The The Self-Concept and Feelings of Guilt and Shame in Patients with Psoriatic Arthritis: A Literature Review
DOI:
https://doi.org/10.57125/FEM.2026.06.30.06Keywords:
Psoriatic arthritis;, self-concept, guilt, shame, alexithymia, depression, Common-Sense Model, psychosomatic medicine;, anxiety;, stress, illness representationsAbstract
Background: Psoriatic arthritis (PsA) is a chronic, systemic autoimmune disease that severely compromises patients' physical and psychosocial well-being. This literature review aims to synthesise contemporary scientific data to examine the multi-layered self-concept in PsA patients and evaluate the bidirectional, stress-mediated relationships between psychological attributes and somatic disease progression from a psychotherapeutic perspective.
Methods: A systematic literature search was conducted across international and national electronic databases (PubMed, ScienceDirect, ResearchGate, eLibrary, CyberLeninka) and finalized in January 2026. The search targeted peer-reviewed clinical, observational, qualitative studies, and meta-analyses published between 2015 and 2025, focusing on psychosomatic manifestations, illness representations, and emotional constructs in PsA.
Results: The findings demonstrate that the self-concept in PsA patients operates across three hierarchical levels: somatic, evaluative, and cognitive-behavioural. At the somatic level, visible skin lesions and chronic pain catalyze body dissatisfaction and skin-related shame. At the evaluative level, shame and unconscious racket guilt, examined through transactional analysis, operate as destructive internalized auto-aggression. Recent neuroimmune data confirm that depression in PsA serves as a true somatic comorbidity driven by the CRH-MC-Th17 axis. At the cognitive-behavioural level, patients exhibit severe cognitive uncertainty across Leventhal’s Common-Sense Model, while alexithymia acts as a key predictor of disease exacerbation.
Conclusion: The review concludes that the psychological burden of PsA is intricately linked to its pathogenetic mechanisms, with unconscious racket guilt and alexithymia representing key predictors of disease exacerbation. Consequently, there is an urgent need to validate specific psychometric tools for guilt in PsA and to integrate specialised psychotherapy alongside psychopharmacotherapy into standard clinical guidelines to improve remission quality and reduce the healthcare system burden.
References
Ritchlin CT, Colbert RA, Gladman DD. Psoriatic arthritis. N Engl J Med. 2017;376(10):957-970. https://doi.org/10.1056/NEJMra1505557
Gladman DD, Antoni C, Mease P, et al. Psoriatic arthritis: epidemiology, clinical features, and pathogenesis. Ann Rheum Dis. 2005;64(Suppl 2):ii14-ii17. https://doi.org/10.1136/ard.2004.032482
Alinaghi F, Calov M, Kristensen LE, et al. Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(1):251-265. https://doi.org/10.1016/j.jaad.2018.06.027
Gelfand JM, Gladman DD, Mease PJ, et al. Epidemiology of psoriatic arthritis in the population of the United States. J Am Acad Dermatol. 2005;53(4):573-577. https://doi.org/10.1016/j.jaad.2005.03.046
Gasparyan AY, Ayvazyan I. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int. 2011;31(11):1409-1417. https://doi.org/10.1007/s00296-011-1999-3
Heinroth JA. [Textbook of disturbances of mental life, or mental disturbances and their treatment]. Leipzig: Vogel; 1818. German.
Alexander F. Psychosomatic Medicine: Its Principles and Applications. New York: W.W. Norton & Company, 1950.
