Geriatric Psychodermatology: Psychocutaneous Disorders in the Elderly
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Diseases of the skin appear to be significantly influenced by emotional factors and most dermatologists encounter patients who report a temporal relationship between disease flare ups and stressful life events. After the death of one's spouse, divorce is considered the single greatest stressor on the Holmes and Rahe Social Readjustment Scale,[ 24 ] which assigns point values to a variety of stress-producing life changes. Other important stressful life events include death of a family member, dismissal from work, personal illnesses and even positive events like marriage, pregnancy or gaining a new family member.
Emotional stressors have been linked to the development and evolution of a variety of cutaneous disorders including acne, vitiligo, alopecia areata, lichen planus, seborrheic dermatitis, atopic dermatitis, pemphigus, urticarial and psoriasis. People with dermatologic illness often claim that their main difficulties arise from others reactions to the disease rather than the illness itself.
A study done by Ginsberg and Link explored feelings of stigmatization in people with psoriasis. Vardy et al. They showed that any link between disease severity and quality of life was completely mediated by expectations of stigmatization. That is, severity of psoriasis had an impact on quality of life only in so far as it influenced expectations of being stigmatized by others.
Among the various cognitive distortions, a few that are frequently encountered are magnifying or minimizing the importance of an event; overgeneralization drawing extensive conclusions from a single event ; personalization taking things too personally and selective abstraction giving disproportionate weight to negative events. At times patients indulge in intentional self-injurious behavior in order to obtain material or social advantage from the illness. Two situations where significant secondary gain is usually present are malingering and factitious disorders.
In malingering there is conscious production of lesions to obtain some benefit of which the person is fully aware for example to obtain financial advantage or to avoid criminal prosecution or military service. On the contrary, patients with factitious disorders generally have some unconscious motive for self-inflicted lesions such as to elicit more attention and care from the family.
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The personality disorders that are frequently present together with dermatological diseases are borderline, narcissistic, histrionic as well as obsessive compulsive personality disorder. Narcissistic personalities place inordinate importance on their appearance hence, may face a personal crisis when faced with cosmetically disfiguring skin disorders. Patients with histrionic personality disorder are excessively emotional and may induce skin lesions as in the case of acne excoriee des jeunefilles to get attention.
The diagnosis of personality disorders is a complex, multi-step process involving collecting information from several sources and administering assessment questionnaires and thus should not be made with certainty on the basis of a brief clinical interview. While carrying out the physical examination there are a few signs that may point to a specific psychological etiology underlying the presenting dermatological complaint.
For example, there are three similar disorders affecting the hair, namely trichotillomania, trichotemnomania and trichoteiromania all of which are classified under dermatitis para-artefacta syndrome which can be distinguished by careful examination. In trichotillomania, there is a typical three zone presentation which if demonstrated confirms the diagnosis. Here, three separate zones in the scalp are identifiable as zone 1 long, unaffected normal hair , zone 2 missing hair or zone of alopecia due to recent hair pulling and zone 3 areas of hair regrowth characterized by hair that is shorter and less regular than normal hair.
In contrast, trichoteiromania is characterized by physical damage to the hair by rubbing and scratching the scalp resulting in pseudo-alopecia. In this condition, macroscopic whitish hair tips with split ends can be seen. In the third disorder, trichotemnomania where hair is intentionally cut off, the presentation is of pseudo-alopecia with hair stubble that appears shaved.
In patients with atypical localization and morphology of lesions, dermatitis artefacta factitious disorders should be suspected and efforts should be made to detect foreign or toxic materials in the lesions. The location of the lesions may also increase or decrease the likelihood of an associated psychiatric condition for example in acne vulgaris or psoriasis lesions in more visible areas like the face and arms are associated with a greater risk of psycho-somatic co-morbidity.
Psycho-dermatological conditions result out of a complex interaction between the dermatological lesion and various internal factors such as personality, cognitive distortions, patient attitudes and external factors such as stigma, life stressors.
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Presence of psychological distress adds significantly to the morbidity associated with the dermatological condition. Hence a combined biopsychosocial approach is essential in understanding and managing psycho-dermatological conditions. Source of Support: Nil. Conflict of Interest: Nil. National Center for Biotechnology Information , U. Journal List Indian J Dermatol v. Indian J Dermatol. Author information Article notes Copyright and License information Disclaimer. Address for correspondence: Dr.
E-mail: ude. Received Jun; Accepted Nov. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.
