Understanding the experiences of anger in the onset and progression of psoriasis: A thematic analysis

Abstract Psoriasis is a chronic inflammatory skin condition, which can be affected by stress. Living with psoriasis can trigger negative emotions, which may influence quality of life. The present study explored the lived experiences of people with psoriasis with attention to the potential role of anger in the onset and progression of the chronic skin condition. Semi‐structured qualitative interviews were conducted with 12 participants (n = 5 females, n = 7 males) recruited from an advert on a patient charity social media platform. Data were transcribed and analysed using thematic analysis. Four key themes were identified: (1) anger at the self and others, (2) the impact of anger on psoriasis: angry skin, (3) shared experiences of distress and (4) moving past anger to affirmation. Findings suggest that anger can have a perceived impact on psoriasis through contributing to sensory symptoms and unhelpful coping cycles, and points to a need for enhanced treatment with more psychological support. The findings also highlight the continued stigma which exists for those living with visible skin conditions and how this may sustain anger for those individuals. Future research could usefully focus on developing targeted psychosocial interventions to promote healthy emotional coping.


| INTRODUCTION
Psoriasis is a chronic inflammatory skin condition arising from the excess production of cells in the upper epidermis, causing raised or thickened patches of skin on the body. 1 There are several types of psoriasis which can all fluctuate, and differ in presentation, including plaque (large scaly patches), guttate (small red patches), pustular (with pustules) and erythrodermic (covering most of the body) which can all occur alongside psoriatic arthritis. 1,2 Although psoriasis is an autoimmune condition, it is multifactorial in expression 3,4 as emotional life events can influence onset and clinical course. Research has focussed on the role of emotions 5,6 and stressful or traumatic life events triggering psoriasis [7][8][9] ; however, studies have reported mixed findings. [10][11][12] As such, questions remain about the role of emotions and experiences, their relationship with symptom severity, and the mechanisms of which trauma may interact with inflammatory markers. 13 The roles of emotion and stress in psoriasis are complicated by visibility, with Western society valuing beauty and myths existing regarding broken skin. 1,14 Having noticeable changes to the skin could cause unwanted attention, remove an individual's control over when they disclose their condition or prompt people to dress differently, attracting more attention. 14 This might explain why skin conditions have been associated with depression, [14][15][16][17] low self-esteem and maladaptive self-beliefs or appearance anxiety. [18][19][20] In an attempt to avoid negative evaluations and humiliation, people with psoriasis may anticipate rejection, withdraw socially 21 or experience shame. 13,22 Anger has been reported in people with skin conditions 23 including alopecia, 4 urticaria 24 and psoriasis 4,25,26 from their uncontrollable nature, or as an outcome of poor mental health. Experiencing anger could impede immune function in a similar way to the stress response 6 and exacerbate skin severity or disease duration. 5,22 For example, an 'itch-scratch cycle' could be triggered by the psychological burden of psoriasis and the internalization of anger, resulting in a behavioural response of scratching. 27 Focussing on the psychological impact of skin conditions has long been seen as necessary 28 if patient treatments are to be optimized, with calls growing for interventions to be more psychologically informed. 29,30 However, the All-Party Parliamentary Group on Skin 31 reported that 98% of people surveyed felt psychologically negatively impacted by their skin condition, but only 18% had received support. Despite the increasing interest in psychosocial aspects of autoimmune conditions, there is a scarcity of research examining anger associated with psoriasis. The purpose of this study was to address this gap by exploring the onset and progression of psoriasis with attention to the role of anger. 32 To our knowledge, there has been no study to date which has qualitatively investigated anger related to psoriasis. Such an approach has a growing body of literature examining a range of health conditions 33,34 including burns, 35 and visible difference. 36,37 2 | MATERIALS AND METHODS

| Participants
Using purposive sampling, 12 participants were recruited in collaboration with the Psoriasis Association UK for semi-structured interview. An advertisement on social media was used to inform that for inclusion, participants had to be (a) aged over 18 years, and (b) be diagnosed with psoriasis. Participants (n = 5 females, n = 7 males) were aged 26-74 years (mean age = 45.16) and were all British. The age of diagnosis of psoriasis ranged from 5 to 46 years (mean age = 19.42), and presentations ranged from guttate, plaque, to severe erythrodermic, and psoriatic arthritis (Table 1).

