ویژگی های شخصیتی در شرایط آلرژیک مزمن و غیر مزمن

In psycho-allergological research, the potential relevance of personality factors in the maintenance and exacerbation of atopic symptoms is still a matter of debate. The present study aimed to assess personality dimensions in chronic atopic disease, i.e. atopic dermatitis (AD) and in acute manifestation of atopy (seasonal allergic rhinitis, SAR). Further, the association of a potentially atopy-specific personality profile with atopy-relevant biological stress responses should be evaluated. Subjects suffering from AD (n = 36), or SAR (n = 20) and non-atopic controls (n = 37) were investigated. To determine different personality domains, Spielberger’s State-Trait Anxiety Inventory (STAI), the Questionnaire for Competence and Control (FKK) and the Questionnaire for Stress Vulnerability (MESA) were administered. To assess the relation between these personality dimensions and biological stress responses, atopics and non-atopic controls were exposed to a standardized laboratory stressor (Trier Social Stress Test, TSST). Endocrine (cortisol, ACTH), immune (total IgE, leukocyte subsets) and physiological (heart rates) measures were recorded before and after the stress test. When compared to healthy controls, AD and SAR patients showed significantly higher trait anxiety (STAI) and stress vulnerability in situations characterized by failure, job overload and social conflicts (MESA). Moreover, AD subjects scored significantly lower in self-competence and self-efficacy (FKK) as well as in recreation ability (MESA). No difference trait anxiety and stress vulnerability could be detected between AD and SAR subjects. Pearson correlational analyses yielded no significant correlation between the different personality domains and the endocrine, physiological and immunological stress responses. However, stress-induced increase in eosinophil number was significantly correlated with the perceived self-competence/self-efficacy in SAR patients.

Atopic dermatitis (AD) is a chronic, inflammatory skin disease with main symptoms such as eczematous skin, erythematous papules and severe pruritus (Boguniewicz, 2004 and Leung et al., 2004). In the last 30 years, the frequency of AD has significantly increased, with a current estimated prevalence of 15–24% in the industrialized countries. Nowadays, AD represents one of the most frequent chronic diseases and accounts for up to 20% of all patients treated in dermatology departments. (Van Moerbeke, 1997 and Mortz et al., 2001). Although AD is not a life-threatening disease, AD symptomatology results in significant morbidity often associated with hospitalization, school absenteeism and missing work days. The unpredictability of the disease, the torturing pruritus and the feeling to be cosmetically disfigured further imposes a psychological burden on AD sufferers and their relatives. It is broadly accepted that numerous factors such as genetic disposition, climate, allergens or microbial organisms (Staphylococcus aureus) are involved in AD ( Sturgill and Bernard, 2004 and Abramovits, 2005). However, research of the last decade strongly suggests the importance of a complex dysregulation of the immune system in the pathology of AD. In AD patients, exposure to environmental allergens leads to B cell activation and hypersecretion of allergen-specific immunoglobulin-E (IgE) initiating acute hypersensitivity reaction of the skin. Additionally, activation of TH2 cells with a predominant secretion of TH2 cytokines (interleukin-4, interleukin-5, interleukin-10) has been reported. A shift towards a TH2-dominated cytokine profile, however, has been found to be responsible for immunoregulatory abnormalities such as an immunoglobulin-switch from other Ig isotypes to IgE or eosinophil recruitment and infiltration into sites of allergic tissue inflammation ( Boguniewicz, 2004 and Allam et al., 2005). Besides abnormal immune responses, psychological factors such as stress or personality have been assumed to play a pivotal role in AD pathogenesis (Buske-Kirschbaum, 2007). The existence of a close relationship between psychological factors and the skin has long been noticed and discussed. In the 1940s, Alexander and French (1948) leading an influential school of psychosomatic thought postulated that the AD child is characterized by a distinct emotional conflict which was felt to revolve around the child’s failure to express anger and hostility stemming from maternal rejection. Although some studies have explored this hypothesis suggesting elevated anxiety, hopelessness and overprotection