1. Background
Vitiligo is an acquired pigment-producing skin disorder with a worldwide prevalence of 0.5% to 2% (1). In some societies and cultures, individuals with vitiligo may face discrimination and have difficulties in finding employment or partners (2). Studies indicate that these patients are at risk of developing various psychological disorders, such as anxiety and depression, due to their different appearance and fear of being judged by others (3), which exacerbates their mental distress and may even lead to suicide, especially if vitiligo affects visible areas of the body (4). A 2017 systematic review and meta-analysis estimated the prevalence of depression among vitiligo patients to be 25% (5). A meta-analysis of 17 studies in 2018 reported the prevalence of depression among vitiligo patients to be between 8% and 33% (6). According to Nasser et al., 78% of these patients experienced varying degrees of anxiety (7). Moreover, numerous studies have revealed that people with skin diseases, particularly vitiligo, experience higher levels of anxiety than others and are more susceptible to psychological complications (8-11).
Certain characteristics, acting as protective or risk factors, can influence patients' adaptation to the disease or the development of psychological complications (1). Forgiveness is one such attribute that plays a significant role in patients' psychophysical health. Forgiveness involves letting go of negative emotions, cognitions, and behaviors such as hostility, revengeful thoughts, and verbal aggression in response to perceived injustices (12). Forgiveness-induced motivational changes ultimately reduce retaliatory intentions while increasing motivations for positive actions and controlling anger towards the offender. In fact, forgiveness helps individuals better cope with problems and reinforces positive internal thoughts (13). The results of a study by Taşçioğlu et al. reported that vitiligo patients with a greater ability to forgive were in better physical condition compared to others (14).
Another important capability for such patients is developing realism and avoiding perfectionism. Perfectionism is characterized by striving for flawlessness, setting excessively high standards for performance, and having a tendency to critically evaluate oneself and others (15). Perfectionism is known to impact an individual’s mental health (16). The negative aspects of perfectionism are associated with the individual's mistakes, causing obsessive-compulsive anxiety and excessive concerns (17). Perfectionism can result in difficulties in recognizing situations, inflexibility, and a tendency toward destructive behaviors, such as high self-expectations and a severe fear of failure (18). Therefore, it is essential to investigate the predictive role of perfectionism in the depression and anxiety of these patients.
Another factor affecting mental health is how vitiligo patients express and control anger, a natural emotion in response to negative events. While some level of anger in response to problems and stressful situations is normal, it can become problematic when expressed excessively (19). Studies have revealed that individuals who control their anger and do not express it excessively have better mental health and experience a higher quality of life (18, 20). Therefore, excessive expression of anger can cause various problems. Research has shown that patients with skin disorders often experience suppressed emotions, feelings of resentment towards others, and increased anxiety (10, 21, 22). Therefore, it is necessary to examine the predictive role of anger expression and control on the levels of depression and anxiety in these patients.
Another influential factor in psychophysical health is alexithymia, which is defined as a disturbance in emotional and cognitive functioning, along with an inability to find the proper words to express feelings and emotions (23). Alexithymia is considered a major problem among many psychologically disordered patients, as it can lead to an inability to verbally express their feelings (24). This condition is often observed in patients suffering from chronic pain and appearance-related problems (25), with its prevalence among vitiligo patients reported to be approximately 13% (26). Alexithymia hinders the regulation and adaptation of emotions (27) and can be a precursor to many physical illnesses, including chronic back pain, tension headaches, bodily pain disorders, and inflammatory bowel diseases, all of which can exacerbate an individual's anxiety (25, 28). Additionally, alexithymia can be an influential psychological factor in the occurrence or progression of an illness (29). Thus, it is essential to determine the role of alexithymia in depression and anxiety in these patients.
A study conducted on patients diagnosed with vitiligo revealed a potential correlation with mental disorders, indicating the involvement of psychological factors in their condition. Gaining a comprehensive understanding of the influence of psychological variables on treatment and interventions for these individuals, particularly in relation to anxiety and depression, is of utmost importance (14, 21, 30). According to the researcher’s investigations, important psychological factors such as forgiveness, perfectionism, anger, and alexithymia, which may be related to the mental health, anxiety, and depression of vitiligo sufferers, have not been addressed in previous studies.
