American Journal of Clinical Dermatology

, Volume 4, Issue 12, pp 833–842

Psychiatric and Psychological Co-Morbidity in Patients with Dermatologic Disorders

Epidemiology and Management
Review Article
  • 273 Downloads

Abstract

Psychiatric and psychological factors play an important role in at least 30% of dermatologic disorders. In many cases the impact of the skin disorder upon the quality of life is a stronger predictor of psychiatric morbidity than the clinical severity of the disorder as per physician ratings. Furthermore, in certain disorders such as acne and psoriasis, the psychiatric co-morbidity, which can be associated with psychiatric emergencies such as suicide, is an important measure of the overall disability experienced by the patient. The severity of depression and increased suicide risk are not always directly correlated with the clinical severity of the dermatologic disorder. Consideration of psychiatric and psychosocial factors is important both for the management, and for some aspects of secondary and tertiary prevention of a wide range of dermatologic disorders. It is useful to use a biopsychosocial model which takes into account the psychological (e.g. psychiatric comorbidity such as major depression and the impact of the skin disorder on the psychological aspects of quality of life) and social (e.g. impact upon social and occupational functioning) factors, in addition to the primary dermatologic factors, in the management of the patient. Some dermatology patients are likely to benefit from psychotherapeutic interventions and psychotropic agents for the management of the psychosocial comorbidity, in addition to the standard dermatologic therapies for their skin disorder.

