Our experience in a psychodermatology liaison clinic at manipal, India.

Psychodermatology is an emerging specialty in dermatology which deals with the interactions between mind and skin. Psychocutaneous diseases can be either primary psychiatric or primary cutaneous, with various degrees of associations between psyche and skin. Unless the dermatologist cultivates a special interest in this field, many an invisible mental disorder may be missed leading to sub optimal treatment of the visible skin condition. Though Dermatology Psychiatry liaison clinics are common in Europe and other western countries, it is just an emerging concept in India. Here we describe the working pattern of psychodermatology liaison clinic established in Manipal in August 2010 and describe briefly the type of cases attended to.

Introduction

Psychodermatology is subspecialty of dermatology which studies the interactions between mind and skin.[1] Psychocutaneous diseases can present either as primary psychiatric diseases such as dermatitis artefacta and delusions of parasitosis or as secondary psychiatric conditions such as depression, anxiety or social phobia due to chronic dermatoses like psoriasis, atopic dermatitis, alopecia areata. While in the former group, the diagnosis is usually straight forward, in the latter group such as psoriasis, atopic dermatitis etc the associated psychiatric co-morbidity may be missed or overlooked. Unless the dermatologist has a special interest in mental health, in a busy practice, the relevant history is not sought. It is imperative to treat the ‘invisible’ mental disease in addition to the ‘visible’ skin disease. In chronic skin diseases, patients feel stigmatized especially when lesions are widespread and may also experience depression. Even in clinical remission, some may have anxiety about possible relapse in future.

The brain and skin have a common ectodermal origin. The relationship between mind and skin can be understood on the basis of the neuro-immuno-cutaneous-endocrine network.[23] The bidirectional brain and skin influences are mediated by neurotransmitters, hormones and neuropeptides. Stress plays an important role in triggering as well as aggravating certain dermatoses.[4] Nearly 30% of dermatology patients have associated psychiatric co-morbidity.[5]

The dermatology – psychiatry liaison concept originated in Europe and slowly spread to the West. There is a dedicated European Society of Dermatology and Psychiatry that holds a congress biennially. The association for Psychocutaneous Medicine of North American too holds regular meetings. In India, this subject has received scantattention. Case reports and few studies appear from time to time. Whilst dermatologists refer cases to psychiatrists, a dedicated liaison clinic is virtually unknown.

We discuss the working pattern of the dermatology-psychiatry-clinical psychology liaison clinic set up at Manipal in August 2010.

Materials and Methods

The period of study was from August 2010 to January 2012. Patients with chronic dermatoses such as psoriasis, eczema as well as those with primary psychiatric conditions were recruited by the dermatologist from the general dermatology out patients and referred to the liaison clinic which functions once weekly from 2:30 to 5:00 pm. Cases were evaluated independently by the three specialists. The psychologist counseled all patients and if stressors were elicited, coping strategies were taught. The psychiatrist after evaluation determined the need for psychopharmacotherapy. Both specialists discussed the case with the dermatologist and standard dermatologic treatment with or without psychopharmacologic agents and/or psychological interventions were advised. All patients were followed up at regular intervals. Psychological interventions were carried out in the clinical psychology department.

We examined 175 cases (117 females; 58 males) aged between 10 and 75 years maximum being in the second and third decade. Out of 175, primary dermatological cases constituted 154 (88%) [Table 1] and primary psychiatric 21 (12%) [Table 2]. The leading primary dermatosis was psoriasis in 40 (23%) while the leading primary psychiatric disease was neurotic excoriations in 6 (3%) patients. Thirty percent had stressors at the onset of the disease. Out of 92 (53%) who needed psychologic interventions, only 25 (27%) underwent the same. 12 patients (48%) underwent one session while only 3 (12%) had more than five sessions. Table 3 shows the various psychological techniques that were carried out. Forty seven patients (30%) with primary dermatosis had an associated psychiatric diagnosis [Table 4] the most common being dysthymia in 22 (46%). The three leading dermatoses with psychiatric co-morbidity were psoriasis, prurigo/generalized pruritus and chronic dermatitis. Most of the patients were followed up at regular intervals.

Table 1

Primary dermatologic cases

Table 2

Primary dermatologic cases

Table 3

Psychological techniques taught

Table 4

Psychiatric diagnosis in primary dermatological conditions

Discussion

The need of a liaison psychodermatology clinic has been well established.[67] A major advantage of a combined clinic is the prompt availability of a psychiatrist, dermatologist and a clinical psychologist at a single visit. Quite often patients express displeasure when a psychiatric referral is made. The stigma of visiting the psychiatry department although has lessened in recent time, stillexists. Our clinic functions in an informal manner without any inhibitions for patients about meeting a mental health professional as there are no boards mentioning the designations of the liaison specialists. The number of patients examined cannot exceed four or five as detailed interviews are carried out.

A level-one dermatologist is a well – informed specialist who can treat psychocutaneous diseases but does not bring about psychological change in the patient while a level – two dermatologist is one who liaises with a clinical psychologist or psychiatrist bringing about psychological changes.[8] By liaisoning, patient can be treated in a holistic fashion thereby addressing both the psychological and the physical needs.

In our study more than one-fourth of patients had stressors. Although stress has been implicated in several dermatoses, psoriasis is the one which is mostly associated with.[9] Stress induced derangements of epidermal function may precipitate inflammatory dermatoses.[10] Nonpharmacologic interventions are stress –reducing adjuncts that can enhance the efficacy of standard dermatogic therapies.[11] Some of the therapies useful in dermatologic patients are biofeedback, relaxation training, hypnosis and psycho-education.

In our study majority of patients were non-compliant with psychological interventions. Probably they did not realize the benefit or were not keen on attending the clinical psychology department. This underscores the need for dermatologists to master selected psychological techniques such as relaxation which can easily be taught to patients in the office. 30% of our patients had psychiatric comorbidity which is in agreement with several studies in psychodermatology.

In conclusion, dermatologist should liaise with psychiatrists or clinical psychologists when managing psychosomatic dermatoses. In university teaching hospitals, l liaison psychodermatology clinics should function on a regular basis. Although monetarily not lucrative, it is satisfying as it offers integrative patient care. Dermatologists should familiarize with selected psychopharmacological drugs and simple nonpharmacologic interventions. Screening for common psychiatric conditions such as anxiety and depression should be objectively done using standard questionnaires. Improving the quality of life is the ultimate purpose of a liaison clinic.