2. Objectives
The present study was performed to predict depression and anxiety in vitiligo patients by considering forgiveness, perfectionism, anger, and alexithymia. The study results appear promising for the prevention, improvement, and promotion of health and quality care in these patients.
3. Methods
3.1. Study Design
This is a cross-sectional, descriptive-analytical study involving a population of all vitiligo patients.
3.2. Study Setting and Participants
Using the convenience sampling method, 119 vitiligo patients who visited Babol Shahid Yahyanejad Hospital from May 2023 to September 2023 and were willing to participate in the study were selected. The inclusion criteria for the study sample were: (1) no physical diseases other than vitiligo, (2) a history of vitiligo for at least 6 months, and (3) at least 18 years of age. Patients with known psychological disorders were excluded from the study. Patients who agreed to participate were first asked to complete an informed consent form and the study questionnaires. All patients were examined by a dermatologist, and their clinical features and demographic information were recorded in the respective checklists. The severity of their vitiligo was determined using the VASI scale. It should be noted that in this study, the assessment of depression and anxiety in vitiligo patients was based solely on the data from the research questionnaires.
3.3. Data Collection and Measurement
All patients were evaluated using the following questionnaires.
3.4. Socio-Demographics Questionnaire
It includes questions about age, gender, marital status, education, occupation, disease status, type of vitiligo, duration of illness, duration of treatment, and the severity of vitiligo.
3.5. Vitiligo Area Scoring Index
It is a quantitative tool designed to measure the extent of skin depigmentation and macular repigmentation in vitiligo patients and their responses to vitiligo therapies in clinical trials. This tool was developed in Vancouver by Hamzavi et al. in 2004 (31). The percentage of vitiligo involvement is calculated using the Palmer method. The axillary region is included with the upper extremities, while the buttocks and inguinal areas are included with the lower extremities. The extent of residual depigmentation is expressed using the following percentages: Zero, 10%, 20%, 50%, 75%, 90%, and 100%. The scale for vitiligo is divided into three stages: Stage 0: Normal pigmentation; stage I: Incomplete depigmentation; and stage II: Complete depigmentation (32). The tool’s validity and reliability have been investigated. To estimate the reliability of the VASI in this study, the test-retest method with a one-month interval was used, in which 15 patients from each group were asked to record the intensity, size, and quantity of depigmentation. The correlation coefficient was calculated to be 89% (31, 33, 34).
3.6. Beck Anxiety Inventory
This 21-item questionnaire is used to assess anxiety. The scoring follows a Likert scale from 0 to 3. The total score of the questionnaire ranges from 0 to 63, with higher scores indicating greater levels of anxiety in the individual. The questionnaire evaluates anxiety across four levels: Scores of 0 - 7 indicate no anxiety, 8 - 15 indicate mild anxiety, 16 - 25 indicate moderate anxiety, and scores higher than 25 (26). In a study by Kaviani and Mousavi, the questionnaire’s validity and reliability were examined, showing good validity (r = 0.72, P < 0.001) and reliability (r = 0.83, P < 0.001). Additionally, Cronbach's alpha coefficient was calculated as 0.92 (35). In the present study, Cronbach's alpha coefficient was reported as 0.896.
3.7. Beck Depression Inventory Short Form
This 21-item tool was designed by Beck et al. to measure depression. The short form of the Beck Depression Inventory, or BDI-S, consists of 13 items scored on a 4-point Likert scale from 0 to 3 (36). The total score is calculated by summing the item scores and ranges from 0 to 39, with higher scores indicating higher levels of depression. Scores of 0 - 3 indicate normal, 4 - 7 indicate mild depression, 8 - 11 indicate mild to moderate depression, 12 - 15 indicate moderate depression, and 15 - 39 indicate severe depression. Rajabi examined the psychometric properties of the BDI-S, with the tool’s Cronbach's alpha coefficient calculated as 0.89 and 0.82 using the split-half method. Additionally, the correlation coefficient between the short (13-item) and full (21-item) forms was 0.67 (37). In the current study, Cronbach's alpha coefficient was reported as 0.838.
