clinical features and personality traits associated with psychological distress in systemic...

Journal of Psychosomatic Re

Clinical features and personality traits associated with psychological

distress in systemic sclerosis patients

Thomas N. Hyphantisa, Niki Tsifetakib, Christina Pappaa, Paraskevi V. Voulgarib,

Vasiliki Siafakaa, Marina Baia, Yannis Alamanosc, Alexandros A. Drososb,4, Venetsanos Mavreasa

aDepartment of Psychiatry, Medical School, University of Ioannina, Ioannina, GreecebRheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece

cDepartment of Hygiene and Epidemiology, Medical School, University of Ioannina, Ioannina, Greece

Received 30 May 2006; received in revised form 27 July 2006; accepted 31 July 2006

Abstract

Objective: The aim of the present study was to identify

certain clinical parameters and personality characteristics asso-

ciated with various forms of psychopathology in systemic

sclerosis (SSc) patients. Methods: Fifty-six SSc patients partici-

pated in the study, and 74 healthy participants served as controls.

A wide range of clinical information was collected, and the

following self-report instruments were used: General Health

Questionnaire, Symptom Distress Checklist-90-R, Defense Style

Questionnaire, Sense of Coherence (SOC) Scale, and Hostility

and Direction of Hostility Questionnaire. Results: The odds of

being assessed with a psychiatric diagnosis upon interview were

4.5 times greater among SSc patients compared with controls.

Disease duration and lower rates of SOC were found to be

0022-3999/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jpsychores.2006.07.028

4 Corresponding author. Department of Internal Medicine, Medical

School, University of Ioannina, Ioannina 45110, Greece. Tel.: +30 26510

99755, +30 26510 97503; fax: +30 26510 97054.

E-mail address: [email protected] (A.A. Drosos).

associated with elevated symptoms of general psychological

distress. Elevated symptoms of depression were strongly

associated with esophageal involvement, hostility, and defense

style used. Elevated symptoms of anxiety were mainly associated

with arthritis-related painful conditions and SOC, while psy-

chotic-like symptoms were only associated with age and a

specific personality structure. Conclusions: SSc patients experi-

ence elevated symptoms of psychological distress. Several

clinical parameters are associated with distress, but the role of

various personality traits could not be disregarded. Early

psychiatric assessment and intervention could prevent psycho-

logical distress in SSc patients.

D 2007 Elsevier Inc. All rights reserved.

Keywords: Systemic sclerosis; Psychological distress; Depression; Personality; Sense of coherence; Ego mechanisms of defense

Introduction

Systemic sclerosis (SSc) is a connective tissue disease in

which inflammatory, fibrotic, and degenerative changes

in the skin (scleroderma) lead to disfiguring skin thickening.

It also affects multiple organ systems, particularly the

musculoskeletal system, the lungs, the heart, the kidneys,

and the gastrointestinal (GI) tract [1,2]. Although SSc cannot

be cured, treatment of involved organ systems can relieve

symptoms and improve function [2]. SSc has an impact on

many aspects of an individual’s life, including psychological

well-being [3,4]. Medical interventions in the areas of

discomfort, dysfunction, and distress could be important

for the management of this progressive disease and the

quality of the patient’s life.

Although evidence suggests that depression contributes

to the disability associated with chronic illnesses [5] and

especially with rheumatic diseases [3,6], few studies have

examined in detail the psychosocial sequelae of SSc [3].

Available data suggest that approximately half of SSc

patients experience mild-to-severe depressive symptoms

[3,7–9]. However, most of these studies have mainly

focused only on depressive symptoms, whereas few detailed

search 62 (2007) 47–56

Table 1

Demographic profiles of SSc patients and healthy controls

Variables

Value

P valueSSc patients

bHealthyQcontrols

Number of participants 56 74

Female/Male (n) 51/5 65/9 NSa

Age (years) NSb

Range 25–70 23–72

MeanFS.D. 52.6F12.4 49.8F10.9

Family status: married, n (%) 38 (67.9) 57 (77.9) NSa

Educational level, n (%) .001a

Primary school

(up to the 6th grade)

14 (25.0) 4 (5.4)

Basic lower education

(7th–8th grade)

7 (12.5) 2 (2.7)

High school education

[gymnasium] (9th grade)

10 (17.8) 4 (5.4)

High school education

(10th–11th grade)

6 (10.8) 14 (18.9)

High school education [lycee]

(12th grade)

8 (14.3) 19 (25.7)

University education

(at least some college/university)

11 (19.6) 31 (41.9)

NS, nonsignificant.a Chi-square test.b Two-tailed t test.

