Journal of Psychosomatic Research 105 (2018) 99–105

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Journal of Psychosomatic Research

journal homepage: www.elsevier.com/locate/jpsychores

Cognitive impairment in patients with psoriasis: A matched case-control T

study
⁎
Marco Innamoratia, , Rossella M. Quintoa, David Lesterb, Luca Iania, Dario Graceffac,
Claudio Bonifatic
a
Department of Human Sciences, European University of Rome, Rome, Italy
b
Stockton University, Galloway, NJ, USA
c
Center for the Study and Treatment of Psoriasis, San Gallicano Dermatologic Institute, IRCCS, Rome, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Background: In the past decade, a few studies have suggested that psoriasis could be associated with the presence
Psoriasis of mild cognitive deficits.
Cognitive impairment Objectives: The aim of the present matched case-control study was to investigate several cognitive domains
Anxiety (executive functions, verbal memory, attention, and language) in a sample of outpatients with psoriasis. We also
Depression
investigated whether cognitive impairment was associated with poor health-related quality of life (HRQoL) in
Quality of life
patients with psoriasis.
Methods: Fifty adult outpatients and 50 age- and sex-matched healthy controls were administered a battery of
neuropsychological tests investigating major cognitive domains, psychopathology (anxiety and depression),
alexithymia, and HRQoL.
Results: At the bivariate level, psoriasis patients (compared to healthy controls) performed worse on most of the
neuropsychological tests, and they also reported more anxiety and depressive symptoms, higher scores for
alexithymia, and worse physical and mental health. At the multivariate level, cognitive performance was in-
dependently associated with psoriasis even when controlling for psychopathology and alexithymia.
Conclusions: Patients with psoriasis show impaired cognitive performance, high levels of anxiety and depression,
and impaired quality of life. Based on the current results, clinicians should assess the presence of psychological
symptoms in their patients and evaluate whether the presence of cognitive deficits is limiting the patients' ability
to cope with the disease.

1. Introduction some researchers, building on the so-called “Brain-skin axis” hypothesis

Psoriasis is a common chronic inflammatory skin disease with
psychiatric and medical comorbidity (e.g., obesity, diabetes mellitus,
and depression) [1,2]. Prevalence estimates for psoriasis range from
1.4% to 3.3% with wide geographical and ethnic differences [3].
Psoriasis causes considerable disability and affects the quality of life of
patients [4–8].
Psychological factors play an essential role in the etiology and
prognosis of psoriasis, and also in the management of the illness [9].
Psychiatric disorders, notably anxiety and depression, are common
comorbidities in psoriasis [10–13]. For example, in the US population,
Cohen et al. [14] found that 16.5% of patients with psoriasis met the
criteria for major depression. Psychological conditions have been gen-
erally considered as responses to the stress of living with a chronic and
disabling condition that also comes with social stigma. Nevertheless,
[15], have begun to study neurocognition in patients with psoriasis
[16–20]. This research has suggested the possible presence of mild
cognitive impairment in up to 44% of patients with psoriasis [18]. For
example, Colgecen and colleagues [16] found deterioration of the
cognitive performance of patients with psoriasis, especially in visual-
spatial and executive tasks, but no correlations with disease char-
acteristics (e.g., duration, severity, and onset age). Gisondi et al. [18]
also reported reduction in cortical thickness in parahippocampal, su-
perior temporal and frontal gyri of the left hemisphere.
However, to date, only a small number of studies, frequently using
small samples, single screening instruments [16], and noncontrolled
cross-sectional designs, have supported these results [17]. Thus, the
objective of the present matched case-control study was to extend re-
sults from previous studies by investigating several cognitive domains
(executive functions, memory, attention, and language) in a sample of

⁎
Corresponding author at: Department of Human Sciences, European University of Rome, Via degli Aldobrandeschi, 190, 00163 Rome, Italy.
E-mail address: marco.innamorati@unier.it (M. Innamorati).