This article has been cited by other articles in PMC. Abstract Psychodermatology is an exciting field which deals with the close relationship that exists between dermatological and psychiatric disorders. Keywords: Bio-psycho-social , evaluation , psychiatric.
Introduction The field of psychodermatology encompasses all conditions involving the mind and the skin. Dermatitis artefacta, trichotillomania, delusional parasitosis, body dysmorphic disorders Dermatosis with a multifactorial basis whose course is subjected to emotional influences-psychosomatic diseases. Psoriasis, atopic dermatitis, acne, chronic forms of urticaria, lichen simplex chronicus, hyperhidrosis Psychiatric disorders secondary to serious or disfiguring dermatosis-somato psychic illnesses.
Approach to a Patient Good interview skills and keen powers of observation are essential for psychiatric assessment in dermatological patients. Interview techniques When conducting the interview one has the option of a classic psychosomatically oriented interview versus a process-oriented structured interview. Interviewing challenges in special populations Interviewing psychotic patients: Psychotic patients may have difficulty following the line of questioning and may not clearly report clarifications related to time, causality and chronological sequence.
Understanding psychopathology underlying dermatological conditions After establishing the basic structure of the interview and creating rapport with the patient, the clinician should delve in depth into the psychosomatic details of the patient's illness. Anxiety disorders When asking details of a co-morbid anxiety disorder it is important to differentiate between persistent, generalized fear and acute anxiety in the form of a panic attack.
Psychotic disorders A completely different category of patients are those with dermatoses as a result of delusional illnesses and hallucinations. Somatoform disorders Patients with somatoform disorders typically present with persistent physical symptoms, with no underlying medical disorder that would explain the nature and extent of the symptoms.
Assessment of stressors and stressful life events Diseases of the skin appear to be significantly influenced by emotional factors and most dermatologists encounter patients who report a temporal relationship between disease flare ups and stressful life events. Attitude towards illness People with dermatologic illness often claim that their main difficulties arise from others reactions to the disease rather than the illness itself. Evaluation of secondary gain At times patients indulge in intentional self-injurious behavior in order to obtain material or social advantage from the illness.
Assessment of personality The personality disorders that are frequently present together with dermatological diseases are borderline, narcissistic, histrionic as well as obsessive compulsive personality disorder. Physical examination from a psychiatric perspective While carrying out the physical examination there are a few signs that may point to a specific psychological etiology underlying the presenting dermatological complaint. Conclusion Psycho-dermatological conditions result out of a complex interaction between the dermatological lesion and various internal factors such as personality, cognitive distortions, patient attitudes and external factors such as stigma, life stressors.
References 1. Relevance of psychiatry in dermatology: Present Concepts. Indian J Psychiatry. Koblenzer CS. Psychosomatic concepts in dermatology. Arch Dermatol. Recognition of depressive and anxiety disorders in dermatological outpatients. Acta Derm Venereal. Detection of psychological distress in patients with psoriasis: Low consensus between dermatologist and patient. Br J Dermatol. Psychodermatology: Psychological and psychiatric aspects of dermatology. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
Alopecia areata and increased prevalence of psychiatric disorders. Int J Dermatol. Lifetime prevalence of psychiatric disorders in patients with alopecia areata. Compr Psychiatry. Clinical management in dermatology. Berlin Heidelberg: Springer-Verlag; Prevalence of somatic and emotional disorders; p. General Approach to evaluating psycho-dermatological disorders.
Psychocutaneous Medicine. Kernberg O. Severe personality disorders. New Haven: Yale University Press; I: History, rationale, and description. Arch Gen Psychiatry. J Clin Psychiatry. Schedules for Clinical Assessment in Neuropsychiatry.
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Fiellner B, Arnetz BB. Psychological predictors of pruritus during mental stress. Acta Derm Venereol. Various studies proved that the inflammatory process within the pilosebaceous unit is modulated by neuropeptides, especially substance P but serum concentration in acne patients was not evaluated 11 , Chronic psychological stress is an important pathogenic factor of acne Difficulties with expressing emotions, especially stress and conflicts, play a significant role as well.
Attempts of an individual to overcome stress and its consequences are defined as coping with stress. The aims of the study were: to evaluate the relationship between acne severity and intensity of emotional stress and scSP, to compare the intensity of adversities and psychological stress and scSP in acne patients and healthy controls and to compare stress coping techniques in both groups. These patients were generally in good health and did not use any medications for 6 months before the study, were not treated for acne before presentation and were healthy otherwise.
