Abstract
Background/Aim: Melanoma, as a type of skin cancer, has undoubtedly gathered the interest of the global community in recent years, due to its rising incidence. Patients suffering from melanoma experience effects on their mental health, mainly depression and anxiety disorders. The present study aimed to examine the association of melanoma with the psychosomatic burden, personality traits, and demographic factors of the participants. Patients and Methods: The psychometric instruments administered were: the Psychopathology Questionnaire (SCL-90), Beck Depression Scale (BDI), Eysenck Personality Questionnaire (EPQ), and Hostility Questionnaire (HDHQ). The research sample consisted of 80 cancer patients, of whom 57.5% were women and 42.5% men, and whose ages ranged from 15 to 85, with a mean age of 56.95 and a standard deviation of 13.52 years. Results: The majority of patients presented introverted hostility (77.5%) and 22.5% presented extroverted hostility. Male cancer patients seemed to score on average statistically significantly higher on the self-criticism scale than females (4.44±2.31 vs. 3.17±1.98, p<0.01) The patients in an advanced stage scored statistically significantly higher on the phobic anxiety scale than the patients in the initial stage (5.17±3.60 vs. 2.86±2.04, p<0.01). Also, early-stage patients presented statistically significantly higher scores on the paranoid hostility scale than advanced-stage patients (2.00±1.18 vs. 1.37±0.89, p<0.05). Conclusion: The majority of patients with melanoma presented introverted hostility, and those in advanced stages scored significantly higher on the phobic anxiety scale compared to the patients in the initial stage.
One of the forms of cancer that has been most investigated, in light of its psychopathological effects, is skin cancer and, in particular, melanoma. An important characteristic of the relationship between melanoma and the psychopathology of diagnosed patients is that approximately 30% of similar studies conclude that this form of cancer is associated with mental disorders, most commonly anxiety and depression (1). Melanoma is a malignant tumor that appears in any part of the skin ranging from the scalp to the palms, soles, and even in the oral cavity. It arises from the abnormal growth, uncontrolled proliferation, and spread of melanocytes, the cells that are responsible for the production of melanin in the body, skin, eyes, and hair. These cells, when affected by melanoma, become cancerous, resulting in the production of dark-colored patches or tumors in affected areas (2). Modern scientific research is often directed towards investigating the psychopathological effects observed in patients who have been diagnosed with melanoma. In fact, a large part of research specifically investigates the connection between depressive disorders, as a galloping form of mental illness of the present era, and the diagnosed morbidity of each melanoma skin cancer patient (3). Mental health can be affected negatively in melanoma sufferers, with patients presenting depressive symptoms and anxiety disorders that have a negative impact on their quality of life, an impact that is compounded by the effects that the disease itself causes on their body, but also by the strong effect of the therapeutic interventions applied (4). For patients suffering from melanoma, the progression of their melanoma tumor and the risk of its metastasis are responsible for causing them depressive and anxiety disorders (5). In recent years, many of the medical studies published, having as their main research object the understanding of the nature of cancer and the patients suffering from it, turn their attention to the investigation of skin cancer, a particularly serious and deadly form of cancer, seeking to identify the previously unknown causal relationship that it develops with various psychopathological disorders, and especially with personality disorders (6, 7). Melanoma patients often experience emotional and social discomfort, as well as various psychosocial disorders. These conditions significantly impact their personality, affecting their social behavior, thoughts, and feelings (8). Melanoma patients also present emotional, mental, and behavioral aggression disorders manifested by intense nervousness – a key symptom of aggression disorders – in the form of anxiety and sleep disorders (9). Patients with melanoma cancer often manifest somatization disorder, experiencing physical symptoms along with anxiety about their prognosis and the outcomes of various therapeutic interventions aimed at prolonging or saving their lives (10). With the appearance of anxiety, depressive disorder, behavioral and personality disorders, as well as physical symptoms, both biological and mental etiologies contribute to understanding the complex effects on the endocrine, nervous, and immune systems experienced by melanoma patients at various stages of disease progression. These effects are closely related to the manifestation of psychosomatic disorders (11). In the present study, we aimed to investigate the correlation between melanoma and psychosomatic burden with personality traits. Additionally, we examined whether demographic factors correlate with psychopathological manifestations and personality traits.
