Liffler P. (1), Peters E.M.J. (2), Gieler U. (3)
(1) Children's Clinic Bellevue, 23769 Fehmarn
(2) Department of Psychosomatics and Psychotherapy, Psychoneuroimmunology Laboratory, Justus Liebig University, Giessen
(3) Department of Dermatology and Allergology and Clinic for Psychosomatics and Psychotherapy, Psychosomatic Dermatology, Justus Liebig University, Giessen
Dr. med. Peter Liffler
04372 - 8064296
0160 - 90918992
Objectives: Clinically, the parents of children with atopic dermatitis often give the impression of increased sensitivity. It was examined, whether the parents show characteristics of “Sensory Processing Sensitivity" (SPS) such as extraordinary perception and processing, hypersensitivity to external stimuli, increased excitability and excessive demands.
Methods: 64 parents of children with atopic dermatitis were therefore examined with the Highly Sensitive Person Scale (Aron 1996) and three proven questionnaires. Parents with atopic disposition and children with atopic dermatitis (n= 44) were compared with non-atopic parents (n=20). In addition, atopic parents of slightly ill children (n = 24) and atopic parents of severely ill children (n = 20) were compared with non-atopic parents of children with atopic dermatitis (n=20).
Results: The comparison of 44 parents with atopic disposition with 20 non-atopic parents showed a significantly higher sensitivity, excitability, a stronger propensity for esoteric thinking and a reduced frustration tolerance in the parents with atopic disposition. They showed significant differences in three other characteristics: the mood was more depressed, life satisfaction was lower and stress increased. There were no significant differences between atopically predisposed parents of slightly ill children and atopically predisposed parents of seriously ill children.
Atopic dermatitis - parents with atopic disposition - Sensory processing sensitivity
Psychological factors are increasingly being included in the study of the etiopathogenesis of chronic inflammatory diseases such as atopic dermatitis (AD) (Dhabhar 2013; Peters et al. 2012; Ring et al. 2012; Senra u. Wollenberg 2014). Previous studies of the relationships between psychological factors and the development and maintenance of an AD have dealt with the effect of acute stress, circumscribed life events, specific personality factors or mental illnesses such as depression. Epidemiological approaches point to significant psychologicalcomorbidities in AD (Dalgard et al. 2015; Cheng et al. 2015; Kim et al. 2015). In summary, decades of research have led to the conclusion that intense psychological stress can at least negatively affect the course of AD, possiblyalso its development and that certain psychological factors, such as the existence of depression and disease-strengtheningbehavioral habits, may be associated with the increased occurrence of AD (Chida et al. 2008). In addition, a psychoneuroimmunological relationship is considered to be established, whichis partly influenced by the severity of the disease and by a number ofinfluencing factors such asgender (Peters 2013). Historisch the AD was associated with personality factors (Alexander 1943). This concept could not be scientifically proven (Gieler et al. 1990).
In the search for possible psychological explanations and therapeutic goals for the potential relationship between psychological factors and AD, the concept of "sensory-processing sensitivity" (SPS) is suitable (Aron and Aron 1997).
In 1996, psychologist Elaine N. Aron first described thecharacteristics of highly sensitive persons (HSP) (Aron 1996). A year later, the now scientifically established term "Sensory-processing sensitivity" (SPS) was introduced (Aron u. Aron 1997). By definition, sensory processing sensitivity does not refer to the sensory organs as solche, but to what happens in the sensory information, is transmitted to the brain or processed there. The construct assumes a more open and subtle perception as well as a more intensive and prolonged central nervous processing of internal and external stimuli (Aron 2006). For example, people with high SPS also report an increased response to stimuli such as pain, caffeine, hunger and loud noises (Liss et al. 2008) and show an affinity for spirituality (Blumentritt 2012). According to Aron, elevated SPS levels are a personality trait and not a disorder; they must be distinguished from seemingly similar characteristics, such as socially reserved behavior, shyness, mental disorders such as neuroticism. Negative emotionality is only found in people with SPS who were affected by an unfavorable parental environment during their childhood (Aron et al. 2012). In this respect, the "sensitive personality", which often appears similar in everyday life, must also be distinguished from an increased SPS, because it can develop a crisisor personality disorders requiring treatmentunder stress (Tölle 2013). The SPS is not assumed to be more susceptible to negative influences in the sense of a diathesis-stress model, but an increased responsiveness to positive and negative impressions (Ellis et al. 2011). According to Boterberg and Warreyn (2016), SPS is a temperament or personality trait present in some individuals that reflects increased sensitivity of the central nervous system and deeper cognitive processing of physical, social, and emotional stimuli. Genetic studies have now shown that higher SPS levels are linked to the serotonin transporter 5-HTTLPR short/short genotype (Licht etal. 2011) and polymorphisms in dopamine neurotransmitter genes and the ADRA2b norepinephrine-related gene variant (Todd et al. 2015). In an exploratory study, SPS was associated with significantly stronger activation in brain areas involved in higher-order visual processing (Jagiellowicz et al. 2011).
