Recognizing Psychocutaneous Disorders in Psychiatric Practice
Recognizing Psychocutaneous Disorders in Psychiatric Practice
Clinical Assistant Professor of Psychiatry, Michigan State University; Director, Psychodermatology Clinic, Jafferany Psychiatric Services, Saginaw, Mich.
First published in Psychiatry Weekly, Volume 7, Issue 3, February 6, 2012
Many dermatological disorders present with significant underlying psychopathology. A relatively new field, psychodermatology, focuses on the many recognized dermatologic and psychiatric disorders that lie at the intersection of the two disciplines. According to Dr. Mohammad Jafferany, an active psychodermatology researcher and specialist in the treatment of psychocutaneous disorders, the specialty is currently more widely recognized in Europe than in the US.
“It is very important that clinicians from the disciplines of psychiatry and dermatology consider the research on psychodermatology and the ways that it can improve their patients’ treatment and well-being,” says Dr. Jafferany. “A number of studies demonstrate a clear connection between various common skin disorders in association with psychiatric disorders. For example, when many of the hormones, cytokines, and neuromediators involved in the onset of stress come into play they disrupt the homeostasis of the skin, whereby disorders like psoriasis and atopic dermatitis either show signs of relapse or show exacerbation of pre-existing lesions. In other instances, psychiatric problems can cause some people to engage in bizarre, self-injurious behaviors, such as skin picking or hair pulling. Some patients inflict self-injury by producing self-cutting lesions on their skin to assume a sick role in the context of severe psychosocial stress. The skin lesions of people with skin disease are clearly visible to others and carry an impression of contagiousness, which can cause suffering from shame, guilt, embarrassment, poor self-image and low self-esteem.
Psychiatric factors, including stress and other emotional triggers, are strongly implicated in the exacerbation and prolongation of the disease course in psychophysiologic disorders, such as psoriasis and atopic dermatitis. Patients experience a close chronological association between stress and exacerbation of their skin disease.
“In psoriasis, for example, over 40% of affected patients experience stress before initial onset, and as many as 80% experience stress before a recurrent flare,” says Dr. Jafferany. “In atopic dermatitis, over 70% of patients experience stressful life events prior to initial onset. Psychotherapy with adjunctive psychiatric medication, such as antidepressants or anxiolytics, is a useful treatment for many disorders in this category, along with usual dermatological treatment.”
Psychiatric Disorders with Dermatologic Manifestations
Here there is no real skin condition, and everything seen on the skin is self-induced. These disorders are known as stereotypes of psychodermatological diseases. Trichotillomania, obsessive-compulsive disorder (OCD), dermatitis artefacta, and delusions of parasitosis are conditions wherein underlying psychopathology may be more detectable than in other similar conditions. Disorders in this category may also be associated with comorbid somatoform disorder, factitious disorder, and impulse control disorder.
Many clinicians say that they often see these types of patients, but they don’t do the necessary liaison between psychiatry and dermatology.
Patients with OCD often engage in ritual behaviors that can involve secondary self-injury, such as excessive hand washing or nail biting, skin picking, and hair pulling. Still other patients may not admit to self-injurious behaviors, which is often the case in dermatitis artefacta.
“Many clinicians say that they often see these types of patients,” says Dr. Jafferany, “but they don’t do the necessary liaison between psychiatry and dermatology. When clinicians in either specialty come across a psychocutaneous problem, they need support. One problem is that many of these patients attach stigma to seeing a psychiatrist. This is a significant difficulty, because there are lots of conditions where they need to be seen by a psychiatrist to find a greater understanding of the emotional and behavioral connection to their disorder and its underlying causes.”
Another reason this type of liaison may not occur is simply because many clinicians do not recognize the need for it. Dr. Jafferany and colleagues conducted a study1 that surveyed psychiatrists on their training, skills, and overall familiarity pertaining to psychodermatological disorders in the clinic. Among 223 respondents, 21% reported a comprehensive understanding of the interaction between the skin and the psyche. Self-inflicted lesions were reported as the most common psychiatric disorder with a cutaneous component that respondents saw in practice, and 22% said they were very comfortable diagnosing and treating these types of disorders. Medication-related rashes were the most commonly cited reason for giving a dermatology referral. Dr. Jafferany notes that lithium has been associated with psoriasis onset and exacerbation and a variety of other dermatological lesions, and lamotrigine has been associated with severe skin blistering and rashes.
Another survey2 by Dr. Jafferany and colleagues assessed dermatologists’ level of training, awareness of, and attitudes toward psychodermatological diseases. The survey results indicated that only 18% of dermatologists knew about the concept of skin and psyche connection. Dermatologists reported acne, atopic dermatitis, and psoriasis as the most common dermatological disorders associated with psychiatric manifestations. Approximately 90% of survey respondents were not aware of any patient of family resources on psychodermatology.
The physician survey also found that 85% of psychiatrist respondents wanted information on more resources and training on psychodermatology (39% of dermatologists expressed interest in attending CME activities). Dr. Jafferany recommends attending the annual meeting of the Association of Psychocutaneous Medicine of North America, which is held each year one day before the annual meeting of the American Academy of Dermatology, which will be held in San Diego, CA on March 15, 2012.
Disclosure: Dr. Jafferany reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.
Trichotillomania Learning Center - www.trich.org
International OCD Foundation - www.ocfoundation.org
European Society for Dermatology and Psychiatry - www.psychodermatology.net
1. Jafferany M, Stoep AV, Dumitrescu A, Hornung RL. Psychocutaneous disorders: a survey study of psychiatrists' awareness and treatment patterns. South Med J. 2010;103:1199-1203.
2. Jafferany M, Vander Stoep A, Dumitrescu A, Hornung RL. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol. 2010;49:784-789.