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Among the skin related chronic diseases, linked to an emotional component, psoriasis is highlighted for being inflammatory, related to the immune system, characterized by erythematous, scaly plaques in any part of the body, including nails and joints, which causes burning, itching and pain (Brazilian Society of Dermatology (SDB), 2012; World Health Organization (WHO), 2016; Zhang et al., 2019). It is an incurable disease, non-communicable and without defined cause (WHO, 2016). In Brazil, it affects about 1% of the population, with regardless incidence of gender or age, peaking at second and fifth decades of life (SDB, 2012).
The skin inflammations generally appear in places like elbows, scalp, knees, pretibial and sacrum area, being also possible the affliction in the entire skin, when 90% of cases refer to vulgar psoriasis which consists in the appearing of erythematous scaly patches. (SBD, 2012; Jesus et al., 2016; Silveira et al., 2017). Factors which trigger and may aggravate this dermatosis are minor injuries, sun burn, infections, systemic drugs and stress (WHO, 2016). Patient with mild psoriasis can be treated with topical medicine, while patients with moderated to severe forms may start phototherapy treatment, besides using active systemic medicine and immunobiological drugs when necessary (SDB, 2012; WHO, 2016).
Yet, besides drug intervention, psychotherapy is significant to contribute to the control or improvement of symptoms (Jesus et al., 2016). Patients diagnosed with dermatological diseases may present suicidal ideation, depression, obesity, anxiety, high alcohol consumption, stigmatization, anger and hostility when compared to the general population (Gonzáles- Parra & Daudén, 2019; Jesus et al., 2016; Liang et al., 2019). The presence of psoriasis in an individual’s life may affect his/her social relationships, self- image, and self-esteem, besides having impact in his/her leisure and professional activities (Kwan et al., 2016; Magin et al., 2010; Zhang et al., 2019).
According to analytical psychology, the interaction among these aspects is part of the psyche, composed of the individual´s conscious and unconscious processes. Consciousness is related to psychic facts and the “Self”, relating to the external contents of the environment and to the internal contents of the unconscious. This comprises the personal contents that can have access to consciousness, and those collective, belonging to humanity. The unconscious has a personal dimension, with individual contents that have been repressed, forgotten, repressed, but that can have access to consciousness; and a collective dimension with contents that are possibilities of behaviors belonging to humanity (Jacobi, 2013; Jung, 2011).
In the personal unconscious, traumatic experiences from childhood or even adult stage may trigger complexes which are characterized for being endowed of a high emotional load, experienced by psyche (Jacobi, 2013). Thus, the regal route that leads to the unconscious is the complexes, since they are also responsible for the symptoms. They, in addition to the physical point of view, can be understood in a symbolic way because they represent something subjective, profound and invisible. Therefore, the symbol acts as a mediator between the unconscious and the conscious, by allowing the psyche to express the unconscious processes in the conscious dimension. (Jacobi, 2013; Zimmermann, 2017).
In an attempt to adapt to the external requirements inherent in living in society, it is possible that there are moments of contradictions, imbalance and tensions from an objective and subjective point of view. Psychic conflict can be installed favoring the appearance of symptomatic acts that can be manifested through the body (Jung, 2002). The disease may be comprehended as a normal but distraught process, once it is an attempt of balance which makes cure possible (Jung, 2011). Therefore, when the conscience refuses to accept unconscious contents that bring intense suffering, they are manifested by symptoms. The disease then reflects a normal process, although disturbed, because it is an attempt to rebalance and compensate the psyche that seeks a cure (Jacobi, 2016; Jung, 2011; Ramos, 2006). Thus, the present study aimed to comprehend the relationship between the situations of psychic conflict and psoriasis in the adulthood, in the light of analytic psychology.
Method
It is a qualitative research, based on the referential of analytic psychology.
Participants
Ten female and male individuals aged between 25 and 57 years participated in outpatient treatment at the Instituto de Medicina Integral Professor Fernando Figueira (IMIP), a philanthropic hospital and affiliated to the Sistema Único de Saúde (SUS), the unified health system in Brazil, located in the city of Recife, state of Pernambuco, Brazil.
Instruments
A sociodemographic questionnaire bearing information on participant (age, sex, schooling, profession, marital status, number of children) and interview script composed by 11 topics which covered themes such as: onset of the disease, reactions about discovering the diagnosis, beginning of treatment, routine of care, involved professionals, experience of having psoriasis, experience of living after 18 years old, perception of the relationship of worsening of symptoms in specific life stages.