2. Hypotheses and goals
On the basis of the considerations presented, it is obvious to look for possible psychological influencing factors of this concept in a disease such as AD. There could be a relationship between the predisposition to increased SPS and the development and expression of an AD. Psychological predictors of itching in AD is by Schut et al. (2014) in a case-control study, where personality traits such as public self-esteem and tolerability were an influencing factor on perceived itching in addition to depression. Should a connection of an increased SPS be confirmed in parents of children suffering from AD, this would have to be taken into account both in primaryand secondary prevention, as well as in therapeutic recommendations. The following questions were pursued accordingly in a case-control study on parents of children suffering from AD:
1. Do parents of AD-sick children, who themselves are or were affected by a disease of the atopic form, differfrom parents without predisposition with regard to their SPS measuredin the HS test?
2. Are atopically inclined parents of severely AD-sick children different from atopically predisposedn parents of slightly AD-sickchildren?
3. Do atopically inclined parents of severely AD-sick children and atopically inclined parents of slightly AD-sick children differ compared to parents who are not atopically inclined?
4. How do the characteristics of the SPS manifest themselves in known and validated personality tests?
3.1 Ethics and participant recruitment
As part of the clinical diagnostics in the Children's Clinic for Pediatric Allergology, Dermatology and Pneumologie, 23769 Fehmarn OT Petersdorf, the parents of children with AD showed evidence of increased sensitivity, such as special care, a pronounced sense of justice, increased excitability and strain as well as the tendency to use complementary medical procedures. These properties seemed clinically important especially for the handling of the parents with infants and toddlers, where upon the HS test (E. Aron 1996) was used. Especially among the atopically inclined parents of children suffering from AD, significantly higher values were noticed.
The participants in the pilot study presented here were recruited from parents of children suffering from AD who accompanied their children during an average of 3 weeks of full inpatient treatment. All parents who were admitted between January 2013 and December 2016 were made aware of the possibility of data analysis in the context of scientific studies. The parents had been fully informed about the analyses and their objectives and had given their consent in writing to theuse of their data for scientific evaluation upon admission. A corresponding ethics vote for the evaluation of the routinely collected data was therefore not considered necessary by the Ethics Committee of the Schleswig-Holstein Medical Association.
3.2 Test Instruments
The following test instruments were used to answer these questions: In addition to the HS test by E. Aron, three proven information questionnaires were used: The Giessen Test (GT), Munich Personality Test (MPT) and the FreiburgPersonality Inventory (FPI-R).
The Highly Sensitive Person Scale (HS test) was developed by Aron in 1996. The 27 Items questionnaire is used to measure increased sensory processing sensitivity (SPS). The questionnaire has been scientifically examined several times. While Aron assumed a one-dimensional structure, other studies found the weakly correlated feature "sensitivity to aesthetic stimuli" in addition to the mainfeatures. HSP scale score patterns in adults were determined as a dichotomous categorical variable with a break point between 10% and 35%, with Aron selecting a cut-off of the 20% with the highest score to define the HSP category. Statistically, the test has good internal consistency and meets the requirements for reliability and validity (Smolewska et al. 2006; Evans u. Rothbart 2008; Boterberg u. Warreyn 2016).
