Illness perception in association with psychological functioning in patients with discoid lupus erythematosus

DEAR EDITOR, Discoid lupus erythematosus (DLE) causes scarring and inflammation; it is therefore unsurprising that the psychological impact on patients is considerable. Patients’ subjective perceptions of their condition may be a better predictor of psychological outcomes than clinician-based assessments of severity. The common sense model of self-regulation of health and illness by Leventhal et al. describes the process by which individuals respond to illness. Individuals actively try to make sense of symptoms, forming cognitive and emotional representations, which, in turn, determine their subsequent coping behaviour. Perceiving DLE to have more severe effects may increase patients’ distress, which may exacerbate disease activity, operating in a negative feedback loop. Asking patients to draw their illness is a useful way to assess their perceptions. Broadbent et al. demonstrated that patients’ drawings of damage to their heart predicted outcomes following myocardial infarction. Furthermore, patients whose drawings increased in size over the recovery period reported greater anxiety and poorer recovery at follow-up, suggesting that drawing size indicates the extent to which patients are preoccupied by their illness. This study aimed to investigate patients’ illness perceptions in association with their psychological functioning compared with objective measures of their disease activity. We hypothesized that patients with negative illness perceptions would have poorer psychological functioning independent of their objective disease severity. A cross-sectional study was conducted at an outpatient dermatology clinic in New Zealand. Inclusion criteria were that patients had a diagnosis of DLE, were aged > 18 years and spoke English. The study was approved by the University of Auckland Human Participants Ethics Committee. Eligible patients were identified from the clinical database and sent an invitation to participate. Consenting patients attended the clinic and completed (i) the Brief Illness Perception Questionnaire (Brief IPQ), a nineitem questionnaire that assesses illness perception dimensions on single-item scales of 0–10; (ii) the Dermatology Life Quality Index (DLQI), and (iii) the Patient Health Questionnaire (PHQ-9), a validated screening tool for depression. Participants were asked to draw their face on a piece of white paper within a printed rectangle (93 9 123 mm), similar to previous studies. Finally, a Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) score, a validated measurement instrument for assessing cutaneous lupus activity and damage, was calculated for each participant by a single observer (P.C.), in order to avoid potential interobserver bias. Drawings were scanned and imported into Image J (National Institutes of Health, Bethesda, MD, U.S.A.). The outside perimeter of each drawn face was traced and the area computed. The number of skin lesions drawn was counted manually by three independent raters. As the distribution of scores was not symmetrical, Spearman’s correlation coefficients (rho) were conducted between measures. SAS software version 9.3 (SAS Institute, Cary, NC, U.S.A.) was used for analysis. Eighty patients were screened for eligibility; two were excluded owing to language barriers. Twenty-four patients (31%) consented to take part [three men, 21 women (six European, 18 Maori/Pacific Islander)]. The mean SD age of the patients was 48 7 13 7 years. Sixteen patients screened positive for depression, six of whom had moderately severe to severe depression. The mean SD DLQI was 8 71 8 29. The mean CLASI activity and CLASI damage scores were 11 13 9 65 and 12 63 9 60, respectively. There were no significant correlations between CLASI scores and DLQI (CLASI damage: q = 0 27, P = 0 21; CLASI activity: q = 0 35, P = 0 09). However, there was a positive correlation between CLASI activity and depression (q = 0 41; P = 0 05). Seven Brief IPQ domains were significantly correlated with psychological functioning, and six were significantly correlated with objective disease ratings (Table 1). The number of skin lesions drawn was positively correlated with CLASI activity (q = 0 42; P = 0 06). Larger drawings of the face after the development of DLE were associated with higher levels of depression (q = 0 53, P = 0 01). Examples of drawings are shown in Figure 1. This is the first study to investigate the relationships between patients’ perceptions of their DLE, objective measures of disease and psychological functioning. The findings suggest that patients with DLE are at increased risk of developing depression. There is an increased risk of depression and suicidal ideation in patients with chronic disfiguring skin conditions such as acne, psoriasis, alopecia areata and dermatitis. Worse active DLE was associated with worse depression in this study. This association has been noted in psoriasis, with an adjusted hazard ratio (HR) for depression being higher in severe compared with mild psoriasis {HR 1 72 [95% confidence interval (CI) 1 57–1 88] vs. HR 1 38 (95% CI 1 35–1 40)}. Therefore clinicians should consider the psychological aspects of illness, particularly in those with severe inflammatory DLE.