https://doi.org/10.1016/j.jpsychores.2017.12.011
Received 31 October 2017; Received in revised form 6 December 2017; Accepted 22 December 2017
0022-3999/ © 2017 Elsevier Inc. All rights reserved.
M. Innamorati et al.
outpatients with psoriasis. We also investigated whether cognitive im-
pairment was associated with decreased health-related quality of life
(HRQoL) in patients with psoriasis. Based on previous research, we
hypothesized that: (1) patients with psoriasis are more likely to have
deficits in most of the cognitive domains investigated when compared
with sex- and age-matched healthy controls, even after controlling for
the severity of anxiety, depression and alexithymia; (2) cognitive im-
pairment is associated with decreased HRQoL; and (3) cognitive im-
pairment severity is not correlated with clinical variables (i.e., severity
of the illness and onset age, even when controlling for socio-
demographic characteristics).
2. Material and methods
2.1. Sample
Fifty adult outpatients (22 women and 28 men) consecutively ad-
mitted at the Center for the Study and Treatment of Psoriasis of the San
Gallicano Hospital (Rome, Italy) between November 2016 and May
2017 participated in a matched-case control study. Inclusion criteria
were age between 18 and 60 years old and a diagnosis of psoriasis
vulgaris with a Psoriasis Area Severity Index (PASI) > 3 [21]. Exclu-
sion criteria were the presence of major diseases of the central nervous
system (e.g., dementia and Parkinson disease) and a history of head
injuries or strokes; the presence of specific medical conditions, such as
hypertension, diabetes mellitus, and dyslipidemia, or other immune-
mediated diseases sharing the same physiological mechanism as psor-
iasis (e.g., Crohn's disease, psoriatic arthritis, and rheumatoid arthritis),
and current major psychiatric disorders (e.g., schizophrenia and bipolar
disorder) or hallucinatory and delusional phenomena; and the inability
to complete the assessment for whatever reasons, including denial of
informed consent.
Each patient was matched for sex and age with a healthy control (22
women and 28 men). The controls were recruited from those attending
adult education classes and from an advertisement posted for estab-
lished community groups. The same inclusion/exclusion criteria used
for the patients were used for the controls. Furthermore, we excluded
possible controls with current or past diagnosis of psoriasis and people
with a positive history of psoriasis in their family members. The so-
ciodemographic and clinical characteristics of the sample are reported
in Table 1. The protocol received approval from the local Institutional
Review Board.
2.2. Measures
All participants were administered a checklist assessing socio-de-
mographic variables (sex, age, marital status, job, school attainment,
and hand laterality) and a battery of neuropsychological tests. Tobacco,
alcohol and drug use were assessed with one item each of the checklist.
Participants were asked whether they were currently smoking tobacco
(and how many cigarettes they were smoking daily), drinking alcohol
beverages (and how frequently they drink during the week), and using
illegal or nonprescribed drugs (including legal highs, and how fre-
quently they used drugs during the week). Neuropsychological tests
were administered in a single session and in a fixed order. For the pa-
tient sample, clinical information (years with the illness, comorbidities,
family history of psoriasis) were retrieved from clinical records, and the
PASI was completed by the dermatologist in charge 7–14 day before
administering the tests. The PASI (score range: 0–72) assesses four body
regions (head, trunk and upper and lower extremities) for the body
surface area involvement of erythema, infiltration, and desquamation
[21].
100
Journal of Psychosomatic Research 105 (2018) 99–105
2.3. Neuropsychological assessment
2.3.1. Cognitive functioning
The Mini Mental State Examination (MMSE) is a widely used and
well-validated screening tool for cognitive impairment [22,23]. The
items of the MMSE include tests of orientation, attention, learning,
calculation, abstraction, information, construction, and delayed recall.
Sum scores range between 0 and 30, with lower scores indicating the
possible presence of cognitive impairment. The diagnostic accuracy and
clinical utility of the MMSE in screening for dementia have been re-
ported [23,24].
The Rey Auditory Verbal-Learning Test (AVLT) [25,26] was used to
evaluate verbal memory. In the present version of the AVLT, a 15 noun-
word list was read five times to the participants with a presentation rate
of one word per second, and after each trial the participant was im-
mediately asked to recall as many words as possible (AVLT-I). After a
20 min delay, the participant was again asked to recall the words from
the list (AVLT-D). The numbers of correct words (range of scores 0–75
points for the AVLT-I and 0–15 for the AVLT-D) and intrusions were
recorded. We used age- and education-corrected scores [27]. The AVLT
has demonstrated good ability to screen for mild cognitive impairment
[28], and good predictive validity for Alzheimer's dementia type [29].
The Trail Making Test (TMT) [30–32] is widely used as a measure of
organized visual search, planning, attention, set shifting, cognitive
flexibility, and divided attention. The test consists of two parts. In part
A (TMT-A), participants are asked to draw a line joining a series of high
contrast dots which are numbered from 1 to 25. In part B (TMT-B),
participants are asked to join a series of numbers and letters in an al-
ternated sequence. A participant's score was taken as the time to
complete the test. The TMT is a reliable measure when testing executive
functioning [32], with good ability to screen for Alzheimer's dementia
type [33].
The Attentive Matrices Test [34] is a measure of selective and sus-
tained attention, with good ability to screen for Alzheimer's dementia
type [35]. The participant is required to find target numbers (from one
to three) in 3 numeric matrices (10 columns of 13 numbers from 0 to 9).
A participant's score is the number of targets correctly found and the
numbers of false alarms and omissions. We used sex-, age-, and edu-
cation-corrected scores [34].
The Forward and Backward Digit Span test [36,37] measures the
longest digit span recalled in both forward and backward recall. For-
ward recall assesses auditory attention and short-term retention capa-
city; backward recall measures the ability to manipulate information in
verbal working memory. The Backward Digit Span has been reported to
have good ability to screen for Alzheimer's dementia type [38]. We used
age- and education-corrected scores [39].
The Clock Drawing Test (Clock Test) [31,40] is a visuospatial task
capable of assessing several abilities including visuoconstructive abil-
ities, and executive and praxic functions. We presented a pre-drawn
circle in which the participants were instructed to draw in the numbers
and then set the time at 2:45 pm. The scoring procedure evaluates
quantity and positioning of numbers and hands (scores range 0–10)
[31]. The Clock Test can reliably screen for cognitive impairment in
clinical settings [41].
The Phonemic Fluency Test (Fluency Test) [31] measures verbal
ability and executive control [31,42,43]. In the Fluency Test, the par-
ticipants are asked to orally produce words beginning with a given
letter. The numbers of unique correct words, repetitions, and intrusions
were recorded. The Fluency Test has good ability to screen for Alz-
heimer's dementia type [33].
The Stroop Color Word Interference Test (Stroop Test) [44,45] is a
reliable measure assessing selective attention, visual attention, and in-
hibitory control, which has been reported being sensitive to lateral and
superior medial lesions of the frontal lobes [46]. We administered a
computerized version of the task, using PsychoPy, version 9. Partici-
pants were placed in front of a laptop (Lenovo® Core i5; screen 15.6″) at
M. Innamorati et al. Journal of Psychosomatic Research 105 (2018) 99–105