The Gießen test (GT) is used for personality diagnostics (Beckmann etal. 1991) and consists of sixscales of 6 items each: Social Resonance (negative social resonant vs. positive social resonant), Dominance (dominant vs. docile), Control (uncontrolled vs. compulsive), Basic mood (hypomanic vs. depressive), Permeability (permeable vs. retentive) and Social Potency (socially potent vs. social impotent). The execution and evaluation of the GT are standardized The retest reliability of the six scales after six weeks was between r=.65 and r=.76. A study on 235 neurotic patients showed a mean internal stability of the scales of r=.86. The items selected according to socio-psychological and depth psychological aspects appear valid in terms of content.
The Munich Personality Test (MPT) is used for the time-economical, dimensional recording of thepersonality structure(Zerssen and Petermann 2012). The main indication is concomitant use within medical orpsycho-therapeutic interventions. The test scales include the personality dimensions extraversion, neuroticism, frustration tolerance, rigidity, isolation tendency, esoteric tendencies and norm orientation as well as an additional "control scale" motivations. All scales have a satisfactory internal consistency (Cronbach's a .68 - .88). The construct validity is given.
The Freiburg Personality Inventory (FPI-R) is a psychological personality test (Fahrenberg et al. 2010) with 138 items and the following scales:life satisfaction, social orientation, performance orientation, inhibition, excitability, aggressiveness, strain, physical complaints, health worries and two secondary scales: extraversion and emotionality in the sense of Eysenck. The comparison of the two representative surveys of 1982 and 1999 showed that the structure of the FPI-R as wellas test methodological statistics and reliability coefficients were very reproducible (Rohrmann u. Spinath 2011).
3.3 Composition of the sample
In total, data from 64 parents (34 mothers and 30 fathers) of a total of 36 consecutively recorded AD-sickchildren couldbe evaluated. 5 parent pairs (drop-outs) had denied participation for personal reasons.4 fathers of the 36 AD-sickchildren were not present for professional reasons. According to the results of an initial allergological questionnaire, 44 parents (25 mothers and 19 fathers) were themselves ill with a disease of the atopic form in the course of their lives. These parents are further referred to as AE. 31 parents (70.4%) were in their early childhood because of AD,13 (29.4%) 14 parents (31.8%) were still adolescents and in adulthood because of hay fever and bronchial asthma, 3 parents(8%) treated for AD.
20 parents (9 mothers and 11 fathers) had never suffered from a disease of the atopic form. These parents are later referred to as NAE.
Of the 36 children, 13 were seriously ill. Kinders with a total IgE of >500 kU/l (average 2177 kU/l), an expansion of eczema of > 50 % of the body surface area and intensive expression were considered to be seriouslyill. In 6 of the severely AD-sickchildren, both parents were atopic, in 7 children only one parent, i.e. 7 children and fathers of severely AD-sickchildren were not atopically predisposed. The median age forchildren affected was 3.3 years (SD 2.9) . The atopically parents ofseverely ADsick children (9 mothers and 11 fathers) are later referred to as AESV.
The 23 kinders with a total IgE of <500 kU/l (average 148.6 kU/l), an expansion of eczema < 5 0% of the body surface area and low to moderate intensity were considered to be slightly ill. The median age of the slightly ill children was 3.4 years (SD 2.2 years). In 8 of the 23 slightly ill children, both parents were atopic, in 11 only one parent and in 4 children both parents were healthy. The atopically parents ofslightly AD-sickchildren (16 mothers and 8 fathers) are later referred to as AELV.
The place of residence of the families was the region in which the children were born and raised (see Table 1 Sample description).
Table 1: Sample description: Non-atopic parents (NAE) versusatopic parents (AE) and atopically inclined parents of seriously ill children (AESV) versus atopically predisposed parents of slightly ill children (AELV)
Note: MW = mean, SD = standard deviation, p-value = statistical significance
The interference statistics of the 3 groups showed no significant differences as shown in Table 1.
The statistical evaluations were carried out with the program IBM SPSS Version 24.0 (IBM Böblingen 2017). For the sample description, the chi-square test was used, in the other comparisons the Mann-Whitney U test for independent samples. This tests whether the central tendencies of two independent samples are different. The Mann-Whitney test is a parameter-free test and independent of the normal distribution and the equality of variances.
