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Temperament-Character Profile and

Psychopathologies in Patients with Alopecia
Areata

Ali Talaei, Yalda Nahidi, Golsan Kardan, Lida Jarahi, Behzad Aminzadeh,
Hasan Jahed Taherani, Mahsa Nahidi & Maliheh Ziaee

To cite this article: Ali Talaei, Yalda Nahidi, Golsan Kardan, Lida Jarahi, Behzad Aminzadeh,
Hasan Jahed Taherani, Mahsa Nahidi & Maliheh Ziaee (2017): Temperament-Character Profile
and Psychopathologies in Patients with Alopecia Areata, The Journal of General Psychology, DOI:
10.1080/00221309.2017.1304889

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THE JOURNAL OF GENERAL PSYCHOLOGY
http://dx.doi.org/./..

Temperament-Character Profile and Psychopathologies in

Patients with Alopecia Areata
Ali Talaeia , Yalda Nahidib , Golsan Kardanb , Lida Jarahic , Behzad Aminzadehd ,
Hasan Jahed Taheranic , Mahsa Nahidia , and Maliheh Ziaeec
a
Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad,
Iran; b Cutaneous Leishmaniasis Research Center, Imam Reza Hospital, Mashhad University of Medical
Sciences, Mashhad, Iran; c Community Medicine Department, Faculty of Medicine, Mashhad University of
Medical Sciences, Mashhad, Iran; d Radiology Department, Shahid Kamyab Hospital, Faculty of Medicine,
Mashhad University of Medical Sciences, Mashhad, Iran

ABSTRACT ARTICLE HISTORY

The aim of this study is to investigate psychopathologies and Received  October 
the temperament-character profile of Alopecia Areata patients Accepted  March 
and to compare them with healthy controls. Patients and con-
KEYWORDS
trols who presented at a dermatology clinic were selected by con- Temperament-Character;
venience sampling to respond to Temperament and Character psychopathology; Alopecia
Inventory (TCI), SCL-90-R, and a checklist about the demographic Areata
data and their dermatologic and psychiatric history. Patients
reported higher harm avoidance and reward dependence than
controls (Cohen’s d = .93 and = .94). A significant correlation
between Harm Avoidance (r = −0.33, p = .02) and Reward Depen-
dence (r = −0.28, p = 0.05) with sex was found (females scored
higher). Lifetime history of AA relapse was significantly associ-
ated with higher psychiatric symptoms; the effect sizes were large
for Obsessive-Compulsive (d = .81) and Paranoia Ideation (d =
.89). The higher psychological symptoms in AA patients with the
history of relapses in this study have a practical message for
clinicians.

SEVERAL REASONS JUSTIFY THE NEED FOR PSYCHOLOGICAL EVALUA-

TIONS in skin diseases: the ectodermal origin of both the brain and the skin, the
neurochemical evidence for the effects of psychological disturbances on the skin,
and the fact that a visible skin disease may cause stigma, shame, and embarrassment
in its bearer, resulting in a stressful social life (Bashir, Dar, & Rao, 2010; Katsarou-
Katsari, Singh, & Theoharides, 2001; Magin, Sibbritt, & Bailey, 2009). In fact, there is
a consensus in the literature that dermatologic diseases are associated with psycho-
logical difficulties and disorders (Fried, Gupta, & Gupta, 2005; Hughes, Barraclough,
Hamblin, & White, 1983). As an instance, skin diseases are found to be associated
with anxiety and depression; the latter is more associated with acne vulgaris, psori-
asis, and eczema (Bashir et al., 2010).

CONTACT Mahsa Nahidi nahidim@mums.ac.ir Resident of Psychiatry, Psychiatry and Behavioral Sciences
Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
©  Taylor & Francis Group, LLC
2 A. TALAEI ET AL.

