Psychology, 2010, 1: 169-172
doi:10.4236/psych.2010.13022 Published Online August 2010 (
Copyright © 2010 SciRes. PSYCH
Life Events and Psychoeducation in Patients with
Systemic Sclerosis
Yue Chen1*, Ji-Zhong Huang2, Yu Qiang2, Mao-Mao Han1, Shi-Chao Liu1, Chun-Lan Cui1
1Department of Geriatrics, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; 2Departmecnt of
Rheumatology, Hangzhou Tongji Hospital, Hangzhou, China.
Received April 8th, 2010; revised June 9th, 2010; accepted June 11th, 2010.
Objective: The purpose of this study was to assess the impact of psychological/psychoeducational assessment in pa-
tients with systemic sclerosis (SSc). Methods: A diagnostic interview was undertaken in order to investigate any tem-
poral connection between an adverse life event and the first appearance of SSc. Following this, the rheumatologist's
assessment of subsequent changes in the SSc were noted. The psychoeducation we did, as an adjunct to conventional
thoracic duct lymphatic drainage therapy (TDD), started in Dec. 2002, and the primary end point was an improvement
in clinical outcome at 1 month after entry. Results: The patients with SSc in the study showed higher percentages of
lower education (69.2%) and working class (63.5%), and reported that the most common life event in adults was di-
vorce or separatio n from spou se, while in ado lescent was difficu lt home cond itions. A favourab le respon se was noted in
all patients who participated in the study; Remission was achieved in 35, while 17 showed some improvement. Conclu-
sions: We conclude that life events were causally related to the onset of SSc and psychoeducation combinated with
conventiona l TDD led to a remission in the majority of patients.
Keywords: Psychosomatic Medicine, Syste mic Sclerosis (SSc), Life Events, Psychoeducation
1. Introduction
Systemic sclerosis (SSc) is a systemic connective tissue
disease and a chronic and potentially life threatening
condition characterized by vascular abnormalities and
fibrosis of the skin and multiple organs [1]. Many factors,
such as environmental factors, can lead to immunologic
system disturbances and vascular changes. It has been
reported on our previous research that social and psy-
chological stresses may trigger these disturbances and
changes [2], and conventional thoracic duct lymphatic
drainage therapy (TDD) for the SSc patients has been
proven effective [3]. Few data relating to a precise psy-
chological event or events underlying the onset of SSc
are available, and this study was set up to determine
whether life events had been causally related to the onset
of SSc and to determine whether psychoeducation com-
binated with TDD had led to an improvement in the SSc.
2. Patients and Methods
2.1 Patients
A total of 52 patients with SSc (mean age 53.6 ± 10.2
years, mean disease duration 3.8 ± 2.3 years), includ-
ing 33 with diffuse cutaneous scleroderma and 19 with
limited cutaneous scleroderma, were included in the
study. Patients were admitted to the Department of In-
ternal Medicine in the First Affiliated Hospital, Zhejiang
University Medical School, Hangzhou, China, between
December 2002 and October 2009 for a routine fol-
low-up evaluation of SSc. Their diagnoses of SSc met
the American College of Rheumatology criteria [4]. For
these patients, the following epidemiological data were
recorded: age, disease duration, previous psychopa-
thology, current treatments, and socioeconomic status.
Scleroderma was further categorized as diffuse or limited
scleroderma as defined by LeRoy et al. [5]. Goldthorpe
and Hope’s [6] occupational classification was used to
distribute the patients into two categories (middle-upper
social class and working class), and their education levels
also were evaluated [7]. The psychoeducation we did, as
an adjunct to conventional TDD, started in Dec. 2002,
and all 52 patients who signed informed consent form,
were on TDD with a satisfactory efficacy.
Life Events and Psychoeducation in Patients with Systemic Sclerosis
2.2 Investigation of Life Events and
A brief life-history was obtained in all cases. The em-
phasis was on the previous health of the patient or mem-
bers of the immediate family, death of anyone close to
the patient, difficulties experienced during different pe-
riods of their life, their relationships with others in the
family, at school or at work, problems with friends, their
hopes and ambitions. A mother’s undue concern for her
child, learning difficulties (due to visual or auditory dis-
ability or dyslexia) and unsatisfactory scholastic achieve-
ment, stability of marriage, change in job conditions,
adjustment to retirement, isolation and loneliness may be
of importance. If a possible connection between an event
and the onset of the SSc was identified, its importance
was discussed in detail with the patient. Each patient also
underwent a psychiatric assessment to look for the pres-
ence / a history of psychiatric illness. The salient features
of the history were reported to the rheumatologist, who
saw the patient again and concluded the consultation, in
order to reassure the patient that their problem was
2.3 Assessment of Outcome
All assessments as to clinical outcome were carried out
by the responsible rheumatologist in simple terms of re-
mitted, improved, and not improved or on-going [3].
