Dr. Levenson is professor in the Departments of Psychiatry, Medicine, and Surgery, chair of the Division of Consultation-Liaison Psychiatry, and vice chair for clinical affairs in the Department of Psychiatry at Virginia Commonwealth University School of Medicine in Richmond.
Disclosure: Dr. Levenson reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
This column begins a series reviewing the interface between dermatology and psychiatry. Dermatologists and primary care physicians frequently encounter important psychiatric issues affecting diagnosis and management of patients with dermatologic complaints. Psychiatrists contend with frequent pruritus and rashes in their patients. A study of psychiatric inpatients excluding those with known skin diseases found that 33% of patients reported itching.1 Psychological factors affect numerous dermatologic conditions including atopic dermatitis, psoriasis, alopecia areata, urticaria and angioedema, and acne vulgaris. Some dermatologic conditions are best considered as idiopathic functional disorders such as idiopathic pruritus, which can be generalized or focal (eg, pruritus ani, vulvae, scroti). Some primary psychiatric disorders present with primarily physical symptoms to dermatologists, including body dysmorphic disorder (BDD) and delusional disorder, somatic type (eg, delusions of parasitosis, delusions of a foul body odor). Indeed, most patients with delusions of parasitosis or BDD avoid visiting psychiatrists or other mental health professionals and resist referral. In addition, dermatologists see patients with compulsive behaviors that may be part of obsessive-compulsive disorder or stand alone (eg, trichotillomania, psychogenic excoriation, onychophagia). Factitious skin disorders include factitious dermatitis (ie, dermatitis artefacta) and psychogenic purpura. Another important aspect of the interface between psychiatry and dermatology is the range of dermatologic adverse reactions to psychotropic drugs. More detailed coverage of these topics can be found elsewhere.2,3 This part of the series focuses on atopic dermatitis and psoriasis.
Atopic dermatitis (ie, atopic eczema) is a chronic skin disorder characterized by pruritus and inflammation (ie, eczema), starting as an erythematous, maculopapular rash. Scratching is hard to resist and leads to excoriation and secondary infection, resulting in lichenification. Atopic dermatitis is the most common inflammatory skin disease of childhood and remains fairly common in adults. It typically begins in children or adolescents with a personal or family history of atopic dermatitis, allergic rhinitis, or asthma. In most patients, atopic dermatitis is a recurrent, relapsing disorder, with a vicious cycle of itching and scratching that leads to chronicity.
Atopic Dermatitis and Stress
The onset or exacerbation of atopic dermatitis often follows stressful life events.4,5 Divorce or separation of parents and severe disease of a family member have been identified as particularly increasing risk.4 Adults with atopic dermatitis are more anxious and depressed compared with clinical and healthy control groups.6,7 Children with atopic dermatitis have higher levels of emotional distress and more behavioral problems than healthy children or children with minor skin problems.
Psychosocial Morbidity in Atopic Dermatitis
Atopic individuals with emotional problems may develop a vicious cycle between anxiety/depression and dermatologic symptoms. In one direction of causality, anxiety and depression are frequent consequences of the skin disorder. The misery of living with atopic dermatitis may have a profoundly negative effect on health-related quality of life (HRQOL) of children and their families. Intractable itching causes significant insomnia, and sleep deprivation leads to fatigue, mood lability, and impaired functioning. Teasing and bullying by children and embarrassment in adults and children can cause social isolation and school avoidance. The social stigma of a visible skin disease, frequent visits to doctors, and the need to constantly apply messy topical remedies all add to the burden of disease. Lifestyle restrictions in more severe cases can be significant, including limitations on clothing, staying with friends, owning pets, swimming, or playing sports. The impairment of quality of life caused by childhood atopic dermatitis has been shown to be greater than or equal to that of asthma or diabetes.8
In the other direction of causality, anxiety and depression aggravate atopic dermatitis. This may occur via several possible mechanisms, including modulation of pruritus perception,9 perturbation of epidermal permeability barrier homeostasis,10 or acceleration of immune responses.6
Psychiatric and Psychological Treatments for Atopic Dermatitis
A wide variety of treatments for atopic dermatitis have been advocated to interrupt the vicious cycle of itching and scratching. Mental health interventions include psychological, behavioral, and psychoeducational therapies and psychotropic medications. There have been several randomized controlled trials of psychological and educational interventions (eg, relaxation training, habit reversal training, cognitive-behavioral techniques, stress management training) as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy, but the evidence base remains limited regarding their efficacy.11 Oral and topical doxepin have been used because its potent antihistaminic effects can reduce itching, and oral doxepin’s sedation can promote sleep. A systematic review of controlled trials12 of 47 different interventions concluded that there was reasonable evidence to support the use of oral cyclosporine, topical corticosteroids, psychological approaches, and ultraviolet light therapy. However, there was insufficient evidence to make recommendations regarding oral or topical antihistamines (eg, doxepin), maternal allergen avoidance for prevention, dietary restriction in established atopic dermatitis, hypnotherapy, and a variety of other orthodox and alternative medical interventions.