Orbai AM, de Wit M, Mease PJ, et al. International patient and physician consensus on a psoriatic arthritis core outcome set for clinical trials. Ann Rheum Dis. 2017;76(4):673-680. https://doi.org/10.1136/annrheumdis-2016-210242
Ogdie A, de Wit M, Callis Duffin K, et al. Defining the core domain set for psoriatic arthritis: report from the OMERACT 2016 Psoriatic Arthritis Working Group. J Rheumatol. 2017;44(11):1677-1681. https://doi.org/10.3899/jrheum.170150
Snoeck Henkemans SVJ, Vis M, Koc GH, Luime JJ, Kok MR, Tchetverikov I, et al. Association between depression, anxiety and inability to achieve remission in rheumatoid arthritis and psoriatic arthritis. Rheumatology. 2025;64(5):2411-2418. https://doi.org/10.1093/rheumatology/keae621
Mease PJ, Armstrong AW. Managing patients with psoriatic disease: the diagnosis and monitoring of cutaneous psoriasis and psoriatic arthritis. Drugs. 2014;74(4):423-441. https://doi.org/10.1007/s40265-014-0191-y
Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017;47(3):351-360. https://doi.org/10.1016/j.semarthrit.2017.05.010
Zhang H, Yang Z, Tang K, Sun Q, Jin H. Stigmatization in Patients With Psoriasis: A Mini Review. Front Immunol. 2021 Nov 15;12:715839. https://doi.org/10.3389/fimmu.2021.715839
Hannech E, Boussaa H, Miladi S, Fazaa A, Souabni L, Kassab S, et al. POS0874 Do patients with psoriatic arthritis experience more feelings of shame and guilt than patients with rheumatoid arthritis? Ann Rheum Dis. 2023;82(Suppl 1):743. https://doi.org/10.1136/annrheumdis-2023-eular.5921
Hannech E, Boussaa H. POS0985 – PARE Factors associated with feelings of guilt and shame in patients with psoriatic arthritis. Ann Rheum Dis. 2023;82(Suppl 1):809. https://doi.org/10.1136/annrheumdis-2023-eular.5796
Blaginina II. [Features of pain syndrome and psycho-emotional status in patients with psoriatic arthritis depending on the presence of signs of autonomic dysfunction]. Bol' Sustavy Pozvonochnik. 2014;(1-2):48-53. Russian.
Gudu T, Gossec L, de Wit M, Scire CA, Ramiro S, Szekanecz Z, et al. Pain catastrophizing in rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: biopsychosocial perspective and impact on health-related quality of life. RMD Open. 2020;6(1):e001185. https://doi.org/10.1007/s00296-021-05070-4
Korotaeva TV. [Influence of the neuropathic component of pain syndrome on clinical and laboratory activity and quality of life in patients with psoriatic arthritis]. Rheumatology Science and Practice. 2014;52(3):297-301. Russian.
Koreshkova KY, Khismatullina ZR. Quality of life in psoriatic arthritis: a review of selected methods and their results. Klin Dermatol Venerol. 2022;21(4):418-424. Russian. https://doi.org/10.25208/vdv1213
Krajewska-Włodarczyk M, Owczarczyk-Saczonek A, Placek W. Fatigue – an underestimated symptom in psoriatic arthritis. Reumatologia. 2017;55(3):125-130. https://doi.org/10.5114/reum.2017.68911
Lubrano E, Ambrosino P, Perrotta F, et al. Psychological health in the management of patients with psoriatic arthritis: an intricate relationship. Rheumatol Ther. 2022;9(2):353-366. https://doi.org/10.1007/s40744-025-00759-5
Fayrushina IF. Fatigue in psoriatic arthritis: is there a link with disease activity and quality of life?. Prakticheskaya meditsina. 2024;22(4):165-171. Russian.
Wong IT, Chandran V, Li S, Gladman DD. Sleep Disturbance in Psoriatic Disease: Prevalence and Associated Factors. J Rheumatol. 2017 Sep 15;44(9):1360-1366. https://doi.org/10.3899/jrheum.161330
Dontsova EV, Novikova LA. [Psycho-emotional state and quality of life of patients with psoriatic arthritis with concomitant metabolic syndrome]. Lechebnoe Delo. 2025;(3-4):59-65. Russian.
Praveenkumar U, Ganguly S, Ray L, Nanda SK, Kuruvila S. Prevalence of Metabolic Syndrome in Psoriasis Patients and its Relation to Disease Duration: A Hospital Based Case-Control Study. J Clin Diagn Res. 2014 Nov;8(11):CC05-CC08. https://doi.org/10.7860/JCDR/2016/17791.7218
Oynotkinova OS, Roytberg GE, Sharkhun OO, Shaposhnikova OA. [Cardiovascular risk in comorbid patients with psoriasis and metabolic syndrome]. Effektivnaya Farmakoterapiya. 2024;20(43):70–76. doi: 10.33978/2307-3586-2024-20-43-70-76. Russian.
Gelfand JM, Yeung H. Metabolic syndrome in patients with psoriatic disease. J Rheumatol Suppl. 2012 Jul;89:24-28. https://doi.org/10.3899/jrheum.120237
Ten Klooster PM. Feelings of guilt and shame in patients with rheumatoid arthritis. Clin Rheumatol. 2014;33(7):903-910. https://doi.org/10.1007/s10067-014-2516-3
Ruzhinskikh AG. [Features of personality and mental characteristics in patients with varying severity of psoriasis]. Sibirskiy Vestnik Psikhiatrii i Narkologii. 2017;(1):52-55. Russian.