Participants were graded on their acne severity using the investigator's global assessment IGA scale presented in Table 1 , 13 , Emotional stress was analyzed with the use of the social readjustment rating scale SRRS by Holmes and Rahe 15 , which consists of 43 stressful life events over the last 12 months that could have contributed to the illness, with relative impact expressed in life change unit on a scale from 1 to Coping inventory for stressful situation CISS questionnaire was used to assess the coping styles for stress The subjects assessed the frequency of their activities undertaken in stressful, difficult situations on a 5-point scale.
The CISS questionnaire measures three dimensions of coping: task-oriented coping, emotion-oriented coping, and avoidance-oriented coping AOC with two subscales: distraction and social diversion. The questionnaire, being a standardized tool, meets the psychometric criteria of the investigating tools. Before performing analysis assumptions were checked. Normality of data was analyzed with Kolmogorov-Smirnov test and equality of variances was checked by Levene's test.
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Written informed consent from all subjects was obtained. The severity of acne vulgaris in the study group is presented in Table 1. Acne patients presented a higher average scSP than controls: 0. As illustrated on Fig. No significant differences were found among acne patients.
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Click for larger image Download as PowerPoint slide Fig. A, b groups followed by the same letter do not differ statistically significantly. Click for larger image Download as PowerPoint slide. Acne vulgaris is the most common inflammatory skin disease of multifactorial pathogenesis. Increased sebum production, excessive and abnormal follicular hyperkeratinization is responsible for the development of microcomedones and proliferation of P.
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The subsequent release of pro-inflammatory mediators in the skin millieau is thought to play the most significant role in the process of lesion formation The activity of sebaceous glands is regulated by a multitude of hormonal and nerve factors Contrary to popular belief, the course of acne is unpredictable, frustrating and often chronic. Persisting acne lesions are increasingly observed and reported in adults This chronic skin disorder induces negative psychological and social effects such as anxiety, decreased self-esteem, depression, suicidal ideation and reduction in social functioning 5.
It negatively affects the quality of life and the psychological consequences of the disease are usually present for many years, even after a successful therapy. On the other hand, the presence of acne-induced psychological problems which may increase stress level, is an indication for psychological and psychiatric evaluations. The psychological and psychiatric interventions should constitute an integral part of comprehensive treatment plan in qualifying individuals who present with this frequently difficult to treat condition.
Stress, the key pathogenic element in the development of numerous dermatoses, remains the essential factor inducing or exacerbating preexisting acne. Immune system is affected by stress via neuropeptide receptors and release cytokines that affect central nervous system.
Chronic psychological stress increases adrenal androgen secretion, stimulates cytokine production, causes growth and increases activity of the sebaceous glands, thus exacerbating acne. In recent years, our knowledge of the role of neuropeptides in the pathogenesis of chronic skin diseases, including acne vulgaris, has expanded.
The majority of adult acne patients are female. Among these patients psychological stress seems to be the crucial factor inducing or exacerbating acne lesions 7. Even mild and moderate forms of acne may be related to severe stress and may negatively affect the quality of life and emotional well-being of patients 8.
In our study, the majority of subjects suffered from mild to moderate acne. Nevertheless, no correlation between the acne severity and stress measured with the SRRS questionnaire was noted. The activity of the pilosebaceous unit is regulated by numerous hormones, medications, neurohormones, neuropeptides, growth factors and cytokines 4 , Incubation of sebaceous glands in a culture medium with selected neuropeptides such as substance P, vasoactive intestinal peptide, neuropeptide Y, calcitonin gene-related peptide revealed that only substance P affected the structure of sebaceous glands and that the effect was dose-dependent The release of neuropeptides is elicited by stress.
Thus, all stressful events and life situations may lead to the development of an inflammatory process by stimulating the release of neuropeptides. In our study, acne patients turned out to have a higher mean concentration of substance P in comparison to controls, but no correlation was found between the clinical state and serum concentration of this neuropeptide. Even mild or moderate acne is a chronic disease, unpredictable and cosmetically disfiguring the face.
As such, it often induces the feelings of low self-esteem, negative image of self, fear, depression, mood swings, suicidal thoughts and tendencies, obsessions, and delusions. Psychological factors, mostly the mechanisms of processing of emotions in stress, are the key factor responsible for exacerbation of acne skin lesions. The pilosebaceous unit works as an endocrinally independent organ and is the control center for a complex neuropeptide regulatory program which functions under control of hypothalamic-pituitary-adrenal HPA axis Healthy human skin produces various neuropeptides, released directly from the sensory neurons as well as skin cells and migratory cells appearing in the course of an inflammatory process.