Table 1
Socio-demographic and clinical characteristics of the sample.

Variables Patients n = 50 Controls n = 50 Test Significance Cohen's d

Sex Matched –
Men 28 (56.0%) 28 (56.0%)
Women 22 (44.0%) 22 (44.0%)
Age 42.02 ± 12.16 42.02 ± 12.16 Matched –
Right-handed 49 (98.0%) 50 (100.0%) 1.00 0.96a
Marital status Std. MH = 1.77 0.08
Not-married 19 (38.0%) 17 (34.0%) 1.08a
Married 26 (52.0%) 32 (64.0%) 0.79a
Divorced/widowed 5 (10.0%) 1 (2.0%) 1.17a
School attainment (number of years) Std. MH = 0.34 0.73
≤8 11 (22.0%) 10 (20.0%) 1.04a
≤ 13 22 (44.0%) 27 (54.0%) 0.82a
≥ 17 17 (34.0%) 13 (26.0%) 1.17a
Job status 0.23 0.82a
Employed 42 (84.0%) 37 (74.0%)
Unemployed 8 (16.0%) 13 (26.0%)
BMI 26.85 ± 5.11 24.93 ± 3.23 t49 = 2.49 0.02 0.37
Obesity Std. MH = 2.14 0.03
Normal weight 19 (38.0%) 24 (48.0%) 0.82a
Overweight 17 (34.0%) 23 (46.0%) 0.79a
Obese 14 (28.0%) 3 (6.0%) 1.56a
Comorbidity with other dermatological diseases 7 (14.0%) 9 (18.0%) 0.79 0.92a
Tobacco use 23 (46.0%) 14 (28.0%) 0.11 1.44a
Nuumber of daily cigarettes 4.18 ± 5.63 2.96 ± 5.63 – – –
Alcohol use 11 (22.0%) 4 (8.0%) 0.12 1.33a
Number of days in a week drinking ≥ 1 alcohol drinks 1.20 ± 2.94 0.36 ± 1.44 – – –
Drug use 0 (0.0%) 0 (0.0%) – –
Sport activities 11 (22.0%) 16 (32.0%) 0.38 0.82a
Diagnosis of psoriasis 50 (100.00%) 0 (0.0%) –
Duration of illness 16.36 ± 14.17 – –
Family history of psoriasis 28 (56.0%) – –
PASI 4.56 ± 2.25 – –