Psoriasis is a chronic, relapsing disease with characteristic scaly lesions varying from pinpoint plaques to extensive skin involvement, nail dystrophy, and often arthritis. Psoriasis is an equally common condition among men and women, affecting 1.5% to 2% of the population in industrialized countries, with onset usually in the third decade of life. Most patients with psoriasis experience unpredictable exacerbations throughout life. The pathogenesis of psoriasis appears to involve genetic and environmental factors, influencing the body’s systems of skin repair, inflammatory defense mechanisms, and immunity.2,3
Psoriasis and Lithium
A particular concern for psychiatrists is lithium-induced psoriasis, which typically occurs within the first few years of treatment. Male patients taking lithium appear to be more susceptible to developing cutaneous reactions to lithium than females. Even a very small amount of psoriasis can be distressing to patients and can undermine medication compliance. Lithium-induced psoriasis is sometimes resistant to psoriatic treatments but resolves after discontinuation of lithium.13 There have also been case reports of psoriasis precipitated or aggravated by olanzapine.14,15
Psychosocial Morbidity in Psoriasis
Psoriasis is associated with a variety of psychological difficulties, including poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation. Psoriasis is associated with substantial impairment of HRQOL, negatively impacting psychological, vocational, social, and physical functioning.16 Not surprisingly, appearance-related concerns dominate the experiences of young people with psoriasis.17 A theme running through the psoriasis literature is conveyed in the conclusion from a systematic review of psychosocial burden of psoriasis: “Social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity.”18
A recent cross-sectional study19 of 265 adults with prevalent psoriasis found that 32% of subjects screened positive for depression, with a graded relationship between depressive symptoms and impairment of HRQOL. Only 16.5% of those with high depression scores were receiving treatment for the condition. Depression was highly associated with both illness-related stress and dissatisfaction with antipsoriatic treatment. It was not associated with objective measures of psoriasis severity.19 A survey of 2,391 Italian adults with psoriasis using the Center for Epidemiological Studies-Depression Scale questionnaire found 62% of patients presenting depressive symptomatology. There was no difference in gender; however, younger men were more likely to report depressive symptoms than older men as were all subjects with less education.20
The emotional effects and functional impact of the disease are not necessarily proportionate to the clinical severity of psoriasis.21 In general, psychological factors, including perceived health, perceptions of stigmatization, and depression, are stronger determinants of disability in patients with psoriasis than are disease severity, location, and duration.22 It is not surprising that perceived stress in patients with psoriasis as well as numerous chronic diseases predicts poorer quality of life.23
Studies of the relationship between psychological factors and psoriatic disease severity have been primarily focused on depression. Some investigators found the condition correlated with objective measures of psoriasis severity24 and others have not.19 In a large double-blind, placebo-controlled trial of etanercept,25 which is an effective treatment for the clinical symptoms of psoriasis, patients who received etanercept had significant improvement in both fatigue and depressive sympomatology. Improvement in fatigue was correlated with decreasing joint pain, but improvement in depressive symptomatology was less correlated with objective measures of skin clearance or joint pain.
In a recent prospective study of patients with psoriasis,26 the frequency of psychiatric disturbance decreased with improvement in the clinical severity and symptoms of psoriasis. Other predictors of psychiatric improvement included no psoriatic involvement on the face and sex (ie, women were less likely to improve psychologically). However, the authors concluded that “dermatologists should be aware that even in the presence of vast clinical improvement patients may still substantially suffer psychologically.”26
Psoriasis and Suicide
In addition to the effects of depression on possibly triggering psoriasis and certainly reducing disease-related quality of life, suicide is a concern. One study found that 10% of adults with psoriasis reported suicidal ideation during the previous 2 weeks.27 Gupta and Gupta28 reported suicidal ideation in 2.5% of psoriasis outpatients and 7.2% of inpatients. In an earlier study of a different sample, Gupta and colleagues29 found that 9.7% of patients with psoriasis reported a wish to be dead, and 5.5% reported active suicidal ideation at the time of study. Death wishes and suicidal ideation were associated with higher depression scores and higher patient self-ratings of psoriasis severity.
