Vitiligo and Psychodrama Therapy

Vitiligo and Psychological Distress: Pilot Study for the Experimentation of a Psychodramatic Psychotherapy Treatment

Università degli Studi di Brescia, Scuola Psicoterapia Psicodrammatica Brescia, Università degli Studi di Trento

The goal of this pilot clinical trial is to assess the effectiveness of psychodramatic psychotherapy in reducing the psychological distress and/or the skin condition in patients with vitiligo. The main questions it aims to answer are: Is there any improvement in terms of psychological distress in patients with vitiligo participating in a psychodramatic psychotherapy, compared to a control group? Is there any improvement in terms of skin condition in patients with vitiligo participating in a psychodramatic psychotherapy, compared to a control group? Participants in the experimental group will receive the dermatological drug treatment usually recommended for vitiligo, and in addition they will participate in a 6 months psychodramatic psychotherapy. Researchers will compare the results of the experimental group with the results of a control group including vitiligo patients who will receive the dermatological pharmacological treatment usually recommended for vitiligo and participate in a 6 months program of self-help activities.

The primary aim of this pilot study is to assess any possible improvement in terms of psychological distress in patients with vitiligo participating in a psychodramatic psychotherapy (PSD), in addition to the usual pharmacological treatment with hydrocortisone and heliotherapy. The secondary aim is to assess any improvement in terms of vitiligo skin condition and/or other systemic autoimmune diseases symptoms. The study will involve 24 patients with vitiligo aged between 18 and 55 years, attending the dermatology services of the Azienda Provinciale per i Servizi Sanitari (APSS) of Trento. Patients will be randomly assigned to one of the two groups: 12 patients will receive the dermatological pharmacological treatment usually recommended for vitiligo, and in addition they will participate in a psychodramatic group psychotherapy for 6 months (PSD experimental group); 12 patients will receive the dermatological pharmacological treatment usually recommended for vitiligo, and in addition they will receive self-help activities for 6 months (non-PSD control group). The experimental group (PSD) will attend the psychodramatic psychotherapy, which will include: 1 individual motivational interview; 1 weekly group session lasting 2 hours for 1 month (total 4 meetings); 1 group session every 15 days lasting 2 hours, for 5 months (total 10 meetings). The control group (non-PSD) will attend self-help activities as follows: 1 individual motivational interview; 1 weekly, 2 hours group meeting, for 1 month (total 4 meetings); 1 group meeting lasting 2 hours every 15 days, for 5 months (total 10 meetings). To all patients participating in the study, the following pharmacological treatment will be administered: Hydrocortisone acetate with the following dosage: 1 Finger Unit /15 cm2 per day. Duration: 10 days a month for 6 months. Free exposure to the sun without photoprotection from 9.00 AM to 11.00 AM. A clinical evaluation will be carried out at: Time 0 (T0): right before the beginning of the intervention Time 1 (T1): after 6 months, at the end of the intervention For both groups, a follow-up will be performed after 6 months from the end of the intervention (psychodramatic psychotherapy or self-help activities).

This experimental arm will include 12 patients with vitiligo (randomly assigned to this arm), attending the dermatology services of APSS Trento. This experimental group will receive the drug treatment usually recommended for vitiligo, in addition to 6 months of psychodramatic psychotherapy.

This is a control arm which will include 12 patients with vitiligo (randomly assigned to this arm), attending the dermatology services of APSS Trento. This control group will receive the drug treatment usually recommended for vitiligo, in addition to 6 months of self-help activities.

The psychodramatic psychotherapy will include a total of 14 meetings during a 6 months period and they will be held in presence (or remotely in case of COVID-19 government restrictions) as follows: 1 individual motivational interview; 1 weekly group session lasting 2 hours for 1 month (total 4 meetings); 1 group session every 15 days lasting 2 hours, for 5 months (total 10 meetings). Patients will also receive the pharmacological treatment usually recommended for vitiligo.

The self-help activities will include: 1 individual motivational interview; 1 weekly, 2 hours group meeting, for 1 month (total 4 meetings); 1 group meeting lasting 2 hours every 15 days, for 5 months (total 10 meetings). Patients will also receive pharmacological treatment usually recommended for vitiligo.

The General Health Questionnaire (GHQ-12), a self-administered questionnaire covering several domains associated with a person's psychological well-being, will be administered to all patients. Scoring is along a 4-point scale (total score ranging from 0 to 36) with higher scores suggestive of more distress.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of the levels of psychological distress of patients with vitiligo, in terms of psychological, functional or physical state.

The Short-Form Health Survey (SF-36): a health status profile originally designed to measure health status and outcomes, will be administered to all patients. This instrument addresses health concepts from the patient's perspective and its 36 questions are meant to reflect 8 domains of health, evaluating any changes in the psychological, functional or physical state of patients. SF-36 scores range from 0 (worst) to 100 (best).

