A review of psychiatric disorders comorbidities in patients with alopecia areata.

This is a review of psychiatric problems in patients with alopecia areata (AA). The electronic database of MedLine/PubMed was searched using the determined keywords. The rate of depression in children and adolescents with AA is up to 50%. Stressful life events are associated with AA. A rate of 39% for generalized anxiety disorders was reported. AA is highly associated with obsessive compulsive disorder (35.7%) in children and adolescents. Schizophrenia tended to be less seen in AA patients.

INTRODUCTION

Alopecia areata (AA) is a common form of nonscarring hair loss. The lifetime incidence of AA is about 2.1%.[1] Its etiology is not exactly known. However, genetic factors,[2] autoimmune conditions,[3] and environmental factors[4] are supposed to play an important role. AA might be a psychosomatic disease precipitated by stressful life events.[5] Therefore, it is suggested that AA can be in the category of primary dermatologic disorders with psychiatric comorbidities or it can be considered as a primary psychiatric disorder with dermatologic problems.[5] The antidepressant effect of citalopram on treatment of AA in patients with major depressive disorder supports this close association.[6] This medication increased the efficacy of a dermatological treatment.[6] Moreover, the concordance rate of at least one psychiatric disorder in children and adolescents with AA is very high and it is up to 78%.[78] That study specified a 50% rate of major depressive disorder and a high rate of obsessive compulsive disorder (OCD).[7] This current paper aims to review the current knowledge about the association between AA and psychological disorders. Furthermore, we would like to suggest new strategies for the future studies.

MATERIALS AND METHODS

The electronic data base of MedLine/PubMed was searched up to November 3rd2013. The terms searched through MedLine/PubMed was “alopecia areata,” “alopecia areata + Depression,” “alopecia areata + anxiety,” “alopecia areata + alexithymia,” and “alopecia areata + schizophrenia.”

Depression

A study estimated a 39% lifetime prevalence rates of major depression in patients with AA.[8] Another retrospective cross-sectional study evaluated the prevalence of comorbid conditions among patients with AA at tertiary care hospitals. The study found high prevalence of depression and anxiety (25.5%) in AA patients during an 11 years period.[9]

There is also a very high rate of major depressive disorder (50%) in children and adolescents with AA.[7] Onset age of AA seems to play a role in its association with different comorbid psychiatric diseases and an increased risk of depression was found in AA patients younger than 20 years old.[10] Therefore, it is not a question that in patients with AA, evaluation of psychological status is of significant importance.[11]

Although AA is not painful or life threatening, its cosmetic aspects have profound negative influence on patients' psychological status and relationships.[11] In Canada, the prevalence of wishes to be dead and acute suicidal thoughts was examined among 480 patients with cosmetically disfiguring dermatological disorders. None of the 45 patients with AA had suicidal ideation.[12]

The higher rates of several negative feelings such as low self-esteem, social discomfort, anger, fears and anxiety in patients with AA in comparison to the controls[13] might be associated with depression. Meanwhile, there is also growing evidence indicating that depression could be prior to AA.[11] Stressful life events were reported in about one fourth of the patients at the onset of the disease or before the aggravation of AA. Others reported family problems, work problems, and mourning.[11] Nevertheless, another study suggests the absence of conscious distress in patients with AA because there were no significant differences in anxiety and depression scores of the AA patients, the epilepsy patients and the control group.[5] In the same study, AA patients experienced more stressful life events than their healthy siblings and being compared to epilepsy patients they were more likely to be a member of a single-parent family.[5] Furthermore; the genogram score, which takes into account all the main features of dysfunction families, traumatic events and physical aspects correlated positively but not significantly with the severity of AA and revealed several items such as “abuse” and “dependencies” to be more prevalent in family of AA patients than atopic dermatitis and psoriasis.[14]

According to these evidences, it is thought that AA and psychiatric disorders might have the same pathogenesis and there are theories that stress neuroendocrine immunology might play an important role.[10] This is supported by an association between AA and subclinical/clinical hypothyroidism as a neuroendocrine autoimmune disease.[1516]

It was also observed in studies that imipramine, an antidepressant drug, and hypnotic approaches not only improved the psychological well-being of depressed patients with AA, but also led to significant hair regrowth, reinforcing the theory of involvement of same factors in their pathogenesis.[1718]

Anxiety

The correlation between AA and anxiety disorders was reported since decades ago. It is not a question that hair abnormalities could have a negative impact on psychological status of the patients with AA. This might cause tremendous anxiety, especially in women and young adults. Physical appearance associated illness and the potential clinical course of the disease are all worrying matters.[19]

About 39% prevalence of generalized anxiety disorders was reported. In the same study, patients also reported an increased rate of anxiety disorders in their first-degree relatives.[8] In 1994, another study came up with the same result of a significantly higher rate of generalized anxiety disorders in AA patients than in the general population.[20] Trait anxiety was learnt to be a risk factor in the onset and course of AA. A higher degree of trait anxiety observed in AA patients than in the healthy control group.[21] In a recent study, anxiety was detected in 13.7% of the AA patients and in none of the control group subjects. It confirmed the previously reported results.[11] Children with AA have more difficulties in concentration and develop more anxiety symptoms.[13] In a small clinical sample of twelve children with AA, on structured interviews, seven had the criteria to be diagnosed with anxiety disorders.[22] One of the most common anxiety disorders coexisting with AA is OCD (35.7%).[7]

As explained previously in AA association with depression, different ages of onset correlate with different psychiatric comorbidities. Anxiety was observed more in AA patients with age of onset between 20 and 39 years.[10] As well as hair regrowth seen in patients who received hypnotic interventions, the same as it was with depression, hypnotic approaches decreased the rate of anxiety in AA patients.[18]

Alexithymia

Alexithymia is thought to be a cognitive deficit in processing and regulation of emotions characterized by difficulty identifying and describing feelings, externally oriented thinking and impaired imaginary capacity.[23] Despite the conflicting results of studies, research data have shown that there is an association between dermatological conditions and alexithymia.[14] AA has also been specifically reported to be associated with alexithymic characteristics. There is a higher prevalence of alexithymia in AA patients than in general population. According to the research data, dermatologists should be aware of alexithymia while evaluating their patients' psychological status.[24]

Schizophrenia

Schizophrenia is a severe mental chronic disorder with the common symptoms of disorganized thinking, delusions and hallucinations. Unlike the other psychiatric disorders reviewed in this article, schizophrenia tended to be less seen in AA patients than the matched controls according to a case control study conducted in Taiwan.[10] Years before this, in 1993 Kubata reported one case of schizophrenic patient who developed AA after the administration of Zotepine (an atypical antipsychotic drug).[25] Following discontinuation or decrease in the dose of Zotepine, the patient recovered from AA.[25] It is not clear whether the pathophysiology of schizophrenia is opposite to AA's. This needs further studies to suggest new treatments in the future studies.