# Reading about Mental Health and Skin. Dermatology [[Mind-Body Connection]] ## Article 1: Psychocutaneous disease Clinical perspectives Helena Kuhn, MD,a Constance Mennella, DO,b Michelle Magid, MD,c,d,e Caroline Stamu-O’Brien, MD,f and George Kroumpouzos, MD, PhDa,g,h Providence, Rhode Island; Austin, Galveston, and Round Rock, Texas; New York, New York; Sa~o Paulo, Brazil; and South Weymouth, Massachusetts - Psychocutaneous disease, defined in this review as primary psychiatric disease with skin manifestations, is commonly encountered in dermatology. - estimated 30% prevalence of psychiatric comorbidity in the outpatient dermatology setting. - Many patients refuse psychiatric treatment ### Types of Psychocutaneous disease - Delusional Infestation - Management - Therapeutic alliance. - Rule out organic causes - Start low dose of antipsychotic. - Neither challenge nor confirm the delusion. - Factitious skin Disorder - Patient self create skin lesions but denies responsibility. - Have history of abuse or neglect during childhood. - Often anxious, secretive, reserved - Management: DA is therapeutic challenge. The pillars of treatment are: 1) psychotherapy for restructuring the patient’s personality, 2) pharmacologic therapy for the psychiatric condition, and 3) treatment of the skin lesions.20 Creating a supportive, nonjudgmental environment helps establish a friendly relation- ship with the patient. Providers should set firm boundaries to avoid exploitation, but expect frequent visits, poor compliance, recurrent relapses, and slow progress overall. Although confrontation is to be avoided, at least initially, there may be a point in management where the potential benefits of direct discussion outweigh the potential adverse con- sequences. - Obsessive-Compulsive and Related Disorders - Excoriation disorder, also named neurotic excoriations and pathological skin picking, describes the repetitive picking of skin resulting in noticeable tissue damage. - Commonly found on face. Picking over areas of defects. - Management : CBT, Habit Reversal training. SSRI. Anxiety management - Trichotillomania (Hair Pulling Disorder) - Scalp, eye brows. - Management: Habit Reversal Training - Body-focused repetitive behavior disorder - Nail biting, nail picking, cheek/lip biting, nose/ear picking, knuckle cracking - Body Dysmorphic Disorder - Preoccupation, intrusive, time consuming. - Face and head commonly affected. - Management. Engaging BDD patients in treat- ment requires an empathetic, nondismissive approach. Although most BDD patients seek cosmetic treatments, rarely does the intervention improve their symptoms; only 2.3% of procedures led to long-term improvements in BDD symptoms.59 First-line therapy is CBT, with SSRIs being used for additional benefit. CBT and SSRIs were effective in 3 and 2, respectively, RCTs.53,60 BDD patients require relatively high doses of SSRIs (eg, fluoxetine $60 mg/day) and longer trial durations, with a mean response time of 6 to 9 weeks. - Eating Disorders - Risk factors include female sex, genetic influences, dissatisfaction with body shape, hirsutism, parental concerns about weight, psychosexual impact of puberty, the influence of peers and society, and psychiatric morbidity, such as depression, anxiety, substance abuse, and personality disorders.62,63 Perfectionism, obsessive- compulsiveness, impulsivity, and sensation seeking are common personality traits in patients with EDs.64![[Screenshot 2022-05-05 at 9.12.24 AM.png]] --- ## Psychodermatology of Acne: Dermatologist's guide to inner side of acne and management approach Melek ASLAN KAYIRAN a, Ayse Serap KARADAGa*, Mohammad JAFFERANYb a Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul,Turkey b Department of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA - Patients with acne or other skin conditions may also develop psychological conditions such as depressions, stress, anxieties, decreased self-esteem, suicidal thoughts. Thus, shouldn't just focus on the skin problem. --- ## Update on Pharmacotherapy in Psychodermatological Disorders Review Article Shrutakirthi D. Shenoi, Savitha Soman1, Ravindra Munoli1, Smitha Prabhu - Psychodermatological (PD) conditions are not uncommon in clinical practice. They may present as primary psychiatric disorders such as delusions of parasitosis (DP), dermatitis artefacta etc., or as chronic dermatoses such as atopic eczema or psoriasis, patients of which may have depression or anxiety secondary to their skin disease. - Depression can be an underlying, co‐existing, or a consequence of the dermatological condition. When features of depression start manifesting and form part of or major component of the skin disease in course of dermatosis, antidepressants are indicated. - ==Bidirectional relationships!== Diseases such as alopecia areata and vitiligo have been found to have a bidirectional relationship with depression in large scale cohort studies.