PASI = Psoriasis Area Severity Index.

Cohen's d = small effects are for a d about 0.20, medium effects are for a d about 0.50, and large effects are for a d about 0.80.
a
Conditional odds ratio.

a standard distance of about 50 cm. This version of the test included
four subtests: (1) participants were presented with a list of squares and
asked to name the color of the ink with which each square was colored
(10 presentations for each of the five colors: orange, yellow, red, blue,
green); (2) participants were asked to read a list of words that name
colors (orange, yellow, red, blue, green) presented on the screen in a
congruent ink color (word ink and word meaning coincided; 10 pre-
sentations for each of the five words); (3) participants were presented
with a list of words that name colors displayed on the screen in an
incongruent ink color (ink and word meaning did not coincide), and
were asked to name the color of the ink and ignore the word's semantic
meaning (10 presentations for each of the five colors); (4) participants
were presented with a list of words that name colors, and asked to read
the word, where the word's meaning and ink color were incongruent
(10 presentations for each of the five colors). We calculated the mean
accuracy and response time (RT) for each subtest and presented as
difference in performance between incongruent and congruent trials
(subtest 4 – subtest 2; subtest 3 – subtest 1) [47,48].
2.3.2. Health-related quality of life
The 12-item Short Form Survey (SF-12) [49] is a reliable and valid
measure assessing two dimensions of health-related quality of life,
mental and physical health [50]. Higher SF-12 scores indicate better
HRQoL. In the present sample Cronbach's alpha was 0.75.
2.3.3. Alexithymia
The Toronto Alexithymia Scale (TAS-20) is a reliable and valid
measure composed of 20 items rated on a five-point Likert-type scale
(from 1, “strongly disagree” to 5, “strongly agree”) [51–53]. The TAS
measures three dimensions of alexithymia: (1) difficulty identifying
feelings; (2) difficulty communicating feelings; (3) and externally-
oriented thinking. Scores > 61 are indicative of severe alexithymia,
and scores between 51 and 60 indicate borderline levels of alexithymia
[52]. Cronbach's alpha in the present sample was 0.82.
2.3.4. Anxiety and depressive symptoms
The Hospital Anxiety and Depression Scales (HADS) is a reliable and
valid measurement instrument composed of 14 items assessing anxiety
and depressive symptoms in clinical and nonclinical populations
[54–56]. The anxiety and depression subscales are comprised of seven
elements each, which are rated on a four-point scale (from 0 to 3). Total
scores range from 0 to 21 for each subscale. A cutoff score above 8 is
used to indicate the possible presence of anxiety or depression [56].
Cronbach's alphas in the present sample were 0.80 and 0.65, respec-
tively for depression and anxiety dimensions.
2.4. Statistical analysis
All statistical analyses were performed using the statistical package
for the social sciences, SPSS 19.0 (IBM Corp., Armonk, NY, USA). Paired
t-tests, McNemar's tests, and Wilcoxon signed rank tests were used to
test group differences. P-values were corrected for multi-testing [57].
Cohen's d corrected for correlated designs and conditional odds ratio
risk were reported as measures of effect size. Conditional odds ratio risk
(COR; [case exposed + control unexposed] / [case unexposed + con-
trol exposed]) was reported as measure of relative risk among psoriasis
patients versus controls in NxN contingency tables.
Considering the high number of significant variables at the bivariate
analyses and a possible problem of multicollinearity among the pre-
dictors, principal component analyses (PCA) were used to reduce the
number of independent variables included in the regression analyses.
Some authors [58] suggested that the proportion of explained variance