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of the levels of psychological distress of patients with vitiligo, in terms of anxiety symptoms

The Beck Anxiety Inventory (B.A.I.), a self-report measure of anxiety, will be administered to all patients. The BAI items are scored on a scale between 0 and 3 and have a maximum score of 63, with higher scores suggestive of higher levels of anxiety.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of the levels of psychological distress of patients with vitiligo, in terms of depressive symptoms

The Beck Depression Inventory (B.D.I.), a 21-question multiple-choice self-report inventory and one of the most widely used instruments for measuring the severity of depression, will be administered to all patients. A value of 0 to 3 is assigned for each answer and then the total score is compared to a key to determine the depression's severity. Higher total scores indicate more severe depressive symptoms.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of the levels of psychological distress of patients with vitiligo, in terms of spontaneity

The Revised Spontaneity Assessment Inventory (SAI-R) will be administered to all patients. The SAI-R is a scale for the assessment of spontaneity, evaluating feelings and thoughts that people experience in different daily situations. It includes 18 items, scored on a 5-point Likert scale. Higher total scores indicate higher levels of spontaneity (score range: 18-90)

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of vitiligo and/or other systemic autoimmune diseases symptoms, in terms of dermatological lesions related to vitiligo and any re-pigmentation

The Vitiligo Extent Score (VES) will be administered. The VES will be administered at Time 0 in order to evaluating the extent of vitiligo, and at Time 1 to evaluate any repigmentation. The VES is a template of vitiligo images that measures vitiligo at 19 different areas of the body. The physician has to score these 19 body areas separately by selecting the image that most resembles to patient's clinical in that body area, ranging from no lesion to almost 100% lesion coverage.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of vitiligo and/or other systemic autoimmune diseases symptoms, in terms of personal perception of the patient

The Self Administered version of Vitiligo Extent score (SA-VES) will be administered. The SA-VES is a patient-reported outcome measurement instrument that is similar to the VES (it includes only 12 areas). It will be self- administered at Time 0 in order to evaluating the extent of vitiligo, and at Time 1 to evaluate any repigmentation.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of vitiligo and/or other systemic autoimmune diseases symptoms, in terms of quality of life associated with the skin condition

Skindex-29, a three-dimensional, dermatology-specific Health-related quality of life questionnaire, will be administered. Skindex-29 items are combined to form three domains: symptoms, emotions, and functioning. The domain scores and an overall score are expressed on a 100-point scale, with higher scores indicating lower levels of quality of life.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

An adaptation of the Vitiligo Questionnaire ITA 4.0 will be administered. The Vitiligo Questionnaire ITA 4.0 measures several aspects of health status in vitiligo patients. It is self-administered and features thirty questions in five sections. These cover biologic factors, symptom status, functional status, treatment outcome perception, and economic impact.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Improvement of other autoimmune diseases, in terms of levels of levels of Thyroid Stimulating Hormone

Blood chemistry tests will be conducted to assess levels of Thyroid Stimulating Hormone (TSH), a pituitary thyroid-stimulating hormone that regulates thyroid activity. Reference values are 0.2-4.5 mU/L. Higher values may indicate thyroid hormone deficiency, lower levels may indicate thyroid hormone excess.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Blood chemistry tests will be conducted to assess levels of S-Free T4-Thyroxine (FT4), a thyroid hormone that regulates the body's metabolism, secretion of which is controlled by thyroid-stimulating hormone (TSH) produced by the pituitary gland. Reference values are 12.0 - 22.0 pmol/L. Higher values may indicate hyperthyroidism, lower levels may indicate hypothyroidism.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Blood chemistry tests will be conducted to assess levels of Anti Thyroglobulin (HTG), antibodies produced against thyroglobulin, a precursor protein of thyroid hormones triiodothyronine (FT3) and free thyroxine (FT4), indicating autoimmune pathology. Threshold value is 115 IU/ml; higher values may indicate possible development of hypothyroidism.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Blood chemistry tests will be conducted to assess levels of Anti Thyroperoxidase (TPO), an antibody which, attacking the enzyme peroxidase, identifying autoimmune thyroid disease. Threshold value is 34 IU/ml; higher values may be associated with either hyperthyroidism or hypothyroidism (depending on whether it's Graves' disease or Hashimoto's thyroiditis).

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Blood chemistry tests will be conducted to assess levels of Antinuclear Antibodies (ANA), antibodies produced by the body's immune system, indicating the presence of autoantibodies in circulating blood. Threshold value is 1:160.

Time 0: Before the beginning of the intervention; Time 1: after 6 months, at the end of the intervention

Inclusion Criteria: Segmental vitiligo with unilateral localization. Non-segmental vitiligo (acrofacial; mucosal with more than one side affected; generalized universal; mixed associated with segmental vitiligo). Vitiligo-associated autoimmune comorbidity referred to in points 1-2: Thyroiditis. Symptoms of depression and/or anxiety and/or low self-esteem associated with Vitiligo mentioned in points 1-2. Exclusion Criteria: Cognitive impairment/dementia (clinically diagnosed). Individual and/or group psychotherapy in progress. Have previously received other psychotherapy. Use of psychiatric drugs in the last 3 months.

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