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Year : 2022  |  Volume : 67  |  Issue : 3  |  Page : 313
An evaluation of anxiety disorder and emotion regulation difficulty in children and adolescents with alopecia areata

1 Department of Child and Adolescent Psychiatry, Yozgat Bozok University, Yozgat, Turkey
2 Department of Dermatology, Yozgat Bozok University, Yozgat, Turkey

Date of Web Publication22-Sep-2022

Correspondence Address:
Dilşad Yıldız Miniksar
Department of Child and Adolescent Psychiatry, Yozgat Bozok University, Yozgat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_685_21

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Context: The relationship between alopecia areata (AA) and emotion regulation difficulty has not yet been fully explained. Aims: The aim of the study was to investigate the levels of anxiety and emotion regulation difficulty in children diagnosed with AA. Settings and Design: This case-control study was done in the university setting. Methods: Behavioral tests measuring anxiety and emotion regulation difficulties, and the measures assessing AA severity were applied to 32 AA patients consulted at Dermatology Clinic of Yozgat Bozok University. A control group was formed of 36 healthy children. Statistical Analysis Used: Kolmogorov-Smirnov normality test, Mann-Whitney U test and Pearson's and Fisher's Chi-square tests and Spearman's correlation test. Results: Evaluation was made of a total of 68 subjects (32 patients, 36 healthy subjects). The Difficulties in Emotion Regulation Scale (DERS)-total score and the DERS-clarity subscore were statistically significantly higher in the control group than in the patient group (P = 0.021, P = 0.003, respectively). No significant difference was determined between the two groups in respect of anxiety levels. No correlation was determined between disease severity and the scales. It was determined that as disease duration increased, so the DERS-non-acceptance subscale score increased, and with an increase in age, the SAI score of the AA patients increased. The DERS-impulse subscale score was seen to be statistically significantly higher in the boys with AA than in girls (P = 0.030). Conclusions: The results of this study showed that a visible, chronic, recurrent disease such as AA is not always seen with high psychiatric comorbidity and that together with the presence of the disease, patient age and disease duration are also important. It can be considered that AA may have been affected by the location, time and conditions of the study.

Keywords: Alopecia areata, anxiety, children and adolescents, emotion regulation

How to cite this article:
Miniksar DY, Çölgeçen E, Cansız MA. An evaluation of anxiety disorder and emotion regulation difficulty in children and adolescents with alopecia areata. Indian J Dermatol 2022;67:313

How to cite this URL:
Miniksar DY, Çölgeçen E, Cansız MA. An evaluation of anxiety disorder and emotion regulation difficulty in children and adolescents with alopecia areata. Indian J Dermatol [serial online] 2022 [cited 2022 Oct 6];67:313. Available from:

   Introduction Top

Alopecia areata (AA) is a disease with a chronic course characterised by sudden limited patchy loss of hair from the scalp or other areas (eg, eyebrows, eyelashes), which can lead to serious cosmetic problems.[1] The possibility of AA occurring at any time in life has been reported to be 1.7%-2%.[2] It can be seen in any age group, and 20% of AA cases are children.[3] Although the pathophysiology is not fully known, autoimmune, genetic and psychological factors are thought to play a role in the etiology.[4],[5]

High rates of psychiatric comorbidity, primarily anxiety and depression, may be seen in AA patients.[6] The outward appearance of the hair is very important, and it has been reported that the presence of AA in females and during adolescence has a high probability of disturbing identity and self-perception.[7] Studies of children diagnosed with AA have determined similar levels of depression and anxiety to those of adults, and higher than those of healthy control subjects, and this has been found to be independent of stressful life events.[8]