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M. Innamorati et al. Journal of Psychosomatic Research 105 (2018) 99–105

should be at least 50%.
Independent associations between psoriasis and neuropsychological
variables (controlling for psychopathology) were calculated by condi-
tional logistic regression analysis with group (patients versus controls)
as the dependent variable. Alternative models with the inclusion of
cigarette smoking, alcohol use, and BMI were tested. Associations were
reported as beta coefficients, odds ratios (OR) and their 95% confidence
interval (95% CI). A significant chi-squared statistic (χ2) indicates good
fit of the model to the data. In the psoriasis group, partial correlations
(rp; controlling for age) were calculated as measures of association
between continuous variables. We performed correlational analyses
both on scores derived from PCA and from single neuropsychological
tests, because although from the former we may derive a composite
score synthetizing the individual's cognitive performance, the in-
formation lost with these synthetic scores is high. (Not all neu-
ropsychological tests are included in the PCA, and for the tests included
not all the variance is reproduced in the factorial solution.) Because of
the high number of tests, corrections were made for multi-testing [57].
All statistics were considered significant if p < 0.05.
3. Results
3.1. Differences between groups
The two groups did not differ in sociodemographic and clinical
variables (Table 1). Patients with psoriasis obtained lower scores on the
MMSE and performed more poorly on most of the neuropsychological
tests administered, except for the AVLT, TMT-A, Digit Span Forward,
repetitions and intrusions on the Fluency Test, or the Stroop Test
(Table 2). Patients with psoriasis also reported more anxiety and de-
pression and alexithymia, and worse HRQoL.
Due to potential problems of multicollinearity among the predictors,
we reduced the number of independent variables through two PCAs. In
the first PCA, we included variables measuring psychopathology and
alexithymia. The analysis resulted in a single component (eigen-
value = 1.99; variance explained = 66.2%). All the variables had
factor loadings ≥0.40 (TAS-20 = 0.79, HADS-A = 0.80, HADS-
D = 0.85). Higher scores on this factor were associated with worse
psychopathology and greater alexithymia. The second PCA with vari-
ables related to cognitive performance resulted in two components
(eigenvalues 2.70 and 1.54, variance explained 33.8% and 19.2%) that
were extracted and orthogonally rotated (VARIMAX). The first com-
ponent (i.e., general cognitive performance) contained most of the
variables with factor loadings ≥ 0.40 (phonemic fluency = 0.50, digit
span backward and clock test = 0.53, MMSE = 0.66, TMT-B/TMT-A
difference = − 0.70, attentive test = 0.71). The second component
(i.e., verbal memory) contained AVLT-I and AVLT-A, with factor load-
ings, respectively, of 0.92 and 0.93. For both components, a higher
score indicates higher cognitive functioning.
Conditional logistic regression model had good fit to the data
(Table 3). General cognitive performance and verbal memory were
independently associated with psoriasis. Patients with psoriasis were
6.7 times more likely to have lower general cognitive performance and
11.1 times more likely to have lower verbal memory than sex- and age-
matched controls. However, the psychopathology and alexithymia
component was not associated with psoriasis. The inclusion of BMI or
alcohol use in the model did not change the results (BMI: χ21
change = 0.66; p = 0.42; alcohol use: χ21 change = 0.37; p = 0.55),
and beta coefficients for both general cognitive performance and verbal
memory remained significant (p < 0.05) and partially stable (beta
coefficients for general cognitive performance ranging between − 1.80
and − 1.91, and beta coefficients for verbal memory ranging between
− 2.54 and − 2.79). However, the inclusion of tobacco use in the model
(χ21 change = 4.02; p < 0.05) changed the beta coefficients slightly
(general cognitive performance: − 1.84 [se = 1.03; OR = 0.16; 95%
CI = 0.021.20]; verbal memory: − 3.39 [se = 1.58; OR = 0.03; 95%

Table 2
Differences between groups on neuropsychological tests.

