International Journal of Psychiatry in Clinical Practice, 2010; 14: 18–22
ORIGINAL ARTICLE
Psychiatric morbidity in dermatological conditions
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Bath on 11/10/14 For personal use only.
MARYAM RASOULIAN1, AZIZEH AFKHAM EBRAHIMI2, MARYAM ZARE2 & ZAHRA TAHERIFAR2 1Rasoul
Akram Hospital, Psychiatry, Tehran, Islamic Republic of Iran, and 2 Clinical Psychology, Tehran Psychiatric Institute, Satarkhan, Islamic Republic of Iran
Abstract Objective. A relationship between psychological factors and skin diseases has long been hypothesized. The objective of this study is to investigate the association of dermatology conditions with depression, anxiety and personality disorders. Method. A total of 144 dermatology outpatients and 100 controls were selected and assessed by the Structured Clinical Interview for DSM III-R personality disorders and the Hospital Anxiety and Depression Scale for presence of personality disorders and anxiety and depression. Results. A total of 77 (70%) of the patients and 26 (20%) of the control group reported moderate to severe anxiety and depression. Twenty-two patients (15.27%) and five controls (5%) suffered from personality disorders. Obsessivecompulsive personality disorder was the most diagnosed personality disorder followed by avoidant, borderline and dependent personalities. Conclusion. The association between dermatological diseases and psychiatric and personality morbidity underscores the deep emotional suffering that can be associated with skin diseases and confirms the importance of psychiatric evaluation of dermatology patients. Our findings highlight the need for a biopsychosocial approach to patients with skin disease.
Key Words: Anxiety, depression, personality disorders, dermatology conditions, HADS
Introduction Psychodermatology or psychocutaneous medicine focuses on the boundary between psychiatry and dermatology. Understanding the psychological nature of skin diseases is critical to the optimal management of psychodermatological disorders. Once the disorder has been diagnosed, management requires a dual approach, addressing both dermatological and psychological aspects. Psychodermatological disorders can be broadly classified into three categories: psychophysiological disorders, primary psychiatric disorders and secondary psychiatric disorders.The term “psychophysiological disorder” refers to a skin disorder such as eczema or psoriasis that is worsened by emotional stress [1]. “Primary psychiatric disorder” refers to a skin disorder such as trichotillomania in which the primary problem is psychological [2]. “Secondary psychiatric disorders” affect patients with significant psychological problems that have a profoundly negative impact on their self-esteem and body image. Depression, humiliation, frustration and social
phobia may develop as a consequence of a disfiguring skin disorder [1]. In addition, concerns have been raised about the potential for deliberate self-harm among patients with skin diseases. Indeed, several cases of patients with dermatological conditions who completed suicide have been reported [3,4]. According to recent studies, psychiatric disorders among patients with skin diseases are frequent. Prevalence estimates range from 25 to 43% with psychiatric morbidity usually taking the form of depressive, anxiety or somatoform disorders [5–7]. Many clinicians and researchers now share the opinion that in many cases the development of a skin disease is caused by psychological stress or is related to certain psychiatric disorders or personality traits. Some authors have reported significantly more interpersonal sensitivity, hysterical, depressive and suspicious personality traits in some dermatology patients [8,9]. A wide range of skin disorders can theoretically be associated with psychiatric morbidity as a result of their effect upon quality of life and body image of
Correspondence: Azizeh Afkham Ebrahimi, Department of Clinical Psychology, Tehran Psychiatric Institute, Niayesh Street, Next to Shahid Mansouri Ave., Satarkhan, Islamic Republic of Iran. Tel: +98 9121 597189. E-mail: [email protected] (Received 19 December 2008; accepted 14 August 2009) ISSN 1365-1501 print/ISSN 1471-1788 online © 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: 10.3109/13651500903262370
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Bath on 11/10/14 For personal use only.
Psychiatric morbidity in dermatological conditions the patient. Therefore reports of 30% or greater psychiatric comorbidity among dermatological patients usually reflects a complex and bidirectional interaction between the psyche and the skin [10,11]. Although a large body of literature has been devoted to the relationship between stressful life events and a variety of dermatological diseases, less attention has been devoted to the role of psychiatric disorders and personality factors in this population [12]. Because of the paucity of literature on simultaneous effect of three psychatric entities on skin diseases the objective of this study is to examine the association of anxiety, depression and Axis II diagnosis in dermatology patients. Our hypothesis is that mood disorders particularly anxiety and depression and certain personality disorders are more frequent in this population compared to healthy controls.
