Acta Derm Venereol 92
Acta Derm Venereol 2012; 92: 304–306
© 2012 The Authors. doi: 10.2340/00015555-1239
Journal Compilation © 2012 Acta Dermato-Venereologica. ISSN 0001-5555
Alopecia areata is not painful or life-threatening, but its
aesthetic repercussions can lead to profound changes
in patients’ psychological status and relationships. The
psycho logical status and personality traits of 73 patients
and 73 controls were evaluated with the Minnesota Multi-
phasic Personality Inventory (MMPI-2). Analysis of the
MMPI-2 profile showed that scores for some scales (i.e.
Depression, Anxiety, Family relationships) were higher
for patients with alopecia areata than for controls. Pa-
tients with alopecia appeared to experience more depres-
sive, hysterical and anxiety feelings, have more hypo-
chondriac tendencies, and to be more in conflict with
their social environment. In order to provide more ef-
fective management, the psychological status of patients
with alopecia areata should be evaluated in dermatolo-
gical settings. Key words: alopecia areata; psychological
status; Minnesota Multiphasic Personality Inventory;
(Accepted July 11, 2011.)
Acta Derm Venereol 2012; 92: 304–306.
Damiano Abeni, Laboratory of Health Services Research,
IDI-IRCCS, IT-00167 Rome, Italy. E-mail: email@example.com
Alopecia areata (AA) is a non-scarring, autoimmune,
inflammatory disorder characterized by patchy areas of
hair loss (1). It has been hypothesized that AA is an organ-
specific autoimmune disease with genetic predisposition
and an environmental trigger (2).
Emotional or stressful life events are often mentioned
as possible causes of onset and exacerbation of the di-
sease, with perceived stress sometimes appearing to be
more important than the stressful situation itself (3, 4).
Many studies focused on personality traits describe
patients with AA as having psychopathological disorders,
such as depression, anxiety, social phobia, adjustment dis-
orders and paranoid disorders, more often than the general
population (5, 6), and psychiatric morbidity has been obser-
ved among patients with skin diagnoses, with a particularly
high prevalence in patients with alopecia (7, 8).
Other studies, however, reveal that anxiety and de-
pression do not play a major role in the aetiopathogene-
sis of the disease, and patients do not have personality
traits that are qualitatively different from other patients
with skin diseases (9).
Different types of alopecia may lead to different
psychological problems. AA is generally more frequent
and is more responsive to medical treatment than other,
more severe, forms of the disease (10, 11).
Although alopecia is not painful or life-threatening,
hair loss can lead to profound emotional stress and
reduced self-esteem (12). These negative effects may
alter patients’ social interactions, daily activities and
The present study evaluated the personality traits and
psychological status of patients with alopecia, using the
Italian version of the Minnesota Multiphasic Personality
Inventory (MMPI-2), which is the most-used personality
measure in clinical psychology. In addition, a psycho-
logical interview was conducted with patients in order
to investigate their present psychological status and to
reveal the presence of any stressful events occurring in
the 6 months preceding the onset of the disease.
MATERIALS AND METHODS
A cross-sectional study was performed in the Dermatological
Day-Hospital of the Istituto Dermopatico dell’Immacolata (IDI-
IRCCS) in Rome, Italy, between November 2009 and October
2010. The study was approved by the ethics committee of IDI-
IRCCS and all participants provided written informed consent.
Inclusion criteria for patients were: age ≥18 years; diagnosis
of AA, totalis, or universalis; Italian language; no dementia or
cognitive impairment, and no use of psychoactive drugs. The
control group included volunteers working at IDI-IRCCS (e.g.
nurses, researchers, administrators). Marital status and educa-
tional level data were collected for both groups. Duration of
disease, family history, and clinical type were collected only
from patients. Patients also underwent a clinical interview fo-
cused on recent stressful life-events (i.e. in the 6-month period
before the onset of AA).
Both the patient group and the control group completed the
pencil and paper version of the MMPI-2 for the psychological
evaluation of personality traits.
The MMPI-2 is a self-administered standardized questionn-
aire. It evaluates personality traits and psychological disorders,
and contains 567 true-false items. It has three validity scales:
L (lie-rational judgements), F (frequency-low frequency of
endorsement) and K (correction-response distortion and normal
profile). Validity scales assess the sincerity of the answers. Ten
clinical scales, denominated Hypochondriasis, Depression,
Hysteria, Psychopathic deviance, Masculinity-Femininity, Pa-
ranoia, Psychasthenia, Schizophrenia, Hypomania and Social
introversion provide a reliable personality profile. In addition,
there are 15 content scales: Anxiety, Fears, Obsessiveness, De-
pression, Health concerns, Bizarre thoughts, Anger, Cynicism,
Psychological Status of Patients with Alopecia Areata
Stefania ALFANI1, Valeria ANTINONE2, Aurelia MOzzETTA2, Cristina DI PIETRO1, Cinzia MAzzANTI3, Piero STELLA3,
Desanka RASKOVICH4 and Damiano ABENI1
1Laboratory of Health Services Research, 2Service of Clinical Psychology and Psychotherapy Psychosomatics, 3Day Hospital Dermatologico, and
4II Dermatology Division, IDI-IRCCS, Rome, Italy
Psychological status of patients with alopecia areata
Antisocial practices, Type A behaviour, Low self-esteem, Social
discomfort, Family problems, Work interference, Negative
The validated Italian version of MMPI-2 (13) was used in
the present study. Following the customary interpretation of
MMPI-2 standardized scores, T-scores over 65 were considered
to be “elevated”. Norms for the MMPI-2 were developed from
both normal and clinical populations.
