Sylvia van Beugen, MSc Joyce Maas, MSc Dr. Antoinette van Laarhoven Dr. Mike Rinck

1. Implicit tendencies regardingstigmatization in psoriasis patients Sylvia van Beugen, MSc Joyce Maas, MSc Dr. Antoinette van Laarhoven Dr. Mike Rinck Prof. dr. Eni Becker Dr. Henriët van Middendorp Prof. dr. Andrea Evers Radboud University Nijmegen Medical Centre Department of Medical Psychology

2. Psoriasis Radboud Expert Centre for Psychology & Medicine Chronicinflammatory skin conditioncharacterized by recurring red patches covered with silvery scales Occurs when skin cells grow too quickly Prevalence: 2% worldwide Substantial influence on daily life

3. Psoriasis: notjust skin deep Worrying Decreasedself-esteem Anxiousmood Problemswithrelationships Depressivemood (e.g. Evers et al., 2005; Fortune et al., 1997;Fortune et al., 2000; Gupta & Gupta, 1998; Rapp et al.1999; Richards et al., 2001; Russo et al., 2004)

4. Psychosocial impact of psoriasis • Psoriasis patients may be confronted with or anticipate reactions of disgust and aversion  negative influence on personal and social life • Over 90% of patients experience stigmatization to some degree (e.g. staring, thinking it’s contagious, negative remarks at gym, hairdresser, pool, job...) • Perceptions of stigmatization are determinants of disability. Potentially even stronger determinants than disease severity and general psychological distress (e.g. Ginsberg & Link, 1993;Hrehorów et al., 2011;Picardi et al., 2005; Richards et al., 2001)

5. Previous research based on questionnaires.. What about implicit processes? (E.g. Heuer et al., 2007; Schmidt et al., 2009; Schuck et al., 2011; Wiers et al., 2010, 2011)

6. What are implicitmeasures and why do we usethem? Limitations explicit measures: • Relyon (and are limited to) patients’ introspection • Socialdesirability Alternative: complement withimplicitmeasures: • Indirect • Immediatereactions • Reactiontimeson computer tasks • Responses to words and pictures  Example: (modified) stroop task (E.g. de Houwer, 2006; Roefs et al., 2011)

7. Implicitprocesses in psoriasis: Stroop task disguststareridiculegrimace shockwhisperfrowningdisgust repelledignoregrimacestare whisperridiculerepelledignore •  Psoriasis patientsslowerthanhealthycontrols to name colors of wordsthat are related to socialevaluation /socialthreat, and to disease-specificwords Fortune et al., 2003

8. Implicit processess and stigmatization / social interaction • Social anxiety: implicit avoidance tendencies towards emotional (angry, happy..) faces. • No difference in explicit valence ratings between social anxiety and healthy controls, but strongerimplicitavoidance reactions in socialanxiety. • Socially anxious people rated happy faces positively, but responded to them with implicit avoidance reactions. (e.g. Heuer et al., 2007, Lange et al., 2008, Roelofs et al., 2010)

9. Implicit interventions: Cognitive Bias Modification • Alcohol dependance: Retraining alcohol approach/avoidance tendencies  less alcohol consumption in hazardous drinkers and less relapse after a year in alcoholic patients • Anxiety: Home-based retraining of attentional response to emotionally negative stimuli  reduced (trait) anxiety & reduced responses to stressors • Social anxiety: Attentionaldisengagement from disgusted faces  significant reductions in social anxiety and trait anxiety, maintained at 4 month FU. (Alcohol: Wiers et al., 2010; Wiers et al., 2011 Anxiety: Amir et al., 2009; See et al., 2009; Social anxiety: Schmidt et al., 2009 )

10. Currentstudy: implicitreactions to stigma-related stimuli Research question: Do psoriasis patients show alteredautomatic approach/avoidance tendencies in response to stigmatization-relatedphotos  ApproachAvoidanceTask (AAT)

11. Participants Psoriasis patients (n = 44; dermatology departments & Psoriasis Association) Healthy controls (n = 44; friends, family, partners of patients) Inclusion criteria: - dermatologist-confirmed diagnosis of psoriasis - age ≥ 18 years Exclusion criteria: - severe physical and/or psychological comorbidity

12. Approach-Avoidance Task (AAT) (Rinck & Becker, 2007 ) Radboud Faces Database (Langner et al., 2010)

13. Approach-AvoidanceTask Patientsperform a joystick taskcontainingpictures, and are instructed to do a taskunrelated to the content of the pictures Example: - Pull greypictures (picturesbecomelargerapproach) - Push sepia pictures (picturesbecome smaller avoid)

14. Stimulus response compatibility effect • People are faster to avoidthan to approach aversive stimuli • People are faster to approachthan to avoid pleasant stimuli (Rinck & Becker, 2007)

15. Socialthreat AAT TASK: push sepia / pull grey C1. neutralfaces C2. disgustedfaces C3. sadfaces C4. happy faces Hypotheses: Psoriasis patients will show: avoidance bias towards disgust sad, neutral, happy  maybealsoavoidance (in linewithsocialanxiety)

16. Preliminaryresults • Psoriasis patients and healthy controls both showed an altered approach/avoidance tendency towards disgusted faces and neutral faces; faster to avoid and slower to approach • This may indicate an implicit bias related to social rejection •  disgust reactions are often feared • However: no group differences.. comparability? • Lack of information on general tendency to avoid disgusted faces in healthy individuals, no comparable studies.

17. Implications and future directions • Follow-up study with matched control group • Other patient samples  current study in alopecia areata • Development of implicit trainings for chronic skin conditions, focusing on stigmatisation For example : - training to reduce behavioral bias towards emotional faces  impact on stigmatization experience?

18. Thankyouforyourattention! Withthanks to… MedicalPsychology, Radboud UniversityMedical Centre • Prof. dr. A.W.M. Evers • Dr. H. van Middendorp • Dr. A.I.M. van Laarhoven Dermatology, Radboud UniversityMedical Centre • Prof. dr. P.C.M. van de Kerkhof Dermatology, Rijnstate hospital • Dr. J.V. Smit BSI Radboud University • J. Maas, MSc • H. Niermann • E. Schoneveld • Dr. M. Rinck • Prof. dr. E. Becker