Method This was a descriptive, cross-sectional study on a total of 144 consecutive patients (54 male and 90 female; aged 18–56) with different dermatological complaints who were attending the dermatology clinic of a training hospital within a 3-month period, from September to December 2007. Illiteracy, accompanying severe medical illnesses such as uncontrolled endocrine abnormalities, cardiovascular, central nervous system and recent drug sensitivity were exclusion criteria. The control group was composed of 100 hospital administrative staff and patients’ relatives who were matched for sociodemographic characteristics of dermatology patients and had no history of major psychiatric and dermatology conditions in addition to exclusion criteria. In the beginning, the objective and procedures of the study were explained to all participants by their treating physician and because the majority of the participants preferred verbal consent over the written one, verbal informed consent was obtained. The patients then referred to a senior assistant of psychiatry for Axis II personality diagnosis who administered the Structured Clinical Interview for DSM Personality Disorders (SCID-II). The presence of anxiety and depression were measured by Hospital Anxiety and Depression Scale (HADS).
Instruments SCID II [13] is a separate instrument for assessing the 11 DSM-III-R personality disorders. It can be used to make Axis II diagnosis dimensionally by noting the number of personality disorder criteria for each diagnosis that is coded “3”. The instrument has comparable procedural validity with an early version
19
of the Personality Disorders Examination and regarding the reliability, the kappa values for the SCID-II on 226 subjects were comparable to other personality assessment instruments [14]. The translated version of the instrument was used in this study. The scale was translated into Farsi language by five independent psychiatrists with good knowledge of English and interview skills. The SCID-II has been extensively utilized with a variety of patient populations in Iran and interrater reliability has been found to be high [15–17] The HADS contains 14 items and consists of two subscales: anxiety and depression. Each item is rated on a four-point scale giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to be a significant case of psychological morbidity while scores of 8–10 represents borderline and 0–7 normal [18]. The scale has been translated and validated in an Iranian population and the results of convergent analysis have yielded high coefficient correlation between subscales (0.47–0.83). The internal consistency of the HADS as measured by the Cronbach’s alpha coefficient has been found satisfactory for both anxiety and depression scales (0.78 and 0.86, respectively) [19]. Statistical analysis was carried out using SPSS version 11.5 for windows. Descriptive statistics and chi-square were calculated for frequencies, differences and associations of categorical variables in two comparison groups. Results The comparison of demographic characteristics of two groups with Fisher’s exact test and chi-square showed no significant differences for age (P⫽0.64), gender (P⫽0.52), education (P⫽0.86) and marital status (P⫽0.70) of patients and controls. The descriptives of anxiety and depression symptoms in patient and control groups are shown in Table I. The results indicate that 77 (70%) of the patients compared to 26 (20%) of the control group and obtained scores within range of moderate to severe anxiety and depression (ⱖ11) on HADS. Table II shows that 22 patients (15.27%) and five controls (5%) suffer from personality disorders. Obsessive-compulsive personality disorder is the most diagnosed personality disorder followed by avoidant, borderline and dependent personalities. None of the patients and controls met the full criteria of schizoid, schizotypal, paranoid, antisocial or passive-aggressive personality disorders. However, both patient and control groups showed the criteria of the latter personality in subthreshold level. The association of dermatological conditions with anxiety, depression and personality disorders in the
20
M. Rasoulian et al.
Table I. Descriptives of anxiety and depression symptoms of HADS in two groups. Anxiety symptoms F∗
%
Patients 144 111 Control 100 20 Total 244 131
77 20 53
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Bath on 11/10/14 For personal use only.
Group
N
Depression symptoms
M (SD) 12.43 (2.57) 8.47 (2.94) 10.81 (3.35)
F 101 26 127
%
Table III.The odds ratios of the association of psychiatric morbidity and dermatological conditions. Morbidity
Patient group (%)
Control group (%)
χ2
P
Odds ratio
49.09 50.65 6.33
ORIGINAL ARTICLE
Psychiatric morbidity in dermatological conditions
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Bath on 11/10/14 For personal use only.