Alopecia Areata (AA) is a chronic medical condition characterized by non-

scarring loss of hair on the scalp and sometimes other parts of the body (Wasserman,
Guzman-Sanchez, Scott, & Mcmichael, 2007). The lifetime incidence of the disease
is almost 2% worldwide, and men and women are affected equally (Kuty-Pachecka,
2015, Villasante Fricke & Miteva, 2015). AA occurs prior to the age of 20 years in
60% of patients (Price, 1991). The interplay between the AA and the psychological
features can be a complex, reciprocal, and non-linear interaction. On the one hand,
in AA, hair loss of scalp, eyebrows, and eyelashes causes emotional stress and dimin-
ished self-esteem (Firooz, Rashighi Firoozabadi, Ghazisaidi, & Dowlati, 2005). On
the other hand, among different factors that have been suggested for influencing
the clinical course of the AA, psychological factors are the prime candidates (Gulec,
Tanriverdi, Duru, Saray, & Akcali, 2004).
Cloninger’s model of personality introduces temperaments as “the automatic
associative responses to emotional stimuli that determine habits and moods” and
characters as “the self-aware concepts that influence our voluntary intentions and
attitudes”; this model assumes the dual genetic-environmental nature of personal-
ity (Cloninger, 1994). Therefore, investigation of personality in AA is of value since
the AA, similarly, is supposed to be influenced by the immunogenetic and envi-
ronmental factors simultaneously (Annagur, Bilgic, Simsek, & Guler, 2013). Erfan
et al. compared the personality of individuals with first onset AA and vitiligo and
healthy controls by Temperament and Character Inventory (TCI). Unlike the vitiligo
patients, the AA ones did not have different temperament-character profiles com-
pared with controls (Erfan et al., 2014). In another study, TCI were administered
to 73 AA patients and 78 controls in Turkey. The patients scored lower in novelty
seeking, reward dependence, and self-transcendence dimensions (Annagur et al.,
2013).
Some studies researched the association between psychopathologies and AA.
One study showed that more than 70% of AA patients had at least one psychi-
atric diagnosis (Cloninger, 1994). Major depressive disorder and generalized anx-
iety appeared to be more common in AA patients (Annagur et al., 2013; Erfan et al.,
2014). A national study in Taiwan on 5117 AA patients and 20468 controls found
more anxiety and less comorbid schizophrenia in individuals with AA, and the age of
onset of the disease contributed to some differences (Annagur et al., 2013). In addi-
tion, AA can negatively impact self-esteem, self-confidence, and body image con-
stituting some subsyndromal morbidities (Magin et al., 2009; Ghanizadeh, 2008).
An investigation of Iranian AA patients by Symptom Checklist-90-R (SCL-90-R)
revealed high rates of anxiety, paranoid ideation, depression, and obsessional com-
pulsion in AA patients, and these psychological disturbances were not associated
to the illness duration (Nematpour, Mousavi, Jemsi, & Talebzadeh, 2009). Another
study in Iran used the SCL-90-R as a screening measure for AA patients and assessed
the SCL-90-R high scorers with interviews based on the Diagnostic and Statisti-
cal Manual of Mental Disorders -Fourth Edition, Text Revision (DSM-IV-TR) and
reported 33% of major depressive disorder among AA patients. Although they found
differences in anxiety and depression between males and females, but education,
 THE JOURNAL OF GENERAL PSYCHOLOGY 3

marital status, and the affected site did not reveal significant effects (Safa, Jebraili, &
Momen-nasab, 2008).
In several Iranian studies that were conducted for psychological evaluation of
AA patients, an important methodological shortcoming was the absence of a con-
trol group for comparing with cases (Ghanizadeh, 2008; Nematpour et al., 2009; Safa
et al., 2008). In addition, to the best of our knowledge, TCI has not been adminis-
tered to the AA population in Iran. In this context, we carried out an investigation
of psychopathologies and temperament-character profile in patients with AA and
compared the results with a matched control group.

