Psychological Interventions in Psoriasis

Principal Supervisor: Name: Dr Andrew Thompson
Department: Psychology
Tel: 0114 222 6637
Email: a.r.thompson@sheffield.ac.uk

Co-supervisor(s): Lead co-supervisor: Professor Andrew Messenger
Department: Infection and Immunity
Tel: 0114 271 2188
Email: a.g.messenger@sheffield.ac.uk

Additional co-supervisor: Name: Professor Paul Norman
Department: Psychology
Tel: 0114 222 6505
Email: p.norman@sheffield.ac.uk

Description of proposed project

Psoriasis is a common chronic inflammatory skin disease that causes disfigurement, pruritus, and difficulties in a wide range of social interactions. People living with the condition often report experiencing intrusive and discriminatory reactions from others, and the condition has been associated with high levels of both depression and anxiety (Ginsburg & Link, 1989, 1993; Richards et al., 2001). Despite a clear need, access to psychological interventions within dermatological services remains limited (Eedy et al., 2008). A recent meta-analysis reported a medium effect size for existing psychological interventions. However, the authors also reported that there were methodological limitations with the existing studies and that relatively few trials of theoretically informed psychological intervention exist (Lavda, Webb, & Thompson, 2012).

The aims of the proposed PhD are to:

(i) develop a theoretically-driven psychological self-management intervention to reduce anxiety and improve well-being in psoriasis;
(ii) to test the feasibility of delivering the intervention, in an accessible and cost efficient format.

Plan of investigation

Study 1 will be a cross-sectional survey to examine the extent to which social anxiety, and appearance concern variables predict quality of life and psychological distress. Measures for study 1 will include: 1. Demographic and medical information, including age, gender, ethnic background. 2. Primary variables: Social anxiety (FNE: Leory, 1983). 3. Secondary variables: Clinician rated severity (Psoriasis Area Severity Index: PASI); patient rated severity; confidence and avoidance of social situations scale (CAS: Kent, 2002); The Dermatology Life Quality Index (DLQI: Findlay, 1994); Hospital Anxiety and Depression scale (HADS: Zigmond & Snaith, 1983). 4. Moderator variables. Appearance Schemas Inventory (ASI-R: Cash, 2003); Skin Shame Scale (SSS: Scott, 2004). Participants for this study will be recruited from the NHS after seeking appropriate ethical approval. The primary analysis for study 1 will be correlational and regression. A preliminary power analysis indicates that 127 participants will be required to detect a medium effect size in a regression analysis with the likely number of independent variables with alpha set at .05 and power set at .80. The results of this study will inform the focus of the treatment elements contained within the intervention.

Study 2 will use qualitative methods and will explore how professionals and people with psoriasis view the draft intervention. Participants for the first part of the study will be the Clinical Nurse Specialists in dermatology at STH (and members of the British Dermatology Nursing Group: BDNG). Nurses will be invited to participate in a focus group where they will be shown the intervention materials and asked to comment on content and acceptability. For the second part of study 2, ten participants with psoriasis will be sought using convenience sampling recruited either from NHS services or support groups operating in the community. This part of the study will use ‘think aloud methodology’, whereby participants will be asked to detail their ‘live’ reactions on the content and layout of the intervention (Yardley et al., 2011). The intervention will be modified on the basis of these studies.

Study 3 will be a feasibility randomised controlled trial (RCT) where participants will be allocated to control or intervention condition. The primary aim of this final study will be to examine the potential for effectiveness of the interventions and to identify the methodological requirements for a definitive trial. A power analysis indicates that 33 participants per group will be required. The measures for study 3 will be the same as for study one, with the addition of collecting informaion at follow-up on the use of the intervention, and satisfaction with the intervention. An open ended question will be included which asks about participants’ experience of using the intervention. Data will be reported and presented according to the CONSORT guidelines. The statistical analysis will be performed on an intention-to-treat-basis. Baseline data will be assessed for comparability between the groups.

The primary outcome will be the self-reported social anxiety score on the short form FNE measure, at 3 months post randomisation. ANCOVA will be used to compare mean 3 month FNE social anxiety scores between the two groups in this parameter, taking a 95% confidence interval (CI) for the mean difference between the two groups, while controlling for baseline FNE scores. In the event of differences between the groups with respect to baseline demographic, physical, and health-related quality of life measurements, further ANCOVAs will be performed controlling for these variables. Secondary outcomes at 3 months follow-up will also be compared between the two groups using ANCOVA. A 95% CI for the mean difference in these parameters between the treatment groups will also be calculated.