Procedure
Participants with psoriasis were referred by the multiprofessional team of the outpatient clinic specialized in IMIP. The data collection was executed by the main researcher in a period of three months. The sampling was intentional and the saturation process was being delineated from information obtained with depth and breadth, which tended to intersubjective repetition between researcher and field participant (Minayo, 2014; 2017).
The interviews were recorded, transcribed and explored according to the content analysis of Minayo (2012). It is composed by the pre-analysis, in order to understand and internalize the philosophical and epistemological terms which makes possible to justify the investigation; the assortment and organization of material, in which the meaning expressed by the interviewees is pursued; data analysis and interpretation, to which trustworthiness, validity and interpretation criteria are assured based on the consulted literature. The analysis was carried out by three researchers with expertise in analytical psychology and qualitative research. We opted to use W (woman) and M (man) followed by numbers to characterize participants.
The project was approved by the Ethic Committee of Research in Human Beings from IMIP, according to Resolution 510/2016 from the National Health Council under CAAE: 95749118.2.0000.5201.
Results
Ten people were interviewed, being five men and five women, in adulthood, with different levels of schooling, being three unemployed in the moment of research. The number of children varied within none and six, with a mean of 2 children per person (Table 1). All participants lived in Great Recife.
From the interviews carried out with the patients and the content brought by them in the moment of speeches, three categories emerged (1) conflicts, beginning and aggravation of symptoms; (2) the experience of negative feelings in psoriasis; and (3) variations and adaptations facing the disease.
Conflicts, beginning and aggravation of symptoms: “my body got plagued”
This first category reveals the relationship between the onset of symptoms of psoriasis and its worsening. Six interviewees established a direct relationship regarding the onset of psoriasis and some remarkable event in life which brought a high psychic mobilization. These events referred to changes of roles related to the loss of beloved relatives, unemployment, pregnancy and divorce, dismissal, imprisonment of son/daughter and high alcohol consumption during life and reduction or abstinence of it. Such situations are articulated also with requirement and possible experiences in adulthood, as it can be observed in the following speeches:
I think it was, I think it was after my son went to the jail. After he went to jail it changed. My life changed a lot… After I find that out, my body got plagued, I couldn’t, couldn’t, after I find out I started the treatment, I couldn’t even walk. (M2)
Really, I passed through many things (sic) which impacted my emotional, you know? Because in that time I also got divorced, gave birth to my daughter, got divorced from her father - my daughter, it was such a trouble, a lot of trouble… (W3)
My, my brother died in October 97, my father died in December 97, the two of them in just one year. Then I spent time with my mother, then it was my mother. There were psychological traumas that I still have today. (W4)
However, three interviewees, when affected by psoriasis, did not relate to any event in their life. Participants M3 and M5 did not make a direct relationship, but cited alcohol abuse over the course of adult life, as expressed in the following statement: “I think I have, I think I have drunk too much, isn’t it… I don’t drink anymore, but I did it a lot” (M3).
Most participants related the worsening of symptoms with specific moments of their life related to stressing situations. Some of the symptoms cited by the participants were spotting, sores, itching and pain. According to the following speeches:
Yes, totally, mainly in the last three months which was the period of ending the monography, I felt the psoriasis aggravating a lot, because in this way, I got really stressed, barely could sleep, a matter of routine, to rearrange job, university and personal problems. (W1)
Yes, I realize that it always get worse in a moment that I get angry, get upset, when I want to do something that doesn’t work… then it starts to itch, my nail (sic) start to itch, I start to get annoyed… (W2)
I think it was, I think it was after my son got arrested. After he got arrested it changed. My life changed a lot. I was… I lost my son to the world, he’s there until now… It’s been six months, from six months until now it’s been worsening… It was just it, a problem this son of mine, because, my younger son got involved with my older son. (M2)
The same participants mentioned above, H3 and H5, did not establish a relationship between worsening symptoms and situations that caused psychic mobilizations. Three participants, two with a complete third degree, related psoriasis to psychological issues:
I did not look for a psychology professional to treat me in relation to, when I was in crisis, but the psychology professional in this process is fundamental, because like this, not everyone has a firm pulse, has a resistance as I did... so then, the psychology professional was getting a little sideways, but he is fundamental in this process. (W1)
Coming there, the Doctor., he said right, right when he saw me he said: “you have psoriasis, let’s treat your mind. In that moment I said: “my mind? So I came to the wrong doctor”… Then through his talking and the research (sic) I understood that psoriasis is an emotional disease. (W4)
"I'm going to put you in a psychologist, that's the way, because you're full of, all busted", "intern me doctor, intern me". I asked her to admit me... "control yourself, control yourself that you will get better". (M4)
In the speeches of the participants of research W4 and M4, the score of the medical team in raising the emotional aspects related to acne is clear. However, only participant W4 reported having undergone psychotherapeutic treatment among all respondents.