[25,26] A systematic review of 35 studies found that chronic pruritus that is unresponsive to topical treatment and oral antihistamines will benefit from oral antidepressants (fluoxetine, fluvoxamine, paroxetine, sertraline, amitriptyline, nortriptyline, doxepin, and mirtazapine) - 22. Vallerand IA, Lewinson RT, Parsons LM, Hardin J, Haber RM, Lowerison MW, et al.Assessment of a bidirectional association between major depressive disorder and alopecia areata. JAMA Dermatol 2019;155:475‐9. - Alopecia areata (AA) is an autoimmune disease characterized by hair loss that can impose a substantial psychological burden on patients, including major depressive disorder (MDD), yet many patients report mental health symptoms prior to the onset of AA. As such, there may be an association between MDD and AA that acts in both directions. - Hair loss then depressed. Or Depressed then hair loss. - 26. Vallerand IA, Lewinson RT, Parsons LM, Hardin J, Haber RM, Lowerison MW, et al. Vitiligo and major depressive disorder: A bidirectional population‐based cohort study. J Am Acad 45. Dermatol 2019;80:1371‐9. - [Vitiligo](https://www.sciencedirect.com/topics/medicine-and-dentistry/vitiligo "Learn more about Vitiligo from ScienceDirect's AI-generated Topic Pages") patients often report their mental health has an effect on their skin. However, it is unknown as to whether a common mental disorder, such as [major depressive disorder](https://www.sciencedirect.com/topics/medicine-and-dentistry/major-depressive-episode "Learn more about major depressive disorder from ScienceDirect's AI-generated Topic Pages") (MDD), can also precipitate the onset of vitiligo. - ![[Screenshot 2022-05-05 at 9.37.48 AM.png]] --- # Management of Psychocutaneous Disorders: A Practical Approach for Dermatologists 1Mohammad Jafferany, 2Barbara Roque Ferreira, 3Ayman Abdelmaksoud, 4Ruzanna Mkhoyan Relationship between Skin and Psyche - Psychiatric disorders represent 30-40% of the associated comorbidity in patients presented to dermatology clinics - Nervous, endocrine and immune systems interact in skin disorders linked with psychosocial stress and may explain the complex relation between the skin and psychiatric disorders. - Stress, physical or mental, plays an important role in immunoprotection, immunoregulation, and immunopathology in psychocutaneous disorder, and is involved in exacerbation of cutaneous disorders.7,8 - In acute stress, there is a rapid physiologic response in the form of release of glucocorticoids, catecholamines and neuropeptides by the already activated immune system resulting in release of inflammatory cells and related mediators, followed by quick termination of the response after resolution of the stressful event. Contrarily, in chronic stress, with increased time and magnitude of stress- releasing hormones secondary to constant, repeated or prolonged periods, suppression and dysregulation of innate and adaptive immune function could be expected.9,10 Stress can induce autoimmune or inflammatory dermatologic disorders through neuroendocrine and neuroimmune dysregulations. That means psychosomatic disorders are reactive skin disorders in a bidirectional relation.11 - The relationship between the skin and psyche is also linked with the gut-brain- skin interaction, through a connection among gut, psychological stress and mental processes and the skin, where mental illness would also be linked with a disorder in the microbiota profile, with a reduction in Lactobacilli and Bifidobacteria. [[Gut brain connection]] - Psychological stress may induce a dysfunction in the gut barrier mediated by glucocorticoids, with subsequent dysfunction in the microbiome with an enhanced uptake of pro-inflammatory mediators from the gut lumen, a process also involving mast cells, which have been considered pivotal cells in several psychodermatologic disorders, namely, the psychophysiological disorders.1,12,13 **Psychophysiological disorders:** • Skin diseases are precipitated or exacerbated by psychological stress; • Patients experience a clear and chronological association between stress and exacerbation of the dermatosis: E.g. • Acne • Alopecia areata • Atopic dermatitis • Psoriasis • Rosacea • Seborrheic dermatitis • Chronic spontaneous urticaria. **Psychiatric disorders with dermatologic symptoms:** - There is no primary dermatosis; if skin lesions are also present, they are self- inflicted; • These disorders are always associated with underlying psychopathology or psychological conflicts and are known as stereotypes of psychodermatologic disorders: E.g. • Obsessive Compulsive Disorders and Body dysmorphic disorder • Delusions of parasitosis • Eating Disorders • Factitious disorders • Skin-picking syndromes. **Dermatologic disorders with psychiatric symptoms:** • Emotional problems are more prominent as a result of having skin disease and the psychological consequences may be more severe than the physical symptoms: E.g. • Alopecia areata • Albinism • Chronic eczema • Hemangiomas • Ichthyosis • Psoriasis • Rhinophyma • Vitiligo. Liaison clinics/Integrated care models - designed to provide a multidisciplinary care for a comprehensive patient treatment. Patients with psychocutaneous disorder are generally of younger age, with higher tendency of female predominance and encompass a diverse racial profile. - Ideally, patients with psychodermatologic disorders should be observed in psychodermatology clinics, with a multidisciplinary team, but there is still a lack of these services, worldwide --- ## Skin and Psychosomatics – Psychodermatology today JDDG Uwe Gieler1, Tanja Gieler2, Eva Milena Johanne Peters3, Dennis Linder4 - Modern psychodermatology relies on the bio-psycho-social disease model in psy- chosomatics, according to which biological, psychological and social factors (on va- rious levels, from molecules to the biosphere) play a major role in the disease patho- genesis through complex, non-linear interactions over the entire disease course. It is nowadays experimentally proven that “emotions get into the skin”. - Recent research shows close anatomical, physiological and functional connections between skin and nervous system, already known to be ontogenetically related. These connections are reflected in many skin diseases where psychological and somatic etiological factors are closely intertwined. - Kind of reminded me about TCM approach, there they see the skin as a reflection of general health condition of the patient Psychosomatics and the bio-psycho-social model - Modern psychosomatic medicine uses the so-called bio-psycho-social model of disease [1–3]. According to this model, biological, psychological and social factors on various levels (from the molecules to the biosphere) contribute significantly to the pathogenesis of any disease, via complex interactions throughout its course. This concept aims to integrate the complexity of causal connections but remains in con- trast with the popular understanding of the term ‘psychosomatic’ – which assumes a simple, monocausal relationship between ‘psychological’ and ‘physical’ events.![[Screenshot 2022-05-05 at 10.40.54 AM.png]] - There are indeed many ontogenetic, anatomical, and functional connections between the skin, the psyche, and also the immune system – e.g. joint origin from the same germinal layer, dense network of free nerve endings in the skin. These connections are the reason that psychoneuroimmunological mechanisms are fre- quently involved in the pathogenesis of dermatoses. This is why skin diseases are classified as ‘paradigmatic’ psychosomatic diseases. Special features of the skin – consequences for skin disease psychosomatics - The fact that the skin is so visible has also contributed to psychoanalytical theories and interpretations of skin diseases by psychoanalysts interested in psy- chosomatic medicine. Psychoanalyst Didier Anzieu was the first to describe the psychological dimension of the skin as a “psychological shell”, coining the term “Skin Ego” [4, 5]. In this theory, Anzieu compares the physiological skin functions with the psychological representations of Ego. According to this theory, children must develop an idea of Self deriving from their own body surface. - Developmental psychology also recognizes a special role of the skin. It postu- lates a very early tactile phase that is important for the development of a person’s identity. Skin diseases may therefore be associated with early attachment disorders in a number of cases. This may occur both in the development of early childhood cognition when dealing e.g. with a genetically determined skin disease, and in the development of Self via “psychoanalytical dialogue with the skin” from a psy- choanalytical point of view [6] - skin diseases that are present before the formation of identity (e.g. port wine stains, hairy nevi) rarely result in psychosocial problems since apparently the patients can integrate the potential defect into their body image. This is in contrast to skin lesions occurring later – e.g. scars after accidents, or vitiligo lesions. These may lead to body image disorders that are very difficult to overcome and may result in suicidal tendencies. - The special features of the skin also result in unusual situations during doc- tor-patient consultations. Sensitive topics and taboos such as sexuality, touch, smells, purity, and body language may constitute an “elephant in the room” – an obvious topic that is not addressed by the participants in the consultation. These topics are frequently addressed only in passing or not at all: Many important issues remain unexpressed, which may decrease therapeutic adherence as well as patient and physician satisfaction. Fortunately, the necessity of specific training in com- munication techniques is being increasingly recognized for both physicians and physician. Implementation of this type of training may over time prove helpful in dealing with difficulties that occur