Variables Patients n = 50 Controls n = 50 Test Significance Cohen's d

MMSE 26.10 ± 2.68 28.54 ± 1.57 t49 = − 5.36 < 0.001⁎⁎ − 0.78
AVLT-I 15.53 ± 7.67 22.86 ± 5.78 t49 = − 5.44 < 0.001⁎⁎ − 0.77
AVLT-I - false recognition 2.24 ± 3.35 1.62 ± 2.15 t49 = 1.13 0.26 0.16
AVLT-D 2.26 ± 1.67 3.96 ± 1.54 t49 = − 6.51 < 0.001⁎⁎ − 0.92
AVLT-D - false recognition 0.76 ± 1.19 0.62 ± 1.09 t49 = 0.59 0.56 0.08
TMTA (seconds) 37.36 ± 14.46 36.60 ± 8.64 t49 = 0.34 0.74 0.05
TMTB (seconds) 60.82 ± 24.19 53.63 ± 14.79 t48 = 2.22 0.03⁎ 0.34
TMTB – TMTA difference (seconds) 23.51 ± 17.26 17.10 ± 11.72 t48 = 2.38 0.02⁎ 0.35
Attentive matrices 49.50 ± 8.00 52.50 ± 5.16 t49 = − 3.14 0.003⁎⁎ − 0.48
Digit span forward 5.47 ± 1.05 5.82 ± 0.71 t49 = − 2.04 0.05 − 0.30
Digit span backward 3.86 ± 0.71 4.33 ± 0.87 t49 = − 2.91 0.01⁎ − 0.41
Clock test 7.93 ± 3.13 9.22 ± 1.27 t49 = − 2.86 0.01⁎ − 0.45
Phonemic fluency test 12.06 ± 3.27 15.08 ± 2.88 t49 = − 5.01 < 0.001⁎⁎ − 0.71
Phonemic fluency – repetitions 1.10 ± 1.25 0.80 ± 1.12 t49 = 1.24 0.22 0.18
Phonemic fluency – intrusions 0.36 ± 1.04 0.44 ± 0.97 t49 = − 0.39 0.70 − 0.05
Stroop test, ink color naming - RT (seconds) 0.14 ± 0.25 0.22 ± 0.21 t48 = − 1.76 0.08 − 0.26
Stroop test, ink color naming - number of errors 2.18 ± 6.73 0.82 ± 1.15 t49 = 1.45 0.16 0.27
Stroop test, word naming - RT (seconds) 0.06 ± 0.16 0.03 ± 0.13 t48 = 1.33 0.19 0.15
Stroop test, word naming - number of errors 0.29 ± 1.00 0.06 ± 0.32 t48 = 1.47 0.15 0.24
SF-12 physical health 51.18 ± 5.87 55.66 ± 3.28 t49 = − 4.79 < 0.001⁎⁎ − 0.72
SF-12 mental health 41.22 ± 6.41 44.85 ± 7.35 t49 = − 2.55 0.01⁎ − 0.36
TAS-20 43.94 ± 11.18 36.18 ± 10.10 t49 = 3.96 < 0.001⁎⁎ 0.56
TAS-20 ≥ 61 4 (8.0%) 1 (2.0%) 0.25 1.13a
HADS-A 5.38 ± 2.73 3.92 ± 3.29 t49 = 2.43 0.02⁎ 0.35
HADS-A ≥ 8 11 (22.0%) 6 (12.0%) 0.30 1.22a
HADS-D 5.20 ± 2.86 2.76 ± 2.66 t49 = 4.46 < 0.001⁎⁎ 0.63
HADS-D ≥ 8 9 (18.0%) 2 (4.0%) 0.04⁎ 1.33a

MMSE = Mini Mental State Evaluation; TMTA = Trail Making Test A; TMTB = Trail Making Test B; TAS-20 = Toronto Alexithymia Scale-20; HADS-A = Hospital Anxiety Depression
Scale - Anxiety; HADS-D = Hospital Anxiety Depression Scale - Depression.
⁎
Significant for p < 0.05 after correction for multi-testing.
⁎⁎
Significant for p < 0.01 after correction for multi-testing.
a
Conditional odds ratio.