Method

Participants
In this study, by the method of convenience sampling, the patients were recruited
from people presented at dermatology clinic of Imam Reza Hospital, Mashhad,
Iran, between April and July 2015. A dermatologist confirmed the diagnosis of AA
patients who were included in the study if they were consented, literate (at least
5 years of education), and older than 12 years of age. Twenty-four AA afflicted
patients (16 females and 8 males) entered the study. A group of 24 healthy controls
(17 females and 7 males) who were matched to patients by sex, education, and mar-
ital status were selected from companions of patients (not only AA cases) attending
the dermatology clinic by the same aforementioned inclusion criteria. The proce-
dure of the study was completely explained to all the participants, and they pro-
vided written informed consents. The study conformed to the 1995 Declaration of
Helsinki and was approved by the Ethics Committee of Mashhad University of Med-
ical Sciences.
Demographic data, history, and characteristics of the AA (illness duration, num-
ber of relapses, affected sites, and amount of affected scalp surface area), and history
of psychiatric visits were obtained by a questionnaire designed for demographic and
clinical features of patients with AA. Participants were informed that they will be
notified of their test results if they provide an email address or a phone number.

Instruments

Temperament and character inventory (TCI)

TCI was designed to assess personality based on the Cloninger psychobiological
model that suggests features of personality as four temperament dimensions of
Novelty Seeking (NS), Harm Avoidance (HA), Reward Dependence (RD), and
Persistence (P) and three character dimensions of Self-Directedness (SD), Coop-
erativeness (CO), and Self-Transcendence (ST) (Cloninger, 1994). Novelty Seeking
denotes tendency toward exploratory behaviors, impulsiveness, and avoidance of
4 A. TALAEI ET AL.

frustration when facing novel stimuli. Harm Avoidance is the bias to have anticipa-
tory fear and to cease responses to aversive situation. Reward Dependence implies
the bias for maintaining the rewarded behavior. Persistence denotes eagerness and
perseverance despite frustration. Self-Directedness characterizes the resourceful-
ness, self-acceptance, and self-determination for regulating behavior to meet one’s
goals. Cooperativeness concerns the capacity to be empathetic and compassionate
and to accept others. At last, Self-Transcendence refers to self-forgetful and spiri-
tual acceptance (Cloninger, 1994). In this study, we used the Persian version of the
125-item TCI that was found to be a valid and reliable measure to assess personality
in Iranian population—with Cronbach’s alpha coefficients of 0.55 to 0.84 for the
seven dimensions—and was used in several studies in Iran (Kazemian, Fayyazi
Bordbar, Samari, Kashani Lotf Abadi, & Farid Hoseini, 2015; Kaviani, 2009; Kaviani
& Pournaseh, 2005).

Symptom checklist--R (SCL--R)

The SCL-90-R is a reliable and well validated self-evaluated questionnaire for assess-
ment of the occurrence of psychological symptoms during the past seven days
(Derogatis, 1994). This 90 item questionnaire uses 5-point scale of intensity from
“not at all” (0) to “extremely” (4) to assign scores to nine subscales of Somatiza-
tion (SOM), Obsessive—Compulsive (O-C), Interpersonal Sensitivity (I-S), Depres-
sion (DEP), Anxiety (ANX), Hostility (HOS), Phobic Anxiety (PHOB), Paranoid
Ideation (PAR), and Psychoticism (PSY). Global Severity Index (GSI) is one of the
global indexes that can be estimated from SCL-90-R results and measures the extent
or depth of the psychiatric disturbances (Derogatis 1994). The Persian version of the
test was used in several studies in Iran (Golshani, Mani, Toubaei, Farnia, Sephery, &
Alikhani, 2016) and appeared to have good validity and reliability—the Cronbach’s
alpha of more than 0.7 for all subscales (2000, Ardakani et al., 2016).

Statistical analysis

We presented the descriptive data by means, standard deviations, Cohen’s d, and per-
centages (Valentine, Aloe, & Lau, 2015). The correlation by using Pearson’s r and lin-
ear regression between variables were reported. All analyses were conducted using
SPSS version 11.5 for Windows.