T.N. Hyphantis et al. / Journal of Psychosomatic Research 62 (2007) 47–5648

reports have investigated the extent to which various

clinical, demographic, or personality features could be

associated with psychological distress in SSc patients. It

has been reported that in chronically painful rheumatologic

conditions, personality factors or coping strategies may be

better predictors of distress and depression than disease

parameters [10]. One study has shown that psychological

factors were the significant correlates of depressive symp-

toms in SSc patients [8], whereas Nietert et al. [11] reported

that clinical features were also significantly correlated to

depression. Nevertheless, it is not known if any studies to

date have focused on clinical parameters that could be

associated with a wide range of psychopathological con-

ditions, such as symptoms of anxiety, depression, paranoid

ideation, or psychosis in SSc patients. In addition, although

recent evidence supports the protective impact of various

psychological factors such as sense of coherence (SOC) [6],

hostility, and defense styles [12] in rheumatic diseases, little

attention has been given to the role that such parameters

play in the development of various types of psychopathol-

ogy in SSc patients.

Therefore, the aim of the present study was to identify

the association between certain personality characteristics

and clinical parameters of disease with various forms of

psychopathology in these patients. For these purposes, a wide

range of clinical, psychological, and demographic parameters

were collected. Screening and dimensional instruments for

the detection of various psychological distress symptoms

were used, while hostility features [13], defense styles [14],

and SOC [15] were assessed in order to identify the structural

personality characteristics of SSc patients and define their

relationship to psychiatric morbidity.

Patients and methods

Participants

A consecutive sample of 56 SSc outpatients with years of

attendance at the outpatient clinic of the Rheumatology

Department of Ioannina Medical School Hospital, Greece,

participated in the study. The University General Hospital

of Ioannina provides secondary and tertiary care for a

population of approximately 350,000 people. Patients

recruited to the study were insured in the state insurance

system. Diagnosis of SSc was confirmed based on the

American College of Rheumatology criteria [16], and

diagnosis of scleroderma subtypes was confirmed via

LeRoy’s criteria [17]. Patients with localized scleroderma

such as morphea or linear scleroderma were excluded from

the study.

Since the focus of the present study was the identi-

fication of protective factors for psychological distress in

SSc patients, it was important to distinguish the factors

that might be associated with psychological distress in

general from those that might be associated with distress

among the SSc patients. Initially, 56 participants randomly

selected from the hospital’s staff list participated in the

study as bhealthyQ controls. Since the age of SSc patients

was higher than that of controls, an additional sample of

18 participants (patients’ relatives) has been added in our

control group. Thus, in the present study, 74 participants

who were not manifesting problems requiring medical or

psychiatric intervention or who were not receiving any

medication at the time of investigation served as bhealthyQcontrols. The demographic profiles of SSc patients and

controls are presented in Table 1. All participants were

able to read and write in Greek, and no one had a history

of psychotic illness, current alcohol and/or drug abuse,

or dementia.

Procedure and study instruments

All the procedures that followed were in accordance with

the ethical standards on human experimentation (World

Medical Association Helsinki Declaration) and with the

local hospital’s ethics committee. After the participants

received a complete description of the study, the voluntary

nature of their participation, and the confidentiality of the

survey, all agreed to participate and a written informed

consent was obtained. This high participation rate may be

due to a good doctor–patient relationship, taking into

consideration that all patients had been followed up by the

same experienced rheumatologist throughout the duration of

the disease. Clinical data and lab results, as well as chart

reviews, were obtained prospectively using a standardized

data collection form along with a request for demographic

T.N. Hyphantis et al. / Journal of Psychosomatic Research 62 (2007) 47–56 49

information and a series of self-report measurements. The

following self-report instruments were used:

1. The General Health Questionnaire (GHQ-28) [18], a

screening instrument, which estimates the likelihood

of participants being assessed of having a psychiatric

diagnosis or disease at interview. The GHQ-28

consists of 28 items belonging to four clusters: (a)

somatic symptoms of depression, (b) anxiety and

insomnia, (c) social dysfunction, and (d) depressive

feelings. Two approaches to scoring the GHQ-28

were applied. First, the traditional GHQ method of

scoring (b0011Q), devised by Goldberg, was carried

out. According to the standardization of GHQ-28 for

the Greek population [19], the best cutoff point of

the Greek version is 5. As the total GHQ-28 score

exceeds this recommended cutoff point, the proba-

bility of being assessed as having a psychiatric

diagnosis at interview increases. Subsequently, the

alternative Likert scoring method b0123Q was carriedout for the four clusters of psychopathology. GHQ-

28 has been widely used in rheumatic diseases, and

studies have shown that it may be used as an

instrument for screening as well as for assessing the

impact of illness on these kinds of diseases [20].