during consultations. - Implication of skin condition to other aspect of life. Psychoneuroimmunology - Is this cause by stress?? - To show that a dermatosis or its clinical course is modulated by stress – either consciously experienced or subliminally present – or in other words, to explain “how emotions get into the skin”, the following conditions must be fulfilled: – There must be an anatomical connection between the skin and the emotional centers in the brain [13]. – It must be proven that stress leads to immunological changes in the skin [13]. – There must be an influence of centrally regulated hormonal processes on skin inflammation. Evidence includes: – There are connections between C fibers in the skin and mast cells – Stress modulates immunological reactions in the skin – Stress leads to irreversible neuroendocrine changes in the skin (animal experiments) – In patients with psoriasis or atopic dermatitis, expression of various neuropeptides and neurotransmitters shows changes that differ from those in healthy controls – Neuromediators can directly modulate inflammatory reactions that occur in chronic-inflammatory skin disease such as atopic dermatitis. Thus, stress reactions in the skin of atopic dermatitis patients can be explained by psychoneu- roimmunological mechanisms [14–30]. [[Book - The Body keeps the score]] Life course perspective Social factor influencing health - Studies from this research area have shown that growing up in financially strained circumstances will have negative results on health later in life (for instance, an increased risk of cardiovascular disease). - If person have chronic disease, and in a financially strained circumstances, will have long term impact on professional opportunities, relationships - ![[Screenshot 2022-05-05 at 10.50.22 AM.png]] **Psychodermatology, psychocardiology, psychogastroenterology, and psychooncology** I think it's just beginning to recognise how much mind-body connection. - The central role of the close connection between skin and psyche in collective cons- ciousness is also expressed in language. There are countless sayings such as “gets under your skin”, being “thin-skinned”, “itching to do something”, “only skin- deep”, “the skin as a mirror of the soul”. Popular wisdom appears to have a clear idea of the interaction between skin and psyche. - Psychodermatology is not the only “psycho” part of a medical specialty. Not only the skin but also other organs and medical fields show close connections with the psyche [42, 43]. Similar studies are conducted in other medical fields, and the- re are similar psychopharmacological and psychotherapeutic approaches – albeit not as extensive. Our language also has expressions that underline the importan- ce of the heart and digestive tract in our collective awareness, such as “having a heart-to-heart”, “wearing your heart on your sleeve”, “this is dear to my heart”, “biting off more than you can chew”, “I need to digest this stroke of fate”, “nau- seating fear” and “gut instinct”. The emergence of such specialties derives from the fact that the reductionist approach of biological medicine – notwithstanding a multitude of successes and breakthroughs – reaches its limits when treating com- plex, chronic diseases with multifactorial causes that include psychosocial factors Selection of psychosomatically relevant symptoms and skin diseases - Pruritus - Atopic eczema, allergies – psychoallergology - Various neuromediators, for instance brain-derived neurotrophic factor (BDNF), are noticeably increased in allergy patients [60]. The Copenhagen City Heart Study found a strong association of stress with the inci- dence of asthma, the number of asthma-related hospitalizations, the prescription of asthma medications, and the incidence of allergic rhinitis and atopic dermatitis [61]. Meta-analyses on the influence of stress on asthma show that in most studies, stress will aggravate existing allergic reactions [62, 63]. Psychosocial stress factors are found more frequently in families with asthmatic children [64–66]. In a pro- spective study, negative life events (change of residence, parents’ divorce, school problems) resulted in an increase of asthma attacks [67, 68]. Altogether, psycho- social stress is a clear predictor of allergic disease [69–71]. During allergy season, students with hay fever achieve markedly lower grades than healthy students [72]. This has also been noted with food allergies [73, 74]. - The psychosomatic aspects of allergies and allergy-like symptoms have only been studied in the last few decades. Atopic dermatitis (atopic eczema), howe- ver, was considered a classic psychosomatic disease right from the beginnings of psychosomatic research, by the pioneers of the field (Alexander, Mitscherlich, M’Uzan, Stephanos and Groddeck). Indeed, atopic dermatitis and psoriasis are the two best-studied skin diseases in terms of psychosomatic aspects. Artefacts and skin picking disorder