T-scores over 65 on the “Lie” scale determine an invalid
Baseline demographic data, including age, sex, edu-
cational level, marital status for both groups, duration
and clinical type of alopecia are shown in Table SI
(available from http://www.medicaljournals.se/acta/co
The study included 73 adult patients with alopecia (40
women, 33 men; age range 18–73 years). The control
group comprised 73 healthy subjects frequency-matched
for sex and age, such that the sex distribution of “cases”
and “controls” was the same, and the mean ages of pa-
tients and controls were 35.2 ± 9.2 and 35.1 ± 9.1 years,
Sixty-five patients and 72 controls were high-school
or college graduates. Thirty-six (49.3%) patients and
43 (58.9%) controls were married, 31 (42.5%) patients
and 28 (38.4%) controls were single, 5 (6.8%) patients
and 2 (2.7%) controls were separated or divorced. Only
one patient (1.4%) was a widower/widow.
Forty-five patients were diagnosed with AA, 19 with
alopecia totalis, and 9 with alopecia universalis, and the
duration of the disease was less than one year for most
The results of the MMPI-2 for the alopecia patients,
compared with the control group, are summarized in
Table I. Analysis of the MMPI-2 profile showed that,
on average, patients and controls had a profile that was
essentially within normal limits. The configuration
of the validity scale showed a valid profile in both
groups, indicating that their responses appeared to be
realistically truthful. The Fisher’s exact test showed
that the scores on the scales of Depression, Hysteria,
Psychopathic deviance, Psychasthenia, Schizophrenia,
Anxiety, Health concerns, Bizarre thoughts and Family
problems were significantly higher in patients compared
with the control group.
When considering the duration of the disease (Table
SII; available from http://www.medicaljournals.se/
acta/content/?doi=10.2340/00015555-1239), the hig-
hest scores were observed for durations between 6 and
11 months rather than for shorter (i.e. < 6-month) or
longer (i.e. ≥ 12-month) periods. In fact, even with small
numbers in each subgroup, a statistically significant
difference is seen for several MMPI-2 scales (those of
Frequency, Hysteria, Psychasthenia, and Anger), and
particularly on the Paranoia and Schizophrenia scales.
Furthermore, other scales showed differences that were
close to the conventional limit of statistical significance:
Psychopathic deviance, Depression, Antisocial practi-
ces, and Family problems. Males had significantly higher
scores than females on the Psychopathic deviance, An-
tisocial practices, and Family problems scales.
Eighteen patients (24.6%) reported stressful events
at the onset or before the exacerbation of alopecia, 10
reported family problems, five reported work problems
and three reported mourning.
The MMPI questionnaire was administered to an
unselected group of patients with alopecia and to a
sample of age- and sex-matched controls. On average
the overall profiles of both groups were within normal
limits, so that specific psychological disease levels were
not reached. However, the alopecia patients had higher
proportions of “above cut-off” scores (particularly
on the Anxiety, Depression, and Family relationships
scales) compared with the controls.
Patients scoring high on the Depression, Hysteria,
Psychopathic deviance, Psychasthenia and Schizo-
phrenia scales were often described as depressive,
Table I. Proportion of patients with alopecia and controls above
the threshold (T>65) for the different Minnesota Multiphasic
Personality Inventory (MMPI) scales
Type A behaviour
Negative treatment indicator
*Fisher’s exact test. Significant values are shown in bold.
Acta Derm Venereol 92
S. Alfani et al.
sad, tense, weak, and self-doubting. They might have
pessimistic worries, show a lack of interest, involve-
ment and initiative, and have feelings of inefficiency,
somatization and indirect expressions of approval being
characteristic, and may feel stressed by their general
High scores on the Health concerns scale indicate
frequent, abnormal health worries, and feeling more
unwell than the average general population; high scores
on the Bizarre thoughts scale may include deranged and
delusional thoughts; high scores on the Family scale
show a likelihood of having a number of problems with
their own partner, or with their children or parents.
As for the role of stress, the most stressful situations
were linked to family problems, thus confirming re-
sults discussed above. The type of stress seems to be
long-standing rather than linked to particular events.
