Skin and Psyche

The skin has a dense innervation with synapses between nerve endings and many cells. These cells communicate via neurotransmitters and their receptors. Thus, the nervous system may influence different skin functions, including immunity. In skin diseases, the equilibrium of these neurotransmitters is disturbed. There are numerous disorders of this neuro-immuno-cutaneous system (NEICS). The present chapter aims at understanding the impact of psyche in inflammatory skin disorders.

Psoriasis is a chronic immune-mediated genetic disease affecting approximately 120 million patients worldwide. Over 40 genes are associated with psoriasis. Common trigger factors include infections, trauma, medications and stress. There is substantial literature describing the link between psychosocial stress and the exacerbation of psoriasis.

We conducted a comprehensive review of the literature regarding pathophysiology, personality traits, quality of life, anxiety, depression, sexual dysfunction, alcohol, smoking and the treatment of psoriasis with respect to stress.

Our understanding of the brain-skin axis may help alleviate the suffering of our psoriatic patient population and shed light on the pathophysiology of psoriasis.

Acne is a multifactorial disorder of the pilosebaceous units. Although many forms of acne can affect all age groups, it is most common in adolescence, when it can be prevalent in up to 80% of the population. Acne vulgaris is often considered a minor disorder, however, it is important to appreciate that the condition can result in severe psychological and social disturbances. Healthcare professionals often underestimate the adverse effects of acne and may lack an empathetic attitude towards the emotional suffering of their patients. It is important to remember that although acne is not a lifethreatening disease, it can cause distress and adverse psychosocial consequences such as depression, poor self-esteem, and social phobia. Body dysmorphic disorder and suicide ideation should also be screened for in patients presenting with poor self-esteem and a lack of social interaction. An association between acne and impaired healthrelated quality of life has also been described. This work aims to highlight the importance of acknowledging the psychological effects of acne and providing patients with effective support. Psychological comorbidities, assessment and treatment options are described.

Body dysmorphic disorder (BDD) is a psychiatric condition with onset in early teens. Incidence and chronicity are about the same as for schizophrenia or obsessive compulsive disorder affecting 1-2% of the population with a chronic progressive course in many cases. A higher prevalence has been noticed among girls. The insight is usually low. Next of kin are often affected by the patients distress and low functioning.

The etiology of BDD is partly explained genetically, partly associated to environmental factors such as abuse or neglect. Neurofunctional imaging and psychological tests reveal an imbalance between global versus local visual processing resulting in high focus on perceiving aberrant details.

Diagnosis of BDD has steadily improved over the last decades with new criteria recently published in the DSM 5. Comorbidity with depression, substance abuse or other anxiety disorders are common and the risk for suicide is high in this group. Treatment consists of SSRI or clomipramine as first and second line medications. Glutamatergic agents, anticonvulsants and neuroleptic agents are currently studied in BDD. The psychological treatment of choice is cognitive behaviour therapy focusing on exposure and ritual prevention. The effects of treatment, medication, therapy or combined treatments are fairly good.

BDD is a common, severely debilitating disorder with early onset where treatment can improve the symptoms and quality of life. Recognising the diagnosis and providing relevant information give affected patients a fair chance to get qualified help.

Dermatologists and patients have long known that skin diseases affect the physical and emotional well-being of a person’s existence. Conversely, the psychological state of a person can also affect his/her skin. In this chapter, we set out the nature and basis of some of the dermatological conditions linked to obsessive compulsive disorders [SPD and Acne excoriee] and also take a look at Dermatitis Artefacta, a poorly understood factitious disorder. We present the process of evaluation and care of this vulnerable group of patients, whilst also highlighting the importance of a holistic approach in a multidisciplinary setting.

The skin is well placed to be the focus of tension reducing and emotion regulating behaviours [1]. High levels of anxiety, in dissociative and obsessive compulsive states is perhaps one of the most significant influences in conditions such as Skin picking disorders [SPD] and Dermatitis Artefacta [DA]. Anxiety can also exacerbate primary skin disorders such as Acne with the development of Acne excoriee.

We know that psychological, psychiatric and psychosocial stress affect over 30% of dermatological patients. Assessment of these co-morbidities is therefore imperative in the overall clinical evaluation of the patient. Therefore an integrated multidisciplinary team approach to manage this group of patients leads to better outcomes.

Delusional infestation (DI) is a psychodermatologic disorder characterized by the presence of a fixed, false belief that one is infested with living or non-living organisms. Patients with DI also endorse associated abnormal cutaneous symptoms such as crawling, biting or itching. DI can be extremely debilitating, as patients seek treatment and resort to self-injurious behaviors to eliminate fictional pathogens. Thus, patients may present with skin changes secondary to skin picking and excoriations. Patients with DI most often seek the help of dermatologists, because they are unable to appreciate a psychiatric etiology for their disorder; dermatologists are key to establishing both treatment and psychiatric referral for these challenging encounters. Having an informed and optimized approach in handling DI patients is vital, as clinical interactions with these patients could otherwise be unproductive and unpleasant. With good therapeutic rapport and a strong doctor-patient relationship, dermatologists may implement effective treatment with newer, second-generation anti-psychotic medications or pimozide. In this chapter, the clinical presentation, diagnostic and interpersonal approach, as well as the treatment of DI, are reviewed.