2. The Symptom Distress Checklist-90-R (SCL-90-R),

a 90-item multidimensional self-report symptom

inventory designed to measure a wide range of

psychopathological symptoms in psychiatric and

medical patients [21]. Its utility as a psychological

screening instrument in rheumatic disease patients

has been well documented [22]; also, it has been

standardized for the Greek population [23].

3. The Defense Style Questionnaire (DSQ), a rating

scale that is designed to estimate behavior suggestive

of 25 ego defense mechanisms, which are psycho-

dynamic in origin, and four defense styles, namely,

bmaladaptive action,Q bimage distorting,Q bself-sac-rificing,Q and badaptiveQ styles [14]. Maladaptive

action style consists of apparent derivatives of

withdrawal, regression, acting out, inhibition, pas-

sive aggression, and projection defense mechanisms

and indicates the participants’ inability to deal with

their impulses by taking constructive action on their

own behalf. Image distorting style consists of

apparent derivatives of omnipotence, splitting, and

primitive idealization defenses, and the essence of

this style is the splitting of the image of self and

other into good and bad and into strong and weak.

Self-sacrificing style consists of apparent derivatives

of reaction formation and pseudoaltruism defense

mechanisms and reflects a need to perceive one’s

self as being kind, helpful to others, and never angry.

Finally, adaptive style consists of apparent deriva-

tives of suppression, sublimation, and humor and is

associated with good coping [14]. DSQ was trans-

lated into Greek with Dr. Bond’s permission, and its

application to the Greek population is now under

investigation by our research team. DSQ has been

used with Greek medical patients [24,25], and

interestingly, the standardization results so far

indicate that the Greek version of DSQ shares

almost the same properties as the original [25].

4. The Hostility and Direction of Hostility Question-

naire (HDHQ) [13] provides a measure of hostility

manifestation that reflects an attitudinal personality

trait and shows the participant’s reaction to frustrat-

ing occurrences. HDHQ has been used with the

general Greek population as well as with psychiatric

or somatic patients [9,24,25].

5. The Sense of Coherence (SOC) Scale is a 29-item

questionnaire based on Aaron Antonovsky’s saluto-

genic theory, which postulates that bsense of

coherenceQ is a global orientation to view the world

and the individual environment as comprehensible,

manageable, and meaningful, claiming that the way

people view their life has a positive influence on

their health [15]. It is considered to be a measure of

the stable dispositional orientation of a person

[15,26], and it is essentially a measure of an

individual’s capacity to cope with stress. Those

having high SOC scores are likely to perceive

stressors as predictable and comprehensible and to

perceive the challenges of life as meaningful and

worth making commitments for, and, in addition,

they have confidence in their capacity to manage. A

growing body of research has used SOC in

rheumatic disorders [6,26,27] and, recently, with

SSc patients [8]. SOC-29 has been translated and

standardized for the Greek population [28].

Clinical feature estimations

Patients were examined by experienced rheumatologists

(NT and AAD), and medical data were collected, including

SSc clinical features as well as laboratory data. Internal organ

involvement was determined by clinical criteria or review of

available objective testing. Skin thickness was estimated

using the Modified Rodnan Skin Thickness Score technique

(assesses the sum of 17 body surface areas, each scored on a

scale of 0–3 for skin thickness, by clinical palpation, with a

maximum score of 51) [29]. A 100-mm visual analogue pain

scale was used to assess the severity of pain. Each patient was

asked to place a mark that corresponds to their current level of

pain intensity between terminal points designated either bnopainQ or bworst possible pain.Q The pain scale is designed to

evaluate the presence or absence of arthritis-related pain and

to obtain information from patients on how their pain has

most often been over the past week, although pain may be

reported to vary over the course of a day or from day to day

[30]. The assessment of internal organ involvement was

based on clinical and laboratory evidence over time. More

Table 2

Psychological distress as measured by GHQ-28 associated with SSc

Healthy controls

(n=74)

SSc patients

(n=56)

P valueaMeanFS.D.

General psychological

health scoreb2.97F3.53 5.84F6.84 .036

GHQ-28 subscalesc

Physical symptom

complaints

12.18F3.24 12.98F4.61 NS

Anxiety 12.41F3.33 13.23F4.79 NS

Social disability 13.70F2.32 14.16F3.78 NS

Depressive feelings 8.54F1.85 10.60F4.37 .029

a Mann–Whitney U tests.b Traditional GHQ method of scoring (b0011Q).c Alternative Likert scoring method (b0123Q).


specifically, esophageal involvement was documented by

manometry, endoscopy, or cine-video barium esophagram

and lower GI tract involvement was documented by

manometry, plain abdominal X-ray, abdominal CT, and

endoscopy [31]. Lung involvement was documented by

chest radiography, computed tomography, echocardiography

with Doppler study, and pulmonary function tests [32].