The connection between neuropeptide secretion during the period of emotional stress and the development of dermal inflammation results in exacerbation of such dermatological conditions as atopic dermatitis, psoriasis and alopecia areata 4. Facial skin of acne patients is characterized by richer innervation, increased number of substance P-containing nerve endings and mast cells, and stronger expression of neutral endopeptidase in sebaceous glands and E-selectin in venules around pilosebaceous glands in comparison to healthy, unaffected skin Substance P induces, both directly and indirectly, inflammation by modulating the release of proinflammatory cytokines and chemokines also in the skin.
This neuropeptide affects the activity of the pilosebaceous unit by stimulating proliferation and differentiation of sebaceous glands, lipid synthesis and induction of neutral endopeptidase expression in sebaceous cells and of E-selectin in perifollicular vessels It has chemotactic effect on monocytes, lymphocytes T and neutrophils 10 , Thus, it seems plausible to investigate the correlation between serum concentration of substance P and acne severity. Current studies have demonstrated a strong association between psychological stress, high-fat diet, intestinal microflora, release of substance P, dermatological state and gastrointestinal disorders Toyoda and Morohashi 18 proved that substance P, which can be elicited by stress, promoted the development of cytoplasmic organelles in sebaceous cells, stimulated sebaceous germinative cells, and induced significant increases in the area of sebaceous glands.
It also increased the size of individual sebaceous cells and the number of sebum vacuoles for each differentiated sebaceous cell, all of which suggests that substance P promotes both the proliferation and the differentiation of sebaceous glands. Our study showed the higher serum concentration of substance P in acne patients in comparison with healthy subjects Emotional stress may affect the intestinal microflora and increase intestinal permeability, what in consequence leads to systemic inflammation in the body.
Probiotics found in food, oxidative stress, regulation of carbohydrate and lipid distribution and even mood play an important role in the etiopathogenesis of acne Probiotics influence the release of substance P in the intestinal tract and the skin Even minute and short-term elevation in circulating substance P may lead to anxiety, depression and aggression Our study used the 4-point IGA scale, which correlates with one of the most commonly used scales for the assessment of acne intensity, i. It is especially applicable in everyday clinical practice as it requires neither lesion count nor photographic records and allows for a speedy and objective assessment of the severity of the disease.
The system, proposed by Allen and Smith Jr, is based on a descriptive text, not on photographs, and demonstrates a higher level of correlation when compared with the Leeds Revised Acne Grading System 13 , Psychodermatology has proposed a classification of disorders of skin conditions associated with mental status by dividing them into four groups: psychophysiologic, primary psychiatric, secondary psychiatric and cutaneous sensory disorders.
The effect of emotional stress on acne has been described as the psychophysiologic disorder by Arck et al. Acne may result in feelings of anxiety, anger and depression, which can worsen if there is no response to acne treatment.
kessai-payment.com/hukusyuu/enlever/hipop-localisation-grace.php Both, mild and moderate acne can be associated with significant depression and suicidal ideation which might even require psychiatric intervention 7 , 8. The psychological evaluation was performed with the use of two questionnaires evaluating the intensity of stress: the Holmes and Rahe's list 15 of stressful life events and coping styles for stress CISS questionnaire. According to the evolutionary standards, stress is defined as a collection of physiological adaptive processes which are the basis for all negative emotions.
Regardless, the process is mostly biological even if its causative factors are psychological in nature. Stressors encompass acute and chronic changes, as well as sequences of stressors. Reactivity of the HPA axis is especially high in case of psychological stressors. The four aspects of stress: the stimuli for stress stressors , subjective experience of stress by a subject, non-specific increased agitation i. Attempts of an individual to overcome stress and its consequences are called coping with stress. In most challenging situations human beings apply various techniques of coping with stress simultaneously.
Resources that facilitate stress coping include individual features, positive perception of self and the world, available social support, group norms and financial means. Our analysis of coping styles revealed significantly higher scores for stress avoidance strategies in acne patients when compared to healthy controls, while other styles did not significantly differ from the general population mean, what might indicate ineffectiveness of coping strategies for stress in people with chronic acne lesions.
The analysis of stressful events based on the SRRS questionnaire revealed that number of stressful events is not a factor that determines the severity of acne. Studies incorporating personality features are necessary to clarify this problem. The study was financially supported by the grant from Poznan University of Medical Sciences, no All authors declare no conflict of interest.