They were based on his previous experience with the
patient, estimation of the degree of reduction of symp-
toms and disability, the ability to return to normal activi-
ties and the quality of life of the patient. The psychiatrist
was also involved in the final assessment.
3. Results
3.1 Patient Characteristics
The entire sample in the study was composed of 52 pa-
tients with a mean age of 53.6 ± 10.2 years and a mean
disease duration of 3.8 ± 2.3 years. The female-to-male
ratio was about 4:1. Table 1 reports the main clinical and
laboratory test features and family status. All 52 patients
were on TDD with a satisfactory efficacy. None of the
patients was receiving psychiatric care at the time of the
3.2 Significant Life Events
A significant life event was identified in 45 out of the
total of 52 patients; this was usually associated with a
good outcome. The most common life events in adults
and in children and young patients are listed in Box 1.
3.3 Clinical Outcome
The outcome was favourable in all 52 patients (Ta ble 2 ).
A favourable outcome was classified as remitted (full
and satisfactory response leading to early discharge),
Box 1. The most common life events in adults and in chil-
dren and young patients
Significant life events
In adults:
·divorce or separation from spouse
·incapacitating illness in patient or close relative
·a bereavement seriously affecting the patient
·moving to new surroundings
In children and young patients:
·difficult home conditions
·serious school difficulties, eg, math calculation
·isolation at home or school
Table 1. Demographic characteristics of the patients with SSc
N = 52
Cutaneous involvement
Diffuse 33
Limited 19
Arthritis 10
Skin ulcers 8
Esophageal involvement 14
Pulmonary fibrosis (computed tomography) 19
Forced vital capacity < 80% 12
Antinuclear antibodies 15
Anti-Scl 70 antibodies 12
Serum creatinine, mean ± S.D. (μmol/L) 76 ± 10
Erythrocyte sedimentation rate, mean ± S.D.(mm/h) 28 ± 13
C-reactive protein, mean ± S.D.(mg/L) 21 ± 8
Family status
Spouse or living partner 31
Alone 21
Children at home 23
Paid job 29
13+yr of education 16
Lower education 36
Middle-upper social class 11
Working class 33
Table 2. Clinical outcome of SSc patients at 1 month after treatment
Therapeutic strategy No of
patients Sex
(F:M) Age range (years) Remitted Improved Not improved
TDD combinated therapy 52 40:12 15~69 35 17 0
Copyright © 2010 SciRes. PSYCH
Life Events and Psychoeducation in Patients with Systemic Sclerosis 171
improved (condition improved but discharge without
supervision not possible), or not improved [3]. These
patients tended to respond favourably to psychoeducation
combinated with TDD (35/52 patients), indicating the
TDD plus psychoeducational intervention being a better
solution to SSc.
3.4 Psychological Diagnosis
Psychological diagnoses [8] (Table 3) showed the usual
range of disorders seen in a group of patients, with the
largest number being in the minor depressive and anxiety
category (17 patients). However, no psychological diag-
nosis was evident in 11 patients. Psychoses were found
in four patients. Psychological diagnoses were scattered
among the various subtypes of SSc without any particu-
lar pattern. No relationship was identified between the
psychological diagnosis and clinical types of SSc.
4. Discussion
Although what causes SSc still is not very clear yet,
many now agree that the disease may occur when the
immune system becomes disordered, attacking the mye-
lin surrounding nerve fibers. Focusing on biology, re-
searchers suspect these attacks may initially be triggered
by infection with a virus, perhaps picked up early in life.
However, social and psychological factors are well-
documented to play a role in the causation of immune
disorders, and there might be a connection of stress to
SSc as well [2]. An adverse life event may be important
in understanding the mode of onset of SSc. Such an event
may be one that the individual has construed as being
threatening, damaging, or even dangerous, and for which
there appears to be no solution. This experience of an
adverse life event may result in distress and /or conflict
leading to mental or physical change or a combination of
the two. In the latter instance it has become customary to
speak of a psychosomatic disorder [9].
Emotional reactions to the significant life events(box1)
are inevitable, and they often have serious effects on the
patient and his family. In many cases they may be re-
sponsible for the onset of SSc in terms of suffering that is
greater than that caused by the physical effects of SSc
[10]. Emotional disturbance may be particularly severe
and prolonged if the patient fails to receive adequate
counselling and support. The emotional and relationship
problems associated with SSc have not always been fully
appreciated by the medical profession, which has tended
to concentrate on the physical effects of this disease [11].
Yet the psychological problems of SSc often cause more
suffering than the physical effects. We recommend that
more attention should be paid to this aspect of the disease
in terms of both clinical care and research [2].
In the study, most of the SSc patients tended to re-
spond favourably to our psychoeducational intervention
(35 patients), which served as an adjunct to conventional
TDD therapy. In the patients showing a good response, a
new optimism emerged rapidly and they were both satis-
fied and confident. Inquiry from a relative or friend con-
firmed this impression. The possible factors contributing
to the improvements are listed in Box 2. By increased
insight we mean enhanced self-knowledge and a better
understanding by the patient of circumstances prevailing
at the time of the onset of the SSc.