In a study that investigated the relationship between AA and depression, anxiety, and alexithymia, while the depression and anxiety levels of the cases diagnosed with AA were higher than those of the control group, no significant difference was determined in the alexithymia points.[9] The underlying reason for focussing on alexithymia in AA is the hypothesis that both alexithymia and the immunological mechanisms triggered by stress may have a common role in the etiopathogenesis of AA.[10] Emotion regulation is the ability of a person to functionally manage and appropriately integrate into life the positive and negative emotions experienced.[11] Emotion regulation is formed of six steps in the form of appropriate behaviour of emotional awareness, understanding emotional response, acceptance of the emotion, using emotion regulatory strategies appropriate to the situation, the ability to control impulsive behaviour and behaving appropriately to the targeted aims while experiencing negative emotions.[12]

It is known that from early childhood onwards, the skin has an important role in emotion regulation.[13] In dermatology, studies are shown to be more in the area of psoriasis with emotion regulation difficulty.[14] It is expected that alexıthymic individuals who experience difficulty in recognising and defining emotion will experience difficulty in coping with difficult emotions and regulating emotions. Therefore, there can be said to be a positive correlation between alexithymia and emotion regulation difficulties.[15] With the greater emphasis on alexithymia in AA, to the best of our knowledge, there have been no studies on the importance of the skin in emotion regulation, and the relationship with the emotion regulation difficulty of alexithymia, and most importantly in children, and this was, therefore, the primary aim of this study. As there is a relationship between depression and anxiety disorders and difficulties experienced in emotion regulation, and AA per se lays the foundation for depression and anxiety, the secondary aim of the study was to investigate the level of anxiety in the patients.[16]

   Subjects and Methods Top

The study protocol was approved by the Ethics Committee of Medical Faculty of Yozgat Bozok University. Informed consent for participation in the study was obtained from the parents or legal guardians of all the children included in the study.

This prospective, case-control study included 32 children and adolescents aged 11-17 years who were diagnosed with AA in the Dermatology Clinic of Yozgat Bozok University. Medical Faculty between March 2020 and December 2020. Patients were excluded from the study if they had a chronic organic disease, cognitive impairment, they were using systemic or psychiatric drugs, or had any dermatological disease other than AA that could affect their appearance. A control group was formed of 36 healthy, age and gender-matched children with no diagnosis of AA.

The ratio of hair loss with scalp involvement in the 32 AA patients was calculated by a dermatologist using the Severity of Alopecia Tool (SALT) score (S1, S2, S3, S4, S5), which was developed by Olsen et al. Disease severity was evaluated in two groups as mild involvement (scalp hair loss <50%: S1, S2) or severe involvement (scalp hair loss ≥50%: S3, S4, S5).[17] The patients were then referred to the Paediatric and Adolescent Psychiatry Department, and the State- Trait Anxiety Inventory (STAI) and the Difficulties in Emotion Regulation Scale (DERS) were applied. The same scales were applied to the control group.

Evaluation of anxiety

The STAI was used to evaluate anxiety, is a self-reported measure with two separate forms for state and trait anxiety. A total of 40 items measure the two types of anxiety with responses given on a 4-point Likert scale. State anxiety is defined as the anxiety about a specific event, and trait anxiety is the characteristic predisposition of an individual to anxiety in response to a stimulus.[18] The scale was adapted to Turkish by Öner and Le Compte in 1983.[19]

Evaluation of difficulties in emotion regulation

The DERS is a 5-point Likert-type self-report scale that contains 36 items and six dimensions.[12] The six subscales are awareness, clarity, non-acceptance, strategies, impulse control, and goals. Higher scores obtained on this scale indicate more difficulties in emotion regulation. The scale was adapted to Turkish by Rugancı and the Cronbach coefficient of the scale was 0.94.[20]

Statistical analyses

In the power analysis, considering a 95% confidence interval, an error margin of 0.05, and a power of 80%, it was calculated that at least 27 people were required for the patient and control groups. Data were analyzed using the Statistical Package for Social Sciences version 17 software. Conformity of the variables to normal distribution was assessed using visual (histograms, probability plots) and analytical methods (Kolmogorov–Smirnov test). Descriptive statistics were stated as mean ± standard deviation, and median values. Categorical variables were compared using the Pearson Chi-square test. In the comparisons of groups of data not showing normal distribution, the Mann–Whitney U-test was applied. Spearman's correlation coefficients were calculated to examine the relationships between variables. A value of P < 0.05 was accepted as statistically significant.