| Procedure
Ethical approval was granted by University Departmental Ethics (ref: 3773). Participants responded to the online advertisement and were given a choice of interview to promote empowerment 38 ; face to face, Skype or telephone, which facilitated choice over visibility. 37 Drawing on previous qualitative research, 39 a semi-structured interview schedule was developed, allowing participants to discuss topics they felt relevant ( Table 2). The interviews lasted approximately 40 min and were audio-recorded.
Braun and Clarke 40 report that meaning in qualitative research is constructed from subjective interpretations, so data collection cannot be predicted with an estimate of required interviews, or with data saturation alone. [40][41][42][43] Therefore, based on the study aims and the strength of interview dialogue, recruitment was continuously evaluated until there was consensus of the data being extensive in information power. 40,44

| Data analysis
Data were analysed with thematic analysis. 40,41,45 Interviews were transcribed verbatim, and participants What is already known about this topic? � Psoriasis is a chronic inflammatory skin condition that has been associated with emotional and psychological distress in some people. � Stress has been found to impact on psoriasis, and has been linked to flare-ups. � It has been suggested that anger could occur as an outcome of living with a visible skin condition.

What does this study add?
� This study is the first, to our knowledge, to use qualitative methods to explore the lived experiences of anger and the role of negative emotion in the onset and progression of psoriasis. � Findings suggest that anger may play a contributory role in the experience of psoriasis for some patients. � The potential contributory role of experiencing trauma was highlighted, with psoriasis in some cases, acting as a secondary trauma.

What are the clinical implications of this work?
� To optimize psoriasis treatments, patient emotional and psychological wellbeing must be considered, to facilitate healthy coping. � There may be value in routinely addressing patient experiences of humiliation and anger, as this is not normally assessed with mainstream mood measures.
were assigned numbers to protect identities. Verbal comments in the form of quotes were used to preliminary code transcripts, extending to full coding across the dataset, and themes were developed based on shared meanings. 40,41 To ensure a valid interpretation of the phenomenon, researchers assessed information power 44 by reviewing data to check themes were relevant to the research aim. 40,41,44

| RESULTS
Thematic analysis revealed four themes and seven subthemes (Table 3).

| Theme 1: Anger at the self and others
Feeling angry became an organizing principle, with anger aimed at psoriasis itself, and the impact it had on daily life. This triggered anger which affected mood, and included adjustment to altered appearance/changing self-perception: Not feeling one-hundred percent confident in…my own skin. (Participant 2).
Participants described being self-conscious as they could not control their personal presentation, and often engaged in checking behaviours to see if their skin was shedding: I'd like to feel one-hundred percent confi-dent…I just get really angry that I have to be double-checking myself. (Participant 12).
Feeling disempowered extended socio-economically with reduced performance and missed opportunities: Notably, anger extended to participants evaluating themselves compared to others, for example, not being able to wear the same clothes as friends: I get very frustrated…we're going away with my friends soon…they're all talking about outfits and I'm getting really annoyed because I'm just going to be in trousers. (Participant 4).
One participant felt that having psoriasis since childhood had impacted on psychosexual development and contributed to negative self-beliefs: I'm in my fifties…never been married, haven't got a girlfriend so it's affected me… when you're in your late teens and early twenties and your mates are getting girl-friends…that passed me by… because I was self-conscious of it…my skin being bad, and thinking 'who would want me?'…'I'm a mess'. (Participant 8).

| Theme 2: The Impact of Anger on Psoriasis: Angry Skin
Participants described how they felt their feelings manifested physically, highlighting the bidirectionality of emotion/body symptoms.

