1. Psychological aspects of skin diseases
Slides prepared by
Dr Nagendra Bendi (Consultant Psychiatrist)
Presented by
Dr Yasir Hameed (ST6-Psychiatry) Hellesdon Hospital Norfolk and Suffolk NHS Trust

2. Learning objectives
To gain more knowledge in the relationship between the skin diseases and mental health.
To understand the various factors involved in complex interface between skin diseases and mental health.
To be able to identify psychiatric disorders and medications associated with skin manifestations.
To broadly explain the interventions provided for individuals with mental health and skin problems.

3. Skin diseases are common:
20% of UK population said to suffer from some form of skin disease at any given time
15-20% of GP workload
6% of hospital outpatients
Gawkrodger 1997: ‘most common industrial disease’

4. Why is skin so important?
Identity, body image
communication/ relationships

5. Research: Psychological consequences of skin disease
Jowett and Ryan (1985):
100 patients with acne, psoriasis or eczema.
Decreased self esteem and self confidence
relationships affected
reduced opportunities for employment
increased anxiety and depression

7. Relationship between skin and psyche
1. Diseases that directly affect both skin and brain (organic relationship)
2. Psychological consequences of skin disease
3. Skin diseases aggravated by psychosocial stress
4. Skin manifestations of psychiatric disease
5. Skin conditions caused by drug treatment of psychiatric disease (and vice versa)

8. Part One
Psychological consequences of skin disease

9. Mr Cormack

10. Mr Cormack 43 years old, car salesman Psoriasis developed 15 years ago
Not good at persevering with treatments
Recent exacerbation affecting face and hands that is worrying him.
GP gives a new cream that he has not tried before.

11. Mr Cormack returns as agreed six weeks later
Says cream is not working
GP, in haste: “Don’t worry, give it more time”
Mr C later admits that he has not been using the cream regularly.
Why not?

12. Mr Cormack returns unexpectedly two weeks later
Says he’s using the cream but it’s still not working. Objectively, the skin lesions already look better.
GP: “What else is worrying you?”
“I’m not sleeping well”
On enquiry: early morning wakening for 3 weeks.
Don’t forget I.C.E.
Ideas I Concerns I Expectations

13. Why might Mr Cormack be depressed?

14. Mr Cormack
“I was a brilliant swimmer when I was at college. I used to win races and be really popular. But after I developed psoriasis, I didn’t like to expose my skin in public so I stopped swimming. People are looking at me as if I’ve got the plague. It’s never going to get better. Now, even my wife doesn’t like to touch me.”

15. Mr Cormack’s early life
“ My mother was often depressed and Dad was always working. I was never very good at school, not like my sister. I think I let my parents down. But they were really pleased when I won my swimming races ”.
Mr Cormack relied on his swimming prowess to bolster his self esteem.

16. Psychodynamic formulation of Mr Cormack’s depressive illness
An attempt to explain the depressive illness in terms of early life experiences, personality development (predisposing factors) and current precipitating and perpetuating factors.

17. What would help Mr Cormack to feel better?

18. In conclusion: I: Possible psychological consequences of skin disease include:
Effects on:
Self esteem
Body image
Relationships
Quality of life
that can all contribute to psychological disturbance and/or psychiatric illness
Minor diseases with possible significant consequences

19. In conclusion (cont.): II: Psychological consequences depend upon:
Nature of skin disease:
severity
Course: acute, progressive or episodic
Cause: congenital or acquired (stage in life)
Location, size, characteristics etc
Personality traits
Social factors
relationships
work, hobbies etc
cultural expectations

20. Measuring psychosocial stress in skin disease
Psoriasis disability index
Dermatitis family impact questionnaire
Dermatology life quality index
Acne disability questionnaire
General health questionnaire (GHQ)
Hamilton rating scales for anxiety and depression.

21. Coping with and adaptation to skin disease.
Adjusting to changes in appearance
Learning to live with uncertainty
Coping with reactions from others
Maladapting: hiding away, (long hair, clothing), structuring life around disease, thinking that others (in addition to themselves) are preoccupied with the disease.

22. Part Two
Skin manifestations of psychiatric disease

23. Skin manifestations of psychiatric illness/psychological distress
Deliberate self harm
Dermatitis artefacta
Parasitosis
Dysmorphophobia
Trichotillomania
Excessive handwashing, neurotic excoriations
Signs of alcohol and substance misuse
Sun sensitivity
Nicotine stained fingers

24. Artefactual lesions Malingering: conscious intent for specific gain
Monosymptomatic hypochondriasis: in response to delusional beliefs
Obsessive compulsive disorder: eg relief of anxiety from repetitive scratching etc
Dermatitis artefacta
Dermatitis artefacta by proxy: lesions on another to satisfy psychological need of perpetrator (Munchausen’s syndrome by proxy)

25. Dermatitis artefacta Highest incidence late teens, early twenties
Often close connection with healthcare field
Past history of serious illness, sexual abuse or loss in childhood not uncommon
Lesions produced secretly and mysteriously
Complicity strenuously denied

26. Clinical picture of D. artefacta
Dramatic lesions, calm manner, thick notes
Not characteristic of known dermatoses
In reach of patient’s hands
Lesions appear fully formed all at same stage of development
‘hollow history’: inability to elicit evidence of evolutionary changes.

32. Why does the patient do this?

33. Dermatitis artefacta cont.
Physical expression of emotional problems
Inability to feel cared for unless something being ‘done’ eg ointment, investigations etc or given eg prescription
Inability to feel self contained
Reaction of family- eg anger with professionals.
‘learn’ that such behaviour is rewarding
Goal: to satisfy an (unconscious) emotional need to be nurtured

34. Wilfred Bion: containment
cf Donald Winnicott: holding
The baby projects distressing feelings and fantasies into his mother.
The mother acts as a container for these intense feelings and fantasies.
The baby is soothed.
doctors as ‘containers’

35. ‘The sorrow that has no vent in tears makes other organs weep’ Henry Maudsley 19th Century

36. Parasitosis
Delusion that their bodies are infested with some type of organism
‘Matchbox sign’: pieces of debris brought as ‘proof’
A symptom, not a disease
Monodelusional hypochondriacal psychosis
Secondary to somatic hallucinations
Ekbom syndrome

38. Dysmorphophobia Cosmetic surgery
Primary complaint of some external physical defect thought to be noticeable to other people, but, objectively, appearance lying within normal limits (hay, 1970)
Cosmetic surgery

39. Trichotillomania Patient pulls out their own hair A symptom
Differential diagnosis
Hair roots undergo pathological change known as trichomalacia

43. Part Three
Skin conditions caused by drug treatment of psychiatric disease (and vice versa):
Lithium
Isotretinoin
Chlorpromazine
Steroids
Lamotrigine

44. Stevens Johnson Syndrome

45. Thank you for listening
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46. Reading
Psychological approaches to dermatology Papadopoulos and Bor. BPS books
Ramsay, B & O’Reagan, M. (1988) A survey of the social and psychological effects of psoriasis. Br J of Dermatology 118,
Gupta, M &Gupta A. (1998) Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. B. J of Derm. 139,
Teshima et al 1982, Psychosomatic aspects of skin disease etc. Psychotherapy and Psychosomatics 37(3)