Patients and Methods
Ethics. The study was conducted in accordance with the Declaration of Helsinki and approved by the Scientific Council of 1st Department of Dermatology-Venereology, Andreas Syggros Hospital, Medical School, National and Kapodistrian University of Athens (protocol code: 257 and date of approval: 20-06-2023). Informed consent was obtained from all subjects involved in the study.
Statistical analysis. The categorical variables that describe the demographic and clinical characteristics of the patients (sex, educational level, marital status, stage of the disease, accompanying diseases, information about the disease from the internet) are presented graphically in bar charts depicting the corresponding percentages in each category. Age as a continuous variable is described by the mean and standard deviation. The Kolmogorov–Smirnov test was applied to investigate whether the scales of depression (BDI), psychopathology (SCL90), personality (EPQ), and hostility (HDHQ) follow a normal distribution. The null hypothesis of normality was rejected for all scales, thus nonparametric tests were applied to examine the relationships of psychometric scales with demographic and clinical patient characteristics. Specifically, the Mann–Whitney test was applied to examine the relationship of the psychometric scales with binary categorical variables (such as sex, marital status, disease stage, etc.) and the Kruskal–Wallis test to examine the relationship of the psychometric scales with the educational level, which had three categories. Spearman correlation coefficients were used to examine the relationship of the psychometric scales with the age of the patients. The χ2 test was applied to examine the relationship of the direction of hostility with the demographic and clinical characteristics of the patients.
In addition, logistic and binomial regression models were applied to examine which patient characteristics influence their psychometric scale scores. A stepwise variable selection method was applied to all models, and only variables found to be statistically significant are presented in the final models. The BDI scale was used as a categorical variable, and logistic regression was applied to select patient characteristics associated with patients experiencing mild or moderate depression versus minimal depression.
The SCL90 psychopathology scales were combined into a psychopathology index to examine which demographic and clinical characteristics influence the psychopathology index. Each scale of the SCL90 was converted into a binary variable where the value is 0 if the score was less than the median, and 1 if the score was greater than or equal to the median. The psychopathology index is derived from the sum of the nine dichotomous variables and ranges from 0 (when a patient scores below the median on all SCL90 scales) to 9 (when a patient scores above the median on all SCL90 scales). The higher the value a patient receives, the more symptoms of psychopathology they exhibit. The psychopathology index expresses the number of “hits” on nine questions (the dichotomous versions of the SCL90 scales), where a “hit” is defined when a patient scores higher than the median on any of the nine questions. We assume that the psychopathology index follows the binomial distribution with nine independent tests, and therefore, binomial regression was applied to examine patient characteristics that influence the psychopathology index.
The EPQ and HDHQ scales are derived from the sum of dichotomous questions, therefore higher scores correspond to more positive responses to the respective questions. Binomial regression was used to examine patient demographic and clinical characteristics affecting the EPQ and HDHQ scales. Statistical analysis was performed with the IBM SPSS Statistics 24 program and the level of significance was set at 5%. The research sample consisted of 80 cancer patients, of which 57.5% were women and 42.5% men, aged from 15 to 85 years old, with a mean age of 56.95 years and a standard deviation of 13.52 years. 25.0% of patients were high school graduates, 41.3% were university graduates, and 33.8% had completed other studies. The majority of patients were married (76.3%) and the rest were single or divorced. Regarding the profession of the patients and specifically whether the income they received was stable or not, 57.5% had a stable income (public employees or pensioners) and 42.5% had a non-stable income (private employees, freelancers, unemployed, students).
Means of data collection. In order to collect the data, the questionnaires were completed anonymously. The participants were informed about the purposes of the study and their participation was voluntary. While maintaining anonymity and confidentiality, the following questionnaires were administered:
Brief Demographic Information Questionnaire.
The Symptom Checklist-90 (SCL-90) (12).
The Beck Depression Inventory (BDI) (13).
Psychometric Personality scale of extraversion, neuroticism, psychoticism (Eysenck Personality Questionnaire, EPQ) (14, 15).