Results
Patients (N = 24) and healthy controls (N = 24) participated in this study with the
mean ages of 25.38 (± 8.32) and 30.67 (± 6.98), respectively. All participants com-
pleted SCL-90-R, but the response rates for TCI were 22 of 24 for both groups. The
average of illness duration was 7.70 years (±5.42) and more than half of the patients
(54%) reported at least one episode of AA relapse. All the cases had scalp involve-
ment; almost half of them (11 of 24) had affected sites other than scalp. Sex, location,
marital status, education level and lifetime history of psychiatric visits of cases and
 THE JOURNAL OF GENERAL PSYCHOLOGY 5

Table . Demographic data of the Alopecia Areata patients and

healthy controls, and medical history and characteristics of the
Alopecia Areata in patients.
Patients n =  (%) Controls n =  (%)

Sex
Female  () ()
Male  ()  ()
Residency
Urban  ()  ()
Suburb  ()  ()
Marital status
Married  ()  ()
Single  ()  ()
Past psychiatric visit  ()  ()
Education
<Diploma  ()  ()
Diploma  ()  ()
>Diploma  ()  ()
Illness duration (years) . (±.)
Affected Part
Scalp  ()
Eyelash ()
Eyebrow  ()
Beard  ()
Body  ()
Limb  ()
Nail  ()
Relapse Episodes
One  ()
Two  ()
>Two  ()
Affected scalp surface area
ࣘ%  ()
>% ()

controls are shown in Table1 . Noteworthy is that all the patients with the history of
psychiatric visits reported attending the psychiatry clinic after the onset of AA.

Temperament - character profiles

Among temperament traits, compared with controls, the patients scored higher in
Novelty Seeking, Harm Avoidance and Reward Dependence but lower in persis-
tence. The effect sizes were large for Harm Avoidance and Reward Dependence
(Cohen’s d = .93 and = .94) but trivial in Novelty Seeking (d = .04) and Persis-
tence (d = .16). As regards character profiles, scores were higher in Cooperativeness
(d = .15) and Self-Transcendence (d = .37) and lower in Self-Directedness (d = .42).
Table 2 shows more details.

Psychopathologies
As indicated in Table 3, although SCL-90-R scores in patients were higher in all
evaluated psychopathologies, the effect sizes were trivial or small. In consistence,
Patients with at least one episode of AA relapse appeared to have higher scores in
all of SCL-90-R dimensions when compared with cases without the history of AA
6 A. TALAEI ET AL.

Table . Mean (SD) and effect size of Temperament and Character Inventory results in Alopecia Areata
patients and healthy controls.
Group
Patient () Control () Cohen’s d

Novelty seeking . (.) . (.) .

Harm avoidance . (.) . (.) .
Reward dependence . (.) . (.) .
Persistence . (.) . (.) .
Self-directedness . (.) . (.) .
Cooperativeness . (.) . (.) .
Self-transcendence . (.) . (.) .

The interpretation of the effect size was as follows: .–., trivial; .–., small; .–., moderate; and >.,
large (Sullivan & Feinn, ).

relapse (Table 4). The effect sizes were large for Obsessive-compulsive and Paranoid
Ideation (d = 0.81 and 0.89) and moderate for Interpersonal Sensitivity (d = 0.76),
Anxiety (d = 0.55), Psychoticism (d = 0.73), Global Severity Index (d = 0.67).
Sex was associated only with Harm Avoidance and Reward Dependence. For
female patients the mean scores of Harm Avoidance (12.5) and Reward Dependence
(10.00) were higher than other groups (male patients and male and female controls).

Table . Mean (SD) and effect size of SCL--R results in Alopecia Areata patients and controls.
Group
Patient () Control () Cohen’s d

SOM∗ . (.) . (.) .