| Sensory symptoms and emotion
Sensory symptoms were described when feeling emotional which was metaphorical for one participant: 'It's crawling on you like bugs' (participant 1), while others described exacerbation with sensory vigilance: 'If I'm feeling down…I tend to feel my psoriasis more' (participant 10).
Some mentioned a temperature change in the skin when angry, and in one case, the 'whole body burned' (participant 6): If you do get angry…it's really quick to see the difference in my skin…the psoriasis I have will become redder, more-scaly…my skin feels hotter. (Participant 11).

| Precipitating vicious cycles
Anger appeared to maintain a vicious cycle of emotions/unhealthy coping. It appeared that anger not only worsened symptoms, but feelings of anger towards symptoms were exacerbated: It just spread so quickly…I was getting upset and stuff about it and I'm sure that accelerated it. (Participant 9).
There was a vicious circle that I'd get tired and I'd get bad tempered, I'd get psoriasis, I'd get more-bad tempered, I'd get more tired. (Participant 3).
I got stuck in a cycle of frustration, depression, anger, anxiety, a lot of anxiety from stress and…the heat of anger. (Participant 6).
These emotions related to psoriasis led participants to respond in a range of ways, some of which were maladaptive and maintained vicious cycles: I was self-medicating with alcohol…the worse it got, the worse I drank, the worse it got. (Participant 8).
I'll get really angry…I'm angry cause I'm stressed, and then my skin will flare, and then if I'm stressed it's cause I'm pissed off and angry, and then my skin will flare…then it's a vicious circle…you feel like shit so you eat, you feel better for a little bit, and then you feel like shit because you've eaten…it's a downward spiral. (Participant 12).

| Theme 3: Shared experiences of distress
Participants discussed similar experiences of mental health conditions, distress, trauma, and the mediating role of confidence.

| Comorbid mental health conditions
Comorbid mental health conditions exacerbated the emotional impact of psoriasis from determining behavioural responses, including anxiety related to appearance and fear of judgement: It was anxiety of people asking me about it and being different. (Participant 2).
I spent an hour in the bathroom crying before I went to the pool because… you could see the psoriasis…I was like so paranoid. (Participant 11).
Mental health presentations were attributed to psoriasis, and importantly, both resulted in and contributed to emotional lability:

| Experiencing trauma
Anger was often precipitated by traumatic experiences, notably, with historical trauma being linked to the onset of psoriasis. This anger contributed to psychological distress and influenced affect through rumination: When I was 12, I was diagnosed with psoriasis…it was put down to the fact that my mother died when I was 6. Connecting with other people with psoriasis helped 'to know that other people out there are going through similar things and are coping well' (participant 11). One participant found 'peace in reading the Bible' (participant 7). In addition, age promoted acceptance, from growing older with the condition, and age at onset: I've got more blasé…I will now wear shortsleeved shirts even though I've got psoriasis on my elbows…there was a time when I wouldn't have. (Participant 7). I've been very lucky in so much that I didn't have it as a child when I suspect it would have affected me much more. (Participant 5).
I got it when I wasn't as vulnerable….the thought of being a teenager with psoriasis is pretty chilling. (Participant 3).
Some participants described gaining experience in managing psoriasis, which made them 'less angry about it now'. (Participant 8) as they had learnt to treat it: It's experience… I know that a flare-up is coming so I take precautions to make sure that it's not as bad. (Participant 8).
I've had it that long I've got used to it. (Participant 10). However, one participant had received specialized support for their psoriasis, which was a 'life-changer' (participant 8): I'd probably be dead by now if it was not for that intervention…it had got that bad. (Participant 8).