3.8. Heartland Forgiveness Scale
This 18-item self-reported instrument was developed by Thompson et al. in 2005 to measure forgiveness and is widely used. The scale consists of three subscales: (1) forgiveness of self (items 1 - 6), (2) forgiveness of others (items 7 - 12), and (3) forgiveness of situations (items 13 - 18). Scoring is based on a 7-point Likert scale, ranging from 1 (Strongly disagree) to 7 (Strongly agree). The total score ranges from 18 to 126, with higher scores indicating higher levels of forgiveness. In the study by Thompson et al., Cronbach's alpha coefficient was calculated as 0.86 for the total forgiveness score, indicating good internal consistency of the instrument (38). The validity and reliability of the Heartland Forgiveness Scale (HFS) have been reported previously in Iran (39-41). In this study, Cronbach's alpha coefficient for the total forgiveness score was calculated as 0.70.
3.9. Multidimensional Perfectionism Scale (MPS)
This 30-item scale, created by Hewitt and Flett in 1991, divides perfectionism into three types: Self-oriented, other-oriented, and socially prescribed perfectionism. The Multidimensional Perfectionism Scale (MPS) uses a 5-point Likert scale for scoring, ranging from 1 (strongly disagree) to 5 (strongly agree). The total score ranges from 30 to 150, with higher scores indicating higher levels of perfectionism (42). In the preliminary validation of the Iranian version for the three subscales mentioned above, good internal consistency was reported for the scale (43). In the present study, the scale’s internal consistency was calculated as α = 0.90.
3.10. Spielberger State-Trait Anger Expression Inventory
This tool, designed by Charles Spielberger, has had its psychometric properties determined and standardized. The first section, consisting of 15 items, measures the current state of anger (items 1 - 15). The second section, including 10 items, assesses trait anger (items 16 - 25). The third section, composed of 32 items, measures the expression and control of anger (items 26 - 57) (44). In some studies, the internal consistency of the STAXI-2 and its subscales has been reported as satisfactory (44, 45). In this study, Cronbach's alpha coefficients for the state, trait, expression, and total STAXI-2 scores were calculated as 0.870, 0.866, 0.857, and 0.887, respectively, indicating the scale’s good internal consistency.
3.11. Toronto Alexithymia Scale
This 20-item tool is scored using a 5-point Likert scale (from 1 = strongly disagree to 5 = strongly agree). Questions 4, 10, 18, and 19 are reverse scored. The minimum and maximum scores for this scale are 20 and 100, respectively (46). The Toronto Alexithymia Scale has three subscales: Difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and externally oriented thinking (EOT). The scale’s internal consistency has been reported as good (47, 48). In the present study, Cronbach's alpha coefficient was reported as 0.752.
3.12. Data Analysis
Descriptive statistics were used in this study. In the hypothesis testing section, the Mann–Whitney U, Kruskal-Wallis, Spearman correlation coefficient, and Generalized Linear Model were implemented. For all statistical analyses, a significance level of less than 0.05 was considered. Data analysis was performed using SPSS-22 (IBM, Armonk, NY, USA).
3.13. Ethical considerations
This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences with the code IR.MAZUMS.REC.1402.161. All participants completed a written informed consent form and were assured that their participation was entirely voluntary and that their information would be kept confidential. Additionally, vitiligo patients whose depression or anxiety scores were evaluated as severe, and those at risk of suicide, were referred to a psychiatrist or psychologist. The participants were informed about the purpose of the study, assured of their voluntary participation, and guaranteed the confidentiality of their information. All participants provided written informed consent.
4. Results
Most study participants were women (58%), married (61.3%), urban residents (74.8%), and had either a bachelor's degree (26.9%) or a diploma (26.1%). The majority of participants were of moderate economic status (73.1%). The mean age of vitiligo patients was 32.12 ± 17.34 years. Table 1 shows the mean, standard deviation, and mean ranks of patients' characteristics in relation to depression and anxiety. Additionally, the mean and standard deviation for anger, perfectionism, forgiveness, and alexithymia were 118.10 ± 18.24, 83.91 ± 48.17, 77.87 ± 11.40, and 51.03 ± 11.06, respectively (Table 1).
