Psychiatric evaluation in dermatology: an overview.

Psychodermatology is an exciting field which deals with the close relationship that exists between dermatological and psychiatric disorders. A combined bio-psycho-social approach is essential for effective evaluation and treatment of these conditions. This review aims to give the practicing clinician an overview of psychiatric evaluation in patients with dermatological conditions.

Introduction

The field of psychodermatology encompasses all conditions involving the mind and the skin. A close relationship has long been hypothesized to exist between these two structures owing to their common embryological origin from the ectoderm and the fact that they are affected by similar neuro-hormonal factors.[12] A need for biopsychosocial approach to patients with skin disease which considers the psychological and issues in addition to the primary dermatological factors is being increasingly recognized to be important in contemporary practice.[134] Thus, it is imperative for clinicians to be aware of overlapping areas between the specialties so that treatment of psychodermatological disorders can be effected by liaison involving a multidisciplinary team comprising dermatologist, psychiatrist, psychologist and family physician. It is towards this objective that this review is directed; to highlight the significant psychological issues coloring the presentation of a patient seeking a dermatologic consultation.

Prevalence of psychiatric co-morbidity among dermatology patients

The current incidence of psychiatric disorders among dermatological patients is estimated at about 30-40%.[5] Gupta and Gupta in 1998 found that acne vulgaris is associated with psychosomatic co-morbidity in 30% of patients.[6] In a survey of 294 alopecia areata patients, the prevalence of major depression was 8.8%[7] Another survey of 31 patients with alopecia areata reported a 74% lifetime prevalence of one or more psychiatric disorders with 39% prevalence of major depression[8] The prevalence of psychiatric disorders among dermatological patients is slightly higher than that of neurological, oncology and cardiac patients combined.[9]

Overview of Psycho-cutaneous Disorders

Currently the most widely accepted system of classification of psycho-cutaneous disorders is that devised by Koo and Lee:[10]

Dermatosis of primary psychological/psychiatric genesis, responsible for self-induced dermatologic disorders. (Dermatitis artefacta, trichotillomania, delusional parasitosis, body dysmorphic disorders)

Dermatosis with a multifactorial basis whose course is subjected to emotional influences-psychosomatic diseases. (Psoriasis, atopic dermatitis, acne, chronic forms of urticaria, lichen simplex chronicus, hyperhidrosis)

Psychiatric disorders secondary to serious or disfiguring dermatosis-somato psychic illnesses. (Adjustment disorders with depression or anxiety seen in conditions like alopecia areata or vitiligo)

Approach to a Patient

Good interview skills and keen powers of observation are essential for psychiatric assessment in dermatological patients. The first contact with the patient must establish an empathetic and reassuring therapeutic atmosphere, in addition to conducting a detailed clinical interview. Ensuring confidentiality and having a positive attitude is a pre-requisite to further exploration of the person's beliefs and views regarding his disease, as well as his subjective emotional experiences during the course of the illness.

Even before beginning the interview preliminary information can be obtained by looking through available medical records if any, which might give a clue to the diagnosis. For example, in somatoform disorders there may be details of several previous consultations for multiple, vague, varying complaints with various investigations having been done for the same.

Interview techniques

When conducting the interview one has the option of a classic psychosomatically oriented interview versus a process-oriented structured interview. Although, classic history taking has several merits of being content-oriented and useful for data collection, the structured interview has the advantage of allowing evaluation of a patient's current level of functioning including his level of anxiety and his reactions to stress. One example of such a structured interview is Kernberg's interview[11] wherein the author suggests that the patient be asked to present an outline of the main reasons for the consultation, including treatment expectations, in addition to a broad overview of the symptomatology and the problems and difficulties associated with it. After this, the patient's ideas and verbalizations are further analyzed using psychodynamic principles. Other validated instruments used to determine presence of psychopathology are Structured Clinical Interview for DSM Disorders (SCID),[12] MINI Neuropsychiatric interview (MINI)[13] and Schedules for Clinical Assessment in Neuropsychiatry (SCAN).[14]

Interviewing challenges in special populations

Interviewing psychotic patients: Psychotic patients may have difficulty following the line of questioning and may not clearly report clarifications related to time, causality and chronological sequence. Corroboration of information from a reliable informant may be required. In people with a firmly held delusional belief system, it is unwise to directly challenge such beliefs and a non-confrontational approach is advocated in such situations.

