Patients' Emotional Talk During Surveillance Cystoscopy for Non-muscle Invasive Bladder Cancer: Opportunities for Improving Communication.

OBJECTIVE: To examine the emotional communication that takes place between patients and health care providers during surveillance cystoscopy for non-muscle invasive bladder cancer (NMIBC). METHODS: Participants were 57 patients with a diagnosis of NMIBC attending for surveillance cystoscopy and 10 health care professionals (HCPs). Cystoscopy procedures were audio-recorded and transcribed verbatim. Two approaches to analysis of transcriptions were undertaken: (1) a template analysis and (2) Verona Coding Definitions of Emotional Sequences. RESULTS: Communication during cystoscopy generally comprised of "social/small talk," "results of the cystoscopy," and "providing instructions to the patient." Emotional talk was present in 41/57 consultations, with 129 emotional cues and concerns expressed by patients. Typically patients used hints to their emotions rather than stating explicit concerns. The majority (86%) of HCPs responses to the patient did not explicitly mention the patient's emotional concern or cue. Urology trainees were less likely than other HCPs to provide space for patients to explore their emotional concerns (t = -1.78, P <.05). CONCLUSION: Emotional communication was expressed by the majority of patients during cystoscopy. While all HCPs responded to patients' emotional communication, there were a number of missed opportunities to "pick-up" on patients' emotional cues and improve communication. Urologists need to be aware of the nuances of patients' emotional communication. Learning to identify and respond appropriately to emotional cues may improve communication with patients.

Healthcare Workers Beliefs about COVID-19; a Longitudinal, Mixed Methods Analysis.

The psychological impact of COVID-19 on Health Care Workers (HCWs) has been widely reported. Few studies have sought to examine HCWs personal models of COVID-19 utilising an established theoretical framework. We undertook a mixed methods study of beliefs about COVID-19 held by HCWs in the Mid-West and South of Ireland during the first and third waves of COVID-19. Template analysis was undertaken on the free text responses of 408 HCWs about their perceptions of the Cause of COVID-19 as assessed by the Brief Illness Perception Questionnaire (B-IPQ). Responses were re-examined in the same cohort for stability at 3 months follow-up (n = 100). This analytic template was subsequently examined in a new cohort (n = 253) of HCWs in the third wave. Female HCWs perceived greater emotional impact of COVID-19 than men (t = -4.31, df405, p < 0.01). Differences between occupational groups were evident in relation to Timeline (F4,401 = 3.47, p < 0.01), Treatment Control (F4,401 = 5.64, p < 0.001) and Concerns about COVID-19 (F4,401 = 3.68, p < 0.01). Administration staff believed that treatment would be significantly more helpful and that COVID-19 would last a shorter amount of time than medical/nursing staff and HSCP. However, administration staff were significantly more concerned than HSCP about COVID-19. Template analysis on 1059 responses to the Cause items of the B-IPQ identified ten higher order categories of perceived Cause of COVID-19. The top two Causes identified at both Waves were 'individual behavioural factors' and 'overseas travel'. This study has progressed our understanding of the models HCWs hold about COVID-19 over time, and has highlighted the utility of the template analysis approach in analysing free-text questionnaire data. We suggest that group and individual occupational identities of HCWs may be of importance in shaping HCWs responses to working through COVID-19.

A digital therapeutic for management of psychosocial aspects of psoriasis: A pre-post proof of concept study.