MARYAM RASOULIAN1, AZIZEH AFKHAM EBRAHIMI2, MARYAM ZARE2 & ZAHRA TAHERIFAR2 1Rasoul
Akram Hospital, Psychiatry, Tehran, Islamic Republic of Iran, and 2 Clinical Psychology, Tehran Psychiatric Institute, Satarkhan, Islamic Republic of Iran
Abstract Objective. A relationship between psychological factors and skin diseases has long been hypothesized. The objective of this study is to investigate the association of dermatology conditions with depression, anxiety and personality disorders. Method. A total of 144 dermatology outpatients and 100 controls were selected and assessed by the Structured Clinical Interview for DSM III-R personality disorders and the Hospital Anxiety and Depression Scale for presence of personality disorders and anxiety and depression. Results. A total of 77 (70%) of the patients and 26 (20%) of the control group reported moderate to severe anxiety and depression. Twenty-two patients (15.27%) and five controls (5%) suffered from personality disorders. Obsessivecompulsive personality disorder was the most diagnosed personality disorder followed by avoidant, borderline and dependent personalities. Conclusion. The association between dermatological diseases and psychiatric and personality morbidity underscores the deep emotional suffering that can be associated with skin diseases and confirms the importance of psychiatric evaluation of dermatology patients. Our findings highlight the need for a biopsychosocial approach to patients with skin disease.
Key Words: Anxiety, depression, personality disorders, dermatology conditions, HADS
Introduction Psychodermatology or psychocutaneous medicine focuses on the boundary between psychiatry and dermatology. Understanding the psychological nature of skin diseases is critical to the optimal management of psychodermatological disorders. Once the disorder has been diagnosed, management requires a dual approach, addressing both dermatological and psychological aspects. Psychodermatological disorders can be broadly classified into three categories: psychophysiological disorders, primary psychiatric disorders and secondary psychiatric disorders.The term “psychophysiological disorder” refers to a skin disorder such as eczema or psoriasis that is worsened by emotional stress [1]. “Primary psychiatric disorder” refers to a skin disorder such as trichotillomania in which the primary problem is psychological [2]. “Secondary psychiatric disorders” affect patients with significant psychological problems that have a profoundly negative impact on their self-esteem and body image. Depression, humiliation, frustration and social
phobia may develop as a consequence of a disfiguring skin disorder [1]. In addition, concerns have been raised about the potential for deliberate self-harm among patients with skin diseases. Indeed, several cases of patients with dermatological conditions who completed suicide have been reported [3,4]. According to recent studies, psychiatric disorders among patients with skin diseases are frequent. Prevalence estimates range from 25 to 43% with psychiatric morbidity usually taking the form of depressive, anxiety or somatoform disorders [5–7]. Many clinicians and researchers now share the opinion that in many cases the development of a skin disease is caused by psychological stress or is related to certain psychiatric disorders or personality traits. Some authors have reported significantly more interpersonal sensitivity, hysterical, depressive and suspicious personality traits in some dermatology patients [8,9]. A wide range of skin disorders can theoretically be associated with psychiatric morbidity as a result of their effect upon quality of life and body image of
Correspondence: Azizeh Afkham Ebrahimi, Department of Clinical Psychology, Tehran Psychiatric Institute, Niayesh Street, Next to Shahid Mansouri Ave., Satarkhan, Islamic Republic of Iran. Tel: +98 9121 597189. E-mail: [email protected] (Received 19 December 2008; accepted 14 August 2009) ISSN 1365-1501 print/ISSN 1471-1788 online © 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: 10.3109/13651500903262370
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Bath on 11/10/14 For personal use only.
Psychiatric morbidity in dermatological conditions the patient. Therefore reports of 30% or greater psychiatric comorbidity among dermatological patients usually reflects a complex and bidirectional interaction between the psyche and the skin [10,11]. Although a large body of literature has been devoted to the relationship between stressful life events and a variety of dermatological diseases, less attention has been devoted to the role of psychiatric disorders and personality factors in this population [12]. Because of the paucity of literature on simultaneous effect of three psychatric entities on skin diseases the objective of this study is to examine the association of anxiety, depression and Axis II diagnosis in dermatology patients. Our hypothesis is that mood disorders particularly anxiety and depression and certain personality disorders are more frequent in this population compared to healthy controls.
