Practical Psychodermatology

Anthony Bewley, Ruth E. Taylor, Jason S. Reichenberg, Michelle Magid, Anthony Bewley, Ruth E. Taylor, Jason S. Reichenberg, Michelle Magid

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118560662
• Edition: 1
• Topic: Medicine
• Subtopic: Dermatology

Skin disease can be more than skin deep
Our skin is one of the first things people notice about us. Blemishes, rashes, dry, flaky skin – all these can breed insecurity, even suicidality, even though the basic skin condition is relatively benign. Skin disease can lead to psychiatric disturbance.

But symptoms of skin disease can also indicate psychological disturbance. Scratching, scarring, bleeding, rashes. These skin disturbances can be the result of psychiatric disease.

How do you help a dermatological patient with a psychological reaction? How do you differentiate psychological causes from true skin disease? These are challenges that ask dermatologists, psychiatrists, psychologists and other health care specialists to collaborate.

Practical Psychodermatology provides a simple, comprehensive, practical and up-to-date guide for the management of patients with psychocutaneous disease. Edited by dermatologists and psychiatrists to ensure it as relevant to both specialties it covers:

• History and examination
• Assessment and risk management
• Psychiatric aspects of dermatological disease
• Dermatological aspects of psychiatric disease
• Management and treatment

The international and multi-specialty approach of Practical Psychodermatology provides a unique toolkit for dermatologists, psychiatrists, psychologists and other health care specialists needing to care for patients whose suffering is more than skin deep.

SECTION 1

Introduction

CHAPTER 1

Introduction

Anthony Bewley,¹ Michelle Magid,² Jason S. Reichenberg³ and Ruth E. Taylor⁴

¹ The Royal London Hospital & Whipps Cross University Hospital, Barts Health NHS Trust, London, UK

² Department of Psychiatry, University of Texas Southwestern, Austin, TX, USA

³ Department of Dermatology, University of Texas Southwestern, Austin, TX, USA

⁴ Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK

Psychodermatology: interfaces, definitions, morbidity and mortality

Psychodermatology or psychocutaneous medicine refers to the interface between psychiatry, psychology and dermatology. It involves the complex interaction of the brain, cutaneous nerves, cutaneous immune system and skin. Psychocutaneous conditions can be divided into three main categories, as illustrated in Figure 1.1.

Figure 1.1 Psychodermatology interfaces (courtesy of Trevor Romain).

Most patients attending psychodermatology clinics have either a primarily dermatological disease with secondary psychosocial co-morbidities or a primarily psychiatric disorder with a significant cutaneous symptomatology (Table 1.1). Clinical research has shown that there is an increasing burden of psychological distress and psychiatric disorder amongst dermatology patients [1]. In addition, stress is frequently reported as a precipitant or exacerbating factor of skin disease and is a major factor in the outcome of treatment [2]. Skin conditions may have a detrimental effect on most aspects of an individual's life, including relationships, work and social functioning. A national survey undertaken by the British Association of Dermatologists (BAD) in 2011 [3] to assess the availability of psychodermatology services, revealed poor provision despite dermatologists reporting:

• 17% of dermatology patients need psychological support to help them with the psychological distress secondary to a skin condition;
• 14% of dermatology patients have a psychological condition that exacerbates their skin disease;
• 8% of dermatology patients present with worsening psychiatric problems due to concomitant skin disorders;
• 3% of dermatology patients have a primary psychiatric disorder;
• 85% of patients have indicated that the psychosocial aspects of their skin disease are a major component of their illness;
• patients with psychocutaneous disease have a significant mortality from suicide and other causes.

Table 1.1 Psychocutaneous disease

Primary dermatological disorders caused by or associated with psychiatric co-morbidity (Figure 1.2)	Primary psychiatric disorders that present with skin disease (Figure 1.3)
Psoriasis, eczema, alopecia areata, acne, rosacea, urticaria, vitiligo Visible differences (disfigurements) Inherited skin conditions (e.g. ichthyosis) May be caused, exacerbated by or associated with: Depression, anxiety, body image disorder, social anxiety, suicidal ideation, somatization, psychosexual dysfunction, schema, alexithymia, changes in brain functioning	Delusional infestation Body dysmorphic disorder Dermatitis artefacta Obsessive-compulsive disorders Trichotillomania Neurotic excoriation Dysaesthesias Somatic symptom disorders Substance abuse Factitious and induced injury Others

Figure 1.2 Patients with dermatological disease such as vitiligo may have psychological co-morbidities even if the condition is hidden or “milder”. Such patients may feel out of control of their bodies, desperate and disempowered.

Figure 1.3 A patient with severe dermatitis artefacta (factitious and induced illness) of the scalp who required the careful input of a psychodermatology multidisciplinary team that included dermatologists, psychiatrists, plastic surgeons, nursing staff and psychologists in order to resolve her dermatological and psychosocial problems.

These findings are not unusual and are mirrored throughout Europe, North America and globally.

The psychodermatology multidisciplinary team

Though patients often present to dermatologists, dermatologists are not usually able, in isolation, to manage patients with psychocutaneous disease. For these patients, there is increas­ing evidence that a psychodermatology multidisciplinary team (pMDT) can improve outcomes [4]. Specialists who make up a pMDT require dedicated training in the management of patients with psychocutaneous disease, though such training is difficult to obtain (Box 1.1). This book, then, is aimed at being a practical, hands on guide to the management of psychodermatological diseases by all healthcare professionals. We are not saying that each patient with a psychocutaneous problem needs to be reviewed by a pMDT as that would be impractical and probably unnecessary. We are saying that for some patients with psychocutaneous disease, a pMDT will be essential for their speedy, appropriate and effective management.

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Box 1.1 Possible members of the psychodermatology multidisciplinary team (pMDT)

• Dermatologists
• Psychiatrists
• Psychologists
• Dermatology and other nursing colleagues
• Child and adolescent mental health specialists (CAMHS)
• Paediatricians
• Geriatricians and older age psychiatrists
• Social workers
• Trichologists
• Primary care physicians
• Child and/or vulnerable adult protection teams
• Patient advocacy and support groups

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DSM-IV and DSM-5

The American Psychiatric Association (APA) has recently published the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (www.dsm5.org). The fourth version of the DSM (DSM-IV-TR, with a text revision) was published in 2000. The aim of the DSM manual is to provide general categorizations and diagnostic criteria for psychiatric disorders. These manuals are tools for healthcare professionals and do not represent a substitute for expert clinical opinion. It is also important to note that categorization of psychodermatological disease is difficult and patients may exhibit symptoms of a variety of DSM diagnoses. For example, a patient with body dysmorphic disease (classified as an obsessive-compulsive related disorder) may have clear psychotic symptoms as well as being depressed at the same time; or a patient with psoriasis (a physical skin disease) may have symptoms of severe anxiety and depression as well as a substance use disorder.

The DSM-IV-TR consists of five axes (broad groups):

Axis I: Clinical psychiatric disorders (e.g. depression, schizophrenia)

Axis II: Personality disorders and mental retardation

Axis III: General medical conditions

Axis IV: Psychosocial and environmental problems

Axis V: Global assessment of functioning (0–100 scale of functioning level)

Of note, the DSM-5 work groups felt that there was no scientific basis for this separation and abandoned the axis system.

ICD-10

The tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) offers a general classification of all disease. As with the DSM-5, it does not include all psychodermatological conditions, but can be helpful in organizing psychodermatological conditions.

We have specifically designed Practical Psychodermat...