Kidney involvement was assessed using arterial blood

pressure, serum creatinine, and urinalysis [33]. The assess-

ment of all SSc cases was made by the aforementioned

rheumatologists based on medical records.

Statistical analysis

The statistical analysis was performed using the Stat-

istical Package for the Social Sciences (SPSS) 10.0 (SPSS

Inc., Chicago, IL, USA) for Windows. Univariate compar-

isons were first conducted between SSc patients and

controls in order to investigate differences in psychopatho-

logical symptoms and their expression. Chi-square analyses

for categorical data (e.g., bpsychiatric casenessQ as indicatedby total GHQ-28 score), two-tailed t tests for continuous

data (e.g., age), and Mann–Whitney tests for the ordinal

variables (i.e., inventories’ scales) were carried out.

Subsequently, a multiple logistic regression analysis was

performed on the entire sample in order to identify protective

factors for psychological distress. Controls and SSc patients

participated in this analysis to determine whether bdiseaseQitself was independently associated with psychological

distress, after controlling for age, sex, and educational level,

as well as to identify other personality factors associated with

psychological distress, independent of the disease. The

dichotomous dependent variable was btotal GHQ score,Qand the cutoff point between psychiatric caseness and

bnoncasenessQ was 5, as found by receiver-operating charac-

teristics analysis for the GHQ-28 in the Greek population

[19]. Disease was treated as an independent variable (SSc vs.

controls), along with age; sex; educational level; DSQ

defense styles; total hostility rates, as measured by HDHQ;

and total SOC score, as measured by SOC.

The nonparametric rank-order correlation coefficients

(Kendall’s tau-b) were calculated next in order to determine

the strength of the relationship between clinical as well as

personality parameters and psychological distress among

SSc patients. Kendall’s tau-b describes the strength of

association between variables measured at the ordinal level;

it is appropriate for a relatively small number of observa-

tions and makes no assumptions about the normality of the

underlying distribution of the data [34].

Separate multiple regression analyses among the SSc

patients were conducted next in order to determine the

independent associations between various clinical parame-

ters and personality factors and certain types of psychopa-

thology in SSc patients. Five analyses were performed, with

the following dependent variables: symptoms of general

psychological distress, depression, anxiety, paranoid idea-

tion, and psychotic-like symptoms, as measured by SCL-

90-R scales; independent variables were the statistically

significant clinical and personality variables, based on the

results of the univariate correlation analysis (Kendall’s

tau-b). Variables were entered into the model if Pb.05 and

were removed from the model if PN.10.

Results

Patient characteristics

All SSc patients completed the study. The majority were

women (91.1%), married (77.9%), with ages ranging from 25

to 70 years [mean (FS.D.)=52.6F12.4 years]. Disease

duration ranged from 1 to 50 years, with a mean (FS.D.) of

15.46F12.16 years. Eleven patients (19.6%) had SSc for

1–5 years, and 45 (80.4%) had SSc for more than 5 years.

Thirty-nine patients (69.6%) had limited scleroderma,

and 17 (30.4%) had diffuse scleroderma. Rodnan sclero-

derma skin score ranged from 2 to 34 [mean (FS.D.)=

11.12F10.07]. Patients’ global assessment of pain, as

measured by the 100-mm visual analogue pain scale, ranged

from 20 to 80 [mean (FS.D.)=43.39F14.5]. Thirty-one

patients (55.3%) had pulmonary involvement. Clinical

evidence of esophageal involvement was present in

32 patients (57.14%). Fourteen patients (25.0%) presented

evidence of lower GI tract involvement, and one patient

showed renal involvement.

Psychological distress measurements

Twenty four out of 56 SSc patients (42.9%) presented

scores indicative of psychiatric bcaseness,Q as estimated by

GHQ-28, in comparison to 14 (18.9%) controls (v2=8.8,

df=1, Pb.003). The mean scores (FS.D.) on GHQ-28 total

index were 5.84F6.84 and 2.97F3.53, respectively

(t=�3.11, df=128, Pb.002). Thus, more than 4 out of

10 SSc patients could possibly be assessed as having a psy-

chiatric diagnosis or disease upon interview. Since common

symptoms of depression such as sleep restlessness, loss of

Table 3

Factors associated with general psychological health in the entire sample

(N=130)