Method This was a descriptive, cross-sectional study on a total of 144 consecutive patients (54 male and 90 female; aged 18–56) with different dermatological complaints who were attending the dermatology clinic of a training hospital within a 3-month period, from September to December 2007. Illiteracy, accompanying severe medical illnesses such as uncontrolled endocrine abnormalities, cardiovascular, central nervous system and recent drug sensitivity were exclusion criteria. The control group was composed of 100 hospital administrative staff and patients’ relatives who were matched for sociodemographic characteristics of dermatology patients and had no history of major psychiatric and dermatology conditions in addition to exclusion criteria. In the beginning, the objective and procedures of the study were explained to all participants by their treating physician and because the majority of the participants preferred verbal consent over the written one, verbal informed consent was obtained. The patients then referred to a senior assistant of psychiatry for Axis II personality diagnosis who administered the Structured Clinical Interview for DSM Personality Disorders (SCID-II). The presence of anxiety and depression were measured by Hospital Anxiety and Depression Scale (HADS).
Instruments SCID II [13] is a separate instrument for assessing the 11 DSM-III-R personality disorders. It can be used to make Axis II diagnosis dimensionally by noting the number of personality disorder criteria for each diagnosis that is coded “3”. The instrument has comparable procedural validity with an early version
19
of the Personality Disorders Examination and regarding the reliability, the kappa values for the SCID-II on 226 subjects were comparable to other personality assessment instruments [14]. The translated version of the instrument was used in this study. The scale was translated into Farsi language by five independent psychiatrists with good knowledge of English and interview skills. The SCID-II has been extensively utilized with a variety of patient populations in Iran and interrater reliability has been found to be high [15–17] The HADS contains 14 items and consists of two subscales: anxiety and depression. Each item is rated on a four-point scale giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to be a significant case of psychological morbidity while scores of 8–10 represents borderline and 0–7 normal [18]. The scale has been translated and validated in an Iranian population and the results of convergent analysis have yielded high coefficient correlation between subscales (0.47–0.83). The internal consistency of the HADS as measured by the Cronbach’s alpha coefficient has been found satisfactory for both anxiety and depression scales (0.78 and 0.86, respectively) [19]. Statistical analysis was carried out using SPSS version 11.5 for windows. Descriptive statistics and chi-square were calculated for frequencies, differences and associations of categorical variables in two comparison groups. Results The comparison of demographic characteristics of two groups with Fisher’s exact test and chi-square showed no significant differences for age (P⫽0.64), gender (P⫽0.52), education (P⫽0.86) and marital status (P⫽0.70) of patients and controls. The descriptives of anxiety and depression symptoms in patient and control groups are shown in Table I. The results indicate that 77 (70%) of the patients compared to 26 (20%) of the control group and obtained scores within range of moderate to severe anxiety and depression (ⱖ11) on HADS. Table II shows that 22 patients (15.27%) and five controls (5%) suffer from personality disorders. Obsessive-compulsive personality disorder is the most diagnosed personality disorder followed by avoidant, borderline and dependent personalities. None of the patients and controls met the full criteria of schizoid, schizotypal, paranoid, antisocial or passive-aggressive personality disorders. However, both patient and control groups showed the criteria of the latter personality in subthreshold level. The association of dermatological conditions with anxiety, depression and personality disorders in the
20
M. Rasoulian et al.
Table I. Descriptives of anxiety and depression symptoms of HADS in two groups. Anxiety symptoms F∗
%
Patients 144 111 Control 100 20 Total 244 131
77 20 53
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Bath on 11/10/14 For personal use only.
Group
N
Depression symptoms
M (SD) 12.43 (2.57) 8.47 (2.94) 10.81 (3.35)
F 101 26 127
%
Table III.The odds ratios of the association of psychiatric morbidity and dermatological conditions. Morbidity
Patient group (%)
Control group (%)
χ2
P
Odds ratio
49.09 50.65 6.33