Psoriasis and Stress
Stress has long been reported to trigger psoriasis.2,3 Uncontrolled studies have reported very high rates of stressful life events preceding the onset of the illness (eg, 68% of adult patients in one study,24 and 50% of children and 43% of adults in another).30 However, perception and recall biases influence such rates. A cross-sectional study23 of 141 adults found that approximately 66% strongly believed that stress was a causal factor for their psoriasis. This belief was significantly associated with higher levels of anxiety, depressive symptomatology, and perceived stress, but there was no association between perceived stress objective measures of psoriasis severity. A large case-control study31 comparing 560 patients with psoriasis to 690 patients with a new diagnosis of skin disease other than psoriasis found a high index of stressful life events associated with patients having more than double the risk of psoriasis compared to low scorers. However, the same study found that current and ex-smokers had approximately double the risk of psoriasis. Not all studies have supported the widely held belief that stressful life events precipitate psoriasis. For example, an investigation32 of outpatients experiencing a recent onset or exacerbation of psoriasis found no difference when comparing them to outpatients with skin conditions in which psychosomatic factors are regarded as negligible. Ultimately, however, most patients who report episodes of psoriasis precipitated by stress describe disease-related stress, resulting from the cosmetic disfigurement and social stigma of psoriasis, rather than stressful major life events or nonspecific distress.2,3
In an experimental study, 40 patients with chronic plaque psoriasis and 40 age-matched normal controls were subjected to acute psychological stressors (ie, cognitive, emotional, social). Patients with psoriasis and, in particular, those who believed that their psoriasis was highly stress responsive, were found to exhibit altered hypothalamic-pituitary-adrenal response to acute social stress, specifically lower post-stressor cortisol levels. The implication is that such patients may perhaps be more vulnerable to flares of their psoriasis.33 The mechanism of stress-induced exacerbations of psoriasis has been speculated to involve the nervous, endocrine, and immune systems, but no definitive pathways have been established. A more direct connection may be the effects of anxiety or depressive symptoms in reducing the threshold for pruritus in psoriatic patients.34
The adverse psychological sequelae of psoriasis are often but not always reduced by effective treatment of the disease, as noted in the study of disease-modifying therapy with etanercept cited earlier.25 A study16 that focused on systematic topical treatment for psoriasis found general quality of life significantly improved following treatment. Body image and appearance, self-esteem, and negative feelings were particularly responsive to clinical change. Domains of spirituality, independence and physical health also improved.
Psychiatric and Psychological Treatments for Psoriasis
There have been case reports of dramatic improvement in psoriasis after anxiolytic drug treatment but no controlled studies. The use of psychological therapies for patients with psoriasis has been proposed based on observations that the severity of their disease may correlate with emotional stress. Meditation, hypnosis, relaxation training, cognitive-behavioral stress management, and symptom control imagery training have received support in controlled trials for their effectiveness in reducing psoriasis activity,2,3 but this evidence base is limited by the size and short duration of the studies. A small (n=51) randomized controlled trial35 of a psychological intervention that entailed seven sessions of individual psychotherapy, including stress management, guided imagery, and relaxation, found some evidence of modest benefit on psoriasis activity.
A small (n=40) nonrandomized, age- and sex-matched case-controlled psychological intervention trial36 investigating the effects of a cognitive-behavioral psoriasis symptom management program showed significant reductions in illness identity (ie, the frequency and severity of symptoms that patients associate with their condition), the strength of belief in severity of consequences of their illness, and patients’ attributions for emotional causes of their psoriasis. PP
1. Mazeh D, Melamed Y, Cholostoy A, Aharonovitzch V, Weizman A, Yosipovitch G. Itching in the psychiatric ward. Acta Derm Venereol. 2008;88(2):128-131.
2. Arnold L. Dermatology. In: Levenson JL, ed. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. 1st ed. Washington, DC: American Psychiatric Publishing; 2005:629-646.
3. Arnold L. Dermatology. In: Levenson JL, ed. Essentials of Psychosomatic Medicine. 1st ed. Washington, DC: American Psychiatric Publishing; 2007:237-260.
4. Bockelbrink A, Heinrich J, Schäfer I, et al. Atopic eczema in children: another harmful sequel of divorce. Allergy. 2006;61(12):1397-1402.
5. Picardi A, Abeni D. Stressful life events and skin diseases: disentangling evidence from myth. Psychother Psychosom. 2001;70(3):118-136.