References

  1. 1.
    Gupta MA, Gupta AK. Psychodermatology: an update. J Am Acad Dermatol 1996; 34: 1030–46PubMedCrossRefGoogle Scholar
  2. 2.
    Picardi A, Abeni D, Melchi CF, et al. Psychiatric morbidity in dermatological outpatients: an issue to be recognized. Br J Dermatol 2000; 143: 983–91PubMedCrossRefGoogle Scholar
  3. 3.
    Medansky RS, Handler RM. Dermatopsychosomatics: classification, physiology, and therapeutic approaches. J Am Acad Dermatol 1981; 5: 125–36PubMedCrossRefGoogle Scholar
  4. 4.
    Koblenzer CS. Psychosomatic concepts in dermatology. Arch Dermatol 1983; 119: 501–12PubMedCrossRefGoogle Scholar
  5. 5.
    Panconesi P. Psychosomatic dermatology. Clin Dermatol 1984; 2: 94–179PubMedCrossRefGoogle Scholar
  6. 6.
    Seville RH. Psoriasis and stress. Br J Dermatol 1977; 97: 297–302PubMedCrossRefGoogle Scholar
  7. 7.
    Polenghi MM, Molinari E, Gala C, et al. Experience with psoriasis in a psychosomatic dermatology clinic. Acta Derm Venereol (Stockh) 1994; 186: 65–6Google Scholar
  8. 8.
    Nyfors A, Lemholt K. Psoriasis in children. Br J Dermatol 1975; 92: 437–42PubMedCrossRefGoogle Scholar
  9. 9.
    Al’Abadie MS, Kent GG, Gawkrodger DJ. The relationship between stress and the onset and exacerbation of psoriasis and other skin conditions. Br J Dermatol 1994; 130: 199–203PubMedCrossRefGoogle Scholar
  10. 10.
    Mazzetti M, Mozzetta A, Soavi GC, et al. Psoriasis, stress and psychiatry: psychodynamic characteristics of stressors. Acta Derm Venereol (Stockh) 1994; 186: 62–4Google Scholar
  11. 11.
    Gupta MA, Gupta AK, Kirkby S, et al. A psychocutaneous profile of psoriasis patients who are stress reactors: a study of 127 patients. Gen Hosp Psychiatry 1989; 11: 166–73PubMedCrossRefGoogle Scholar
  12. 12.
    Ginsburg IH, Link BG. Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989; 20: 53–63PubMedCrossRefGoogle Scholar
  13. 13.
    Gupta MA, Gupta AK. Quality of life of psoriasis patients. J Eur Acad Derm Venereol 2000 Jul; 14 (4): 267–71CrossRefGoogle Scholar
  14. 14.
    Fortune DG, Richards HL, Griffiths CE, et al. Psychological stress, distress and disability in patients with psoriasis: consensus and variation in the contribution of illness perceptions, coping and alexithymia. Br J Clin Psychol 2002; 41 (Pt 2): 157–74PubMedCrossRefGoogle Scholar
  15. 15.
    Gupta MA, Gupta AK, Watteel G. Early onset (<age 40 years) psoriasis is associated with greater psychopathology than late onset psoriasis. Acta Derm Venereol 1996; 76: 464–6PubMedGoogle Scholar
  16. 16.
    Niemeier V, Nippesen M, Kupfer J, et al. Psychological factors associated with hand dermatoses: which subgroup needs additional psychological care? Br J Dermatol 2002; 146: 1031–7PubMedCrossRefGoogle Scholar
  17. 17.
    Feldman SR, Fleischer Jr AB, Reboussin DM, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997; 37 (4): 564–9PubMedCrossRefGoogle Scholar
  18. 18.
    Kirkby B, Richards HL, Woo P, et al. Physical and psychological measures are necessary to assess overall psoriasis severity. J Am Acad Dermatol 2001; 45 (1): 72–6CrossRefGoogle Scholar
  19. 19.
    Fortune DG, Main CJ, O’Sullivan TM, et al. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis-specific stress. Br J Dermatol 1997; 137: 755–60PubMedCrossRefGoogle Scholar
  20. 20.
    Gupta MA, Gupta AK, Haberman HF. Psoriasis and psychiatry: an update. Gen Hosp Psychiatry 1987; 9: 157–66PubMedCrossRefGoogle Scholar
  21. 21.
    Fava GA, Perini GI, Santonastaso P, et al. Life events and psychosocial distress in dermatologic disorders: psoriasis, chronic urticaria and fungal infections. Br J Med Psychol 1980; 53: 277–82PubMedCrossRefGoogle Scholar
  22. 22.
    Matussek P, Agerer D, Seibt G. Aggression in depressives and psoriatics. Psychother Psychosom 1985; 43: 120–5PubMedCrossRefGoogle Scholar