Odds ratio (95% CI) P value

Disease (healthy=0, scleroderma=1) 4.5 (1.324–15.332) .016

Sex 2.3 (0.478–11.234) NS

Age 0.9 (0.942–1.038) NS

Educational level 1.1 (0.873–1.468) NS

DSQ maladaptive action defense style 1.1 (1.002–1.139) .05

DSQ image distorting defense style 1.0 (0.989–1.071) NS

DSQ self-sacrificing defense style 1.0 (0.989–1.126) NS

DSQ adaptive defense style 0.9 (0.902–1.024) NS

HDHQ total hostility 1.2 (1.102–1.403) .001

SOC 0.9 (0.964–1.008) NS

This table presents the results of a multivariate logistic regression analysis

with the general health index of GHQ-28 as the dependent variable and the

major demographic variables and the major personality variables studied as

the independent variables. The predictive values were calculated based on

the probability of being a bpsychiatric case,Q and the cutoff value between

bcaseQ and bnoncaseQ was 0.500. The multivariate regression analysis

correctly classified 84.1% of the cases, with a Cox and Snell R2=.370.


energy, and poor appetite could also be symptoms of SSc, it

is important to distinguish between somatic symptoms and

the more specific affective symptoms of depression. Analysis

of GHQ-28 subscales that differentiate the bphysicallyexpressed depressive symptomsQ from bdepressive feelingsQrevealed that SSc patients have much higher values on the

depressive feelings subscale as compared with controls

(Pb.001), indicating that btrueQ depressive symptoms are

elevated in SSc patients (Table 2). On the other hand,

Table 4

Clinical features and personality traits associated with general psychological dist

Independent variables

Dependent variables

General psychological distress

Univariate analyses Multiple regression

Kendall’s tau-b b P v

General

Sex �0.019Age �0.067Years of education �0.168Clinical

Disease duration 0.28544 0.206 0.0

Pain 0.1844

Total skin score 0.1824

Pulmonary involvement 0.096

Esophageal involvement 0.124

Lower GI tract involvement 0.035

Personality traits

Maladaptive action 0.620444

Image distorting 0.471444

Self-sacrificing 0.134

Adaptive style 0.089

HDHQ total hostility 0.651444 0.303 0.0

SOC �0.608444 �0.333 0.0

a Two independently produced multiple regression analyses with the general

based on SCL-90-R subscales’ scores. Selection of independent variables was bas

variables of univariate comparisons were chosen as independent variables. Only

4 Pb.05.

44 Pb.01.

444 Pb.001.

although SSc patients also presented higher scores on

SCL-90-R general psychological distress and depression

scales, as compared with controls (1.26F0.55 vs. 0.78F0.42,

Pb.001, and 01.43F0.73 vs. 0.91F0.61, Pb.001, respec-

tively), the more severe psychopathological symptoms of

paranoid ideation and psychoticism were not elevated

among SSc patients, as compared with controls (1.01F0.69 vs. 0.94F0.59, P=NS, and 0.57F0.41 vs. 0.45F0.33,

P=NS, respectively).

Multiple logistic regression analysis

When all major demographic and personality variables

were taken into account, multiple logistic regression analysis

revealed that disease (i.e., SSc) was associated with

psychological distress, independently of age, sex, or educa-

tional level. The odds of being assessed with a psychiatric

diagnosis or disease upon interview were 4.5 times greater

among SSc patients compared with controls (Pb.016). Other

personality parameters that were independently associated

with psychiatric morbidity were btotal hostilityQ rates, as

measured by HDHQ (Pb.001), and maladaptive action

defense style, as estimated by DSQ (Pb.05; Table 3).

Clinical features and personality traits associated with

psychological distress

Tables 4 and 5 summarize the results of the univariate

analyses and multiple regression analyses performed to

ress and depressive symptoms in SSc patients (n=56)

Depressive symptoms

analysisa Univariate analyses Multiple regression analysisa

alue (b) Kendall’s tau-b b P value (b)

�0.065�0.036�0.143

41 0.148

0.146

0.21144

0.118

0.433444 0.382 0.011

0.060

0.559444 0.246 0.044

0.415444

0.136

�0.03131 0.645444 0.356 0.024

22 �0.605444psychological distress and depressive symptoms as the dependent variables,

ed on the results of univariate comparisons, and the statistically significant

statistically significant results are shown in each analysis.