Psychometric Hostility and Direction of hostility Questionnaire (HDHQ) (16).
Results
Most patients had early-stage cancer (62.5%), while 37.5% were at an advanced stage. Approximately half of the patients did not have accompanying diseases (55.0%), while the rest stated that they do. In addition, patients were asked whether they had been informed about their illness on the internet, with 61.3% responding that they had not. In Table I, the BDI depression, SCL90 psychopathology, EPQ personality, and HDHQ hostility scales of the patients are detailed. The majority of patients presented introverted hostility (77.5%) and 22.5% presented extroverted hostility.
Descriptive statistics of patient psychometric scales.
No statistically significant differences were observed in the depression, psychopathology and personality scales between men and women. Male cancer patients seemed to score on average statistically significantly higher on the self-criticism scale than females (4.44±2.31 vs. 3.17±1.98, p<0.01). In addition, males scored statistically significantly higher on the introverted hostility scale than females (12.59±5.58 vs. 9.39±4.54, p<0.01).
In terms of the educational level, marital status, and psychometric scales of the patients, no statistically significant relationships emerged. Patients who had a fixed income scored on average statistically significantly higher on the psychoticism scale than patients who did not have a fixed income (9.22±2.43 vs. 7.53±2.89, p<0.05). When comparing the psychometric scales of the patients according to the stage of the disease (Table II), patients in an advanced stage scored statistically significantly higher on the phobic anxiety scale than patients in the initial stage (5.17±3.60 vs. 2.86±2.04, p<0.01). Also, early-stage patients presented statistically significantly higher scores on the paranoid hostility scale than advanced-stage patients (2.00±1.18 vs. 1.37±0.89, p<0.05). Early-stage patients scored on average statistically significantly higher on the extraversion scale than advanced-stage patients (5.86±2.15 vs. 4.90±2.02, p<0.05).
Means, standard deviations and Mann–Whitney test of psychometric scales with disease stage.
Investigating the correlation of the patients’ psychometric scales in terms of co-morbidities and their habit of seeking information about their disease on the internet revealed no statistically significant differences. Correlation coefficients of the psychometric scales with age scale showed a statistically significant relationship with the depression scale. As the age of the patients increased, the levels of depression seemed to decrease (r=−0.276, p=0.013).
Logistic and binomial regression models to investigate the relationships of psychometric scales with patient demographic and clinical characteristics. Table III shows the logistic regression model of the BDI depression scale (mild or moderate versus minimal depression), where the variables found to be statistically significantly related to depression were age, sex, and the interaction of sex with disease stage. Specifically, men who were in an advanced stage of the disease were 14 times more likely to experience moderate or mild levels of depression than men who were in the initial stage. Women at an advanced stage had a 10% lower relative likelihood of experiencing mild or moderate depression than women at an early stage. Older patients showed a lower relative probability of experiencing mild or moderate depression. Specifically, if the age increased by one year, the relative probability decreased by 4% (OR=0.96, p=0.038).
Logistic regression of depression.
In Table IV, the binomial logistic regression model presents the demographic and clinical characteristics of the patients that are statistically significantly associated with the psychopathology index. Patients with higher educational levels were 36% less likely to score above the median on any of the psychopathology scales than patients who were high school graduates. The interaction of the marital status with the stage of the disease was found to be statistically significantly related to the psychopathology index, that is, the marital status of the patients seemed to have a statistically significant effect on the relationship between the stage of the disease and the psychopathology index. Specifically, married patients with the disease at an advanced stage were 62% more likely to score above the median on some scale of psychopathology than married patients at an early stage of the disease. Patients who were single or divorced and in an advanced stage were 40% less likely to score above the median on some scale of psychopathology than single or divorced patients in an early stage of the disease. Therefore, psychopathology symptoms were increased in married patients when the stage of the disease is advanced compared to the corresponding patients who were in the initial stage. However, the same burden of psychopathology symptoms in advanced versus early-stage patients was not observed when patients are single or divorced.
Binomial logistic regression of the psychopathology index.