  23. 23.
    Arnetz BB, Fjellner B, Eneroth P, et al. Stress and psoriasis: psychoendocrine and metabolic reactions in psoriatic patients during standardized stressor exposure. Psychosom Med 1985; 47: 528–41PubMedGoogle Scholar
  24. 24.
    Rubino IA, Sonnino A, Pezzarossa B, et al. Personality disorders and psychiatric symptoms in psoriasis. Psychol Rep 1995; 72: 547–53CrossRefGoogle Scholar
  25. 25.
    Vidoni D, Campiutti E, D’Aronco R, et al. Psoriasis and alexithymia. Acta Derm Venereol (Stockh) 1989; 146: 91–2Google Scholar
  26. 26.
    Goldsmith LA, Fisher M, Wacks J. Psychological characteristics of psoriatics. Arch Dermatol 1969; 100: 674–6PubMedCrossRefGoogle Scholar
  27. 27.
    Gupta MA, Gupta AK, Schork NJ, et al. Depression modulates pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Psychosom Med 1994; 56: 36–40PubMedGoogle Scholar
  28. 28.
    Gupta MA, Gupta AK, Kirkby S, et al. Pruritus in psoriasis: a prospective study of some psychiatric and dermatologic correlates. Arch Dermatol 1988; 124: 1052–7PubMedCrossRefGoogle Scholar
  29. 29.
    Gupta MA, Gupta AK, Schork NJ, et al. Suicidal ideation in psoriasis. Int J Dermatol 1993; 32: 188–90PubMedCrossRefGoogle Scholar
  30. 30.
    Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998; 139 (5): 846–50PubMedCrossRefGoogle Scholar
  31. 31.
    Morse RM, Perry HO, Hurt RD. Alcoholism and psoriasis. Alcohol Clin Exp Res 1985; 9: 396–9PubMedCrossRefGoogle Scholar
  32. 32.
    Mills CM, Srivastava RD, Harvey IM, et al. Smoking habits in psoriasis: a case control study. Br J Dermatol 1992; 127: 18–21PubMedCrossRefGoogle Scholar
  33. 33.
    Gupta MA, Schork NJ, Gupta AK, et al. Alcohol intake and treatment responsiveness of psoriasis: a prospective study. J Am Acad Dermatol 1993; 28: 730–2PubMedCrossRefGoogle Scholar
  34. 34.
    Gupta MA, Gupta AK, Watteel GN. Cigarette smoking in men may be a risk factor for increased severity of psoriasis of the extremities [letter]. Br J Dermatol 1996; 135: 859–60PubMedCrossRefGoogle Scholar
  35. 35.
    Layton M. Optimal management of acne to prevent scarring and psychological sequelae. Am J Clin Dermatol 2001; 2: 135–41PubMedCrossRefGoogle Scholar
  36. 36.
    Wu SF, Kinder BN, Trunnell TN, et al. Role of anxiety and anger in acne patients: a relationship with severity of the disorder. J Am Acad Dermatol 1988; 18 (2 Pt 1): 325–33PubMedCrossRefGoogle Scholar
  37. 37.
    Gupta MA, Gupta AK. The psychological comorbidity in acne. Clin Dermatol 2001; 19: 360–3PubMedCrossRefGoogle Scholar
  38. 38.
    Mallon E, Newton JN, Klassen A, et al. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999; 140 (4): 672–6PubMedCrossRefGoogle Scholar
  39. 39.
    Smithard A, Glazebrook C, Williams HC. Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community based study. Br J Dermatol 2001; 145 (2): 274–9PubMedCrossRefGoogle Scholar
  40. 40.
    Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997; 137 (2): 246–50PubMedCrossRefGoogle Scholar
  41. 41.
    Roy A. Suicide. In: Sadock BI, Sadock VA, editors. Kaplan & Sadock’s comprehensive textbook of psychiatry. 7th ed on CD-ROM. Folio Infobase. Philadelphia (PA): Lippincott Williams & Wilkins, 2000Google Scholar
  42. 42.
    Gupta MA, Gupta AK, Schork NJ, et al. Psychiatric aspects of the treatment of mild to moderate facial acne: some preliminary observations. Int J Dermatol 1990; 29 (10): 719–21PubMedCrossRefGoogle Scholar
  43. 43.
    Rubinow DR, Peck GL, Squillace KM, et al. Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin. J Am Acad Dermatol 1987; 17 (1): 25–32PubMedCrossRefGoogle Scholar
  44. 44.
    Gupta MA, Johnson AM, Gupta AK. The development of an Acne Quality of Life scale: reliability, validity, and relation to subjective acne severity in mild to moderated acne vulgaris. Acta Derm Venereol 1998; 78 (6): 451–6PubMedCrossRefGoogle Scholar