The conclusion that emerges from this study is that an
adverse life event had continued to affect the emotional
state of nearly four-fifths of the patients with SSc and
this in turn played a major role in the progress of the dis-
order and its resistance to treatment. However, no rela-
tionship was identified between the psychological diag-
nosis and clinical types of SSc. Such a psychological
intervention could usefully be included in the normal SSc
assessment, as it should both improve patient care and be
cost effective [12]. To our knowledge this is the first re-
search yet in China from a rheumatology-psychiatry li-
aison team [13]. The procedure described above has a
simplicity and commonality which may recommend it for
further consideration and research.
5. Acknowledgements
This study was supported by grant No. B340406052 from
the Science and Technology Foundation of Shanghai
Railway Bureau (Hangzhou, China) to Drs. Huang and
Table 3. Psychological diagnosis
Major depressive disorder
Delusional disorder
Minor depressive or anxiety disorder
Psychosocial problems
Clinical disorder (ie, psychological concern over a medical illness)
No diagnosis
Box 2. The possible factors con tributing to th e improvements
Factors contributing to improvements
·increased insight
·opportunity to talk and ask question
·evidence of emotional reaction during interview
·attention received
·the power of suggestion
·placebo effect
Copyright © 2010 SciRes. PSYCH
Life Events and Psychoeducation in Patients with Systemic Sclerosis
We are grateful to Dr. Qie Hong-li for her helpful
comments on the paper.
[1] V. D. Steen and T. A. Medsger, “Severe Organ Involve-
ment in systemic Sclerosis with Diffuse Scleroderma,”
Arthritis & Rheumatism, Vol. 43, No. 11, 2000, pp. 2437-
[2] Y. Chen, J. Z. Huang, Y. Qiang, J. Wang and M. M. Han,
“Investigation of Stressful Life Events in Patients with
Systemic Sclerosis,” Journal of Zhejiang University Sci-
ence B, Vol. 9, No. 11, 2008, pp. 853-856.
[3] J. Z. Huang and J. Zhu, “Thoracic Duct Drainage Ther-
apy,” Chinese Publishing House of International Broad-
cast, Beijing, 1991, pp. 217-223.
[4] A. T. Masi, G. P. Rodnan and T. A. Medsger, “Prelimi-
nary Criteria for the Classification of Systemic Sclerosis
(Scleroderma),” Arthritis & Rheumatism, Vol. 23, No. 5,
1980, pp. 581-590.
[5] E. C. LeRoy, C. Black and R. Fleischmajer, “Scleroderma
(Systemic Sclerosis): Classification, Subsets, and Patho-
genesis,” Journal of Rheumatology, Vol. 15, No. 2, 1988,
pp. 202-205.
[6] J. H. Goldthorpe and K. Hope, “The Social Grading of
Occupations,” Oxford University Press, Oxford, 1974, pp.
[7] B. Archenholtz, E. Nordborg and T. Bremell, “Lower
Level of Education in Young Adults with Arthritis Start-
ing in the Early Adulthood,” Scandinavian Journal of
Rheumatology, Vol. 30, No. 6, 2001, pp. 353-355.
[8] American Psychiatric Association, “Mental Disorders, 4th
Edition (DSM-IV),” APA, Washington, D.C., 1994.
[9] C. C. Chen, A. S. David and H. Nunnerly, “Adverse Life
Events and Breast Cancer: Case Control Study,” British
Medical Journal, Vol. 311, No. 7019, 1995, pp. 1527-
[10] S. R. Dube, D. Fairweather, W. S. Pearson, V. J. Felitti, R.
F. Anda and J. B. Croft, “Cumulative Childhood Stress
and Autoimmune Diseases in Adults,” Psychosomatic Med-
icine, Vol. 71, No. 2, 2009, pp. 243-250.
[11] U. M. Anderberg, I. Marteinsdottir, T. von Theorell and L.
Knorring, “The Impact of Life Events in Female Patients
with Fibromyalgia and in Female Healthy Controls,” Eu-
ropean Psychiatry, Vol. 15, No. 5, 2000, pp. 295-301.
[12] T. N. Hyphantis, N. Tsifetaki, C. Pappa, P. V. Voulgari,
V. Siafaka and M. Bai, “Clinical Features and Personality
Traits Associated with Psychological Distress in Systemic
Sclerosis Patients,” Journal of Psychosomatic Research,
Vol. 62, No. 1, 2007, pp. 47-56.
[13] K. Mulligan and S. Newman, “Psychoeducational Inter-
ventions in Rheumatic Diseases: A Review of Papers
Published from September 2001 to August 2002,” Cur-
rent Opinion in Rheumatology, Vol. 15, No. 2, 2003, pp.
Copyright © 2010 SciRes. PSYCH