Chimenti MS, Fonti GL, Conigliaro P, Hitaj J, Triggianese P, Teoli M, et al. Evaluation of alexithymia in patients affected by rheumatoid arthritis and psoriatic arthritis: A cross-sectional study. Medicine (Baltimore). 2019 Jan;98(4):e13955. https://doi.org/10.1097/MD.0000000000013955
Larsen MH, Krogstad AL, Wahl AK, et al. Alexithymia, illness perception and disease self-management in patients with chronic inflammatory skin and joint diseases. Acta Derm Venereol. 2023;103:adv00892. https://doi.org/10.2340/00015555-2707
Tang FY, Xiong Q, Gan T, Yuan L, Liao Q, Yu YF. The prevalence of alexithymia in psoriasis: A systematic review and meta-analysis. J Psychosom Res. 2022 Oct;161:110993. https://doi.org/10.1016/j.jpsychores.2022.111017
Sampogna F, Puig L, Spuls P, Girolomoni G, Radtke MA, Kirby B, et al. Prevalence of alexithymia in patients with psoriasis and its association with disease burden: a multicentre observational study. Br J Dermatol. 2017 May;176(5):1195-1203. https://doi.org/10.1111/bjd.15243
Turri M, Capparelli E, Del Vescovo S, Iacovantuono M, Monosi B, Mori G, et al. Exploring the relationship between alexithymia, pain perception, and disease burden in a cohort of patients with psoriatic arthritis [abstract]. Reumatismo. 2021;73(S1):2002. https://doi.org/10.4081/reumatismo.2025.2002
English F. The substitution factor: Rackets and real feelings. Trans Anal J. 1971 Oct;1(4):225-230. https://doi.org/10.1177/036215377100100408
Berne E. Games People Play: The Psychology of Human Relationships. New York: Grove Press; 1964.
Dowlatshahi EA, Wakkee M, Arends LR, Nijsten T. The prevalence and odds of depressive symptoms and clinical depression in psoriasis patients: a systematic review and meta-analysis. J Invest Dermatol. 2014 Jun;134(6):1542-1551. https://doi.org/10.1038/jid.2013.508
Mathew AJ, Chandran V. Depression in Psoriatic Arthritis: Dimensional Aspects and Link with Systemic Inflammation. Rheumatol Ther. 2020 Jun;7(2):287-300. https://doi.org/10.1007/s40744-020-00207-6
Kotsis K, Voulgari PV, Tsifetaki N, Machado MO. Anxiety and depressive symptoms and illness perceptions in psoriatic arthritis and associations with physical health-related quality of life. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1593-601. https://doi.org/10.1002/acr.21725
Dantzer R, O'Connor JC, Lawson MA, Kelley KW. From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci. 2008 Jan;9(1):46-56. https://doi.org/10.1038/nrn2297
Schwarcz R, Bruno JP. The kynurenine pathway and neuroinflammatory disorders. Nat Rev Neurosci. 2012 Jul;13(7):465-477. https://doi.org/10.4103/1673-5374.198971
Raison CL, Miller AH. Is depression an inflammatory disorder? Curr Psychiatry Rep. 2011 Dec;13(6):467-475. https://doi.org/10.1007/s11920-011-0232-0
Snoeck Henkemans SVJ, Vis M, Koc GH, Luime JJ, Kok MR, Tchetverikov I, et al. Association between depression and anxiety and inability to achieve remission in rheumatoid arthritis and psoriatic arthritis. Rheumatology (Oxford). 2025 May;64(5):2411-2418. https://doi.org/10.1093/rheumatology/keae621
Wang X, Wu L, Liu J, Ma C, Liu J, Zhang Q. The neuroimmune mechanism of pain induced depression in psoriatic arthritis and future directions. Biomed Pharmacother. 2025 Jan;182:117865. https://doi.org/10.1016/j.biopha.2024.117802
Karamova AE, Vorontsova AA, Obraztsova OA, Nikonorova ER, Nikonorov AA, Deryabin DG, et al. [Blood cytokines in psoriasis: Association with clinical scores of the disease severity and psoriatic arthritis]. Annals of the Russian Academy of Medical Sciences. 2023;78(4):281-288. https://doi.org/10.15690/vramn8808 Russian.
