Effectiveness of Acceptance and Commitment Therapy on Psychological Symptoms in Vitiligo Patients

EXTENDED ABSTRACT

Background

Vitiligo is a chronic skin disorder characterized by depigmented patches resulting from loss of melanocytes [1]. Its prevalence has been reported at approximately 1% of the general population [1, 2]. Because the disorder alters visible appearance, it can adversely affect psychological health, quality of life, self-confidence, social participation, and interpersonal relationships; depression, isolation, and other psychological symptoms are common among affected patients [2–4]. These concerns may be particularly relevant during adolescence and early adulthood, when appearance and social relationships have considerable developmental importance [5]. Psychological interventions have therefore been considered alongside dermatologic management. Previous work cited in the article showed that cognitive-behavioral therapy could improve body image and reduce negative feelings in patients with vitiligo, although dropout and nonresponse remain recognized limitations of cognitive-behavioral approaches [6–8]. Acceptance and Commitment Therapy (ACT) emphasizes willingness to experience difficult internal events rather than attempting to suppress or control them and seeks to improve psychological flexibility through acceptance, present-moment awareness, cognitive defusion, values clarification, and committed action [9, 10]. By strengthening acceptance and value-based behavior, ACT may be suitable for patients whose appearance-related thoughts and emotions cannot readily be eliminated. However, psychological interventions have been studied less often in vitiligo than in several other chronic dermatologic conditions. The present study therefore evaluated the effectiveness of ACT on psychological symptoms in patients with vitiligo, focusing on depression, anxiety, experiential avoidance, quality of life, and mindfulness.

Methods

This quasi-experimental study used a pretest-posttest design with an unequal control group. The target population consisted of soldiers and other military personnel with vitiligo who were serving at armed-forces military centers in Tehran in 2020. Sampling was nonrandom, accessible, and purposive. Patients with a diagnosis of vitiligo documented in their medical records and confirmed by a dermatologist were referred to a clinical psychologist. Eligible participants were then allocated to experimental and control groups. Initially, 20 participants were placed in each group. Inclusion criteria were a dermatologist-confirmed diagnosis of vitiligo, no pharmacological treatment for vitiligo or psychiatric disorders, and no concurrent psychological intervention. Exclusion criteria included initiation of medication for vitiligo or psychiatric disorders, an acute psychiatric disorder or suicidal ideation, and unwillingness to continue participation. All participants completed the study questionnaires before the intervention. The control group received no intervention during the study and was offered ACT after completion for ethical reasons. ACT was administered to the experimental group according to the treatment manual described by Hayes and colleagues [9]. The protocol contained at least 12 sessions of approximately 50 minutes, although treatment extended to as many as 21 sessions for some participants because the intervention prioritized therapeutic process over rigid content delivery. The program progressed through orientation and ACT formulation, creative hopelessness and examination of attempts to control internal experiences, mindfulness and acceptance strategies, cognitive defusion, clarification of personal values, commitment to value-based behavior, review of progress, relapse prevention, and termination. Treatment was delivered by a clinical psychologist trained in ACT. Sessions were recorded with consent, and two randomly selected sessions were independently reviewed by two doctoral-level clinical psychology trainees with ACT training. Treatment-integrity agreement was acceptable (kappa=0.76). Anxiety was assessed with the 21-item Beck Anxiety Inventory [11, 12], depression with the Beck Depression Inventory-II [12, 13], quality of life with the 26-item WHOQOL-BREF [14, 15], experiential avoidance with the 9-item Acceptance and Action Questionnaire [16, 17], and mindfulness with the 15-item Mindful Attention Awareness Scale [18, 19]. Statistical analysis was performed with SPSS version 19 using descriptive statistics and multivariate analysis of covariance (MANCOVA), after assessment of distributional and variance assumptions with the Kolmogorov-Smirnov and Levene tests and evaluation of the multivariate model with Wilks' lambda. The study used a significance level of 0.01. Ethical approval was documented by AJA University of Medical Sciences in letter No. 03/DEN11/1234 dated 1403/03/03 (Solar Hijri), and written informed consent was obtained from all participants.