O-C . (.) . (.) .
I-S . (.) . (.) .
DEP . (.) . (.) .
ANX . (.) . (.) .
HOS . (.) . (.) .
PHOB . (.) . (.) .
PAR . (.) . (.) .
PSY . (.) . (.) .
GSI . (.) . (.) .
∗ Somatization (SOM), Obsessive—Compulsive (O-C), Interpersonal Sensitivity (I-S), Depression (DEP), Anxiety (ANX),
Hostility (HOS), Phobic Anxiety (PHOB), Paranoid Ideation (PAR), Psychoticism (PSY), Global Severity Index (GSI).

Table . Mean (SD) and effect size of SCL--R results by history of Alopecia Areata relapse.
History of relapse
Yes (n = ) No (n = ) Cohen’s d

SOM∗ . (.) . (.) .

O-C  (.) . () .
I-S . (.) . (.) .
DEP . (.) . (.) .
ANX . (.) . (.) .
HOS . (.) . (.) .
PHOB . (.) . (.) .
PAR  (.) . (.) .
PSY . (.) . (.) .
GSI . (.) . (.) .
∗ Somatization (SOM), Obsessive—Compulsive (O-C), Interpersonal Sensitivity (I-S), Depression (DEP), Anxiety (ANX),
Hostility (HOS), Phobic Anxiety (PHOB), Paranoid Ideation (PAR), Psychoticism (PSY), Global Severity Index (GSI).
 THE JOURNAL OF GENERAL PSYCHOLOGY 7

Table . Regression coefficients on indicators of TCI- dimensions to the sex of participants.

Unstandardized Coefficients Standardized Coefficients
B Std. Error Beta t Sig.

NS (Constant) . . . . .

HA (Constant) − . . − . − . .

RD (Constant) − . . − . − . .

P (Constant) . . .  .

Sd (Constant) . . . . .

Coop (Constant) − . − . − . .

St (Constant) − . . − . − . .
 : adjustedr: .,  : adjustedr: . ,  : adjustedr :.,  : adjustedr : ,  : adjustedr : −.,  : adjustedr :.,  :
adjustedr :..

By using multiple linear regressions (Table 5), sex was significant predictor of Harm
Avoidance and Reward Dependence. For predicting Harm Avoidance based on sex,
a significant regression equation was found, with an R2 of 0.09 (p = .02). For predict-
ing Reward Dependence based on sex, a significant regression equation was found,
with an R2 of 0.06 (p = 0.05). As shown in Table 6, age was associated only with
Self-Directedness (r = .33, p < .05) and there was no association between illness
duration and TCI results.
Illness duration, age of onset, affected sites, and the severity of scalp involvement
were not significantly associated with SCL-90-R and TCI results (results are not
shown here).

Discussion
In the current study, we found that patients with AA scored higher in TCI tempera-
ment dimensions Harm Avoidance and Reward Dependence with large effect sizes;
females had higher scores in these subscales as well. Psychopathologies, as measured
by SCL-90-R, did not differ between cases and controls. Interestingly, compared with
cases without a history of AA relapse, patients with at least one episode of relapse
reported higher psychiatric symptoms.
A high Harm Avoidance score indicates a cautious, pessimistic, doubtful, shy,
and fatigable personality. On the other side, a person with low Harm Avoidance
would be risk taking, optimistic, energetic, and outgoing(Cloninger, Svrakic, &

Table . Inter-correlations of TCI- dimensions with age and illness duration.

P ST RD CO HA SD NS Disease duration age

age . . − . − . − . .∗ . − . 

Disease duration . . − . − . − . . . 
NS . − . . − .∗ − . − . 
SD − .∗ .∗ . .∗∗ − .∗ 
HA . . .∗∗ − . 
CO − .∗ . . 
RD . . 
ST .∗∗ 
∗ correlation is significant at the . level, ∗∗ correlation is significant at the ..
8 A. TALAEI ET AL.