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M. Innamorati et al.
Table 3
Conditional logistic regression analysis.
Beta coefficients SE (Beta)
Component 1 – general cognitive performance −1.90 0.91
Component 2 – verbal memory −2.45 1.04
Component 3 – psychopathology and 0.78 0.51
alexithymia
Fit indices: −2LL = 18.82; χ23 global = 30.97; p < 0.001; χ23 Previous step change = 49.11; p < 0.001.
Component 1 (a higher score indicates higher cognitive functioning) = MMSE, digit span backward, phonemic fluency, attentive matrices, TMTB – TMTA difference, and clock test have
factor loadings ≥ 0.4 on this component.
Component 2 (a higher score indicates higher cognitive functioning) = ALVT-I and AVLT-D have factor loadings ≥ 0.4 on this component.
Component 3 (a higher score indicates higher psychopathology) = HADS-A, HADS-D, and TAS-20 have factor loadings ≥ 0.4 on this component.
CI = 0.0020.75]), suggesting that only verbal memory was in-
dependently associated with psoriasis.
3.2. Associations between cognitive performance and HRQoL in patients
with psoriasis
Cognitive functioning components were not significantly associated
with physical and mental health (general cognitive performance:
rp = 0.19 and 0.06, respectively, for physical and mental health; verbal
memory: rp = 0.15 and 0.18, respectively, for physical and mental
health), consistent with results from individual neuropsychological
tests (only four significant tests before correction for multi-testing and
no one after this correction. Physical health was associated with the
number of errors at the Stroop word naming [rp = − 0.21] and color
naming [rp = − 0.22], and scores at the Clock Test [rp = 0.25]. Mental
health was associated only with the AVLT-D [rp = 0.22]).
Cognitive functioning components were also not significantly asso-
ciated with years with the illness (general cognitive performance
rp = 0.21; p = 0.14; verbal memory rp = − 0.17; p = 0.25) and PASI
scores (general cognitive performance rp = −0.20; p = 0.17; verbal
memory rp = 0.03; p = 0.83), consistent with individual neu-
ropsychological tests (only four significant tests before correction for
multi-testing and no one after this correction. PASI scores were asso-
ciated with the Attentive Matrices [rp = −0.32], and years with the
illness was associated with the TMT-B [rp = −0.29], the AVLT-I
[rp = − 0.29], and MMSE scores [rp = −0.38]).
4. Discussion
Patients with psoriasis performed worse on most neuropsycholo-
gical tests than sex- and age-matched healthy controls (hypothesis 1),
although, in the multivariate analysis, only episodic memory as as-
sessed with the AVLT was independently associated with psoriasis when
controlling the effect of psychopathology and tobacco use. Our results
are consistent with the conclusions reached from the few studies that
have been published [16–20], despite some inconsistencies [16–18].
Marek-Jozefowicz et al. [17] reported impaired performance on the
TMT and Stroop Test which supported their conclusion of a possible
dysfunction of the prefrontal cortex in these patients while, in our
sample, the effects for these tests were nonsignificant and small. Some
differences in the research designs might explain these inconsistencies
(e.g., cross-sectional vs. age- and sex-matched case control study design,
different versions of the Stroop Test, and differences in the mean se-
verity of the illness in the patients). However, it is evident that the
performance on the TMT of patients from the two studies was com-
parable (TMT-A = 37.4 [SD = 14.5] seconds in our sample and 36.0
[SD not reported] in Marek-Jozefowicz et al.'s study; TMT-B = 60.8
[SD = 24.2] in our sample and 65.0 [SD not reported] in Marek-Jo-
zefowicz et al.'s study) while the performance of controls was not. Fi-
nally, our results do not fully support the hypothesis of a specific dys-
function of the prefrontal cortex, but rather a possible dysfunction
Journal of Psychosomatic Research 105 (2018) 99–105
Odds ratio 95% confidence intervals lower 95% confidence intervals upper Significance
(OR) level level
0.15 0.03 0.88 0.03
0.09 0.01 0.66 0.01
2.17 0.80 5.94 0.13
involving a more diffuse neural network [59]. Although we did not
investigate brain functioning directly, previous lesion and functional
neuroimaging studies suggests a sensitivity of specific tests to the
functioning of different cerebral areas [46,60].
The largest differences between groups were on the AVLT (d of
− 0.92 and − 0.77, respectively, for the AVLT-D and the AVLT-I).