Table 1.Correlation Between Mean Scores of Depressions, Anxiety and Demographic Variables
| Variables | Frequency (%) | Depression | Anxiety | ||
|---|---|---|---|---|---|
| Mean ± SD | Mean Ranks | Mean ± SD | Mean Ranks | ||
| Gender | |||||
| Woman | 69 (58.0) | 5.26 ± 5.30 | 66.97 | 13.54 ± 9.04 | 68.71 |
| Man | 50 (42.0) | 2.82 ± 3.92 | 50.38 | 8.65 ± 8.35 | 48.74 |
| P-value a | 0.008 | 0.001 | |||
| Marital status | |||||
| Single | 46 (38.7) | 4.91 ± 5.24 | 64.86 | 11.52 ± 9.21 | 60.25 |
| Married | 73 (61.3) | 3.81 ± 4.67 | 56.94 | 11.48 ± 9.005 | 59.84 |
| P-value a | 0.212 | 0.950 | |||
| Occupation | |||||
| Employee | 15 (12.6) | 2.93 ± 4.04 | 50.70 | 8.67 ± 7.35 | 49.63 |
| Self-employed | 39 (32.8) | 3.10 ± 3.47 | 55.35 | 9.44 ± 7.85 | 51.96 |
| worker | 5 (4.2) | 4.60 ± 6.14 | 20.59 | 14.00 ± 11.20 | 67.70 |
| Other | 60 (50.4) | 5.27 ± 5.62 | 55.42 | 13.33 ± 9.68 | 67.18 |
| P-value b | 0.330 | 0.097 | |||
| Education | |||||
| High-school and lower | 29 (24.4) | 5.24 ± 6.04 | 63.86 | 13.21 ± 9.16 | 66.95 |
| Diploma | 31 (26.1) | 3.23 ± 3.71 | 58.15 | 11.35 ± 9.68 | 68.18 |
| Associate degree | 7 (5.9) | 3.14 ± 3.02 | 57.36 | 7.57 ± 0.45 | 45.71 |
| Bachelor’s degree | 32 (26.9) | 4.81 ± 5.71 | 61.33 | 11.00 ± 10.37 | 59.81 |
| Master and higher | 20 (16.8) | 3.80 ± 3.68 | 60.73 | 11.40 ± 10.37 | 58.05 |
| P-value b | 0.891 | 0.638 | |||
| Disease status | |||||
| Stable | 59 (49.6) | 3.97 ± 4.32 | 59.78 | 9.66 ± 7.06 | 52.80 |
| Developing | 42 (35.3) | 5.02 ± 5.64 | 63.19 | 12.67 ± 10.43 | 62.56 |
| Accumulating | 13 (10.9) | 2.77 ± 4.76 | 50.8 | 13.08 ± 9.87 | 65.65 |
| Developing and accumulating | 5 (4.2) | 4.60 ± 5.50 | 61.60 | 19.20 ± 11.69 | 85.20 |
| P-value b | 0.679 | 0.203 | |||
| Type of vitiligo | |||||
| Focal | 9 (7.6) | 4.67 ± 5.67 | 63.00 | 8.78 ± 7.41 | 49.17 |
| Segmental | 10 (8.4) | 3.70 ± 5.35 | 56.15 | 10.50 ± 9.27 | 55.05 |
| Mixed | 1 (0.8) | 0.001 ± 0 | 21.00 | 8.00 ± 0 | 48.50 |
| Generalized | 82 (68.9) | 4.22 ± 4.63 | 61.06 | 11.73 ± 8.57 | 62.00 |
| Acrofacial | 17 (14.3) | 4.65 ± 5.90 | 57.85 | 12.59 ± 12.17 | 59.68 |
| P-value b | 0.793 | 0.829 | |||
| Age (y) | 119 (100) | 34.17 | 12.32 | ||
| P-value | 0.131 (-0.14) | 0.093 (-0.016) | |||
| Duration of illness (Month) | 119 (100) | 109.15 | 106.52 | ||
| P-value c | 0.604 (-0.05) | 0.604 (-0.09) | |||
| Duration of treatment (Month) | 119 (100) | 70.24 | 74.44 | ||
| P-value c | 0.746 (-0.03) | 0.361 (-0.08) | |||
| Illness severity | 119 (100) | 10.77 | 10.94 | ||
| P-value c | 0.058 (-0.017) | 0.240 (-0.011) | |||
a Mann-Whitney.
b Kruskal-Wallis.
c Spearman Correlation.