However, when looking at differences in the MMPI-
2 between patients with higher and lower levels of
stress, only slight differences were observed, and such
differences reached statistical significance only on the
Schizophrenia and the Depression scales.
Interestingly, the larger differences on the MMPI-2
scales were observed for the “duration of disease” vari-
able, with higher scores for patients with an intermediate
duration of disease (i.e. 6–12 months). The pattern was
constant over most of the scales, and more apparent on
the of Hysteria, Paranoia, Psychasthenia, Schizophrenia,
and Depression scales. A possible explanation could
be that by the time they reach this period patients have
realized more fully what the negative implications of
their disease may be, but have not yet acquired the
necessary skills to cope with them.
This study defines a profile of the domains in which
patients with alopecia seem to experience a higher bur-
den. The main limitation of the study is the length of
the questionnaire, and thus the time needed to complete,
score, and interpret it. Despite its limitations the MMPI-
2 can provide a specific diagnosis on the psychological
status of patients. However, having highlighted the
anxious-depressive traits of this population, this study
might encourage dermatologists and clinical psycholo-
gists to use other, simpler instruments to evaluate their
patients’ psychological discomfort. For instance, the
12-item General Health Questionnaire has been shown
to perform well in dermatological patients (14, 15), and
it may be of help in identifying patients with specific
needs, and thus in providing more comprehensive care
for the complex situation of these patients.
This study was financially supported, in part, by the “Progetto
Ricerca Corrente 2009” of the Italian Ministry of Health.
The authors would like to thank Dr Marialucia Benvenuti and
Dr Stefania Mariani for their help in data collection.
Delamere FM, Sladden MJ, Dobbins HM, Leonardi-Bee J. 1.
Interventions for alopecia areata. Cochrane Database Syst
Rev 2008; 16: CD004413.
Manolache L, Benea V. Stress in patients with alopecia 2.
areata and vitiligo. J Eur Acad Dermatol Venereol 2007;
Picardi A, Abeni D. Stressful life events and skin diseases: 3.
disentangling evidence from myth. Psychoter Psychosom
2001; 70: 118–136.
Picardi A, Pasquini P, Cattaruzza MS, Gaetano P, Baliva 4.
G, Melchi CF, et al. Psychosomatic factors in first-onset of
alopecia areata. Psychosom 2003; 44: 374–381.
Ruiz-Doblado S, Carrizosa A, Garcia-Hernandez MJ. 5.
Alopecia areata: psychiatric comorbidity and adjustment
to illness. Int J Dermatol 2003; 42: 434–437.
Manolache L, Oprea C, Benea V. Stress and anxiety in- 6.
volved in alopecia areata. Dermatol Psychosom 2003; 4:
Picardi A, Abeni D, Melchi CF, Puddu P, Pasquini P. Psy-7.
chiatric morbidity in dermatological outpatients: an issue to
be recognized. Br J Dermatol 2000; 143: 983–991.
Koo JY, Shellow WV, Hallmann CP, Edwards JE. Alopecia 8.
areata and increased prevalence of psychiatric disorders. Int
J Dermatol 1994; 33: 849–850.
Carrizosa A, Estepa-Zabala B, Feràndez-Abascal B, Garcia-9.
Hernandez MJ, Ruiz-Doblado S. Alopecia areata: a specific
personality. Int J Dermatol 2005; 44: 437–438.
Baranda L, Layseca-Espinosa E, Abud-Mendoza C, Gon-10.
zàlez-Amaro R. Severe and unresponsive HIV-associated
alopecia areata successfully treated with thalidomide. Acta
Derm Venereol 2005; 85: 277–278.
Tan E, Tay YK, Goh CL, Chin Giam Y. The pattern and 11.
profile of alopecia areata in Singapore – a study of 219
Asians. Int J Dermatol 2002; 41: 748–753.
Firooz A, Firoozabadi MR, Ghazisaidi B, Dowlati Y. Con- 12.
cepts of patients with alopecia areata about their disease.
BMC Dermatol 2005; 5: 1.
Hataway SR, McKinley JC. MMPI-2, Minnesota Mul-13.
tiphasic Personality Inventory-2-Manuale. Firenze: OS,
Organizzazioni Speciali, 1995.
Picardi A, Adler DA, Abeni D, Chang H, Pasquini P, Rogers 14.
WH, Bungay KM. Screening for depressive disorders in
patients with skin diseases: a comparison of three screeners.
Acta Derm Venereol 2005; 85: 414–419.
Picardi A, Abeni D, Mazzotti E, Fassone G, Lega I, Ramieri 15.
L, et al. Screening for psychiatric disorders in patients
with skin diseases: a performance study of the 12-item
General Health Questionnaire. J Psychosom Res 2004;
Acta Derm Venereol 92