The binomial logistic regression model with the factors estimating the psychoticism scale of the EPQ was investigated. Sex, disease stage, and age did not appear to be related to the psychotic scale, although patients with stable incomes appeared to be 40% more likely to answer positively to some of the psychotic symptom questions in relation to patients who did not have a fixed income (OR=1.40, p=0.003). Male cancer patients were 22% less likely to respond positively to any of the questions regarding neuroticism symptoms than females (OR=0.78, p=0.021). Patients who were of a higher educational level were 29% less likely to respond positively to the questions regarding the symptoms of neuroticism than patients who were high school graduates (OR=0.71, p=0.010). Also, patients with comorbidities were 25% less likely to respond positively to the neuroticism questions than patients without comorbidities (OR=0.75, p=0.010).
Table V presents the binomial logistic regression model for the extraversion scale of the EPQ. Sex and age were not found to be significantly related to the extraversion scale, although the interaction of the educational level of the patients with the stage of the disease was found to be significant. University-educated patients diagnosed with advanced cancer were 34% less likely to respond positively to any of the extraversion questions than similarly educated patients with early-stage cancer. Therefore, university education appears to reduce the likelihood of extraversion symptoms in advanced-stage patients relative to early-stage patients. No statistically significant differences were observed between the patients of the other educational levels.
Binomial logistic regression of the extraversion scale of the EPQ.
Binomial logistic regression revealed that disease stage significantly affects the lie scale of the EPQ. Patients in an advanced stage of the disease had a 24% higher probability of answering positively to any of the questions related to the lie scale than patients in the initial stage (OR=1.24, p=0.044). The marital status of the patients affected the relationship between the stage of the disease and their critical mood. Specifically, patients who were married and diagnosed with an advanced stage of cancer were 36% less likely to respond positively to the questions regarding their critical mood than patients who were in the early stage. Single or divorced patients were 65% more likely to be critical of others when they had advanced disease than patients who were in the early stages of the disease. Therefore, marriage appears to protect patients who are at an advanced stage in developing a critical attitude toward others. The symptoms of paranoid hostility were statistically significantly related to the stage of the disease in which the patients were (Table VI). Advanced-stage patients were 37% less likely to respond positively to the questions related to paranoid hostility than early-stage patients (OR=0.63, p=0.022).
Binomial logistic regression of HDHQ paranoid hostility.
Table VII presents the model that includes patient demographic and clinical characteristics associated with the patients’ tendency to be self-critical. Patients who had a fixed income were 43% more likely to respond positively to the questions related to their being self-critical than patients who did not have a fixed income (OR=1.43, p=0.041). Patients with a higher education were more likely to respond positively to the questions describing the symptoms of self-criticism than patients who were high school graduates (OR=1.62, p=0.024 and OR=2.12, p<0.001 respectively). The relationship between the stage of the disease and their self-critical mood was influenced by the sex of the patient and the presence of co-morbidities since, the interaction of sex with the stage of the disease (OR=0.42, p=0.008) and the comorbidities with disease stage (OR=0.45, p=0.017) were statistically significant. Specifically, men with comorbidities were 70% less likely to respond positively to some of the questions describing self-critical symptoms when they were at an advanced stage than men with comorbidities who were at an early stage. Compared to men without comorbidities, advanced-stage patients were 34% less likely to develop self-critical symptoms than early-stage patients. Women with comorbidities at an advanced stage of the disease were 31% less likely to respond positively to any of the self-criticism questions than women with comorbidities at an early stage of the disease. Women without comorbidities were 56% more likely to respond positively to some of the self-assessment questions than patients in the early stages. Therefore, the presence of comorbidities in women reduced the likelihood of self-criticism when they were at an advanced stage compared to those at an early stage. Men at an advanced stage were less likely to develop self-criticism than men at an early stage, whether comorbidities were present or not.
Binomial logistic regression of HDHQ self-criticism.
Patients who were married were more likely to answer positively to some of the questions regarding delusional guilt symptoms than patients who were single or divorced. Patients who had a fixed income and were in an advanced stage of the disease were about 50% less likely to answer positively to any of the delusional guilt questions than patients who were in the early stage. Also, advanced-stage patients without a stable income were 55% more likely to respond positively to questions about delusional guilt than early-stage patients. Therefore, income instability in advanced stage patients appeared to be an aggravating factor in the emergence of delusional guilt.