Background: Despite the psychosocial challenges of living with psoriasis many patients may not be able to access appropriate services to manage these challenges. Mobile health interventions may be helpful as a means to support patients in managing the impact of their condition. Objective: To conduct a preliminary examination of the feasibility and acceptability of a bespoke psoriasis-specific digital therapeutic solution (hereafter termed Allay), and to provide initial data on psychological changes pre-post. Methods: Phase one proof of concept pre-post study. Eligible patients were provided with Allay on their smartphone and assessed at baseline and at 12 weeks on a range of indices of well-being. Participants experiences on usability were collected by telephone interview at 4 weeks, 8 and 12 weeks. Results: Out of 66 participants recruited, 59 persisted in using Allay after the familiarisation phase, and 34 participants completed the 12 weeks programme. Participants showed a statistically significant improvement between induction and the end of the 12 weeks programme on Quality of life, Resilience, Perceptions of 'Overall impact' of psoriasis, and 'Emotional impact'. There was a significant change over the course of using Allay for symptoms of depression but not anxiety. While there was an interaction effect of changes in severity of psoriasis symptoms over the course of the study for dermatology-specific measures, there was no interaction between such changes in psoriasis symptoms and changes in depression, resilience or beliefs in emotional impact. Conclusions: Study results suggest that the use of Allay as an adjunct to medical management of psoriasis may help patients improve resilience, mood, beliefs about their condition and enhance their quality of life. Given that this is a phase one proof of concept study, and our rates of attrition further research is necessary to examine comparative effectiveness and stability of these findings.

Evidence of high levels of anxiety and depression in polymorphic light eruption and their association with clinical and demographic variables.

BACKGROUND: Polymorphic light eruption (PLE) is a prevalent photosensitivity condition associated with psychological distress. Objective To examine patients with PLE for evidence of anxiety and depression, the influence of demographic and clinical variables, and the coping strategies used. METHODS: In a cross-sectional design, patients with PLE (n = 145) who had attended a hospital dermatology department completed validated questionnaires assessing anxiety, depression, social anxiety, and coping strategies. Clinical variables examined were: (i) number of months of the year affected by PLE; (ii) facial involvement; (iii) time taken for the rash to resolve; and (iv) whether the patient ever used steroids for their condition. RESULTS: Participants ranged in age from 16-78 (mean 44 years, SD 11.9), 81% female, with a mean age at onset of PLE of 28 years. Evidence of high levels of anxiety and depression was found in PLE, with 22% and 8% of patients scoring as probable cases for anxiety and depression, respectively. Higher levels of anxiety were associated with younger age of onset of PLE (r = -0.25, P < 0.01) and facial involvement (t = 2.84, P < 0.01), and depression was also associated with facial involvement (t = 3.60, P < 0.01). Furthermore, higher levels of depression and anxiety were associated with the use of maladaptive coping strategies, and depression was found to be the principal predictor of quality of life. CONCLUSIONS: High levels of anxiety and depression occur in PLE. Clinicians should be alert to the potential need for psychological management, particularly in patients with facial involvement and a younger age of onset of PLE.

Alcohol consumption and psychological distress in patients with psoriasis.

BACKGROUND: Psoriasis has been associated with excessive alcohol consumption and psychological distress. OBJECTIVES: To investigate the level of alcohol use in a psoriasis population and to determine whether alcohol consumption is linked to psychological distress in patients with psoriasis. METHODS: Ninety-five patients with chronic plaque psoriasis completed validated questionnaires designed to assess psychological distress, current and past alcohol consumption and self-reported physical severity of psoriasis. RESULTS: Using different measures of alcohol consumption, between 17% and 30% of patients were classified as having difficulties with alcohol. Thirteen per cent and 18% of patients with psoriasis believed that they had a current or past drinking problem, respectively. There was a modest but significant association between levels of anxiety and depression and weekly alcohol consumption (r = 0.29, P < 0.01 and r = 0.24, P = 0.03, respectively). Those patients who believed that they had an alcohol problem had higher levels of anxiety (P = 0.03), depression (P < 0.01) and psoriasis-associated disability (P = 0.04). There was a modest but significant association between physical severity of psoriasis and weekly alcohol consumption (r = 0.27, P = 0.02). CONCLUSIONS: A significant minority of patients with psoriasis consumes excessive alcohol. Patients with psoriasis should be assessed for excessive alcohol use and appropriate interventions initiated. Further studies are required to investigate whether such interventions are effective in combating alcohol abuse and in improving the psychological and physical aspects of psoriasis.

