Egyptian Journal of Psychiatry

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 39  |  Issue : 2  |  Page : 53--56

Dermatological diseases among patients with psychiatric disorders


Alshimaa M Abbas Mostafa1, Hisham Salah2, Reham W Doss1, Ahmed E El-Din Arafa3,  
1 Department of Dermatology, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
2 Department of Psychiatry, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
3 Department of Public Health, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt

Correspondence Address:
Hisham Salah
MD Psychiatry Cairo University, Department of Psychiatry, Faculty of Medicine, Beni-Suef University, Beni Suef, 12572 Al-Remaya, Giza
Egypt

Abstract

Background Skin diseases and psychiatric disorders are related to each other. So, the aim of this research is to study the prevalence and distribution of skin diseases among patients with psychiatric disorders in Beni Suef Governorate. Patients and methods A total of 302 patients with psychiatric disorders attending the outpatient clinic of the Psychiatry Hospital in Beni Suef were assessed for psychiatric and dermatological diseases throughout the period between January 2016 and June 2016. Results Out of the 302 patients, 111 (36.7%) were diagnosed as schizophrenia, 91 (30.2%) with major depressive disorder, 36 (11.9%) with bipolar I disorder, 32 (10.6%) with obsessive compulsive disorder, and 32 (10.6%) with anxiety disorders. Of these patients, 267 (88.4%) had dermatological disorders and infectious dermatological disorders constituted 49.8% of the total skin diseases. Conclusion Skin diseases particularly those of infectious pattern were prevalent among patients with psychiatric disorders.



How to cite this article:
Abbas Mostafa AM, Salah H, Doss RW, El-Din Arafa AE. Dermatological diseases among patients with psychiatric disorders.Egypt J Psychiatr 2018;39:53-56


How to cite this URL:
Abbas Mostafa AM, Salah H, Doss RW, El-Din Arafa AE. Dermatological diseases among patients with psychiatric disorders. Egypt J Psychiatr [serial online] 2018 [cited 2018 Nov 20 ];39:53-56
Available from: http://new.ejpsy.eg.net/text.asp?2018/39/2/53/231703


Full Text

 Introduction



The common embryological origin of central nervous system and skin has resulted in an assumption that mental and skin disorders may interact with each other. On one hand, patients with dermatological morbidities have a higher prevalence of psychiatric dysfunction than the general population. On the other hand, patients with common primary psychiatric disorders usually show associated dermatological manifestations (Koblenzer, 1983).

Understanding the psychiatric factors that may play a role in dermatological disorders is essential. In many cases, the effect of the skin disease on the quality of life is a stronger predictor of psychiatric morbidity than the clinical severity of the disorder. More serious, in certain disfiguring disorders, the psychiatric comorbidity can be associated with psychiatric emergencies such as suicide (Picardi et al., 2000). While many dermatologists underestimate the psychological backgrounds of their patients’ skin disorders, patients with psychiatric disorders tend to deny their psychopathology and seek instead help of dermatologists for their skin manifestations (Savin and Cotterill, 2004).

Elenkov and Chrousos (2006) explained this interplay by the excessive stimulation of the stress pathway (hypothalamic–pituitary–adrenal axis) in addition to the effect of glucocorticoids and catecholamines. This pathway, side by side with the hormones and neurotransmitters, regulates major immune functions such as antigen presentation, leukocyte proliferation and traffic, secretion of antibodies and cytokines, and Th1 and Th2 responses, thus having the potential to affect skin diseases. Further, many skin diseases diagnosed in psychiatric patients can be attributed to lack of care and inappropriate nursing (Folsom et al., 2002).

Though the concept of brain–skin interaction is not new, the lack of awareness among dermatologists and psychiatrists toward this concept in addition to the lack of standard guidelines make managing of those patients challenging (Fliege et al., 2005).

Previous national literatures have extensively investigated the psychological and emotional impacts of different dermatological diseases (Saleh et al., 2008; Zaher et al., 2010); however, there is scarce data regarding the prevalence of dermatological diseases among patients with primary psychiatric disorders. Meanwhile, the aim of this study is to detect the prevalence and patterns of different skin diseases in patients with primary psychiatric disorders in the Beni Suef Governorate, Egypt.