   Results Top

The evaluation was made of a total of 68 subjects (32 patients, 36 healthy control subjects). The AA group comprised 20 males and 12 females with a mean age of 14.81 ± 2.42 years (range, 11-17 years). The healthy control group comprised 15 males and 21 females with a mean age of 15.00 ± 2.07 years (range, 11-17 years). In the evaluation of the SALT score in the AA group, hair involvement was determined as mild (S1, S2) in 25 patients, and severe (S3, S4, S5) in 7. The duration of disease in the AA group was determined as 0-1 month in nine patients, 2-3 months in five patients, 4-6 months in three patients, 7-12 months in seven patients, 13-24 months in four patients, and >60 months in four patients [Table 1].
Table 1: Clinical characteristics of patients with alopecia areata and the control group

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No statistically significant difference was determined between the two groups in respect of the STAI scores (SAI score: P = 0.334; TAI score: P = 0.782). The DERS-total score and the DERS-clarity subscore were statistically significantly higher in the control group than in the patient group (P = 0.021, P = 0.003, respectively) [Table 2] [Figure 1].
Figure 1: Comparison of scale scores between alopecia areata and control groups

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Table 2: Differences between groups

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The relationships were examined between the SALT score, disease duration and age (AA group-control group-total) and the DERS- total and subscales and the STAI scores. A significant positive correlation was determined between disease duration and DERS- non-acceptance subscale score (P = 0.014). A significant positive correlation was determined between age (AA group and total) and the SAI score (AA group: P = 0.027, total group: P = 0.003) [Table 3].
Table 3: Correlation of DERS subscales and total scores and severity and duration of alopecia areata with STAI scores

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In the AA group, comparisons were made of the scale and subscale scores according to gender. The mean impulsiveness score of males diagnosed with AA was determined to be statistically significantly higher than that of the female AA patients (P = 0.030) [Table 4]. In the control group, no statistically significant difference was determined in the scale and subscale scores according to gender (P > 0.05) [Figure 2].
Figure 2: Comparison between the DERS-Impulse subscores of the groups by gender

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Table 4: The relationship between gender and scales and subscales in the alopecia areata group

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   Discussion Top

Although several studies have been conducted on the subject of AA, there is no study in the literature that has examined the relationship between AA and emotion regulation difficulty in children and adolescents. The results of the current study showed that the emotion regulation difficulty of 32 cases diagnosed with AA was not greater than that of the control subjects, but on the contrary emotion, regulation difficulty was found to be greater in the control group. No significant difference was determined between the groups in respect of the levels of anxiety. Although no correlation was determined between the disease severity and the scale scores, it was observed that as the disease duration increased, so the DERS-non-acceptance subscale score increased, and as age increased, so the SAI score increased in the children and adolescents with AA. The DERS-impulsivity subscale score was determined to be higher in males with AA than in females.

In AA, which has a chronic and repetitive course and can lead to serious cosmetic problems, the lifetime psychiatric comorbidity rate has been reported as 60.4%.[1],[21] Although it is not a painful or life-threatening disease, it has been shown that because of the aesthetic side effects, AA patients are more predisposed to psychiatric diseases and these patients have a greater tendency to depression and hysteria, anxiety and hypochondria than healthy individuals.[22] In adolescence when body image and cosmetic concerns increase and peer acceptance is important, as AA is a visible disease, it can lead to more psychiatric problems.[7] In a detailed study of children diagnosed with AA, Liakopoulou et al.[8] determined that these children were more depressive and anxious. However, in the current study, the anxiety levels of the AA patients were not determined to be higher than those of the control group. This could be explained by the study having been conducted during the COVID-19 pandemic so that aesthetic concerns related to hair loss could have been decreased because of the implementation of quarantine and the social isolation of these children. Furthermore, while there is known to be similar psychiatric comorbidity in the mild form of AA as in the general population, the comorbidity rate is unknown in the severe forms (totalis, universalis).[6] The scale scores could have been affected in the current study by the fact that 78.13% of the AA group had mild involvement and alopecia totalis was seen in only one patient.