6. Hashizume H, Horibe T, Ohshima A, Ito T, Yagi H, Takigawa M. Anxiety accelerates T-helper 2-tilted immune responses in patients with atopic dermatitis. Br J Dermatol. 2005;152(6):1161-1164.
7. Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders. Am J Clin Dermatol. 2003;4(12):833-842.
8. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60(8):984-992.
9. Gupta MA, Gupta AK. Depression modulates pruritus perception. A study of pruritus in psoriasis, atopic dermatitis and chronic idiopathic urticaria. Ann N Y Acad Sci. 1999;885:394-395.
10. Garg A, Chren MM, Sands LP, et al. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137(1):53-59.
11. Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne S. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev. 2007;(3):CD004054.
12. Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess. 2000;4(37):1-191.
13. Yeung CK, Chan HH. Cutaneous adverse effects of lithium: epidemiology and management. Am J Clin Dermatol. 2004;5(1):3-8.
14. Latini A, Carducci M. Psoriasis during therapy with olanzapine. Eur J Dermatol. 2003;13(4):404-405.
15. Ascari-Raccagni A, Baldari U, Rossi E, Alessandrini F. Exacerbation of chronic large plaque psoriasis associated with olanzapine therapy. J Eur Acad Dermatol Venereol. 2000;14(4):315-316.
16. Skevington SM, Bradshaw J, Hepplewhite A, Dawkes K, Lovell CR. How does psoriasis affect quality of life? Assessing an Ingram-regimen outpatient programme and validating the WHOQOL-100. Br J Dermatol. 2006;154(4):680-691.
17. Fox FE, Rumsey N, Morris M.”Ur skin is the thing that everyone sees and you cant change it!”: exploring the appearance-related concerns of young people with psoriasis. Dev Neurorehabil. 2007;10(2):133-141.
18. Kimball AB, Jacobson C, Weiss S, Vreeland MG, Wu Y. The psychosocial burden of psoriasis. Am J Clin Dermatol. 2005;6(6):383-392.
19. Schmitt JM, Ford DE. Role of depression in quality of life for patients with psoriasis. Dermatology. 2007;215(1):17-27.
20. Esposito M, Saraceno R, Giunta A, Maccarone M, Chimenti S. An Italian study on psoriasis and depression. Dermatology. 2006;212(2):123-127.
21. Russo PA, Ilchef R, Cooper AJ. Psychiatric morbidity in psoriasis: a review. Australas J Dermatol. 2004;45(3):155-159.
22. Richards HL, Fortune DG, Griffiths CE, Main CJ. The contribution of perceptions of stigmatisation to disability in patients with psoriasis. J Psychsom Res. 2001;50(1):11-15.
23. O’Leary CJ, Creamer D, Higgins E, Weinman J. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res. 2004;57(5):465-471.
24. Devrimci-Ozguven H, Kundakci TN, Kumbasar H, Boyvat A. The depression, anxiety, life satisfaction and affective expression levels in psoriasis patients. J Eur Acad Dermatol Venereol. 2000;14(4):267-271.
25. Tyring S, Gottlieb A, Papp K, et al. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: double-blind placebo-controlled randomised phase III trial. Lancet. 2006;367(9504):29-35.
26. Sampogna F, Tabolli S, Abeni D. The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study. Br J Dermatol. 2007;157(3):508-513.
27. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006;54(3):420-426.
28. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol. 1998;139(5):846-850.
29. Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN. Suicidal ideation in psoriasis. Int J Dermatol. 1993;32(3):188-190.
30. Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17(3):174-178.
31. Naldi L, Chatenoud L, Linder D, et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol. 2005;125(1):61-67.
32. Picardi A, Pasquini P, Cattaruzza MS, et al. Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study. J Psychosom Res. 2003;55(3):189-196.
33. Richards HL, Ray DW, Kirby B, et al. Response of the hypothalamic-pituitary-adrenal axis to psychological stress in patients with psoriasis. Br J Dermatol. 2005;153(6):1114-1120.
34. Gupta MA, Gupta AK, Schork NJ, Ellis CN. Depression modulates pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Psychosom Med. 1994;56(1):36-40.
35. Zachariae R, Oster H, Bjerring P, Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. J Am Acad Dermatol. 1996;34(6):1008-1015.
36. Fortune DG, Richards HL, Griffiths CE, Main CJ. Targeting cognitive-behaviour therapy to patients’ implicit model of psoriasis: results from a patient preference controlled trial. Br J Clin Psychol. 2004;43(Pt 1):65-82.