| DISCUSSION
This study explored the experiences of people with psoriasis, with attention to the role of anger. Our findings support previous research, 4,5,22,25,26 shed light on the perpetuating factors for anger, and to our knowledge, is the first study to qualitatively investigate anger and psoriasis. The themes identified demonstrate that anger was experienced from psoriasis itself, feeling out of control, and life circumstances 46 which all perpetuated anger 22 and created vicious cycles of emotion/increased symptoms. As illustrated in Figure 1, participants described how anger emerged and was exacerbated by anxiety, low self-esteem, and lack of confidence. 4,23 Self-directed and internalized frustrations were expressed at having to alter personal presentation and adjusting to changing self-perceptions. A twofold process of social evaluations was outlined; firstly, individuals were negatively evaluated by other people, 14 triggering social avoidance; and secondly, evaluated themselves compared to others, and felt frustrated at covering their skin and not achieving their 'potential'. For some, this sense of underachieving resulted from a disruption to psychosexual maturation in adolescence lasting into early adulthood with negative beliefs about self/desirability being maintained in later life. 19,20 The complexities of backgrounds influenced anger, with the trauma reported in this study being similarly found in psoriasis 7,10,11 and other autoimmune conditions. 47 Participants perceived that anger caused by trauma had negatively impacted their health and contributed to both the onset and progression of psoriasis, suggesting that the challenges of living with psoriasis could serve as a secondary trauma.
Findings support the stress-disease cycle 48 with the stress of psoriasis contributing to disease itself and causing further stress as an outcome. For example, the efforts of participants to self-manage their stress from psoriasis resulted in maladaptive coping, such as alcoholism 49 and overeating. This highlights potential targets to support patients in developing adaptive coping strategies, as enhancing self-efficacy could indirectly improve physical symptoms through stress reduction. Similarly, co-morbid mental health conditions influenced behaviour and emotion, such as increasing sensory awareness of psoriasis, suggesting a quasi-sensory hyperawareness. 50,51 The findings included compulsive picking alongside co-morbid obsessive-compulsive disorder and borderline personality disorder, supporting the 'itch-scratch cycle' 27 or evidencing psychological symptoms. [52][53][54] The close, symbolic relationship between anger, heat and redness/inflammation that is commonly metaphorical was reported as a lived, physical sensation, with skin temperature changes when angry. While there is limited research on blood flow in psoriatic plaques, temperature differences could be explained by basal flux/emissivity in psoriatic regions. 55,56 Despite the challenges, not all individuals experienced severe anger, but instead described the occasional frustration. This was explained by several protective factors, including acceptance 14 gaining experience, perceived support/connecting with others, romantic relationships 23,36 spiritual frameworks, and professional intervention. These could be a central focus of future interventions to therapeutically buffer the negative effects of psoriasis and encourage healthy coping. 57,58

| Implications
This study highlights the need for clinicians to consider psychosocial factors in the management of psoriasis, and for further research to improve understandings of the role of emotions to enhance patient wellbeing; physically and psychologically. It may be worthwhile considering experiences of humiliation and anger, as these are not assessed with mainstream mood measures. Future research could also examine the relationship between historical trauma and severity of psoriasis, and the relationship between historical trauma and secondary, appearance or symptom related trauma. Herein may lie targeted psychosocial strategies which may indirectly contribute to the moderation of associated auto-immune inflammatory responses through enhancing adaptation. 59,60 There may be opportunities for clinicians to incorporate such interventions practically, or at developmental stages of vulnerability. 61

| Limitations
There were several limitations to this study. Participants were all British (not representing non-British/BAME patients), complex in backgrounds and self-selecting (no measure of psoriasis severity). Thus, findings may only reflect the experiences of a subgroup of people who felt motivated to discuss emotions and psoriasis. Future studies could explore these concepts in a wider demographic or employ quantitative methods with standardized psychometric measures. Prospective, longitudinal studies could also be used to observe the evolving experience, and adaptations required for adjusting to psoriasis.

| CONCLUSION
Anger was common for participants, and the causes reflect a complex interplay between developmental stage, symptom severity, social circumstance and trauma. However, the findings suggest anger could arise from adjusting to living with a visible skin condition. While expensive systemic/biologic drugs may offer a quick solution to the physical symptoms of psoriasis, they cannot resolve the underlying emotional burden. Findings from this study suggest that to optimize psoriasis treatments, treatment and management regimens must extend beyond physical symptoms and address contributory psychosocial factors.