals with psoriasis change the way they present themselves in relation to others, and this may correspond to a given personality profile. Patients may behave in this manner to reduce emotional and behavioural conflicts that could damage

with lower satisfaction with life (Díaz Morales & Sánchez López, 2002). The graph in Figure

Fig. 1. Graphical representation of psoriasis (red) and non-dermatological (blue) profiles.

The results of our study indicate that individuals with psoriasis tend to avoid distancing themselves from others or disagreeing with them. This is suggested by their high scores on acquiescence, low dissatisfaction and low dominance, which could be interpreted as a protective mechanism used by psoriasis patients due to their fear of being rejected or discriminated against (Ulnik, 2007; Ginsburg & Link, 1989; Lu, Duller, van der Valk, & Evers, 2003; Schmid-Ott et al., 2005). This is reflected in an increased tendency to be externally focussed, as shown by other studies: psoriasis patients have low scores on narcissistic traits, are more altruistic and more orientated towards others, and are less aggressive in the face of criticism (Bahmer, 2007). Whereas Matussek et al. (Matussek et al., 1985) found that psoriasis patients presented greater aggressivity toward others compared to the healthy population, the findings in our study are compatible with later studies which reported a decreased ability to express anger toward others (Ginsburg & Link, 1993) and a greater tendency among psoriasis patients who were more sensitive to stress to seek approval, to avoid expressing negative emotions and to avoid being rejected (Gupta et al., 1989). Other studies have also reported that these patients show difficulties in expressing feelings of anger and being assertive, which may be a factor making them vulnerable to stress (Devrimci Ozguven et al., 2000), and could explain the higher level of acquiescence observed in the psoriasis sample. The most relevant aspect of this is that, in contrast to the healthy population, individuals with psoriasis change the way they present themselves in relation to others, and this may correspond to a given personality profile. Patients may behave in this manner to reduce emotional and behavioural conflicts that could damage

1 depicts these differences.

\*p> .05; \*\* p>.01; \*\*\*p>.000.

their relationship with others. It has been found that these patients present attentional bias and are more responsive to subtle signs of rejection (Fortune et al., 2003). The tendency to avoid rejection is compatible with other findings which suggest that the only association with decreased quality of life in psoriasis patients was due to the fear of being rejected rather than to the physical characteristics of the lesions, their localization, or severity (Fortune, Main, O'Sullivan, & Griffiths, 1997).

The available data also shows that psoriasis patients have lower scores in self-directedness, which reinforces the tendency to be non-dominant and suggests that they are dependent, sociable and easily influenced, as reported by other authors (Kilic et al., 2008). However, our results indicate that individuals with psoriasis do not have a greater tendency to avoid pain, unlike the findings of Kilic who reported that psoriasis patients had higher scores on the harm-avoidance item. The high vulnerability to stress found in these patients (Valverde et al., 2005) may reinforce their tendency to avoid conflict with others, and may be related to the avoidance behavior reported in other studies (da Silva et al., 2006; Magin, Adams, et al., 2009). Some authors have explained these differences as being a way to compensate for poorly regulated emotions that may modulate outbreaks of psoriasis plaques (Picardi et al., 2005) and which has been confirmed by other studies (Richards, Fortune, et al., 2005). These personality traits suggest that, regardless of stressful events or lesion severity, psoriasis may be negatively affected by difficulties in managing emotions.

Concerning the clinical index, psoriasis patients as a group have lower scores than the healthy population. This decreased level of adjustment has also been found in other studies (Dooley & Finlay, 1990). Given that a low clinical index has been associated with lower life satisfaction in general (Díaz Morales & Sánchez López, 2002), this could indicate why psoriasis patients have less quality of life than the healthy population (Van Voorhees & Fried, 2009), as well as accounting for the psychological disturbances, such as anxiety, depression and sexual problems, that have been reported in other studies (eg, Mercan, 2008). The foregoing suggests that the personality variables measured by MIPS are poorly adjusted in the psoriasis population, which probably underlies the psychiatric vulnerability reported by other studies (Mastrolonardo et al., 2007; Picardi et al., 2005; Richards, Ray, et al., 2005; Valverde et al., 2005). Therefore, as suggested by other authors (Gieler, Niemeier, Brosig, & Kupfer, 2002; Melamed & Yosipovitch, 2004), psychological variables should be assessed in these patients, who should be referred to mental health specialists (Ginsburg, Prystowsky, Kornfeld, & Wolland, 1993; Schneider et al., 2006; Woodruff et al., 1997; Yosipovitch & Samuel, 2008).