 Patients and methods



In this cross-sectional study, 302 patients with psychiatric disorders were recruited from the outpatient clinic of the Psychiatry Hospital, Beni Suef Governorate through the period from January 2016 to June 2016 in a consecutive manner. Being a general hospital, the Hospital of Psychiatry in Beni Suef usually offers medical service to patients from low and middle socioeconomic standards.

All patients with primary psychiatric disorders who accepted to participate in the study were included. All patients were subjected to history taking and general examination.

Assessment of the psychiatric condition was done according to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Axis I Disorders (SCID-I) Arabic version (Hatata et al., 2004). SCID-I is a semistructured interview for making the major Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Axis I diagnoses. The SCID is broken down into separate modules corresponding to the categories of diagnoses. Most sections begin with an entry question that would allow the interviewer to skip the associated questions if not met.

On the other hand, full dermatologic status was comprehensively performed. This examination began with visual observation of the whole skin and was performed by two dermatologists and their diagnoses were compared for agreement. Skin infections were diagnosed on the basis of clinical picture without laboratory investigations. Dermatological diagnoses and classification of skin diseases were done as described elsewhere (Moftah et al., 2013).

For data collection, a case report form including cells for the sociodemographic characteristics of patients such as sex, age, residence, occupation, and marital status was prepared. The form included spaces for the psychiatric diagnosis and the dermatological ones.

The study was approved by the Research Ethics Committee of the Faculty of Medicine, Beni Suef University. The patients were informed of the purpose of the study and its consequences with confirming confidentiality of data.

Data were analyzed using the software, then processed and tabulated. Frequency distribution with its percentage and descriptive statistics with mean and SD were calculated. χ2-Test, t-test, and correlations were done whenever needed. P values of less than 0.05 were considered significant (IBM, 2011).

 Results



A total of 302 patients with primary psychiatric disorders participated in the study; 206 (68.2%) men and 96 (31.8%) women with a mean age of 33.9±12.3 years. Less than half of the patients were married and most of them were living in rural areas and had no job. Precisely, 161 (53.3%) of the patients were current smokers while the remaining proportion were either ex-smokers or nonsmokers ([Table 1]).{Table 1}

Of the 302 patients, 267 (88.4%) had dermatological diseases, while 35 (11.6%) were free from dermatological diseases. In those patients, 111 (36.7%) were diagnosed as schizophrenia (99 with skin diseases and 12 without), 91 (30.2%) with major depressive disorder (82 with skin diseases and nine free from them), 36 (11.9%) with bipolar I disorder (29 with skin diseases and seven free), 32 (10.6%) with obsessive compulsive (27 with skin diseases and five free), and 32 (10.6%) with anxiety disorders (30 with skin diseases and two without) ([Table 2]).{Table 2}

Regarding diagnosis of infectious skin diseases in patients with psychiatric disorders, 24% of patients had fungal infection, 12.7% had bacterial infection, 7.9% with viral infection, and 5.2% with parasitic infestations, whereas in noninfectious skin diseases, acne was the most likely disease to be diagnosed followed by hair loss, itching, and eczema ([Table 3]).{Table 3}

 Discussion



The interaction between psychiatric and dermatological disorders may result in many skin diseases among psychiatric patients. While many psychiatric patients feel stigmatized for being assessed by psychiatrists, dermatologists in many cases do not consider evaluating their patients for psychiatric disorders. Side by side with the deficiencies in nursing care, both the psychiatric disorders and their dermatological consequences tend to prolong and exacerbate (Picardi et al., 2000).

In the current study, 267 (88.4%) patients with psychiatric disorders showed dermatological manifestations. This prevalence is consistent with a previous national study by Moftah et al. (2013), who conducted their study on 200 patients with primary psychiatric disorders and diagnosed skin diseases in 71.5% of them. Also, Mookhoek et al. (2010) examined 91 psychiatric patients in the Netherlands and reported skin diseases in 77% of them.

The association between dermatological diseases and each of schizophrenia and depression was noticed in our study which is consistent with that of Folsom et al. (2002) who conducted their study on elderly, homeless patients. Patients with schizophrenia and depression cannot carry out their regular daily activities and usually do not seek help making them more liable to get chronic and infectious skin diseases (Hays et al., 1995). Also, we found that 84.4% of patients with obsessive compulsive disorder had dermatological diseases. A similar association was suggested by Demet et al. (2005).