Adherence to treatment in patients with psoriasis.

Non-adherence to medication is a chronic problem that impacts on healthcare professionals and patients alike. In psoriasis, a condition that presents patients with frequent and disabling physical, psychological and social effects, studies consistently suggest that up to 40% of patients do not use their medication as directed. Thus it is probable that poor adherence contaminates the clinical picture of response effectiveness in everyday practice. This educational paper reviews research that investigates adherence to medication in patients with psoriasis. It provides an overview of contributing factors and mediating variables. It is proposed that three specific facets appear to optimize patient adherence: an effective doctor-patient relationship; optimism with the treatment prescribed; and a limited 'nuisance' value of treatment in terms of side-effects and hassle of use. Various strategies to address adherence are suggested and it is argued that in order to enhance our understanding of adherence in patients with psoriasis, there needs to be an increasing focus on patients' beliefs about their condition and its management.

Response of the hypothalamic-pituitary-adrenal axis to psychological stress in patients with psoriasis.

BACKGROUND: Psoriasis may, in some patients, be triggered and/or exacerbated by stress. OBJECTIVES: As activation of the hypothalamic-pituitary-adrenal (HPA) axis is critical to a successful stress response we investigated this in patients with psoriasis. METHODS: Forty patients with chronic plaque psoriasis and 40 age-matched normal controls experienced three randomly presented acute psychological stressors (cognitive, emotional and social). Serial serum cortisol, pulse rate and blood pressure assessments were undertaken at baseline and following each of the stressors. Salivary cortisol samples were collected at 09.00 h on the day of testing. RESULTS: In control subjects there was a significant (r = 0.38; P < 0.05) correlation between pulse rate and serum cortisol level following the social performance stressor; this was not evident in the psoriasis group (r = 0.07; not significant). Patients who believed that their psoriasis was highly stress responsive had significantly lower salivary cortisol levels at baseline (P < 0.01) and lower serum cortisol levels following the social performance stressor (P = 0.016) than patients with nonstress-responsive disease who believed that stress had no impact. In contrast, there was no difference between the groups for change in pulse rate poststressor. CONCLUSIONS: This study shows that patients with psoriasis, and in particular those whose disease appears to be stress responsive, exhibit an altered HPA response to acute social stress. The implication is that such patients may perhaps be primed to flares of their psoriasis. Whether this is genetically predetermined and/or a consequence of the distress of living with psoriasis remains to be determined.

Gene expression profiles in psoriasis: analysis of impact of body site location and clinical severity.

BACKGROUND: Psoriasis is characterized by symmetry of plaques and modulation of multiple genes within those plaques. OBJECTIVES: We compared gene expression profiles of plaques of psoriasis at different anatomical sites for both symmetrical and asymmetrical disease to ascertain whether the same genes were expressed. METHODS: Gene expression profiles were analysed in biopsies from lesional and uninvolved skin from two groups of patients with either predominantly symmetrical or truncal plaques of psoriasis vulgaris, and from normal skin of healthy volunteers. Genomic analyses were performed using cDNA array and kinetically monitored reverse transcriptase-initiated polymerase chain reaction (kRT-PCR) approaches. A cluster of genes upregulated in involved psoriasis skin as compared with normal skin was identified using each of these two technologies. RESULTS: Clustering of patients based on their gene expression profile did not reveal any correlation with family history of psoriasis, age at onset or association of psoriasis with arthritis. There was no difference in gene expression profile between the type (symmetrical vs. truncal) or location (left vs. right side of body) of psoriatic plaques. Gene expression profiles of involved psoriatic skin analysed by kRT-PCR analysis did correlate with both global (Psoriasis Area and Severity Index) and local (erythema, desquamation and plaque elevation) clinical severity. CONCLUSIONS: These results indicate that it may be feasible to analyse the molecular effects of pharmacological agents on psoriatic skin in 'minizone' protocols, that the obtained data can be correlated with clinical severity and that plaques of psoriasis in the same individual express the same genes.