Przybeck, 2006). The existing literature on the personality of AA patients is not

considerable, and the findings are not consistent. Carrizosa et al. reported that
individuals with AA did not have different personality traits from patients
with other dermatological diseases(Carrizosa, Estepa-Zabala, Fernandez-Abascal,
Garcia-Hernandez, & Ruiz-Doblado, 2005). In contrast to this, patients with psori-
asis, vitiligo, acne, and atopic dermatitis were found to have higher Harm Avoidance
than controls, while AA patients did not appear to have more Harm Avoidance than
controls(Annagur et al., 2013; Erfan et al., 2014; Kılıç, Güleç, Gül, & Güleç, 2008;
Kim et al., 2006; Ozturk et al., 2013). In our study, we found significantly higher
Harm Avoidance in AA patients, and therefore we indicated that AA is similar to the
aforementioned dermatological disorders regarding the Harm Avoidance dimen-
sion of personality. Also, our finding is theoretically consistent, since depression
and anxiety disorders are more likely in AA patients, and depressive conditions are
related with higher Harm Avoidance (Chu et al., 2012; Ruiz-Doblado, Carrizosa, &
Garcia-Hernandez, 2003; Sasayama et al., 2011). However, it should be noted that
our AA patients did not report more depressive or anxiety symptoms.
Individuals who score high in Reward Dependence are empathetic, social, tender,
dependent, and amiable, versus cold, socially detached and distant, tough and prac-
tical, and alone (Cloninger, 1994; Annagur et al., 2013). Our results were in contrast
to prior studies who found decreased (Annagur et al., 2013) or no different Reward
Dependence(Erfan et al., 2014) in AA patients compared with controls. The high
Reward Dependence score of our patient group was unexpected, which was also the
case in the study of Kilic et al., who found high Reward Dependence in psoriasis
patients (Kılıç et al., 2008).
In the current study, females scored higher in Harm Avoidance and Reward
Dependence, and sex was a significant predictor for these subscales. Noteworthy is
the absence of significant interaction between group and sex. Sex differences in per-
sonality are supported by extensive research in different contexts (Hansenne, Del-
hez, & Robert Cloninger, 2005; Miettunen, Veijola, Lauronen, Kantojärvi, & Jouka-
maa, 2007; Snopek, Hublova, Porubanova, & Blatny, 2012). A meta-analytic inves-
tigation on 32 studies found gender differences in Harm Avoidance and Reward
Dependence (higher in females) but not in Novelty Seeking and Persistence and
advised the TCI users to take in to account these sex differences (Miettunen et al.,
2007).
Hair loss can have prominent impacts on one’s life by lowering the self-
confidence, altering the self-image, and inducing social isolation (Masmoudi
et al., 2013). Masmoudi et al. reported poor quality of life and reduced sense of
well-being in AA patients and argued that this justifies the screening of psychiatric
disorders in AA (Masmoudi et al., 2013). As a vivid example, all the patients in
our study with past psychiatric visits reported attending the psychiatrist after the
onset of the disease. Most of prior studies on AA found depressive and anxiety
symptoms as the major comorbidities of the AA (Chu et al., 2012; Ruiz-Doblado
et al., 2003). In an investigation on 294 AA patient, Koo et al. described that major
depressive disorder, generalized anxiety disorder, social phobias, and paranoid
 THE JOURNAL OF GENERAL PSYCHOLOGY 9