4. Results and interpretation
4.1 Comparison of atopic parents (AE) versus non-atopic parents (NAE)
AE differed significantly from NAE in 4 scales (see Table2). AE show significantly higher values of the PLC (p=.000), express more "esoteric tendencies" (p=.011), show a lower "frustration tolerance" (p=.005) and an increased "excitability" (p=.013). The "basic mood" tends to be significant (p=<.10) more depressed (p=.059), the "lifesatisfaction" is lower (p=.062) and "stress" tends to be higher (p=0.58).
Table 2: Group comparison: Atopic parents (AE) versus non-atopic parents (NAE)
Note: MW= mean, SD= standard deviation, pvalue=statistical significance
Statistically significant at the following levels *≤.05; **≤.01; ≤,001. Mann-Whitney-T
4.2 Subgroup analysis
Atopically predisposed parents of seriously ill children(AESV) and atopically predisposed parents of slightly ill children (AELV) versus non-atopic parents (NAE)
AESV differed significantly from NAE in 3 scales (see Table 3): they show significantly increased PLC values (p=.001), a lower "frustration tolerance" (p=.016) and a higher "excitability" (p=.030). In 3 other scales, theytended todifferentiate significantly (p=<.10): they estimate their "social prestige" less (p=.084), weremore "dutiful" (p=.095) and tended to be more prone to "esoteric thinking" (p=.079).
AELV differed significantly from NAE in 4 scales (see Table 3):They show significantly increased SPS values (p=.000), more often "esoteric tendencies" (p=.007), a lower "frustration tolerance" (p=.012)and an increased "excitability" (p=.032). Tends to be significant (p= <. 10) they also differed in a further5 scales: their "basicmood" was more depressed (p=.065), the "lifesatisfaction" lower (p=.076), the "socialcaring" more pronounced (p=. 093), the "stress" increased (p=.091) and the"physical complaints" increased (p=.080).
Table 3: Subgroup comparison: Atopically predisposed parents of seriously ill children (AESV) and atopically predisposed parents of slightly ill children (AELV) vs. non-atopic parents (NAE)
Note: MW = mean, SD = standard deviation, p-value = statistical significance
Statistically significant at the following levels *≤.05; **≤.01; ≤,001. Mann-Whitney Test
In the direct comparison (t-test) of the group AESV and AELV there are no differences (not shown here).
The test results confirmthe hypothesis that AE properties of the construct of "sensory-processing sensitivity" show, as described by Boterberg and Warreyn (2016) also with reference to experimental investigations by Jagiellowicz et al. (2011). The properties are significantly confirmed with the test results of the AE. The increased esoteric tendencies are described as a tendency to the spirituality of Blumentritt (2012) and may be characteristic of AE. This property could be related to the statement in the AWMF Sk2 guideline, according to which almost half of AD patients, or their parents, favor complementary medical treatments (Werfel et al. 2016).
AELV tends to show more evidence of SPS than AESV. These results speak against a dependence of the SPS on the development of the disease of the children and confirm the assumption that the SPS is not a diathesis-stress model, but an increased responsiveness due to the more intensive sensory processing (Ellis et al. 2011).
Due to the relatively small sample and the recording in a specialized children's hospital, the study is certainly only representative to a limited extent. However, it should give a first indication of whether the increased SPS and a correspondingly shaped parenting style, as it had clinically appeared to the authors, could be a psychological cofactor in dealing with the AD-sick child, especially the age group of 0- to 6-year-olds with the highest 12-month prvälenz (Schmitz et al.2014). Because of the potential importance for amore effectivetreatment, more attention should be paid to this relationship in further studies with larger groups and in different settings.
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Dr. med. Peter Liffler
8. Short biography of the first author
Dr. med. Peter Liffler, specialist in paediatrics and adolescent medicine
Chief Physician of the Children's Rehabilitation Center Fehmarn (1988-90), the Therapeutic Agent Westfehmarn (1992-94) and the Bellevue Specialist Clinic (1995-2017). Head of the test model (§ 63 SGB V) of the GKV "Outpatient rehabilitation of diseases of the atopiccircle" (1995-2000). Development of an innovative form of care for allergy patients and infants with atopic dermatitis" (2012-2017).
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