Results

All analyzed participants were male. Mean age was 20.0 years in the experimental group and 20.70 years in the control group; 78% of participants were single and 58% had higher-education qualifications. During the study, nine participants from the experimental group and seven from the control group were lost because of treatment discontinuation, transfer of service location, exemption from military service, or incomplete study questionnaires. Consequently, the final analysis included 11 participants in the ACT group and 13 in the control group. Descriptive pretest-posttest scores showed the strongest changes in depression, experiential avoidance, and quality of life. In the ACT group, mean depression decreased from 19.33±6.56 to 10.44±7.45, whereas the control group changed from 18.33±6.69 to 14.79±7.11. Experiential avoidance in the ACT group decreased from 47.43±12.77 to 29.50±12.14, compared with 44.67±10.55 to 41.56±9.76 in controls. Mean quality-of-life score increased from 36.76±12.43 to 49.71±14.65 in the ACT group and from 31.44±9.11 to 34.91±10.34 in the control group. Anxiety decreased from 16.51±3.56 to 13.66±4.16 in the ACT group but changed from 13.65±4.11 to 14.31±3.76 in controls. Mindfulness increased from 34.45±13.65 to 37.56±12.76 in the ACT group, while the control-group mean changed from 42.56±15.36 to 32.44±11.87.

Table 2. Mean and standard deviation of study variables before and after the intervention in the experimental and control groups.

The Kolmogorov-Smirnov and Levene tests supported the assumptions required for MANCOVA. Wilks' lambda indicated a significant overall group effect on the combined outcome variables (P≤0.001), supporting follow-up covariance analyses. After adjustment for pretest scores, ACT produced statistically significant between-group effects on depression (MS=77.65, F=34.56, P=0.001, effect size=0.49), experiential avoidance (MS=55.45, F=22.45, P=0.001, effect size=0.35), and quality of life (MS=81.43, F=32.49, P=0.001, effect size=0.56). In contrast, the adjusted between-group differences were not significant for anxiety (MS=87.33, F=0.087, P=0.23, effect size=0.02) or mindfulness (MS=76.33, F=0.075, P=0.12, effect size=0.04). Thus, the intervention was associated with improved depressive symptoms, increased quality of life and acceptance, and reduced experiential avoidance, while the study did not demonstrate significant effects on anxiety or mindfulness. The authors interpreted the pattern as consistent with ACT's emphasis on greater willingness to experience difficult internal states and increased engagement in value-based behavior rather than direct elimination of all symptoms.

Table 3. Analysis of covariance results for the study outcomes after adjustment for pretest scores.

Conclusion

Acceptance and Commitment Therapy improved several clinically relevant psychological outcomes in men with vitiligo, particularly depression, experiential avoidance, and quality of life. The findings support ACT as a potentially useful evidence-based psychological intervention alongside medical care for vitiligo. Interpretation should account for the small final sample, restriction to male soldiers and military personnel, and absence of a follow-up assessment, all of which limit generalizability and the ability to determine persistence of benefit. The study authors recommended broader future research including women, nonmilitary populations, follow-up assessments, and examination of treatment mechanisms.