as well as maternal rejection is more frequent in families with AD children, the maternal rejection/suppressed anger and hostility hypothesis could not be conclusively supported (Ring and Palos, 1986 and Pauli-Pott et al., 1999). However, the general idea was followed by numerous investigators attempting to identify a specific conflict or distinct personality profile which characterizes the AD patient, and may make an individual more vulnerable to developing AD. In this line of research it has been suggested that AD sufferers display an atopy-specific personality pattern characterized by increased neuroticism, hostility, anxiety, hypersensitivity, aggressiveness, feelings of inferiority, tension, depression, restlessness, insecurity, lability and rigidity (Greenhill and Finesinger, 1942, Rogerson, 1947 and Kepecs et al., 1951). More recent data show that atopics are more intelligent, timid, suspicious, anxious, depressive, emotionally less stable and show higher interests in power and social influence with concurrent lower need for affiliation and achievement (White et al., 1990, Arima et al., 2005 and Bahmer et al., 2007). It should be emphasized, however, that the approach to link a distinct personality profile to AD has been criticized and is still a matter of debate. The available data are quite heterogenous, and there are reports which failed to show any relationship between personality and AD (Gieler et al., 1985). It has further been argued that the personality pattern described in AD patients may not reflect an atopy-specific personality profile but rather a personality structure of the ‘chronically ill’ which would question the etiological significance of the proposed AD personality pattern (White et al., 1990). Moreover, it is not clear whether the personality structure described in AD patients represents a premorbid personality profile that may be of etiological significance, or whether, due to the debilitating effects of a chronic skin disease, AD sufferers may exhibit ‘reactive’ personality structures (which in turn may have an impact on the disease course). Finally, it has been criticized that most of the studies did not address the question what the underlying (psychobiological) mechanisms of a relationship between distinct personality characteristics and AD might be. The specific goal of the present study was thus to evaluate whether AD patients exhibit a distinct personality profile that is atopy-specific, and can also be distinguished from other forms of atopy such as seasonal allergic rhinitis (SAR). SAR is a highly common atopic disorder affecting between 9% and 24% of adults, and up to 42% children in the industrialized countries (Nathan et al., 1997). The main symptoms of SAR are rhinorrhea, sneezing, pruritus and congestion. Immunopathology of SAR resembles the pathology described in AD and allergic asthma (AA) in that IgE hypersecretion in response to allergen exposure, mast cell degranulation and release of vasoactive mediators, activation of mainly TH2 cells with a release of a predominant TH2-specific cytokine profile and eosinophil activation and infiltration can be found (Wilson et al., 1994, Nouri-Aria et al., 2000 and Borish, 2003). However, in contrast to AD which is considered to be chronic manifestation of atopy, SAR is an acute, intermittent atopic disorder closely linked to the exposure of mostly seasonal occurring allergens such as dander or pollen ( Salib et al., 2003). Thus, the existence of two atopic disease forms that share key aspects of immunopathogenesis but can manifest in a chronic (AD) or an acute/intermittent (SAR) form may represent a unique model to study the effect of acuity/chronicity of a given disease on personality characteristics. Additionally, the study addresses the question whether possible atopy-specific personality traits are linked to endocrine and immunological stress responses in AD and SAR patients. This idea evolved from recent findings of our laboratory showing significantly altered cortisol and/or catecholamine responses in AD and SAR patients when confronted with psychosocial stress. (Buske-Kirschbaum et al., in preparation). In addition, stress-induced changes of immune functions known to be pathologically relevant were altered in AD sufferers (Buske-Kirschbaum et al., 2002a). Based on these observations we presumed that an atopy-specific personality structure in AD and SAR patients may be linked to an altered biological stress response that may render the person more vulnerable to develop and exacerbate atopic symptomatology especially under stressful conditions.