Successful treatment of psoriasis improves psoriasis-specific but not more general aspects of patients' well-being.

BACKGROUND: Psoriasis has a detrimental effect on patients' quality of life. However, there is a relative dearth of information on which aspects of a patient's well-being are affected by successful treatment. OBJECTIVES: To investigate whether, and to what extent, improvement in the clinical severity of psoriasis induced by photochemotherapy with psoralen plus ultraviolet A (PUVA) translates into meaningful changes in beliefs about psoriasis, coping, stress, distress or disability. METHODS: In a prospective study, 72 patients were assessed before PUVA therapy and again when they had achieved clearance of their psoriasis. RESULTS: Patients demonstrated significant reductions in psoriasis-related disability, psoriasis-related stress or daily hassles and in the frequency of psoriasis-related symptoms. By comparison, there were no significant differences in levels of anxiety, depression or worrying. Similarly, patients' perceptions about cure, potential chronicity, causes, consequences and coping also remained unchanged. CONCLUSIONS: These results suggest that while clearance of psoriasis produces a significant reduction in factors specific to psoriasis (disability and stress), it does not impact upon psychological distress, on patients' beliefs about psoriasis or on coping. This observation highlights the complex features of patients' psychological experience of psoriasis and may provide further impetus for integration of psychological interventions into standard care protocols.

Detection of psychological distress in patients with psoriasis: low consensus between dermatologist and patient.

BACKGROUND: Researchers have indicated that 30-40% of patients with psoriasis suffer significant psychological distress. For the appropriate clinical management of the patient with psoriasis it is important that dermatologists are able to recognize this distress. OBJECTIVES: To examine the level of agreement between dermatologists and patients with psoriasis as to the presence of clinically significant psychological distress. METHODS: Forty-three consultations between dermatologists and patients with psoriasis were assessed. Following the consultation two assessments were undertaken: the patients completed measures of anxiety and depression, and the consulting dermatologists recorded whether they believed the patient to be psychologically distressed and, if so, their subsequent action. At the end of the study, all dermatologists who participated completed the Jefferson Scale of Physician Empathy. RESULTS: Self-report questionnaires indicated that 37% and 12% of patients were identified as probable clinical cases for anxiety and depression, respectively. In general, the level of agreement between patient rating and dermatologist rating as to the presence of anxiety or depression was low (kappa statistic 0.24 and 0.26, respectively). Dermatologist empathy level did not appear to influence identification of distress. In only 39% of cases were the psychological difficulties of significantly distressed patients raised by dermatologists during the consultation. CONCLUSIONS: Agreement between dermatologists and patients with psoriasis regarding the presence of clinically significant psychological distress was low. When dermatologists did identify patients as being anxious and/or depressed, in the majority of cases no further action was taken following the consultation. This study highlights a number of areas for improvement in the psychological management of patients with psoriasis.

Development of the PSORIQoL, a psoriasis-specific measure of quality of life designed for use in clinical practice and trials.