The experience of negative feelings in psoriasis: “I’ve already felt a leper dog”
This category is meant to approach the negative intensity of feelings which was experienced by the interviewees. Almost all of the participants related being ashamed because of the visual aspect of the disease. Practically everyone who admitted this feeling did or started to use strategies to avoid being noticed and to notice people's prejudice when wearing long-sleeved clothes and long pants, gloves. The feeling of shame is one of the main factors of limitation in the life of interviewees, being this related to clothing or leisure.
I still feel ashamed in any place I go, I feel ashamed to portray my hand many times, when I’m going to make any service I know use a glove because I got ashamed…(W3)
Then I passed a lot of time only wearing long sleeves shirt, long pants, with no shorts… In a small family party, I only wear long pants, long sleeves shirt… “Dude, use a tank top”, I said “ I don’t like it”, ashamed. (M4)
One of the interviewees, with psoriasis located in visible area, relates the difficulty in hiding the dermatosis, as exposed in the speech: “I found that bat, heh…if it was in a hidden body part, you could hide, heh, but not in the face…” (W5). It was present in the speeches the feeling of rejection and prejudice from others, expressed by the looking, through provocations and mean comments, by the avoidance of others in relation to the person with psoriasis, as the speech of participant W4 shows: “What hurt me the most and hurts until now, which I cannot accept, is the looking people gave me. I felt like a leper dog, you know? People rejecting me this way…” About that, participant M3 also relates:
People keeps asking me whether is it scabies, others keep mocking me… you take a bus and that person sees it, then you… the person walks away from you… Even my wife said that if it was a communicable disease she wouldn’t be with me… It’s difficult, you know…”
Changes and adaptation facing the disease: “That man is over”
The present category relates about the changes imposed to the routine of the interviewees. After the psoriasis onset, most of participants related about changes that occurred in their professional and personal lives. It is evident in their speeches the deprivations the dermatosis caused in their lives, as it is exposed hereafter:
Painter, I am a painter. And after it happened I cannot ascend, huh, I got up in any height, any ladder, any scaffold, nowadays I cannot do this anymore, that man is over, I’m unutilized for labor, I cannot work anymore. (M1)
Why would I go to the beach, to do what? Because I can’t swim? Would I go to the beach 5AM to swim and leave? Swim and come back home? I can’t. It’s hard for me. I hope, what I hope is to get better, from now on. (M2)
Only one participant affirmed having a normal life after psoriasis diagnosis.
I accept it nowadays, I have a normal life like anyone. Nowadays I go to the beach even with the lesions, because the… the main factor between patient and psoriasis is to accept it, so I accept it nowadays, quietly. (W1)
Discussion
The majority of participants of the present study have linked the onset of psoriasis to a significant moment of their lives with high affective load which preceded the sickening in adult stage. This fact confirms analytical psychology point of view about the creation of complexes in during life, and not only in the childhood (Jung, 2011). Although the etiology of psoriasis is poorly defined, it is perceived through the executed interviews, that experiencing situations of high stress level plays a major role when related to genetic factors, present notions in the findings of the research.
From the applying of the Word Association Test to his patients, Jung (2011) testified the existence of complexes and considered the relation between body and mind in its entirety as the processes happen simultaneously. In the same way, Ramos (2006) affirmed that the psychosomatic must be understood from the holistic point of view, recognizing the interdependence between body and mind, both in disease and health, without reducing the disease’s causes only as organic or psychological.
The base concept of psychosomatic, inside the analytic perspective, is based in the model of the biopsychosocial disease, in which body, psyche and social environment are influenceable among themselves. The psychosomatic disturbs arise by many psychic and psychosocial factors, once distinct stressing situations may lead to the affliction of the same disease (Morschitzky & Sator, 2013).