The results of the study have also shown that almost half of the dermatological manifestations in psychiatric patients were infectious. In consistence, Kuruvila et al. (2004) detected a higher prevalence of infectious skin diseases in psychiatric patients in India in comparison to their healthy controls (68.7% in cases vs. 50.3% in controls). Moftah et al. (2013) even detected higher rates of infectious skin diseases in patients with primary psychiatric disorders. To understand the previously mentioned high prevalence rates of infections among psychiatric patients, a study by Segerstrom and Miller (2004) reported that psychiatric disorders are closely associated with chronic stress that result in decreased lymphocyte proliferation and natural killer cell cytotoxicity leading to higher susceptibility to infectious skin diseases. However, negligence and lack of care should not be overlooked as predisposing factors for these high rates of skin infections. Further, inclusion of patients from low to middle socioeconomic standard, known to be exposed to insanitary environment and have no access to appropriate health services, could explain the high rates of infectious skin disease in our study. This suggestion could be supported by the low rates of infectious skin diseases in psychiatric patients in the Netherlands (17.6%) (Mookhoek et al., 2010).

 Conclusion



Skin diseases, particularly those of infectious pattern, are common among patients with primary psychiatric disorders. A dual approach of assessment for both dermatological and psychiatric disorders should be considered. Further research about whether psychiatric intervention could lower the high rates of skin diseases in psychiatric patients is needed.[16]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Demet MM, Devici A, Taskin EO (2005). Obsessive-compulsive disorder in a dermatology outpatient clinic. Gen Hosp Psychiatry 27:426–430.
2Elenkov IJ, Chrousos GP (2006). Stress system-organization, physiology and immunoregulation. Neuroimmunomodulation 13:257–267.
3Fliege H, Rose M, Arck P (2005). The Perceived Stress Questionnaire (PSQ) reconsidered: validation and reference values from different clinical and healthy adult samples. Psychosom Med 67:78–88.
4Folsom DP, McCahill M, Bartels SJ (2002). Medical comorbidity andreceipt of medical care by older homeless people with schizophrenia or depression. Psychiatr Serv 53:1456–1460.
5Hatata H, Khalil A, Asaad T, Abo Zeid M, Okasha T (2004). Dual diagnosis in substance use disorders (MD degree thesis). Faculty of Medicine, Ain Shams University.
6Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K (1995). Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 52:11–19.
7IBM (2011). IBM Statistical package for the social science IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows (Version 20.0). Armonk, NY: IBM Corp.
8Koblenzer CS (1983). Psychosomatic concepts in dermatology. Arch Dermatol 119:501–512.
9Kuruvila M, Gahalaut P, Zacharia A (2004). A study of skin disorders in patients with primary psychiatric conditions. Indian J Dermatol Venereol Leprol 70:292–295.
10Moftah NH, Kamel AM, Attia HM, El-Baz MZ, Abd El-Moty HM (2013). Skin diseases in patients with primary psychiatric conditions: a hospital based study. J Epidemiol Glob Health 3:131–138.
11Mookhoek EJ, van De Kerkhof PC, Hovens JE, Brouwers JR, Loonen AJ (2010). Skin disorders in chronic psychiatric illness. J Eur Acad Dermatol Venereol 24:1151–1156.
12Picardi A, Abeni D, Melchi CF (2000). Psychiatric morbidity in dermatological outpatients: an issue to be recognized. Br J Dermatol 143:983–991.
13Saleh HM, Salem SAM, El-Sheshetawy RS, El-Samei AM (2008). Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata. Egypt Dermatol Online J 4:1–28.
14Savin JA, Cotterill JA (2004). Psychocutaneous disorders. In: Champion RH, Burton JL, Ebling FJ, editors. Rook/Wilkinson/Ebling. Textbook of dermatology. 5th ed. Oxford: Blackwell Scientific Textbook of Dermatology. 7th ed. Oxford: Blackwell Scientific Publications. p. 16.1.
15Segerstrom SC, Miller GE (2004). Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull 130:601–630.
16Zaher HAM, Amin ME, Rakhawy MY (2010). Coping with depression and anxiety in patients with psoriasis. Egypt J Psychiatry 31:57–63.