Psoriasis can affect every aspect of life – relationships, social life, lifestyle and work and is associated with increased levels of depression and anxiety. Understanding the beliefs, behaviours and emotions of people with psoriasis is essential to formulating effective and appropriate management plans with patients.

Psychological factors in people with psoriasis, such as alexithymia, anticipation of harm and stigma together with time constraints in clinic and skin-focused consultations, can lead to distress and life-impact going un-recognised and untreated. There is some evidence that treating distress can have a positive impact on the severity of psoriasis, and that distress in the form of worry is a major determinant of the outcome of treatment.

Screening for quality of life impact and distress in clinic using relevant questionnaires is a useful tool to identify patients in need of further support, and also provides a trigger to initiate discussion. A patient-centred consultation with setting of agendas for patient and clinician is an efficient way of targeting consultations. Questioning style in clinic is key to eliciting relevant responses which guide treatment decisions and inform treatment goals. Setting of patient-derived treatment goals and step-by-step minitargeted approach to reaching the final goal ensures response to treatment is accompanied by improved life-impact.

Communicating measures of distress, quality of life and patient-derived treatment goals to general practitioners provides an educational tool and will raise the standard of care for people with psoriasis.

The impact of dermatological conditions on a patient's life is frequently underestimated. Patients with skin conditions experience several physical complaints, including itch, pain and fatigue. Furthermore, in comparison to the general population, patients report a decreased psychological well-being, lowered quality of life and feelings of stigmatization and shame. Psychological treatments are widely used in addition to regular dermatological treatments to improve physical and psychological functioning of patients with chronic skin conditions. These treatments are usually aimed at changing the psychosocial factors that can influence the onset and/or course of skin conditions, such as dysfunctional coping behaviors, itch-scratching problems and stress. There are unimodal interventions in which single treatments are used, for example psychoeducation or relaxation exercises, and multimodal treatments in which a variety of different interventions are applied based on cognitive-behavioral therapy and self-management principles. Furthermore, a distinction can be made between interventions that focus primarily on skin-related psychosocial problems, interventions that focus on itch-scratching problems, and interventions that are focused on psychiatric problems in the dermatological practice. This chapter gives an overview on the psychosocial factors relevant for dermatological conditions, relevant diagnostic methods and the content and scientific evidence of specific psychological treatments in these different categories.

From a psychoanalytical point of view, almost all dermatological disorders can be considered psychodermatological disorders, because psychoanalytical conception of psychosomatics is not based on the absence of an organic aetiology, or on the real somatic condition of the disease. In all of them – either self inflicted or not, delusional or real, chronic or acute - a psychodynamic approach can be made and can turn out useful, depending more on the patient than on the disorder itself.

Psychoanalytic evaluation can contribute to the dermatologic practice at many different levels: a) establishing the level of psychological/psychiatric functioning during the consultation; b) typifying the kind of unconscious conflicts and emotions that the patient expresses through his/her complaints and symptoms; c) detecting the defence mechanisms that the patient uses to cope with reality, with stress and with his disease; d) choosing the treatment taking into account the unconscious preferences and meanings of the prescriptions; and e) giving skills to improve doctor-patient relationship.

What the psychoanalyst hears in the doctor’s consulting room gives him the possibility to infer that there are unconscious factors which play a role in the motive and time of consultation, the self-destructive patterns of behaviour that worsen the disease, the kind of complaint or suffering privileged by the patient, the acceptance or rejection of a treatment or a medicine and even the location of the lesions.

There is a need for a holistic view when treating dermatological patients. Dermatologists believe that psychiatric disorders are substantially less frequent than they actually are in many skin conditions. In many skin conditions the frequency of psychiatric disorders are underestimated by dermatologists. Diagnosing psychodermatological disorders, particularly depression, could in some cases, be lifesaving. In at least university teaching hospitals, psychodermatology clinics should function on a regular basis. The most natural location of such a clinic is within an ordinary dermatology clinic containing an interdisciplinary team of a dermatologist, psychiatrist, psychologist, social worker and experienced nurse. Instruments used include somatic examination, laboratory tests, and radiology facilities such as magnetic resonance, and neurophysiological examination. Treatment is composed of skin handling, emolliants, hydrocolloid dressings, ultraviolet light therapy, cognitive behavioural therapy, and/or pharmacotherapy using antidepressants or antipsycotics. These psychodermatological clinics, depending on refunding, may not be lucrative from the refunding perspective but they offer integrative patient care and may limit number of hospital admissions and improve the quality of life of these patients, this being the ultimate purpose.