Discussion
This study attempted to explore the correlation between the development and diagnosis of melanoma and the manifestation of different psychopathological factors, such as depressive disorder, personality disorders, aggression disorders or intermittent explosive disorder, as well as different kinds of somatization disorders or somatic symptom disorders and psychosomatic burden disorders. The quantitative research revealed that there were no significant differences between men and women who manifest depression, personality disorders, other forms of psychopathology, as well as general symptoms of hostility towards others. However, men in the research sample showed higher indicators of self-criticism and a tendency towards introverted hostility, which are symptoms associated with hostility disorders. This fact proves that the appearance of psychopathological disorders in patients suffering from melanoma is not influenced by sex. Furthermore, middle-aged people were more susceptible to the manifestation of melanoma, since according to the data recorded so far, the diagnosis of melanoma is more frequent in men aged 70-75 and women aged 65-70, two age groups that are close to the average of the research sample of the present quantitative research, i.e., 56.95 years (17).
Moreover, according to the results obtained, the vast majority of patients suffering from melanoma stated that they also had symptoms of introverted hostility towards others. Only 2 out of 10 participants admitted that their mental health is affected by extroverted hostility. The existing scientific literature confirms the manifestation of symptoms within the spectrum of introverted and extroverted aggression disorders, alongside symptoms of nervousness, sleep disorders, and anxiety (9, 18).
The educational level of the participants diagnosed with melanoma was shown not to affect the manifestation of various psychopathological diseases, while at the same time it was shown that patients with a stable income suffering from melanoma showed higher levels of psychoticism (a personality disorder), compared to patients without a stable income. The literature review confirmed the correlation between the manifestation of melanoma and the presence of symptoms related to personality disorders, highlighting symptoms such as social and emotional distress (8).
The presence of somatoform disorders, specifically the manifestation of phobic anxiety, is more frequent in patients suffering from melanoma at an advanced stage. However, this pattern does not hold true for the manifestation of paranoid hostility, a type of hostility disorder, which is more common in patients with early-stage melanoma. Interestingly, in early-stage patients, paranoid hostility often coexists and is combined with an increased tendency to externalize their feelings and thoughts. The literature review, however, simply confirms the finding of the quantitative research, emphasizing that the appearance of somatoform disorders in patients diagnosed with melanoma is influenced by biological and molecular changes in the body, as well as psychological burdens related to the disease itself and the stress of treatments and disease progression (10). In addition, the quantitative research showed that both the patients’ habit of seeking health information from the internet, as well as the presence of co-morbidities with other diseases do not affect the development of psychopathological diseases in melanoma patients. At the same time, it was found that older patients suffer less from depressive disorder. For its part, the literature review did not address the influence of the above factors on the psychopathology of melanoma patients. Furthermore, it did not confirm that older patients show a lower incidence of depressive disorder symptoms (19). Furthermore, from the analysis of the data obtained through the research, it was revealed that on the one hand high school graduates present an increased probability of manifesting some form of psychopathology, compared to patients with a higher educational level, and on the other hand that the patients who are in an advanced stage of melanoma cancer appear more prone to personality disorders compared to patients in the initial stage of disease progression, as shown by the high values they scored on the lie scale. However, the literature review found no evidence that personality disorders are associated with melanoma cancer staging, and there was no mention of the patient’s educational level as a factor contributing to any form of psychopathology (3, 8, 9, 19).
Also, it was revealed that men who are in an advanced stage of their melanoma progression were significantly more prone to the manifestation of a depressive disorder when compared to men who were in the initial stage of the disease. Conversely, the opposite trend was observed for women. At the same time, since the sample in one of the two studies used to examine the link between melanoma and depression consisted of exactly the same number of men and women, the literature review revealed that men and women suffer equally from a depressive disorder that is often triggered by the physical and psychological burden of the treatment process, relative to the stage of melanoma progression. Finally, the review of existing literature demonstrated that male and female patients who experience anxiety about the progression of their melanoma equally exhibit stronger symptoms of depression and anxiety. However, this finding was not confirmed by the quantitative research in this study (20-22).