Recently, Moradi et al. [60] investigated which brain regions activa-
tions are important for the estimation of performance on the AVLT, and
reported that the top predictors were medial temporal lobe structures
and amygdala for the estimation of AVLT-I and angular gyrus, hippo-
campus, and amygdala for the estimation of the AVLT Percent Forget-
ting (an index calculated by subtracting the score of AVLT-D to the
score of the last trial used to calculate the AVLT-I). Otherwise, pho-
nemic fluency (d = − 0.71) seems to activate both frontal areas and
some non-frontal brain areas (e.g., the thalamus, parietal and temporal
lobes) [46]. Finally, Stonnington et al. [61], investigated the ability of
T1 weighted magnetic resonance images to predict individuals' per-
formances on neuropsychological tests, and reported that MMSE scores
(d = −0.78 in our study) correlate significantly with whole brain grey
matter changes associated with Alzheimer's disease.
HRQoL was not significantly associated with cognitive performance
(hypothesis 2). Thus, our results did not support the hypothesis that a
poor cognitive performance could negatively affect the quality of life of
patients, possibly through a reduced capacity for regulating the inner
states of people with cognitive impairment when facing potential
stressors. Unfortunately, to the best of our knowledge, no previous
studies have examined this association in psoriasis. However, Stites
et al. [62] investigated how awareness of their diagnostic label could
impact self-reported quality of life in older adults with varying degrees
of cognitive impairment, and found that those patients with mild cog-
nitive impairment who were aware of their diagnosis (compared to
those who were unaware) had lower satisfaction with daily life and
worse physical well-being.
Correlations among illness characteristics (i.e., the severity and
chronicity of psoriasis) and performance on the neuropsychological
tests were weak and non-significant (hypothesis 3). These results are
consistent with the results of Marek-Jozefowicz et al.'s [17] and Col-
gecen et al.'s [16] studies. Colgecen et al. [16] reported no correlations
between disease characteristics and performance on neuropsycholo-
gical tests, while Marek-Jozefowicz et al. [17] found no associations
between performance on neuropsychological tests and PASI scores, and
significant but weak associations with the duration of illness.
4.1. Limitations
Our results should be viewed in the light of several limitations. First,
our sample included only 50 patients with a limited range of PASI
scores and future studies with larger samples and more severe forms of
psoriasis should be carried out. Second, we were unable to compare
results from neuropsychological testing with neuroimaging investiga-
tions, which could have enabled us to shed light on the underlying
103
M. Innamorati et al.
brain anomalies sustaining cognitive deficits shown by patients with
psoriasis. Third, psychopathology and alexithymia were assessed only
by self-report measures and social desirability may have biased our
results. Fourth, despite the fact that the groups did not differ in edu-
cation, some of the controls possibly were attending adult education
classes and, therefore, they may have been better prepared for the test-
taking. Fifth, the cross-sectional design of our study prevents us from
drawing causal inferences. Nevertheless, our study has some strengths,
including the ability to control the effect of multiple potential con-
founders (e.g., age, sex, BMI, alcohol and tobacco use, and anxiety and
depression).
5. Conclusions
Patients with psoriasis show impaired cognitive performance,
especially impaired episodic memory, high levels of anxiety and de-
pression, and impaired quality of life. Based on the current results,
clinicians should assess the presence of psychiatric symptoms in their
patients and evaluate whether the presence of cognitive deficits is
limiting their ability to cope with the disease. The recognition of psy-
chiatric symptoms and mild cognitive deficits in patients with psoriasis
could help optimize the effectiveness of treatments and management of
the patients. Additional studies are needed to examine the underlying
brain anomalies and the temporal relationships between cognitive im-
pairment and psoriasis.
Conflict of interest statement
The authors report no conflicts of interests related to this work.
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