BACKGROUND: Patients with psoriasis have significant impairment in their quality of life (QoL). Several patient-completed instruments are available to measure outcome in dermatological conditions but these primarily focus on severity of disease rather than on QoL. OBJECTIVES: To develop a new instrument specifically designed to measure QoL in psoriasis-the Psoriasis Index of Quality of Life (PSORIQoL). METHODS: The content of the instrument was derived from qualitative interviews with 62 psoriasis patients in the U.K., Italy and the Netherlands. Content analysis of the interview transcripts from the three countries identified potential items for the questionnaire. All further stages of the project were conducted in the U.K. only. Face and content validity were determined by means of a focus group held with seven psoriasis patients and face-to-face interviews with a further 21 patients. A new draft version of the PSORIQoL, together with the Dermatology Life Quality Index (DLQI) and the General Well-Being Index (GWBI), were completed by a new sample of psoriasis patients contacted by mail, in order to determine construct validity. A subsample of the respondents completed a similar package 2 weeks later, to assess reproducibility (reliability). RESULTS: The first version of the PSORIQoL consisted of 61 items covering the needs identified in the interviews as having been affected by psoriasis or its treatment. These included fear of negative reactions from others, self-consciousness and poor self-confidence, problems with socialization, physical contact and intimacy, limitations on personal freedom and impaired relaxation, sleep and emotional stability. Following the focus group and field-test interviews, a new draft measure consisting of 45 items was completed by 148 patients, 88 of whom completed and returned a similar package 2 weeks later. Application of Rasch analysis identified a final 25-item version of the PSORIQoL. This version had a test-retest reliability coefficient of 0.89, indicating good reproducibility. The levels of association with the DLQI and PGWB indicated that the PSORIQoL measures a related but distinct construct. CONCLUSIONS: The PSORIQoL appears to be a practical, reliable and valid instrument for measuring the impact of psoriasis on QoL. It remains necessary to establish the instrument's responsiveness to changes in QoL associated with treatment.

Patients' strategies for coping with psoriasis.

There is a paucity of research on the types of strategies that patients with psoriasis use to cope with the impact of their condition. By contrast there are a number of studies assessing coping by patients with nondermatological disease. The purpose of the present study was to examine strategies for coping in patients with psoriasis and investigate whether they differ as compared with normal controls and patients with other major medical diseases. Two hundred and fifty patients with a definite dermatologist-confirmed diagnosis of psoriasis participated in this cross-sectional study. Patients were assessed by psoriasis area severity index and all patients completed the COPE questionnaire and psoriasis disability index. Sixty healthy, control participants completed the COPE questionnaire for comparison purposes. Mean COPE scores from patients with psoriasis were also compared with published COPE scores from other medical diseases. The coping strategies most frequently used by patients with psoriasis were acceptance, planning, active coping and positive reinterpretation. The least frequently used were alcohol and nonprescription drugs, religion, and denial of their condition. Despite reporting greater disability, patients with severe psoriasis did not significantly differ from those with mild/moderate disease in their use of particular forms of coping strategies. Patients with psoriasis as a whole tended to use significantly less active coping strategies, planning, positive reinterpretation and humour when compared with normal controls. There was marked similarity in the frequency of use of particular coping strategies between patients with psoriasis and patients with other medical conditions. Similar types of coping strategies are utilized by patients regardless of whether their illness is visible (psoriasis) invisible (chronic fatigue syndrome, atrial fibrillation), has significant physical impairment (spinal cord injury), or is life-threatening (cancer, and myocardial infarction). It appears that illness brings with it a generic form of coping that may require shaping to fit the individual demands of diseases such as psoriasis.

A cognitive-behavioural symptom management programme as an adjunct in psoriasis therapy.

BACKGROUND: Patients with psoriasis may experience significant psychological and social disabilities. Stress or distress are proposed aggravators of the disease process in psoriasis. Preliminary studies to date have suggested that adjunctive psychological therapies may be effective in the clinical management of psoriasis. OBJECTIVES: To examine whether a 6-week multidisciplinary management approach, the Psoriasis Symptom Management Programme (PSMP) for patients with psoriasis improves clinical severity of psoriasis and its associated psychological distress and disability. METHODS: In a case-control study, patients with psoriasis attending an out-patient psoriasis specialty clinic chose to receive standard psoriasis treatment alone (n = 53) or to enter the PSMP as an adjunct to standard therapy (n = 40). They were assessed at baseline, at the end of the 6-week PSMP and after 6 months follow-up. RESULTS: As compared with standard treatment alone, analysis of covariance indicated that participation in the PSMP resulted in a greater reduction in clinical severity of psoriasis (P = 0.001), anxiety (P = 0.001), depression (P = 0.001), psoriasis-related stress (P = 0.001) and disability (P = 0.04) at 6 weeks and 6 months follow-up. CONCLUSIONS: The management of the physical aspects of psoriasis and its psychological effects are significantly improved for patients who opt for a 6-week integrated multidisciplinary approach. Furthermore, the techniques learnt by participation in the PSMP facilitate continued control of psoriasis for at least 6 months.

