Table 2 highlights some of the psychiatric associations of primary dermatologic disorders; this group can be further divided into 3 subcategories.
- Disorders that have a primary dermatopathologic basis but may be influenced by psychosomatic factors, eg, psoriasis, atopic dermatitis, urticaria and angioedema, lichen planus, acne, and alopecia areata.
- Disorders that represent an accentuated physiologic response, eg, hyperhidrosis and blushing.
- Disorders that result in an emotional reaction primarily as a result of cosmetic disfigurement, social stigma, and the overall impact of the disorder on the quality of life of the patient.
These 3 subcategories are not mutually exclusive. Most of the disorders in the first category, such as psoriasis, atopic dermatitis, chronic urticaria, lichen planus, and alopecia areata, have an immunologic component. Second, most of these primary dermatologic disorders have been associated with both psychiatric comorbidity,3 (most frequently depressive disease and anxiety disorders) and with psychosocial stress, which typically is reported to exacerbate the skin disorder.
In up to 70% of cases of psoriasis, atopic dermatitis, chronic urticaria, and acne, psychological stress has been identified as an exacerbating factor. Some reports suggest that psoriasis is one of the most stress-reactive dermatoses. The association between stress and exacerbations of alopecia areata and lichen planus is less robust. A wide range of other dermatologic disorders, such as viral infections of the skin, and a range of other skin disorders that may also be immunologically mediated, such as vitiligo, may be exacerbated by psychological stress and have a psychosomatic component. However, an exhaustive review of these disorders is outside the scope of this paper. In some disorders, such as psoriasis, a significant component of the psychosocial stress arises from the impact of the skin disorder on quality of life and the daily hassles associated with having to cope with a chronic disfiguring disorder.4
Some of the major psychiatric disorders (DSM-IV-TR) that are encountered in dermatology include mood disorders: major depressive disorder; anxiety disorders: obsessive-compulsive disorder (OCD), social phobia, anxiety disorder caused by a general medical condition, and PTSD; somatoform disorders: body dysmorphic disorder (BDD); psychotic disorders: delusional disorder, somatic type encountered in delusions of parasitosis, and shared psychotic disorder or folie deux; and eating disorders: anorexia nervosa and bulimia nervosa. The personality disorders, especially borderline, narcissistic, histrionic, and obsessive-compulsive, may be encountered in certain groups of dermatology patients. Among these, the most frequently encountered psychiatric disorders are major depressive disorder, anxiety disorders, and somatoform disorders.
Major depressive disorder
Depressive disease is one of the most commonly encountered psychiatric syndromes in dermatology. A direct correlation has been observed between the severity of depression and pruritus or itch severity in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Pruritus is one of the most bothersome symptoms in dermatology and has been associated with suicide. The sleep difficulties encountered in depressive disease may lower the threshold for pruritus perception; alternatively, intractable pruritus may further contribute toward disruption of sleep.
The severity of the skin disorder and severity of depression and suicidal ideation are generally correlated in some disorders, such as psoriasis. In other conditions, such as acne, the severity of depression and suicidal ideation are often not related to the severity of the dermatosis. Even mild acne has been associated with depression, suicidal ideation, and completed suicide.5 The high prevalence of psychiatric morbidity among patients with mild to moderate acne is most likely due to the fact that the peak incidence of acne occurs during mid-adolescence, a life stage that is also associated with depressive disease and body image disorders. The association between acne and depression is further confounded by reports of a possible link between isotretinoin (which is used to treat acne) and suicide.6
Some of the compulsive scratching and picking of the skin in OCD may exacerbate psoriasis as a result of the Koebner phenomenon, and exacerbate eczema and a wide range of other pruritic conditions, or further contribute to the inflammatory process in acne, and/or lead to scarring that is encountered in acne excorie. OCD may also result in hand dermatitis caused by excessive handwashing. In some instances OCD may manifest as an obsessive preoccupation with some aspect of the skin, and these symptoms may overlap with BDD.
Patients with hyperhidrosis and rosacea often perspire or blush excessively and may develop a social phobia as a result. Social phobia is also encountered in patients with cosmetically disfiguring skin conditions such as acne and psoriasis, and may interfere with normal socialization. Exposure to the feared social situation may trigger a situationally bound panic attack, which in turn can cause flare-ups of the underlying skin condition. Social phobia is typically underdiagnosed because the very nature of the disorder prevents patients from seeking medical help.
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3. Gupta MA, Gupta AK. Psychodermatology: an update. J Am Acad Dermatol. 1996;34:1030-1046.
4. 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;11:166-173.
5. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol. 1998;139:846-850.
6. Hull PR, D'Arcy C. Acne, depression, and suicide. Dermatol Clin. 2005; 23:665-674.
7. Pistiner M, Pitlik S, Rosenfeld J. Psychogenic urticaria. Lancet. 1979;ii:1383.