disorder were higher compared with control population (Koo, Shellow, Hallman, &
Edwards, 1994). In China, Tan et al. compared 168 AA cases and 100 controls by
SCL-90-R and found significant differences in all the nine dimensions (Tan, Lan,
Yu, & Yang, 2015). In contrast to these studies, our AA patients did not have higher
psychopathologies than controls in Iran, where women use the hijab to cover their
bodies and hairs. Therefore, an existing AA lesion can be hidden that decreases the
social stress thatotherwise would be experienced by an AA patient with a visible
lesion. This decrement in social stress can be a potential explanation for the absence
of higher psychiatric symptoms in our AA group that consisted mostly of females
(16 females and 8 males).
Contrary to illness duration, age of onset, affected sites, and the severity of scalp
involvement (percentage of affected surface area of scalp), AA relapse was a signif-
icant predictor for Obsessive-Compulsive, Interpersonal Sensitivity, Anxiety, Para-
noid Ideation, Psychoticism, and Global Severity Index in our research. Few stud-
ies have highlighted the relation between illness duration or number of relapses
and psychological features; one can safely assume that they did not find signif-
icant associations. Some of the studies that reported on these variables did not
find association between psychological disorders and the number of AA relapses
(Aghaei, Saki, Daneshmand, & Kardeh, 2014) or between SCL-90-R or TCI results
and illness duration (Annagur et al., 2013; Nematpour et al., 2009). Aghaei et al.
found that anxiety and depression in AA patients are higher in patients at the
first episode than patients with multiple relapses. They argued that when patients
experience repeated episodes of AA, they become accustomed to their condition,
and hence their psychiatric symptoms attenuate over time (Aghaei et al., 2014).
Our results strongly oppose their results as we found differences with moderate to
large effect sizes in six dimensions of SCL-90-R in patients with the history of at
least one AA relapse. The difference between cases and controls in Global Sever-
ity index—which measures the current level of the psychological disturbances- is
the best single indicator of the negative impacts of AA relapses on psychologi-
cal wellbeing in our study. AA induces stressful social life, and it can be influ-
enced by psychological disturbances (Gulec et al., 2004) and thus regarding our
results, it is reasonable to argue that AA relapse is associated with higher psy-
chological symptoms. Tan et al. extended the evidence in this direction as they
demonstrated that Global Severity Index and the other nine dimensions of SCL-
90-R were associated with the disease duration and the age of onset (Tan et al.,
2015).
This study suffered from several limitations. All the psychometric measures used
in this study were self-administered that may cause mono-method bias. Further,
the data related to the severity of AA were reported by patients themselves; a pre-
cise description of the clinical picture of the patients by a dermatologist would be
more reliable. Finally, this study was cross-sectional in design and thus could not
address the direction of casual relations. Longitudinal studies with large and well-
characterized samples can overcome this and delineate on the direction of causality.
10 A. TALAEI ET AL.

In conclusion, this study shows that, compared with non-affected individuals,

patients with AA have different personality, as our cases reported more harm avoid-
ance and reward dependence. Moreover, patients with AA relapse reported more
psychiatric symptomatic behaviors. Besides, this study suggests the importance of
consideration for the effects of cultural variables on psychological features in skin
disorders. As we proposed above, the cultural practice of wearing the hijab by
females in Iran, which hides AA lesions, can contribute to notable differences in
results relative to studies of other countries—we did not find higher psychopatholo-
gies in AA patients. The best way to consider this cultural confounding factor in Iran
is to select larger samples of males and females and to compare them separately. In
addition, further longitudinal studies are needed to distinguish the causal direction
of AA relapse and psychiatric symptoms. These results call for attention toward the
psychological aspects of AA management beside hair regrowth.

Author notes
Ali Talaei is Associate Professor of Psychiatry at Mashhad University of Medical Sciences. Yalda
Nahidi is Associate Professor of Dermatology at Mashhad University of Medical Sciences. Gol-
san Kardan is Dermatologist at Mashhad University of Medical Sciences. Lida Jarahi is Associate
Professor of Community Medicine at Mashhad University of Medical Sciences. Behzad Amin-
zadeh is Radiologist at Mashhad University of Medical Sciences. Hasan Jahed Taherani is Resi-
dent of Community Medicine at Mashhad University of Medical Sciences. Mahsa Nahidi is Res-
ident of Psychiatry at Mashhad University of Medical Sciences. Maliheh Ziaee is Specialist in
Community Medicine at Mashhad University of Medical Sciences.

Funding
Preparation of this manuscript was supported by Grant from PBSRC, MUMS.

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