Interviewing patients with personality disorders: Borderline personality disorder is associated with a distinct pattern of emotional instability, in addition to ambiguity regarding one's own self-image, aims and internal preferences. Patients often experience repeated emotional crises and there may be a history of multiple past attempts at intentional self-harm. Such patients are often ‘difficult’ as their instability in interpersonal relationships and self-image are also manifested in their relationship with their dermatologists and other health care providers.

Interviewing children: Children comprise of another category of patients presented to dermatology who need special care and attention during the initial evaluation. One can endeavor to obtain information regarding the child's mental-makeup by opting for tests like the three wish test which are non-threatening and non-intrusive.

Interviewing elderly people: When interviewing geriatric population it is important to remember that cognitive impairment and sensory impairments may be obstacles in conducting an effective interview and have to be anticipated and handled appropriately.

Understanding psychopathology underlying dermatological conditions

After establishing the basic structure of the interview and creating rapport with the patient, the clinician should delve in depth into the psychosomatic details of the patient's illness.

Firstly, it is important to obtain a chronology and evolution of all symptoms including psychiatric problems. For example, a close connection has been determined between depression and itching, both in laboratory studies[15] and in clinical trials with dermatological patients. In psoriasis, severity of pruritus correlates directly with the severity of depressive symptoms.[1617] In some vulnerable adolescents, even mild acne may precipitate an eating disorder like anorexia nervosa.[1819] Conversely the endocrine changes associated with binge eating may cause acne to flare up.[20] In disorders like irritant dermatitis following repeated hand washing, the primary problem is an obsessive compulsive disorder usually associated with thoughts of contamination, which secondarily gives rise to the skin condition. A similar disorder is lichen simplex chronicus which is a chronic pruritic lichenoid plaque with thickening of involved skin areas that is initiated and maintained by rubbing or scratching. In diseases characterized by disfigurement leading to stigmatization like alopecia areata, psoriasis and acne vulgaris psychiatric manifestations like depressive disorders and social phobia would likely occur as sequelae of the dermatological illness rather than precede it. Secondly, each symptom should be explored qualitatively.

Anxiety disorders

When asking details of a co-morbid anxiety disorder it is important to differentiate between persistent, generalized fear and acute anxiety in the form of a panic attack. Generalized anxiety is characterized by “free-floating” anxiety that is generalized and persistent but not restricted to any particular environmental circumstances. On the other hand, in panic disorder, recurrent, unpredictable episodes of severe anxiety with autonomic arousal occurs, which usually last for a few minutes and terminate spontaneously. Panic disorder may or may not be associated with agoraphobia, which is a fear of open spaces perceived difficulty of immediate escape to a safe place. Most anxiety disorders are associated with symptoms of autonomic arousal like palpitations, chest pain, choking sensations and occasionally feelings of unreality (depersonalization or derealization). Skin diseases are frequently associated with anxiety disorders which are atopic dermatitis, nummular eczema, dyshidrosiform eczema, seborrheic dermatitis, acne vulgaris and rosacea.[21] In obsessive compulsive disorders, patient's report about repetitive, intrusive, irrational, distressing thoughts (e.g., thoughts of contamination) which are usually associated with stereotypical, repetitive acts aimed at providing a sense of relief from the obsessional thought. (e.g., compulsive washing). When dealing with dermatological disorders related to impaired impulse control like dermatitis para- artefacta syndrome (neurotic excoriations, acne excoriee, onychophagia, trichotillomania) it is important to probe the emotional dimensions of the condition. Taking neurotic excoriations as a prototype, here at the beginning of the skin picking behavior, there is a progressive build-up of a feeling of tension, which may or may not be accompanied by itching, followed by excoriation of the skin in the second phase and subsequently a third phase of satisfaction or relief after this act. Acne excoriee is the special form of skin picking syndrome in the face in which there is minimal acne and significant scarring as a result of repeated manipulation of the facial skin.