Table 5

Clinical features and personality traits associated with anxiety, paranoid ideation, and psychotic-like symptoms in SSc patients (n=56)

Independent variables

Dependent variables

Anxiety symptoms Paranoid ideation Psychoticism

Univariate

analyses

Multiple

regression

analysisaUnivariate

analyses

Multiple

regression

analysisaUnivariate

analyses

Multiple

regression

analysisa

Kendall’s tau-b b P value Kendall’s tau-b b P value Kendall’s tau-b b P value

General

Sex �0.038 �0.035 0.054

Age �0.118 �0.201 �0.365444 �0.345 0.009

Education �0.148 �0.058 0.101

Clinical

Disease duration 0.189 0.142 0.135

Pain 0.282444 0.313 .009 0.153 0.023

Skin score 0.009 0.145 0.166

Pulmonary involvement 0.122 0.021 0.148

Esophageal involvement 0.114 0.087 0.009

Lower GI involvement 0.018 0.007 0.012

Personality

Maladaptive action 0.528444 0.615444 0.2174

Image distorting 0.378444 0.413444 0.100

Self-sacrificing 0.132 0.137 0.024

Adaptive style 0.095 0.123 0.009

Total hostility 0.570444 0.330 .05 0.630444 0.351444

SOC �0.479444 �0.627444 �0.351 .02 �0.390444 �0.373 .05

a Three independently produced multiple regression analyses with the anxiety, paranoid ideation, and psychoticism symptoms as the dependent variables,

based on SCL-90-R subscales’ scores. Selection of independent variables was based on the results of univariate comparisons, and the statistically significant

variables of univariate comparisons were chosen as independent variables. Only statistically significant results are shown in each analysis.

4 Pb.05.

444 Pb.001.


elucidate the factors most closely associated with certain

forms of psychological distress.

General psychological distress symptoms, as measured

by the SCL-90-R general distress index (GDI), were found

to be correlated with disease duration, total skin score,

arthritis-related pain, total hostility, SOC, maladaptive

action, and image distorting defense styles. Multiple

regression analysis revealed that longer disease duration,

low levels of SOC, and high total hostility scores were the

variables most closely associated with elevated general

psychological distress symptoms in SSc patients. These

factors together accounted for 53.8% of the variance in GDI

scores [F(7,44)=9.46, Pb.0001].

Depressive symptoms were found to be correlated with

total skin score, esophageal involvement, total hostility, and

SOC, as well as with maladaptive action and image

distorting defense styles. Multiple regression analysis

revealed that esophageal involvement, higher HDHQ total

hostility rates, and DSQ maladaptive action defense style

were the variables most closely associated with elevated

symptoms of depression. The final model was also

significant and accounted for 45.3% of the variance in the

SCL-90-R depression scale [F(6,45)=8.02, Pb.00001].

Anxiety symptoms were found to be correlated with

arthritis-related pain, total hostility, SOC, maladaptive

action, and image distorting defense styles. Arthritis-related

pain and higher rates of HDHQ total hostility were the

variables most closely associated with elevated anxiety

symptoms in multiple regression analysis. The final model

accounted for 39.2% of the variance in the SCL-90-R

anxiety scale [F(5,46)=7.56, Pb.0001].

The more severe psychopathological symptoms that

belong to the psychotic spectrum (i.e., paranoid ideation

and psychotic-like symptoms) were found to be associated

with age and personality factors, whereas none of the

clinical parameters studied participated in the final regres-

sion equation. Thus, elevated paranoid ideation symptoms

were found to be most closely associated with lower SOC

rates, whereas elevated psychotic-like symptoms were

associated with lower SOC rates and younger SSc patients.

The final models accounted for 46.7% of the variance in the

SCL-90-R paranoid ideation scale [ F (5,46)=9.93,

Pb.00001] and for only 23.7% of the variance in the

SCL-90-R psychoticism scale [F(4,47)=4.95, Pb.002],

indicating that other unmeasured variables may also play a

crucial role in the development of psychosis.

Discussion

The results of the present study revealed that a high

proportion of SSc patients could be assessed as having a

psychiatric diagnosis or disease upon interview. The disease

itself was found to be strongly associated with psycholog-

ical distress, and the odds of being assessed with a


psychiatric diagnosis upon interview were 4.5 times greater

among SSc patients compared with controls. In addition,

among the SSc patients, various forms of psychopatholog-

ical symptoms were found to be positively associated with

certain clinical variables and discrete personality character-

istics. In particular, disease duration and lower rates of SOC

were found to be closely associated with general psycho-

logical distress. Symptoms of depression were found to be

associated with clinical manifestations such as esophageal

involvement, as well as with specific personality character-

istics such as hostility and defense style used. Anxiety was

mainly associated with arthritis-related painful conditions

and hostility, while psychotic-like symptoms were only

associated with age and a specific personality structure.

