Volume-1 Issue-5 November, 2011
Consultation Liaison Psychiatry, Focus: Dermatology
For generations people have been aware of profound impact the skin disorders have on psychosocial aspects of individuals and vice versa. It is recently that we have been able understand the biological connection between them. Psychocutaneous disorders encompass a wide variety of dermatological diseases that may be affected by the presence of psychiatric symptoms or stress and psychiatric illnesses in which the skin is the target of disordered thinking, behavior, or perception. Important among them are Atopic dermatitis, Psoriasis, Utricaria, Alopecia Areata, Acne Vulgaris, Seborrheic Dermatitis, Trichotillomania and Delusion of parasitosis.
Considering the brevity of space here, only pruritic lesions have been discussed especially the ITCH part! Scratching in response to the pruritus can lead to lichenification, excoriations, and infections. Stressful life events often precede the onset and exacerbation. How stress affects the disorder is unclear, but it may involve interactions between the CNS and the immune system. For example, there is evidence in animal models that corticotropin-releasing hormone (CRH), a principal coordinator of the stress response system, also has pro- inflammatory actions through its activation of mast cells and subsequent release of vasoactive and pro-inflammatory mediators. Well-controlled studies have found adult patients with pruritic lesions tend to be more anxious and depressed than clinical and disease-free control groups. Anxiety or depression may exacerbate lesions by eliciting scratching behavior. In another study of pruritus associated dermatological conditions, depressive symptoms appeared to amplify the itch perception. Many patients report that pruritus is aggravated by emotional distress. Stress-induced pruritus may result from a perturbation of the epidermal barrier function resulting in inflammation and pruritus.
Psychiatric evaluation and treatment is recommended for patients who have comorbid anxiety and depressive symptoms or stressors that may contribute to difficulties in management of the disorder. Different modalities of psychiatric treatment for exist. Some strive to reduce stress and interrupt the vicious circle of itching and scratching. Controlled studies have established that relaxation training, habit reversal training, cognitive-behavioral techniques, and stress management training lead to significant and stable adjunctive treatment responses beyond those of standard medical care, as well as reduce anxiety and depression. Controlled trials of psychotropic drug treatment found that topical doxepin cream was effective in reducing pruritus in dermatitis patients, probably related to doxepin’s potent histamine antagonism. Amitriptyline, another antidepressant with histamine receptor antagonism, decreased the fragmentation of sleep and reduced the time spent in stage 1 sleep, which secondarily reduced the amount of scratching during the night.
Overall, liaison with Psychiatry will likely to have better quality of life in such patients & clinicians satisfaction.
Faculty, Dept of Psychiatry, Aims
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