At the same time, married patients battling advanced-stage melanoma were shown to be more vulnerable in terms of their psychopathology than married patients with early-stage cancer, but without developing a significant critical attitude towards others, although single and divorced patients have more vulnerable psychopathology during the initial stage of their illness.
Through the above research, it was demonstrated that the scale of self-criticism largely depends on sex and the stage of melanoma development, but not on the presence of co-existing diseases. Specifically, it was observed that men with advanced-stage melanoma, regardless of whether they have accompanying diseases or not, show a reduced tendency to be self-critical, which is indicative of hostility expression.
This research also focused on the examination of delusional guilt, another symptom of aggression disorders, in order to identify the way it coexists with other clinical and demographic factors that characterize the cases of the participating patients. It therefore becomes clear that the instability of their income, combined with the advanced stage of their cancer, enhances the manifestation of delusional guilt, although, in an earlier phase of the research, the existence of an unstable income appeared to work inversely proportionally in terms of the manifestation of psychoticism and, more generally, personality disorders in melanoma patients (11). According to the existing scientific literature, melanoma is a type of skin cancer that is diagnosed more and more often in patients around the world, due to a modern lifestyle and the current culture of beauty that pushes many women and men to opt for unusual methods of beautification. Overexposure to the sun through tanning or exposure to the harmful radiation emitted by artificial tanning, combined of course with poor nutrition, the application of harmful chemicals on the skin, and a weakened immune system from other factors, although a very important factor in the occurrence of melanoma cancer is hereditary predisposition (23).
Conclusion
The psychopathological factors investigated in this study include mental, emotional, behavioral, cognitive, and physical symptoms triggered by the very diagnosis of melanoma and the challenging (and often prolonged) battle to combat it. These factors encompass depressive disorder, different personality disorders, intermittent explosive disorder, as well as various somatoform disorders. Therefore, through the study of modern medical literature, it becomes apparent that the majority of scientists identify a strong connection between a series of common, yet complex psychopathological symptoms and morbidity from melanoma. Notably, there is a prevalence of cases where melanoma coexists with depressive disorder and anxiety, which are general symptoms of various psychopathological disorders (24, 25). In fact, through the quantitative research conducted in this work, it was found that melanoma can cause a range of symptoms in patients that fall under various psychopathology disorders examined here. These symptoms include depression, paranoid-delusional guilt, self-criticism, hostility (both paranoid and non-paranoid), extraversion, a tendency to lie, phobic anxiety, and psychosis (26). Finally, the research showed that the psychopathology of patients suffering from melanoma is potentially influenced by various demographic and clinical factors, including sex, age, income, marital status, education level, as well as sources of information about the disease (27, 28). Additionally, the presence of accompanying diseases and the staging of the melanoma, can also impact psychopathology (29). Studies have focused on the relationship of depression in choroidal melanoma (CM) patients to treatment techniques showing that patients with CM having undergo proton beam therapy seem to be more depressed compared to a sample of healthy individuals, and the level of depression is correlated with their visual acuity (30). Depression is one of the most common psychological disorders and cross-sectional studies have found an association between depression, hopelessness and hastened death in terminally ill patients with cancer (31). Acting individually or in combination, these factors can cause the manifestation of broad depressive symptomatology, disorder, hostility, personality disorders, and somatization disorders.
Footnotes
Authors’ Contributions
KK participated in the acquisition, analysis, and interpretation of data and wrote the first draft of the manuscript. VN participated in the study concept and design, acquisition and interpretation of the data, drafting, and critical revision of the manuscript for important intellectual content. AS participated in the study concept and design, interpretation of data, and critical review and supervision of the manuscript for important intellectual content. ST participated in the acquisition of data and critical review of the manuscript. CP participated in the critical review of the manuscript, the overall supervision, and corrected the final draft. AS participated in the study concept and design, the interpretation of data, the critical review of the manuscript, the overall supervision, and corrected the final draft. All Authors have read and agreed to the published version of the manuscript.
Conflicts of Interest
All Authors have no conflicts of interest to declare in relation to this study.
Funding
This research received no external funding.
- Received June 28, 2024.
- Revision received July 23, 2024.
- Accepted July 26, 2024.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