Psychotic disorders

A completely different category of patients are those with dermatoses as a result of delusional illnesses and hallucinations. Persistent delusional disorder is a psychiatric diagnosis that should be considered in such people, and is a condition wherein long standing delusions constitute the only or the most conspicuous clinical characteristic and which must have been present for at least 3 months. Characteristically, the dermatologist is most frequently confronted with patients having monosymptomatic delusions which are generally a circumscribed, firmly held unshakeable belief while the rest of the character and personality appear unchanged. Various delusions encountered amongst the dermatology patients include delusional parasitosis, olfactory reference syndrome (delusion of body odor which may be associated with olfactory hallucinations), hypochondriacal delusions and delusional dysmorphophobia. Delusional parasitosis is the most frequent delusional disorder that is presented to dermatologists.[22] Symptomatically, the patient complains of itching, tingling and pain with the conviction that the symptoms are due to some form of parasitic invasion. Many times, the patient brings the removed assumed pathogen to the clinician in jars or boxes (matchbox sign), requesting diagnostic procedures. Body dysmorphic delusions consist of an excessive preoccupation with an imagined bodily defect or disfigurement which takes on delusional proportions. It must be kept in mind that a delusional disorder may co-exist with a major depressive episode where the patient experiences delusions that are secondary to his depressed mood, and typically represents a more severe form of depressive illness. If delusions become more bizarre, disorganized, clearly implausible and not derived from everyday experience then schizophrenia should be considered in the differential diagnosis.

Somatoform disorders

Patients with somatoform disorders typically present with persistent physical symptoms, with no underlying medical disorder that would explain the nature and extent of the symptoms. They repeatedly seek medical advice despite negative investigation findings and re-assurances by doctors that the symptoms have no physical basis. Some specific variants of somatoform disorders that may be encountered in a dermatological setting are localized or generalized somatoform itching, cutaneous dysesthesias in the form of trichodynia or glossodynia which comes under the persistent somatoform pain syndrome and hyperhidrosis which falls in the category of somatoform autonomic dysfunction. Somatoform disorders must be distinguished from hypochondriacal disorders where the patient misinterprets harmless physical symptoms as evidence of a serious and progressive underlying physical disorder which may or may not be named by the patient. This is accompanied by persistent refusal to accept the advice and reassurance of several doctors that there is no major illness or abnormality present.

Depressive disorder and suicidal risk

If a co-morbid depressive disorder is suspected, it is important to look into the entire constellation of depressive symptoms like low mood, easy fatigability, anhedonia, sleep disturbance, excessive/inappropriate guilt, psychomotor agitation/retardation, and recurrent thoughts of death with/without suicidal ideation. Some of these symptoms can have a bearing on the associated dermatological problem. For example, sleep difficulties can complicate symptoms like pruritus and psychomotor agitation experienced by some patients can be associated with rubbing, scratching or picking of the skin. Suicidal ideations must be recognized early and must be differentiated from a death wish. A death wish is a passive desire to stop living whereas active suicidal ideas involve thoughts of actually ending one's life. Enquiries must be made as to the frequency and duration of suicidal thoughts, whether any suicidal plans or arrangements have been made which would help in determining the level of intentionality for suicide and thereby the extent of the problem. An urgent psychiatric referral is recommended for patients thought to have high suicidal risk. Certain dermatological disorders like acne conglobata (especially in men), dermatitis artefacta syndrome, body dysmorphic disorder, progressive systemic scleroderma, metastasizing malignant melanoma are particularly associated with a high risk of suicide.[23]

Assessment of stressors and stressful life events

Diseases of the skin appear to be significantly influenced by emotional factors and most dermatologists encounter patients who report a temporal relationship between disease flare ups and stressful life events. After the death of one's spouse, divorce is considered the single greatest stressor on the Holmes and Rahe Social Readjustment Scale,[24] which assigns point values to a variety of stress-producing life changes. Other important stressful life events include death of a family member, dismissal from work, personal illnesses and even positive events like marriage, pregnancy or gaining a new family member. Emotional stressors have been linked to the development and evolution of a variety of cutaneous disorders including acne, vitiligo, alopecia areata, lichen planus, seborrheic dermatitis, atopic dermatitis, pemphigus, urticarial and psoriasis.