  45. 45.
    Layton AM, Seukeran D, Cunliffe WJ. Scarred for life? Dermatology 1997; 195 Suppl. 1: 15–21PubMedCrossRefGoogle Scholar
  46. 46.
    Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol 1999; 140 (2): 273–82PubMedCrossRefGoogle Scholar
  47. 47.
    Physicians’ Desk Reference. 56th ed. Montvale (NJ): Medical Economics Data Production Company, 2002Google Scholar
  48. 48.
    Gupta MA, Gupta AK. Dermatological complications. Eur Eating Disorders Rev 2000; 8 (2): 134–43CrossRefGoogle Scholar
  49. 49.
    Gupta MA, Gupta AK, Haberman HF. Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Dermatol 1987; 123: 1386–90PubMedCrossRefGoogle Scholar
  50. 50.
    Sneddon J, Sneddon I. Acne excoriee: a protective device. Clin Exp Dermatol 1983; 8: 65–8PubMedCrossRefGoogle Scholar
  51. 51.
    Cotterill JA. Dermatologic non-disease: a common and potentially fatal disturbance of cutaneous body image. Br J Dermatol 1981; 104: 611–9PubMedCrossRefGoogle Scholar
  52. 52.
    American Psychiatric Association Committee on Nomenclature and Statistics. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994Google Scholar
  53. 53.
    Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs 2001; 15: 351–9PubMedCrossRefGoogle Scholar
  54. 54.
    Kilpelainen M, Koskenvuo M, Helenius H, et al. Stressful life events promote the manifestation of asthma and atopic diseases. Clin Exp Allergy 2002; 32: 256–63PubMedCrossRefGoogle Scholar
  55. 55.
    Faulstich ME, Williamson DA. An overview of atopic dermatitis: toward a bio-behavioral integration. J Psychosom Res 1985; 29: 415–7PubMedCrossRefGoogle Scholar
  56. 56.
    Howlett S. Emotional dysfunction, child-family relationships and childhood atopic dermatitis. Br J Dermatol 1999; 140 (3): 381–4PubMedCrossRefGoogle Scholar
  57. 57.
    Buske-Kirschbaum A, Gierens A, Hollig H, et al. Stress-induced immunomodulation is altered in patients with atopic dermatitis. J Neuroimmunol 2002; 129: 161–7PubMedCrossRefGoogle Scholar
  58. 58.
    Pauli-Pott U, Darui A, Beckmann D. Infants with atopic dermatitis: maternal hopelessness, child-rearing attitudes and perceived infant temperament. Psychother Psychosom 1999; 68: 39–45PubMedCrossRefGoogle Scholar
  59. 59.
    Kodama A, Horikawa T, Suzuki T, et al. The effect of stress on atopic dermatitis: investigation in patients and the great Hanshin earthquake. J Allergy Clin Immunol 1999; 104 (1): 173–6PubMedCrossRefGoogle Scholar
  60. 60.
    Buske-Kirschbaum A, Geiben A, Hollig H, et al. Altered responsiveness of the hypothalamus-pituitary-adrenal axis and the sympathetic adrenomedullary system to stress in patients with atopic dermatitis. J Clin Endocrinol Metab 2002; 87: 4245–51PubMedCrossRefGoogle Scholar
  61. 61.
    Kemp S. Atopic eczema: its social and financial cost. J Pediatr Child Health 1999; 35 (3): 229–31CrossRefGoogle Scholar
  62. 62.
    Schmid-Ott G, Kuensebeck HW, Jaeger B, et al. Validity study for the stigmatization experience in atopic dermatitis and psoriatic patients. Acta Derm Venereol 1999; 79 (6): 443–7PubMedCrossRefGoogle Scholar
  63. 63.
    Kiebert G, Sorensen SV, Revicki D, et al. Atopic dermatitis is associated with a decrement in health-related quality of life. Int J Dermatol 2002; 41: 151–8PubMedCrossRefGoogle Scholar
  64. 64.
    Absolon CM, Cottrell D, Eldridge SM, et al. Psychological disturbance in atopic eczema: the extent of the problem in school-aged children. Br J Dermatol 1997; 137 (2): 241–5PubMedCrossRefGoogle Scholar
  65. 65.
    Linnet J, Jemec GB. An assessment of anxiety and dermatology quality of life in patients with atopic dermatitis. Br J Dermatol 1999; 140 (2): 268–72PubMedCrossRefGoogle Scholar
  66. 66.