Keywords: Acceptance and Commitment Therapy, Psychological Symptoms, Vitiligo

REFERENCES

1. Mohmoud ZM, Elsayed SS, Ahmed FM. Psychosocial status and quality of life among vitiligo patients. Benha Journal of Applied Sciences. 2023;8(4):67-79. Link
2. Elbuluk N, Ezzedine K. Quality of Life, Burden of Disease, Co-morbidities, and Systemic Effects in Vitiligo Patients. Dermatologic Clinics. 2017;35(2):117-28. DOI: 10.1016/j.det.2016.11.002
3. Thomson J. Defining the psychological comorbidity in vitiligo: systematically casting the net wide. British Journal of Dermatology. 2018;178(4):826-26. Link
4. Ahmed A, Steed L, Burden-Teh E, Shah R, Sanyal S, Tour S, Dowey S, Whitton M, Batchelor JM, Bewley AP. Identifying key components for a psychological intervention for people with vitiligo-a quantitative and qualitative study in the United Kingdom using web-based questionnaires of people with vitiligo and healthcare professionals. J Eur Acad Dermatol Venereol. 2018;32(12):2275-83. DOI: 10.1111/jdv.15168
5. Berk LE. Development through the lifespan. Sage Publications. 2022. Link
6. Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of vitiligo: a preliminary investigation into the effects of cognitive-behavioural therapy. British Journal of Medical Psychology. 1999;72(3):385-96. DOI: 10.1348/000711299160077
7. Rakitzi S. Clinical Psychology and Cognitive Behavioral Psychotherapy: Recovery in Mental Health. Springer Nature. 2023. Link
8. Fernandez E, Salem D, Swift JK, Ramtahal N. Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of Consulting and Clinical Psychology. 2015;83(6):1108. Link
9. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press. 2011. Link
10. Hayes SC, Pierson H. Acceptance and commitment therapy. Encyclopedia of Cognitive Behavior Therapy. 2005:1-4. DOI: 10.1007/0-306-48581-8_1
11. Beck AT, Epstein N, Brown G, Steer R. Beck anxiety inventory. Journal of Consulting and Clinical Psychology. 1993;60(3):532-42. DOI: 10.1207/s15327752jpa6003_10
12. Fata L, Birashk B, Atefvahid MK, Dabson KS. Meaning Assignment Structures/Schema, Emotional States and Cognitive Processing of Emotional Information: Comparing Two Conceptual Frameworks. IJPCP. 2005;11(3):312-26. Link
13. Beck AT, Steer RA, Brown GK. Beck depression inventory. New York: Harcourt Brace Jovanovich; 1987.
14. Amir M, Marcelo F, Herrman H, Lomachenkov A, Lucas R, Patrick D, LIDO Group. Reliability, validity and reproducibility of the WHOQOL-BREF in six countries. Qual Life Res. 2000;9(3):320. Link
15. Nejat S, Montazeri A, Holakoue K, Mohammad K, Majdzadeh M. Quality of Life of Tehran's Population by WHOQOL-BREF questionnaire in 2005. Hakim Res J. 2007;10(3):1-8. Link
16. Hayes SC, Strosahl K, Wilson KG, Bissett RT, Pistorello J, Toarmino D, Polusny MA, Dykstra TA, Batten SV, Bergan J, Stewart SH. Measuring experiential avoidance: A preliminary test of a working model. Psychol Rec. 2004;54:553-78. DOI: 10.1007/BF03395492
17. Zargar F, Farid AA, Atef-Vahid MK, Afshar H, Omidi A. Comparing the effectiveness of acceptance-based behavior therapy and applied relaxation on acceptance of internal experiences, engagement in valued actions and quality of life in generalized anxiety disorder. J Res Med Sci. 2013;18(2):118. PMID: 23914213
18. Brown KW, Ryan RM. Mindful attention awareness scale. Journal of Personality and Social Psychology. 2003. DOI: 10.1037/t04259-000
19. Manavipour D, Baghdasarianc A, Sakhlo SK. Psychometric properties of the mindfulness inventory. Journal of Industrial/Organization Psychology. 2014;4:49-56. Link
20. Beck JS. Cognitive behavior therapy: Basics and beyond. Guilford Publications. 2020. Link
21. Montgomery K, Thompson AR. The potential role of mindfulness in psychosocial support for dermatology patients. Clinics in Dermatology. 2018;36(6):743-7. DOI: 10.1016/j.clindermatol.2018.08.010
22. Shahmoradi Z, Khaleghipour S, Masjedi M. Comparing effectiveness of “Schema Therapy” and “Mindfulness-Based Cognitive Therapy” on maladaptive schemas and general health in patients with Vitiligo. Journal of Health Promotion Management. 2019;7(6):42-52. Link
23. Gloster AT, Walder N, Levin ME, Twohig MP, Karekla M. The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science. 2020;18:181-92. DOI: 10.1016/j.jcbs.2020.09.009
24. Bennett R, Oliver J. Acceptance and commitment therapy: 100 key points and techniques. Routledge. 2019. DOI: 10.4324/9781351056144
25. Zakiei A, Khazaie H, Rostampour M, Lemola S, Esmaeili M, Dürsteler K, Brühl AB, Sadeghi-Bahmani D, Brand S. Acceptance and commitment therapy (ACT) improves sleep quality, experiential avoidance, and emotion regulation in individuals with insomnia-results from a randomized interventional study. Life. 2021;11(2):133. DOI: 10.3390/life11020133
26. Dehghani M, Saf AD, Vosoughi A, Tebbenouri G, Zarnagh HG. Effectiveness of the mindfulness-acceptance-commitment-based approach on athletic performance and sports competition anxiety: A randomized clinical trial. Electro Physician. 2018;10(5):6749. PMID: 29997757 DOI: 10.19082/6749
27. Twohig MP, Levin ME. Acceptance and commitment therapy as a treatment for anxiety and depression: A review. Psychiatric Clinics. 2017;40(4):751-70. DOI: 10.1016/j.psc.2017.08.009