Summary

Psoriasis is a visible skin condition that can be associated with distress and difficulties engaging in everyday activities. There are few interventions available to people with psoriasis that are aimed at assisting adjustment. The primary aim of the project is to develop an intervention that will reduce distress and assist people in increasing their well-being. The interventions/support will be delivered via both online and traditional media. A steering group (made up of a network of clinicians and academics from different disciplines) will oversee the development of the content of the intervention. The content of intervention will also be informed by the results of a preliminary survey (study 1) and guided by existing therapeutic techniques. Studies 2a and 2b will explore user acceptability and usability of the intervention with both NHS dermatology nurses and people with psoriasis. People will be encouraged to voice their views on all aspects of the intervention including likely usefulness of the content, appearance of the content, feasibility of following the advice etc. A final study will be conducted to begin to test whether or not the invention can make a difference to key areas of distress. This study will involve placing some people into an active treatment group where they will receive the intervention and placing other people in a control condition. However, everyone who participates would be offered access to the intervention.

Additional Information

Dr Thompson is an experienced research and clinical supervisor and has successfully supervised 35 postgraduate students (DClins and PhDs) and has been an external examiner for both individual PhD candidates as well for other academic clinical psychology programmes. He is currently supervising one PhD student and four DClin trainees. In addition, he is registered with the Health Professions Council as both a practitioner in Clinical and in Health Psychology and has fourteen years of experience of providing psychological interventions and psychotherapy within the NHS. Dr Thompson currently provides two clinical sessions per week into Rotherham District General Hospital where he sees patients with long-term health problems (including skin conditions). He has recently been advising The All Party Parliamentary Group on Skin Conditions as part of their review of the psychological needs of people living with skin conditions and is an advisory member of the British Dermatology Nursing Groups psychodermatology special interest group. He has received funding from a range of sources in the past including The Healing Foundation (Identifying factors and processes contributing to successful adjustment to disfiguring conditions) and has supervised Research Associates. He currently has a small international seed corn fund awarded by The Tropical Health Education Trust with a view to developing self-help interventions that might be made accessible in developing countries.

Select relevant recent publications

Clarke, A., Thompson, A.R., Rumsey, N., Newell, R., Newman, S., Jenkinson, E (in press). A clinical manual for of intervention for addressing appearance concern associated with disfigurement.
Wiley Ersser SJ, Cowdell F, Latter S, Jackson K, Farasat H, Thomas PW, Drury A, Thompson AR, Ware F, Gardiner E, Flohr C. (in press). Psychological and educational interventions for atopic eczema in children.Cochrane Database of Systematic Reviews
Lavda, A., Webb, T., & Thompson, A. (2012). The effectiveness of psychological interventions for adults with skin conditions: A meta-analysis. British Journal of Dermatology. 167, 970-979 DOI: 10.1111/j.1365-2133.2012.11183.x
James, H., Shipley, M., Newman, S., & members of The Appearance Research Collaboration (ARC incl. A. R. Thompson as an author and PI). (2012). The Impact of Appearance Concerns on Depression and Anxiety in Rheumatoid Arthritis. Musculoskeletal Care DOI: 10.1002/msc.1020
Webster, R., Norman, P., Goodacre, S., & Thompson, A. R. (2012). The prevalence and correlates of psychological outcomes in patients with acute non-cardiac chest pain: A systematic review. Emergency Medicine Journal, 29, 617-621 doi:10.1136/emermed-2011-200526
James, H., Jenkinson, E., Harrad, R., Ezra, Newman, S., & members of The Appearance Research Collaboration (ARC). (2011). Appearance concerns in ophthalmic patients. Eye, 25, 1039-1044. doi:10.1038/eye.2011.116
Lavda, A. C., & Thompson, A. R. (2010). Managing the psychosocial impact of skin conditions 2: Behavioural interventions for nurses. Dermatological Nursing, 9, 38-41
Thompson, A. R., Clarke, S. A., Newell, R., Gawkrodger, G., & The Appearance Research Collaboration. (2010). Vitiligo linked to stigmatisation in British South Asian women: A qualitative study of the experiences of living with vitiligo. The British Journal of Dermatology,163, 481-486.
Palayiwa, A., Sheeran, P., & Thompson, A. R. (2010). “Words Will Never Hurt Me”: Implementation Intentions Regulate Attention to Stigmatising Comments about Appearance. Journal of Social & Clinical Psychology, 29, 575-598.
Thompson, A. R., & Broom, L. (2009). Positively managing intrusive reactions to disfigurement: An interpretative phenomenological analysis of naturalistic coping. Diversity in Health & Care, 6, 171-180
Thompson, A. R. (2009). Managing the psychosocial impact of skin conditions: theory & the nursing role. Dermatological Nursing, 8, 43-48.
Grandfield, T., Thompson, A. R., & Turpin, G. (2005). An Attitudinal Study of Responses to Dermatitis Using the Implicit Association Test. Journal of Health Psychology, 10, 821-829.