Mahajan S, Mehta S, Das S, Jain U, Chauhan S, Dhankhar S. The Bidirectional Relationship between Psoriatic Arthritis and Mental Health: A Comprehensive Review. Curr Rheumatol Rep. 2025 Aug 15;21(2). https://doi.org/10.2174/0115733971402784250807191227
Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense representation of illness danger. In S. Rachman (Ed.), Contributions to Medical Psychology (Vol. 2, pp. 7–30). New York: Pergamon Press.
Mishel MH. Uncertainty in illness. Image J Nurs Sch. 1988 Winter;20(4):225-32. https://doi.org/10.1111/j.1547-5069.1988.tb00082.x
Erskin J, Dures S. Exploring the illness representations of people with psoriatic arthritis: a secondary analysis of focus group data. Rheumatol Adv Pract. 2018;2(2):rky023. https://doi.org/10.1093/rap/rky023
Fortune DG, Richards HL, Main CJ, Griffiths CE. What patients with psoriasis believe about their condition. J Am Acad Dermatol. 1998 Aug;39(2 Pt 1):196-201. https://doi.org/10.1016/s0190-9622(98)70074-x
Pearl RL, Wan J, Takeshita J, Gelfand JM. Stigmatizing attitudes toward persons with psoriasis among laypersons and medical students. J Am Acad Dermatol. 2019 Jun;80(6):1584-1589. https://doi.org/10.1016/j.jaad.2018.08.014
Wan MT, Pearl RL, Chiesa Fuxench ZC, Takeshita J, Gelfand JM. Anticipated and Perceived Stigma Among Patients With Psoriasis. J Psoriasis Psoriatic Arthritis. 2020 Jul;5(3):93-99. https://doi.org/10.1016/j.jaad.2018.08.014
Grossschaedl K, Weger W, Graier T, Salmhofer W, Mrowietz U, Wolf P. Psoriasis and its impact on close relatives and partners of patients – A cross-sectional questionnaire study. Skin Health Dis. 2024;4(3):e355. https://doi.org/10.1002/ski2.355
Dures E, Hewlett S, Lord J, Bowen C, McHugh N, Tillett W; PROMPT Study Group. Important treatment outcomes for patients with psoriatic arthritis: a multisite qualitative study. Patient. 2017;10(4):455-462. https://doi.org/10.1007/s40271-017-0221-4
Furst DE, Tran M, Sullivan E, Pike J, Piercy J, Herrera V, Palmer JB. Misalignment between physicians and patient satisfaction with psoriatic arthritis disease control. Clinical Rheumatology. 2017;36(9):2045-2053. https://doi.org/10.1007/s10067-017-3578-9
Ilyin EP. [Psychology of Aggressive Behavior]. Saint Petersburg: Piter; 2014. Russia.
Terluin B, van Marwijk HW, Adèr HJ, de Vet HC, Penninx BW, Hermens ML, et al. The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry. 2006;6:34. https://doi.org/10.1186/1471-244X-6-34
Derogatis LR. SCL-90-R: Symptom Checklist-90-R Administration, Scoring, and Procedures Manual. 3rd ed. Minneapolis: National Computer Systems; 1994.
Butcher JN, Dahlstrom WG, Graham JR, Tellegen A, Kaemmer B. Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for Administration and Scoring. Minneapolis: University of Minnesota Press; 1989.
Widdowson M. Avoidance, vicious cycles, and experiential disconfirmation of script: Two new theoretical concepts and one mechanism of change in the psychotherapy of depression and anxiety. Transactional Analysis Journal. 2014;44(3):194-207. https://doi.org/10.1177/0362153714554207
Spillekom-van Koulil S, Ferwerda M, van Beugen S, van Middendorp H, van de Kerkhof PCM, van Riel PLCM, et al. Tailored Therapist-guided Internet-based Cognitive-behavioural Treatment for Psoriasis and Rheumatoid Arthritis: Two Case Reports. Acta Derm-Venereol. 2018;98(2):218-224. https://doi.org/10.2340/00015555-2803
van Beugen S, Ferwerda M, Spillekom-van Koulil S, Smit JV, Zeeuwen-Franssen MEJ, Kroft EBM, et al. Tailored Therapist-Guided Internet-Based Cognitive Behavioral Treatment for Psoriasis: A Randomized Controlled Trial. Psychother Psychosom. 2016;85(5):297-307. https://doi.org/10.1159/000447267
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