Table 2 displays significant positive correlations between anxiety and depression with anger, perfectionism, and alexithymia. As the mean scores of these variables increased, the scores for depression and anxiety also significantly increased. Additionally, a significant negative correlation was observed between anxiety, anger, perfectionism, and forgiveness. Therefore, an increase in the mean score of forgiveness led to a significant decrease in the scores for anger, perfectionism, and anxiety (Table 2).
Table 2.Correlation of Mean Scores of Study Variables in Vitiligo Patients (Spearman's Rank Correlation Coefficient)
a Correlation is significant at the 0.01 level (2-tailed).
b Correlation is significant at the 0.05 level (2-tailed).
Table 3 shows that only anxiety had a significant predictive correlation with depression scores. For each unit increase in the anxiety score, the depression score increased by 0.20 units (Table 3).
Table 3.Predictive Role of Factors Related to Depression in Vitiligo Patients Based on Generalized Linear Model
| Parameters | B | Std. Error | Sig. |
|---|---|---|---|
| (Intercept) | -1.420 | 4.6750 | 0.761 |
| Gender | |||
| Male | -1.011 | 0.8035 | 0.208 |
| Female | 0 | - | - |
| Marital status | |||
| Married | -1.242 | 1.0705 | 0.246 |
| Single | 0 | - | - |
| Vitiligo types | |||
| Focal | -.715 | 1.6921 | 0.673 |
| Segmental | -1.090 | 1.4328 | 0.447 |
| Mixed | -1.945 | 4.3785 | 0.657 |
| Generalized | -1.216 | 1.8608 | 0.514 |
| Acrofacial | 0 | - | - |
| Age | 0.007 | 0.0443 | 0.866 |
| Anger | 0.004 | 0.0245 | 0.856 |
| Perfectionism | 0.035 | 0.0263 | 0.181 |
| Forgiveness | -0.024 | 0.0359 | 0.512 |
| Alexithymia | 0.073 | 0.0424 | 0.085 |
| Anxiety | 0.190 | 0.0518 | 0.000 |
Anger, forgiveness, alexithymia, and depression had a predictive role in anxiety. For each unit increase in anger, alexithymia, and depression scores, the anxiety score increased by 0.12, 0.19, and 0.54 units, respectively. Conversely, each unit increase in the forgiveness score resulted in a 0.13 unit decrease in the anxiety score among the patients (Table 4).
Table 4.Predictive Role of Factors Related to Anxiety in Vitiligo Patients Based on The Generalized Linear Model
| Parameters | B | Std. Error | Sig. |
|---|---|---|---|
| (Intercept) | -4.627 | 7.8358 | 0.555 |
| Gender | |||
| Male | -1.615 | 1.3491 | 0.231 |
| Female | 0a | - | - |
| Marital status | |||
| Married | 1.460 | 1.8014 | 0.418 |
| Single | 0a | - | - |
| Vitiligo types | |||
| Focal | 3.484 | 2.8233 | 0.217 |
| Segmental | 2.264 | 2.4010 | 0.346 |
| Mixed | 4.455 | 7.3415 | 0.544 |
| Generalized | 2.993 | 3.1158 | 0.337 |
| Acrofacial | 0a | - | - |
| Age | -0.046 | 0.0742 | 0.535 |
| Anger | 0.116 | 0.0397 | 0.004 |
| Perfectionism | -0.001 | 0.0445 | 0.977 |
| Forgiveness | -0.132 | 0.0591 | 0.025 |
| Alexithymia | 0.189 | 0.0700 | 0.007 |
| Depression | 0.535 | 0.1458 | 0.000 |
5. Discussion
This study aimed to predict depression and anxiety in vitiligo patients by considering forgiveness, perfectionism, anger, and alexithymia in hospitals affiliated with Babol University of Medical Sciences in 2023.