Professor Messenger is a consultant dermatologist at STH and Sheffield Children’s Hospital. He has wide experience in commercial and non-commercial clinical trials in psoriasis and other dermatological diseases. He has supervised research projects with dermatology trainees and visiting fellows and acted as supervisor of one MSc student and co-supervisor of two PhD students. He leads the CLRN Dermatology Local Specialist Group and is a member of the national CLRN Dermatology Specialist Group.

Select relevant recent publications

Messenger AG, Knox EG, Summerly R, Muston HL, Ilderton E (1982) Case clustering in pityriasis rosea: support for the role of an infective agent. Br Med J i, 371-373
Elliott K, Stephenson T, Messenger AG (1999) Differences in hair follicle dermal papilla volume are due to extracellular matrix volume and cell number: implications for the control of hair follicle size and androgen responses. J Invest Dermatol 113, 873-877
Birch MP, Messenger JF, Messenger AG (2001) Hair density, hair diameter and the prevalence of female pattern hair loss. Br J Dermatol 144:297-304
Tan KT, Messenger AG. (2009) Frontal fibrosing alopecia: clinical presentations and prognosis. Br J Dermatol 160: 75-9
Messenger AG, McKillop J, Farrant P, McDonagh AJ, Sladden M. British Association of Dermatologists’ guidelines for the management of alopecia areata 2012. (2012) Br J Dermatol 166:916-26
Glaser RL, Dimitrakakis C, Messenger AG. (2012) Improvement in scalp hair growth in androgen-deficient women treated with testosterone: a questionnaire study. Br J Dermatol 166:274-8

Paul Norman is Professor of Health Psychology at TUOS will provide additional supervision. He has some 20 years of experience of supervising PhD students, and to date has supervised or co-supervised 12 students to successful completion. He has also successfully supervised 7 DClinPsy dissertations. He is currently supervising 4 PhD students and 7 D ClinPsy students. His research focuses on the psychological determinants of health behaviour and psychological adjustment to illness. His research combines a focus on both theoretical and applied issues. He has over 90 journal publications on these topics. He currently holds three research grants totalling almost £900k. These are to (i) develop and evaluate an online intervention to promote healthy lifestyle habits, (ii) develop and evaluate a brief intervention to increase adherence to asthma medication and (iii) examine the correlates of psychological adjustment to IBD.

Relevant recent publications

Chittem, M.R., Norman, P., & Harris, P. (in press). Relationships between perceived diagnostic disclosure, patient characteristics, psychological distress and illness perceptions in Indian cancer patients. Psycho-Oncology.
Webster, R., Norman, P., Goodacre, S., Thompson, A. (2012). The prevalence and correlates of psychological outcomes in patients with acute non-cardiac chest pain: A systematic review. Emergency Medicine Journal, 29, 267-273.
White, K. M., Terry, D. J., Troup, C., Rempel, L., Norman, P., Mummery, K., Posner, N., Riley, M., & Kenardy, J. (2012). An extended theory of planned behavior intervention to promote physical activity and healthy eating among older adults diagnosed with Type 2 diabetes and cardiovascular disease. Journal of Aging and Physical Activity, 22, 281-299.
Conner, M., Godin, G., Norman, P., & Sheeran, P. (2011). Using the question-behavior effect to promote disease prevention behaviors: Two randomized controlled trials. Health Psychology, 30, 300-309.
Conner, M.T., Sandberg, T, & Norman, P. (2010). Using action planning to promote exercise behavior. Annals of Behavioral Medicine, 40, 65-76.
Evans, D., & Norman, P. (2009). Illness representations, coping and psychological adjustment to Parkinson’s Disease. Psychology and Health, 24, 1181-1196.
Gangstad, B., Norman, P., & Barton, J. (2009). Cognitive processing and posttraumatic growth following stroke. Rehabilitation Psychology, 54, 69-75.
Field, E., Norman, P., & Barton, J. (2008). Cross-sectional and prospective associations between cognitive appraisals and posttraumatic stress disorder symptoms following stroke. Behaviour Research and Therapy, 46, 62-70.