Psychological influences in psoriasis.

It has long been recognized that living with a chronic condition, such as psoriasis, can have considerable impact on the individual concerned. In turn there is increased understanding that the psychological distress encountered as a result of this experience can have implications for the course of the disease. This short review takes this as a starting point and reviews psychological influences in psoriasis. The nature of the link between psoriasis and stress is explored and its implications for the patient are discussed in psychological and clinical terms. There seems little doubt that stress, either environmental or psoriasis induced, impacts on our patients and has important implications for the management of psoriasis.

Physical and psychologic measures are necessary to assess overall psoriasis severity.

BACKGROUND: The assessment of psoriasis severity is complex and involves both the physical and psychologic assessment of the individual patient. OBJECTIVE: We compared the Salford Psoriasis Index and several other tools for assessing psoriasis severity for their abilities to assess both the physical and psychologic effects of psoriasis. METHODS: A total of 101 patients (44 women, 57 men) were assessed by means of the Salford Psoriasis Index (SPI), Psoriasis Area and Severity Index (PASI), Self-Administered PASI (SAPASI), Psoriasis Disability Index (PDI), Hospital Anxiety and Depression Scale (HADS), and Illness Perception Questionnaire (IPQ). RESULTS: The "signs" score of SPI (which measures the clinical extent of psoriasis), PASI, and SAPASI correlated well with each other (r = 0.69-0.99; P <.01). They also correlated significantly, but not as strongly, with scores of psoriasis-induced disability, the PDI and SPI "psychosocial disability" score (r = 0.46-0.51; P <.01), but not with general measures of psychologic distress. There was no significant correlation between the historical treatment, "intervention," score in SPI and either the physical or the psychologic score in the SPI. The PDI and "psychosocial disability" score of SPI correlated well with each other (r = 0.69; P <.01) as well as with the depression and anxiety subscale scores of HADS (r = 0.33 and r = 0.37; P <.01, respectively), the total number of symptoms suffered by the patient (r = 0.38; P <.01), and the belief that stress or worry were associated with psoriasis (r = 0.33; P <.01). CONCLUSION: Physical scores of psoriasis severity such as PASI, SAPASI, and the "signs" component of SPI give a partial indication of psychosocial disability caused by psoriasis. In many patients, however, the physical score does not reflect psychosocial disability. Patients should be assessed by a more holistic approach, which takes into account both physical and psychologic measurements, such as used in SPI, when assessing the severity of psoriasis.

The contribution of perceptions of stigmatisation to disability in patients with psoriasis.

OBJECTIVE: The aim of the present study was to assess the significance of general and psoriasis specific psychological variables in patients with psoriasis and to examine the relative importance of disease status and these psychological variables in predicting psoriasis-related disability. METHOD: A total of 115 patients with psoriasis underwent clinical assessment and completed a number of psychological and psoriasis specific questionnaires. RESULTS: High levels of self-reported distress were identified with 43% and 10% of patients scoring as probable cases on the Hospital Anxiety and Depression Scale (HADS) subscales of anxiety (mean 9.3+/-4.9) and depression (mean 4.8+/-3.7), respectively. Multiple regression analysis indicated that clinical severity of psoriasis and anatomical area of involvement had no impact on psychological distress and disability. Perceptions of stigmatisation were significantly related to both psychological distress and degree of disability (P's<.001) and accounted for a significant amount of the variance in disability over and above general psychological distress (F change=11.03; P<.001). CONCLUSION: Psychological factors were much stronger determinants of disability in patients with psoriasis than disease severity, location or duration. This has important implications in relation to the clinical management of psoriasis.