3.1. Personality characteristics in AD and SAR patients An ANOVA of the personality data yielded a significant group effect in trait anxiety (Table 1), self-concept (Table 2) stress vulnerability in situations characterized by failure, job overload and social conflicts and recreation ability (Table 3). Table 1. Trait anxiety (STAI) in patients with atopic dermatitis (AD), seasonal allergic rhinitis (SAR) and non-atopic controls Groups AD patients SAR patients Controls F df p Anxiety 42.1 ± 2.1 39.5 ± 1.4 35.2 ± 1.0 5.1 90 .007∗ Mean ± SEM are reported. Table options Table 2. Stressvulnerability (MESA) in patients with atopic dermatitis (AD), seasonal allergic rhinitis (SAR) and non-atopic controls Groups AD patients SAR patients Controls F df p Failure 14.8 ± .48 14.5 ± .48 13.1 ± .37 4.8 64 .01∗ Job overload 12.9 ± .53 11.8 ± .58 10.9 ± .34 4.6 66 .01∗ Social conflicts 12.3 ± .43 11.5 ± .59 10.6 ± .33 4.1 65 .02∗ Criticism 11.4 ± .61 11.4 ± .57 10.7 ± .38 .7 67 .48 Uncertainness 12.4 ± .50 11.3 ± .53 11.1 ± .31 2.9 66 .06 Recreation ability 9.1 ± .54 8.7 ± .52 7.6 ± .31 3.4 65 .04∗ ΣStress vulnerability 73.8 ± 2.4 69.4 ± 2.57 64.0 ± 1.21 6.4 64 .003∗ Mean ± SEM are reported. Table options Table 3. Locus of control/self-concept in patients with atopic dermatitis (AD), seasonal allergic rhinitis (SAR) and non-atopic controls Groups AD patients SAR patients Controls F df p Self-concept 29.4 ± 1.22 31.8 ± 1.44 33.8 ± .68 4.3 69 .02∗ Internality 30.1 ± 1.20 32.7 ± .93 32.7 ± .68 2.5 69 .09 Powerful others control 25.0 ± 1.10 24.3 ± .98 24.1 ± .97 .21 68 .08 Chance control 23.1 ± .92 21.1 ± 1.01 22.1 ± .97 1.0 69 .36 Self-efficacy 59.5 ± 1.82 64.5 ± 2.24 66.5 ± 1.03 5.0 69 .009∗ Externality 48.1 ± 1.43 45.4 ± 1.73 46.5 ± 1.45 .79 68 .46 ΣLocus of control/self-concept 11.4 ± 2.60 19.1 ± 3.51 19.9 ± 2.29 3.1 68 .04∗ Mean ± SEM are reported. Table options Post hoc analyses revealed that compared to the non-atopic control group, AD and SAR patients showed significantly higher levels of trait anxiety and stress vulnerability and indicated a significantly lower level of positive self-concept (all p < .05). No difference in these personality domains could be detected between the two atopic groups, i.e. the AD and SAR patients (all p > .05). t-Tests further revealed significantly higher trait anxiety in AD (t = 2.9; p = .004) and SAR (t = 2.56; p = .01) patients when compared to the control group. Further, SAR patients showed significantly higher levels of stress vulnerability (t = 2.1; p = .04), especially in situations characterized by failure (t = 2.4; p = .02) when compared to the controls. AD subjects were found to score significantly higher in stress vulnerability (t = 3.77; p < .001), i.e. in situations characterized by failure (t = 2.86; p = .006), job overload (t = 3.11; p = .003), social conflicts (t = 3.1; p = .003) or uncertainness (t = 2.38; p = .02). AD patients were further found to indicate significantly reduced recreation ability (t = 2.51; p = .01). When compared to the control group, AD but not SAR patients differed significantly from non-atopics in positive self-concept (t = 3.1; p = .002), self-efficacy (t = 3.36; p = .001) and locus of control (t = 2.44; p = .02) (for SAR patients all p > .05). 3.2. Association between personality characteristics and biological stress responses in AD and SAR subjects The endocrine and immunological responses to the TSST in AD and SAR patients and the non-atopic controls are described elsewhere (Buske-Kirschbaum et al., 2002b and Buske-Kirschbaum et al., in preparation). Briefly, after being exposed to the TSST, AD, SAR and control subjects showed a significant increase of cortisol, ACTH and leukocyte numbers (lymphocytes, neutrophils, eosinophils, basophils). However, when compared to the control subjects, cortisol and ACTH responses to the stressor were found to be significantly reduced in AD patients and in SAR patients. It is of note that In SAR patients, attenuated cortisol and ACTH levels in response to the stressor were found only during the times of allergic flare ups, i.e. times of pollen exposure (Buske-Kirschbaum et al., in preparation). Pearson correlational analyses yielded no significant correlation between the different personality domains and any of the endocrine (cortisol, ACTH), physiological (heart rates) and immunological (leukocyte subsets, total IgE) stress responses neither in AD and SAR patients nor in the non-atopic control group (all p < .05). Only changes of eosinophil numbers in response to the stressor were significantly associated with the self-concept, and locus of control (FKK) in SAR patients ( Table 4).