About the aggravation of dermatosis, it can be considered that the experience of stressing situations, such as the ones mentioned by the interviewees, may lead to the weakening of the individual’s immune system, acting as a trigger. In the same way, the existence of the disease itself, by its visible spots, itching and the act of itching may cause anxiety and depression, as well as affecting self-esteem and sociability, leading to the worsening of symptoms itself, in a cyclic movement (Jesus et al., 2016; Morschitsky & Sator, 2013).
Jung (1973) affirms that physical and psychic symptoms work as symbolic manifestations of pathogenic complexes and that it is possible to discover complexes loaded of affects, like they were an old sore, inside hysteric patients, a notion which can be extrapolated to individuals without the hysteric component. In this way, according to Ramos (2006), the symptom works as the best expression of a conflict which was lived and repressed, considering that the conscious and unconscious aspects of the psyche act in a compensatory manner, this one appears as part of the psyche’s homeostasis.
The somatization of the patient do not happen because of the fact that it doesn’t symbolize, but because of the symbolization is happening in the somatic level, which was the case of the participants of the present research. The symbol is then considered the third factor existing between psyche and soma, being expression of these, in which assumes dysfunctional character. Thus, the symbol represents a change in the relationship between ego and Self, where the ego corresponds to the center of consciousness and the Self to the center of the total personality, being a form of expression of the conflict, originated from the complexes, through the body (Ramos, 2006).
Still, not all of the participants related the onset of psoriasis to some remarkable event, resulting from an experienced conflict, which was the case of participants W2, M3 and M5. To this may be related the fact of the patients aren’t in psychotherapy and a certain resistance in talking about possible experiences with high affective load. It can also be considered the lack of knowledge of them in relation to emotional factors as influence to the sickening, leading to face the crisis in a solely somatic perspective.
The negative feeling experienced by the participants of the research in face of looks and comments from known and unknown people are related to the shadow of the latter in relation to the dermatosis itself. According to Jung (2011), an unconscious part of the personality exists and is projected in the individuals of same gender, identified as the archetype of the shadow. This one represents negative and positive aspects of the personal sphere which are little known or even unknown by the ego. Jung understands the shadow as being presented in the others, but denied to who is seeing it (Von Franz, 2016).
When facing situations such as the ones cited by the participants (loss of beloved relatives, unemployment, pregnancy and divorce, dismissal, prison of son/daughter and high consumption of alcohol during life and reduction or abstinence of it), their personas suffered changes and adaptations. The archetype of persona, unlikely the shadow, is nearer to the conscience and is understood by Jung as if it were a mask. This archetype has as objective producing a determined effect among others, showing acceptance in the social environment, in the same time that hides the true nature of the individual (Jung, 2008). For example, the participant W4, which had the extinction of the daughter persona when lost both parents; the participants M1 and W1 which lost the role of employees, these people had to assume new personas, being something natural and adaptative. However, in the analytic point of view, it is primordial that the individual know how to differentiate what is to others and what is to himself, for he/she doesn’t identify him/herself solely with the social role which he/she represents.
Psoriasis, whilst symbol-symptom, when described as conflicts, negative feelings and provoked changes, may promote an approach of the unconscious to the conscience, favoring the process of individualization of each patient, for it is a possibility of the originated potential totality might be reach, which leads to the differentiation of the individual towards the collective.
Therefore, the findings of the research indicate signs of the onset of psoriasis linked to significant events of high affective load during adulthood and the consequences in the life of those who live with dermatosis. For it is a skin disease which involves at least physical and psychic characteristics, it is highlighted the importance of the following by the specialist physician and a psychology professional, as a way of providing treatment and integral care to the individual.
As a suggestion to further researches, it is considered important that this phenomenon be investigated also in the perspective of patients treated in particular healthcare, besides exploring the perception of those who live daily with the patient and the specialist professionals that are responsible for their treatment.
Author’s contribution
Mírian Dias: Conceptualization; Formal analysis; Acquisition of financing; Investigation; Methodology; Project administration; Resources; Writing - original draft; Writing - revision and edition
Camila Vieira: Conceptualization; Formal analysis; Methodology; Supervision; Validation; Writing revision.
Lygia Carmen Vanderlei: Conceptualization; Methodology; Supervision; Validation; Writing revision.
Leopoldo Barbosa: Conceptualization; Methodology; Acquisition of financing; Supervision; Validation; Writing revision.
