The interface between psychiatry and dermatology is multidimensional and begins in early development. The skin is a vital organ of communication and the earliest social interactions between the infant and its caregivers occur via the body, especially through touch. A disruption in tactile nurturance, for example, as a result of a skin disorder during infancy or due to childhood abuse and/or neglect can be associated with serious psychiatric morbidity in later life including major depressive disorder, body image pathologies, a tendency to self-injure and dissociative states when there is significant psychological trauma present in association with the neglect. The importance of the skin in social communication is further exemplified during adolescence when the development of a cosmetically disfiguring skin disorder such as acne can be associated with depression, suicidal ideation and body image disorders including eating disorders. The role of the skin as an organ of communication remains important throughout the life cycle, as the development of a disfiguring skin condition at any life stage can have a significant impact on the quality of life of the patient. In certain conditions such as acne and psoriasis, the psychiatric comorbidity and the impact of the skin disorder on the quality of life of the patient are often the most important component of the overall morbidity associated with the skin condition.
Psychiatric disorders in the dermatological patient are generally assumed to be secondary to the skin disorder; however, in some instances they may be primary and/or have a direct impact on the course of the dermatological symptoms. Pruritus severity in psoriasis and atopic dermatitis has been noted to correlate directly with the severity of depressive symptoms in the patient, suggesting that depression may modulate pruritus perception. Depressive disease is one of the most frequently encountered psychiatric disorders in dermatology and may be a feature of a wide range of conditions including psoriasis, acne, chronic idiopathic urticaria and atopic dermatitis. Depressive symptoms may also present as somatic equivalents, for instance cutaneous dysaesthesias for which no physical basis can be identified. Psoriasis and acne have been associated with suicidal ideation and suicide. In psoriasis the frequency of suicidal ideation generally increases with increasing psoriasis severity; however among acne patients, the severity of the skin lesions and frequency of suicidal ideation do not show a consistent relationship, as even mild-to-moderate acne has been associated with depression, suicidal ideation and completed suicide.
Some of the other psychiatric syndromes in dermatology include OCD which may manifest as repetitive hand washing or bathing, trichotillomania, onychophagia, neurotic excoriations or an excessive concern about a minor or imagined 'defect' in the skin. Social phobia or social anxiety disorder can be a feature of a wide range of cosmetically disfiguring conditions or conditions that become more visible when the patient is autonomically aroused such as rosacea and hyperhydrosis. PTSD is often under-recognised and may be an underlying problem in the self-induced dermatoses such as trichotillomania and dermatitis artefacta. BDD or dysmorpho-phobia is often encountered in patients who present with an excessive concern about a minimal or imagined dermatological problem such as minimal acne, wrinkles or vascular markings.
Overall, it is important to evaluate and manage the psychiatric comorbidity in the dermatological patient, as they can contribute towards a large proportion of the overall morbidity associated with the skin disorder and usually have a significant impact on the quality of life of the patient. In some instances, the psychiatric comorbidity such as depressive disease can have an adverse impact on dermato-logical aspects of the disorder due to poor adherence to treatment or a possible direct effect on certain symptoms such as pruritus. Certain body image pathologies may predispose the patient to overestimate the severity of their dermatological symptom, which may culminate in excessive concerns about minor problems or patient dissatisfaction with treatment outcome. It is therefore increasingly recognised that an improvement in psychiatric comorbidity is an important measure of treatment outcome for a wide range of dermatological patients.
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