The mean scores of the study participants indicated that their levels of depression and anxiety were mild. Additionally, over one-third of the patients suffered from mild to severe depression and anxiety. In the US, Cukor et al. reported low levels of depression and moderate levels of anxiety among vitiligo patients (9). However, Nasser et al. and Kussainova et al. found that most vitiligo sufferers experienced moderate to high levels of anxiety and depression (7, 10). Differences in cultural support for such patients could potentially impact their levels of depression and anxiety, which may explain the varying findings of these studies. Furthermore, the studies used different questionnaires to assess anxiety and depression, which could have led to different results. Nesayan et al. indicated a higher prevalence of anxiety, depression, and other psychological disorders in individuals with vitiligo compared to the general population (11). The present study's results demonstrated a significant correlation between the mean scores for depression and anxiety and gender. Women in the study had significantly higher mean scores for depression and anxiety compared to men. Other demographic variables did not show any significant correlation with depression. Gerogianni et al. also reported a significant correlation between anxiety, depression, and gender, with women exhibiting higher levels of anxiety and depression than men (49). Similarly, Önen et al. in Turkey found a significant correlation between the female gender and increased mean scores of anxiety and depression in vitiligo sufferers (50). Sawant et al. also showed that women with vitiligo had significantly higher levels of depression compared to men, consistent with the findings of the current study (51). In contrast, Alharbi did not report any significant correlation between gender, anxiety, and depression in vitiligo patients (52). Kao et al. also found no significant correlation between gender and the mean scores for anxiety and depression in such patients, aligning with the present research (53).
These differing results may be attributed to various cultural environments and conditions in the countries studied, which could potentially cause differences in the manifestation of anxiety and depression between women and men (54-56). Additionally, the use of different assessment tools for anxiety and depression in these studies may have contributed to the varying results (57, 58).
The findings of this research exposed a significant correlation between forgiveness, perfectionism, anger, alexithymia, anxiety, and depression scores, suggesting that higher levels of perfectionism, anger, and alexithymia are associated with increased depression and anxiety in patients. Additionally, the findings revealed a negative correlation between forgiveness and both anxiety and depression. In this study, anxiety was the only predictor of depression, while forgiveness, anger, alexithymia, and depression were predictors of anxiety in vitiligo sufferers. Furthermore, the study found that forgiveness, anger, alexithymia, and depression were predictors of anxiety in vitiligo patients.
Consistent with these findings, Narimani et al. conducted a cross-sectional study on the predictive role of alexithymia and mindfulness in depression and anxiety in women with cancer. The results indicated that personality traits and mindfulness are important factors contributing to depression and anxiety among cancer patients, and improving these indicators can significantly reduce anxiety and depression (8). Besharat et al. found a relationship between perfectionism and anxiety with the mediating role of emotion regulation difficulties. The results showed that perfectionism and emotion regulation difficulties can predict the severity of depression and anxiety symptoms (59). Although the study revealed that perfectionism is correlated with depression and anxiety, it was not a predictor of depression and anxiety among the patients. In Turkey, Namdar also found a significant positive correlation between alexithymia and the presence of anxiety and depression in vitiligo sufferers (30). Stanley et al. identified anger as a contributing factor to the prevalence of anxiety and depression (60).
By analyzing the findings of the present study and comparing them with prior works, it can be concluded that several significant factors, including alexithymia, anger, and forgiveness, may serve as indicators of anxiety in individuals diagnosed with vitiligo. The results also revealed that anxiety is the only main predictor of depression in such patients.
The limitations of this study include its correlational design and the use of self-report measures to collect data. Although measures with known reliability and validity were chosen, the accuracy of responses largely depended on the participants’ readiness, motivation, and memory. Additionally, convenience sampling limited the generalizability of our findings.
Despite these limitations, this study was the first to examine the predictive role of psychological factors in relation to anxiety and depression in vitiligo patients with an acceptable sample size. Therefore, we believe that this study is promising for future researchers to further investigate the question of how addressing such variables can prevent anxiety and depression in vitiligo sufferers.
5.1. Conclusions
The findings of this study emphasize the crucial role of addressing psychological factors in the care of vitiligo patients to enhance their overall well-being and quality of life. By further investigating and implementing interventions targeting these factors, we can gain a deeper understanding of the mental health challenges faced by individuals living with vitiligo. This knowledge can be used to develop more effective strategies for supporting these individuals and promoting their mental health and emotional resilience. Ultimately, a holistic approach to the management and treatment of vitiligo, which includes attention to psychological factors, can lead to improved outcomes and an enhanced quality of life for patients.