In the present study 42.9% of SSc patients could be

assessed as having a psychiatric diagnosis upon interview,

while true depressive symptoms are elevated in SSc

patients, as compared with controls. It has been suggested

that patients with a high GHQ-28 score (z5) should be

evaluated by a psychiatrist [19]. Although this percentage

must be interpreted with caution since psychometric tests

cannot replace a formal psychiatric evaluation [35], the

presence of high values on psychiatric symptoms warrants

attention in the clinical management of SSc patients. These

findings are in agreement with those by Roca et al. [7] who

reported that nearly half of their SSc patients also had true

depressive symptoms in the moderate-to-severe range.

Moreover, Benrud-Larson et al. [36] reported that approx-

imately one half of the patients displayed depressive

symptoms according to the Beck Depression Inventory,

whereas Matsuura et al. [8] found that depression sympto-

matology was detected in 46% of SSc patients studied. The

present results are also similar to those reported by a

previous study of the same rheumatology department [9], in

reference to depressive symptoms. This study also reported

higher rates for psychotic-like symptoms in SSc patients, an

effect that was not observed in our patients, possibly due to

different sample sizes used.

Results derived from multiple logistic regression analysis

on the entire sample further supported the aforementioned

findings since the odds of being assessed with a psychiatric

diagnosis upon interview were 4.5 times greater among SSc

patients compared with controls. Although causal inferences

cannot be drawn as this is a cross-sectional study and

bidirectional causal pathways are likely to link the disease

with psychiatric morbidity, the present findings add further

evidence concerning the relationship between this chronic

deteriorating physical disease and psychopathology.

Focusing exclusively on the SSc patients, elevated general

psychopathological symptoms, as measured by SCL-90-R,

were found to be strongly associated with higher rates of

hostility, lower levels of SOC, and longer disease duration.

Hostility features represented a key variable associated

with elevated psychological distress symptoms among the

SSc patients. Thus, total hostility accounted for 41.1%,

49.3%, and 37.5% of the total variance in general

psychological distress, depression, and anxiety scales,

respectively. It has been suggested that depression is linked

strongly with attitudinal forms of hostility [37]. It has

already been mentioned that bhostilityQ was found to be

independently associated with psychiatric morbidity in all

participants. Therefore, it could be suggested that hostility is

not a bspecificQ factor associated with psychological distress

in SSc patients. Rather, it is a protective factor for

psychopathology development in general. Nevertheless, it

is important to address it in order to provide the optimal care

for individuals with SSc.

The protective impact of SOC has been examined in

rheumatic disease patients [6,27,28] and, recently, in SSc

patients [8]. These studies reported that low levels of SOC

were mainly associated with depression both in rheumatoid

arthritis (RA) and SSc patients, whereas high levels of SOC

were correlated with eliminated anxiety in RA patients [27].

The present results showed that low levels of SOC were

significantly and bspecificallyQ associated with elevated

general psychological distress in SSc patients. Low levels

of SOC reflect individuals who do not perceive stressors as

predictable and explicable, with no confidence in their

capacity to overcome stressors and with the absence of any

motivation in order to face difficulties or challenges [8,15].

Present findings and the aforementioned studies highlight

the role of SOC in the expression of psychological

problems in SSc, and since SOC is a simple and an easy-

to-administer tool, it could be used by rheumatologists to

detect psychological vulnerability in SSc patients and to

refer them to counselors and specialist psychotherapists in

order to prevent the development of psychopathology in

these patients.

Disease duration was also found to be strongly associated

with general psychological distress, indicating that the long

duration of the illness with its accompanying physical and

psychological burden, as well as the uncertainty over its

course and outcome, plays a major role in the development

of psychopathology.

Arthritis-related pain and higher hostility rates were found

to be associated with elevated anxiety symptoms in SSc

patients. A correlation between arthritis-related pain and

psychological distress has also been reported in SSc patients

[38], while Benrud-Larson et al. [36] found that pain was

significantly related to depressive symptoms. A growing

body of research focuses on the debate about the relationship

of pain and depression, raising questions of whether

depressive symptoms develop secondary to pain or vice

versa [39]. Undoubtedly, chronic pain leads to interference in

physical functioning and social adjustment, which then

causes negative affects, including depression, anxiety, and

anger [40]. It has also been suggested that pain need not reach

severe levels for it to affect SSc patients’ functions [36]. The

present results have shown that arthritis-related pain is

mainly associated with anxiety symptoms in SSc patients.