Attitude towards illness

People with dermatologic illness often claim that their main difficulties arise from others reactions to the disease rather than the illness itself.[25] Perceptions of stigmatization are common amongst those with a visible skin disease. A study done by Ginsberg and Link (1989) explored feelings of stigmatization in people with psoriasis.[26] According to the result, beliefs about stigmatization could be grouped in to several dimensions: anticipation of rejection, feelings of being flawed, sensitivity to the opinions of others, secretiveness and the more positive dimension, attitudes which had a negative correlation with the others e.g., “If my child were to have psoriasis, I think he could develop his potential just as though he did not have it”. Vardy et al., 2002 highlighted the importance of stigma by using structural equation modeling to examine the link between disease severity, felt stigma and quality of life in psoriasis. They showed that any link between disease severity and quality of life was completely mediated by expectations of stigmatization. That is, severity of psoriasis had an impact on quality of life only in so far as it influenced expectations of being stigmatized by others.[27] Another dimension that can be explored in this context are various cognitive distortions that people often harbor in their minds which if identified can provide a suitable foundation for cognitive therapy. Among the various cognitive distortions, a few that are frequently encountered are magnifying or minimizing the importance of an event; overgeneralization (drawing extensive conclusions from a single event); personalization (taking things too personally) and selective abstraction (giving disproportionate weight to negative events)

Evaluation of secondary gain

At times patients indulge in intentional self-injurious behavior in order to obtain material or social advantage from the illness. Two situations where significant secondary gain is usually present are malingering and factitious disorders. In malingering there is conscious production of lesions to obtain some benefit of which the person is fully aware for example to obtain financial advantage or to avoid criminal prosecution or military service. On the contrary, patients with factitious disorders generally have some unconscious motive for self-inflicted lesions such as to elicit more attention and care from the family.

Assessment of personality

The personality disorders that are frequently present together with dermatological diseases are borderline, narcissistic, histrionic as well as obsessive compulsive personality disorder. Narcissistic personalities place inordinate importance on their appearance hence, may face a personal crisis when faced with cosmetically disfiguring skin disorders. Patients with histrionic personality disorder are excessively emotional and may induce skin lesions as in the case of acne excoriee des jeunefilles to get attention. In obsessive compulsive personality disorder, there is extreme preoccupation with perfectionism, control and orderliness and may be seen in patients with compulsive behaviors like washing/picking of the skin or in patients with excessive body concerns who are unduly bothered by minor or non-existent imperfections in the skin. The diagnosis of personality disorders is a complex, multi-step process involving collecting information from several sources and administering assessment questionnaires and thus should not be made with certainty on the basis of a brief clinical interview.

Physical examination from a psychiatric perspective

While carrying out the physical examination there are a few signs that may point to a specific psychological etiology underlying the presenting dermatological complaint. For example, there are three similar disorders affecting the hair, namely trichotillomania, trichotemnomania and trichoteiromania (all of which are classified under dermatitis para-artefacta syndrome) which can be distinguished by careful examination. In trichotillomania, there is a typical three zone presentation which if demonstrated confirms the diagnosis. Here, three separate zones in the scalp are identifiable as zone 1 (long, unaffected normal hair), zone 2 (missing hair or zone of alopecia due to recent hair pulling) and zone 3 (areas of hair regrowth characterized by hair that is shorter and less regular than normal hair). In contrast, trichoteiromania is characterized by physical damage to the hair by rubbing and scratching the scalp resulting in pseudo-alopecia. In this condition, macroscopic whitish hair tips with split ends can be seen. In the third disorder, trichotemnomania where hair is intentionally cut off, the presentation is of pseudo-alopecia with hair stubble that appears shaved.

In patients with atypical localization and morphology of lesions, dermatitis artefacta (factitious disorders) should be suspected and efforts should be made to detect foreign or toxic materials in the lesions. The location of the lesions may also increase or decrease the likelihood of an associated psychiatric condition for example in acne vulgaris or psoriasis lesions in more visible areas like the face and arms are associated with a greater risk of psycho-somatic co-morbidity.[28] In obsessive compulsive disorder associated with compulsive washing, one may find eczematous lesions in areas that are frequently washed, most often the hands.

Conclusion

Psycho-dermatological conditions result out of a complex interaction between the dermatological lesion and various internal factors such as personality, cognitive distortions, patient attitudes and external factors such as stigma, life stressors. Presence of psychological distress adds significantly to the morbidity associated with the dermatological condition. Hence a combined biopsychosocial approach is essential in understanding and managing psycho-dermatological conditions.