    Ginsburg IH, Prystowsky JH, Kornfeld DS, et al. Role of emotional factors in adults with atopic dermatitis. Int J Dermatol 1993; 32: 656–60PubMedCrossRefGoogle Scholar
  67. 67.
    Scheich G, Florin I, Rudolph R, et al. Personality characteristics and serum IgE level in patients with atopic dermatitis. J Psychosom Res 1993; 37: 637–42PubMedCrossRefGoogle Scholar
  68. 68.
    Ullman KC, Moore RW, Reidy M. Atopic eczema: a clinical psychiatric study. J Asthma Res 1977; 14: 91–9CrossRefGoogle Scholar
  69. 69.
    Koblenzer CS, Koblenzer PJ. Chronic intractable atopic eczema. Arch Dermatol 1988; 124: 1673–7PubMedCrossRefGoogle Scholar
  70. 70.
    Hashiro M, Okumura M. The relationship between the psychological and immunological in patients with atopic dermatitis. J Dermatol Sci 1998; 16 (3): 231–5PubMedCrossRefGoogle Scholar
  71. 71.
    Michaelsson G. Chronic urticaria. Acta Derm Venereol (Stockh) 1969; 49: 404–16Google Scholar
  72. 72.
    Stewart JH, Goodman MM. Earthquake urticaria [case report]. Cutis 1989; 43: 340PubMedGoogle Scholar
  73. 73.
    Rees L. An aetiological study of chronic urticaria and angioneurotic oedema. J Psychosom Res 1957; 2: 172–89PubMedCrossRefGoogle Scholar
  74. 74.
    Juhlin L. Recurrent urticaria: clinical investigations of 330 patients. Br J Dermatol 1981; 104: 369–81PubMedCrossRefGoogle Scholar
  75. 75.
    Anderson RT, Rajagopalan R. Effects of allergic dermatosis on health-related quality of life. Curr Allergy Asthma Rep 2001; 1: 309–15PubMedCrossRefGoogle Scholar
  76. 76.
    Poon E, Seed PT, Greaves MW, et al. The extent and nature of disability in different urticarial conditions. Br J Dermatol 1999; 140: 667–71PubMedCrossRefGoogle Scholar
  77. 77.
    Badoux A, Levy DA. Psychologic symptoms in asthma and chronic urticaria. Ann Allergy 1994; 72: 229–34PubMedGoogle Scholar
  78. 78.
    Hashiro M, Okumura M. Anxiety, depression, psychosomatic symptoms and autonomic nervous system function in patients with chronic urticaria. J Dermatol Sci 1994; 8: 129–35PubMedCrossRefGoogle Scholar
  79. 79.
    Sheehan-Dare RA, Henderson MJ, Cotterill JA. Anxiety and depression in patients with chronic urticaria and generalized pruritus. Br J Dermatol 1990; 123: 769–74PubMedCrossRefGoogle Scholar
  80. 80.
    Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980; 137: 535–44PubMedGoogle Scholar
  81. 81.
    Gupta MA, Gupta AK. Age and gender differences in the impact of psoriasis upon the quality of life. Int J Dermatol 1995; 34: 700–3PubMedCrossRefGoogle Scholar
  82. 82.
    Hyman SE. The suicidal patient. In: Hyman SE, Tesar GE, editors. Manual of psychiatric emergencies. 3rd ed. Boston (MA): Little, Brown and Company, 1994: 21–27Google Scholar
  83. 83.
    Koo JYM, Pham CT. Psychodermatology- practical guidelines on pharmacotherapy. Arch Dermatol 1992; 126: 381–8CrossRefGoogle Scholar
  84. 84.
    Folks DG, Kinney FC. The role of psychological factors in dermatologic conditions. Psychosomatics 1992; 33: 45–54PubMedCrossRefGoogle Scholar
  85. 85.
    Gupta MA. Dermatology. In: Stoudemire A, Fogel BS, editors. Psychiatric care of the medical patient. New York: Oxford University Press, 1993: 681–690Google Scholar
  86. 86.
    Gupta MA, Gupta AK. Use of eye movement desensitization and reprocessing (EMDR) in the treatment of dermatologic disorders. J Cutan Med Surg 2002; 6 (5): 415–21PubMedCrossRefGoogle Scholar
  87. 87.
    Gupta MA, Gupta AK. The use of psychotropic drugs in dermatology. Dermatol Clin 2000 Oct; 18 (4): 711–25PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2003

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of Western OntarioLondonCanada
  2. 2.Mediprobe LaboratoriesLondonCanada
  3. 3.Division of Dermatology, Department of MedicineUniversity of TorontoTorontoCanada
  4. 4.LondonCanada

Personalised recommendations