Although alexithymia and AA have common immunological mechanisms, which are aggravated by stress, several studies have determined no significant relationship between alexithymia and AA. They have even focussed on the extreme difference in the psychological dimension in these patients.[9],[10] It is thought that alexithymic individuals are inadequate in recognising emotions and in coping with their own impulsive emotions, and therefore cannot sufficiently regulate emotions.[15] When it is considered that in most studies, alexithymia is not seen in AA cases, and there is a positive relationship between emotion regulation difficulty and alexithymia, mood regulation difficulty is not an expected result in these patients. In the current study, in contrast to greater emotional difficulty in the AA group than in the control group, it was determined that the AA group experienced less difficulty than the control group. In a study by Mennin et al.[23] it was shown that the individuals who experienced greater emotion regulation difficulty tended to show more anxiety symptoms. The reason for the lesser difficulty in emotion regulation of the AA patients than the control group in the current study could be because the anxiety levels were not high. In a previous study, the DERS-clarity subscore, representing the understanding of emotional response, was low in the AA group and was strongly associated with the psychiatric dimension experienced by the AA patients.[9] In the current study, the DERS-clarity subscore was determined to be significantly higher in the control group. No significant difference was determined between the groups in respect of the other DERS subscale scores, which could be attributed to the majority of the patient group having AA of mild severity.

In a previous study of children and adolescents diagnosed with AA, it was observed that as the disease duration increased, so depressive symptoms also increased. This was thought to be due to feelings of hopelessness and despair developing as a result of no improvement over time.[24] The nature of AA is both chronic and repetitive.[1] It has been reported that the correlation between depressive symptoms and the difficulties experienced in emotion regulation and the significance of the subscale of non-acceptance of emotion with an increase in disease duration, could be a response attributable to the loss of hope of recovery over time in AA patients.[16] Consistent with these findings in the literature, in the current study, it was determined that as the disease duration increased, so there was an increase in the DERS-non-acceptance subscale score.

The SAI score of AA children and adolescents was found to increase together with age in the current study. Although the mean age of the control group was similar to that of the AA group, the relationship between age and state anxiety was not statistically significant. At the time of presentation, the AA group had limited areas of alopecia that were visible in the hair. As the hair has an important place in body perception and these children were in adolescence, which is the time of the greatest aesthetic concerns, it has been reported in the literature that the status of intervention with this disease could increase anxieties.[7]

In the current study, the DERS-impulse subscale score of the male AA patients was determined to be higher than that of the females. In a previous study of attention deficit and hyperactivity disorder (ADHD), it was determined that boys who experienced emotion regulation difficulty were more impulsive and aggressive, and there was a relationship between impulsivity and hyperactivity and emotion regulation.[25] The DERS-impulse subscale scores of the male AA patients without alopecia in the current study were not higher than those of the females. The fact that 62.5% of the AA group and 41.67% of the control group were male, could have turned the relationship between impulsivity and male gender in favour of the AA group.

The main limitation of this study was that the sample size was small and as the majority of the AA cases were of mild severity, it was not possible to evaluate severe cases. In addition, not knowing the psychiatric condition before AA development is another limitation of our study. The fact that the study coincided with the COVID-19 pandemic period and that we could not evaluate the pre-pandemic period can be counted as another limitation.

   Conclusion Top

In conclusion, the results of this study demonstrated that although AA is a disease in which greater psychiatric comorbidities are experienced, the emotion regulation difficulty and anxiety levels of the AA patients in this study were not found to be higher than those of the control group. The coping mechanisms used by individuals with chronic diseases may make them stronger as they are sufficiently aware of their situations. It can also be considered that the period of the COVID-19 pandemic, which resulted in social isolation, may have been an advantage in reducing the anxieties of patients about the visible AA, characterised by hair loss and directly related to body image.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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