Depressive symptoms of SSc patients were found to be

associated with hostility, maladaptive action defense style,


and esophageal involvement. GI tract disease is a well-

known, major cause of morbidity in SSc patients [41],

especially esophageal involvement [42]. A high proportion

of our SSc patients presented esophageal involvement

(57.14%), and according to the results of multiple regression

analysis, these patients presented elevated symptoms of

depression. These findings are in agreement with a recent

report by Nietert et al. [11], who also found that high levels

of depression were associated with worse upper GI tract

functioning. Thus, the results of the present study further

confirm this association.

As previously mentioned, maladaptive action defense

style and hostility were also found to be strongly associated

with symptoms of depression in SSc patients. It is worthy to

note that SOC initially entered into the regression equation,

but it was excluded when the defense style was taken into

account, indicating that maladaptive action style is strongly

associated with elevated symptoms of depression compared

with SOC. Thus, the authenticity of the previously reported

[8] significant role of SOC in the development of depressive

symptoms in SSc patients is challenged since other person-

ality variables, such as the individual’s defensive profile,

may play a crucial role. On the other hand, the results of the

multiple logistic regression analysis presented in Table 3

indicate that maladaptive style is associated with psycho-

logical distress in general, not exclusively in SSc patients.

Thus, it could be suggested that elevated symptoms of

depression in SSc patients follow the general trend; that is, a

maladaptive defensive profile could, in general, lead to

elevated symptoms of depression. These findings are in

accordance with recent evidence that suggests that malad-

aptive defense style scores were significantly higher in those

with major depression [43] and that higher maladaptive

scores were significantly related to the presence and severity

of patient-reported depression symptoms [44]. Although not

disease specific, the contribution of these parameters to the

lives of the patients cannot be discarded. Our recent studies

have shown that psychologically mature patients with

inflammatory bowel disease had lower rates of relapses

[25] and that immature ego defenses underlie poor adherence

in type II diabetes patients [24]. The early evaluation of such

traits could provide information on the management of

personality difficulties and the subsequent psychosocial

problems that interfere with several aspects of the disease,

such as adherence and compliance to treatment.

Low levels of SOC and maladaptive action defense style

characterize those SSc patients of our sample who were

vulnerable to psychosis. Studies investigating factors

associated with serious psychopathological features in SSc

patients are rare. There is only one previous study derived

from the same department of rheumatology that has reported

high rates of paranoid ideation and/or psychotic-like

symptoms in SSc patients, as compared with healthy

controls [9], suggesting that the stressful overload of

scleroderma probably creates a psychotic triggering.

According to the results of the present study, a fragile

personality organization may play a more crucial role for

development of delusional or psychotic psychopathology,

especially in the younger age group, while clinical

parameters of SSc did not correlate with psychotic

symptoms. Considering that SSc rarely affects the brain in

a direct way [45], the results of the present study indicate

that delusional or psychotic vulnerability is mediated

through previous underlying structural personality charac-

teristics rather than through the extent, duration, or severity

of the disease.

The results of the present study are suggestive and not

conclusive. The sample size and the limitation of using only

self-reported measures of psychological distress prevent us

from generalizing the findings. In addition, since the

controls of the present study were not allowed to have

any problems that require medical or psychiatric interven-

tion, the differences observed between patients and controls

do not necessary reflect differences between SSc patients

and the general population. Rather, these results provide a

measure of difference between SSc patients and healthy

participants. In addition, future studies are needed to

investigate whether the psychological distress seen in SSc

patients is beyond that expected from patients with other

chronic conditions.

In conclusion, the results of the present study suggest that

SSc patients presented elevated symptoms of psychological

distress, mainly true depression symptoms. Clinical param-

eters of the disease, such as disease duration, arthritis-

related pain, and esophageal involvement, are associated

with various forms of psychopathology. Moreover, person-

ality features such as maladaptive defenses, higher rates of

hostility, and lower SOC rates also warrant attention in the

clinical management of SSc patients since some of these

traits could be modified by proper psychotherapeutic

approaches. Evidence suggests that SOC could be modified

after psychoanalysis or psychoanalytic treatment [46],

psychotherapy [47], or inpatient treatment of psychosomatic

patients [48]. Thus, it is essential for rheumatologists to

better identify patients at risk of developing psychiatric

disease. GHQ-28 and/or SOC could be a useful and time-

efficient method for rheumatologists to detect major

psychiatric symptoms and crucial personality traits that

warrant attention and intervention to prevent further

deterioration of SSc patients.

Future longitudinal studies are needed to determine

whether these and other clinical features and personality

factors could associate with long-term adjustment to this

deteriorating illness and to identify protective factors that

may prevent the negative physical and psychological

consequences of the disease.

Acknowledgments

The authors would like to thank Dr. Katerina Antoniou,

Lecturer of Pharmacology, Medical School, University


of Ioannina, for her important comments and her help-

ful criticism.

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