Somatization disorders in dermatology

"Mens Sana in Cute Sana"-A State of the Art of Mutual Etiopathogenetic Influence and Relevant Pathophysiological Pathways between Skin and Mental Disorders: An Integrated Approach to Contemporary Psychopathological Scenarios

The negative socioeconomic impact of mental health disorders and skin diseases has increased in part due to the conflict between Russia and Ukraine, which has been a fertile ground for the emergence of psychopathologies. It is firmly established that there is a direct thread of etiopathogenetic communication between skin diseases and neuropsychiatric disorders, and the literature has tried to reveal the pathophysiological mechanisms governing such bidirectionality. This paper discusses this complex network of molecular pathways that are targeted by conventional and biological pharmacological agents that appear to impact two pathological spheres that previously seemed to have little connection. This molecular discussion is supplemented with a literature review, from a clinical viewpoint, regarding skin-brain etiopathogenetic bidirectionality. We focus on post-traumatic stress disorder (PTSD), which can be considered for all intents and purposes a systemic inflammatory disease that also affects the skin. A brief overview is also provided on the diagnostic-therapeutic and follow-up potential of oxidative and inflammatory markers potentially involved in the pathophysiological mechanisms treated. The aim is to clarify how these mechanisms may be useful in defining different stress-coping strategies and thus individual phenotypes of stress sensitivity/resistance in order to promote personalized medicine in the field of psychodermatology.

Somatization in dermatology

Medically unexplained dermatologic symptoms, such as pruritus, numbness and burning are known as somatization. These cutaneous symptoms can be very difficult to treat because of an absence of an objective explanation and they may not fit neatly into any known dermatological or psychiatric condition. These disorders are more commonly encountered in primary care and in dermatology, rather than in psychiatry. Certain skin disorders, for example, pruritus, could be a manifestation of somatization and others may predispose to somatic symptoms, for example, atopic dermatitis and psoriasis. Although there has been increasing research in the interconnection between psychiatry and dermatology, psychodermatology is a relatively new crossover discipline in clinical practice and recognition of psychodermatological conditions, such as cutaneous somatic disorders, can be difficult. Somatization may occur with or without the existence of a dermatological disease. When a dermatological disorder is present, somatization should be considered when the patient is worrying too much about their skin, spending too much time and energy on it and especially if the patient also complains of many non-cutaneous symptoms. Purely cutaneous somatic conditions include for example, the genital pain syndromes or Gardner-Diamond syndrome, characterized by unexplained bruising, which usually affects women. Effective management tools may include mindfulness therapies, pharmacotherapy with selective serotonin reuptake inhibitors, tricyclic antidepressants and cognitive conduct therapy. Electroconvulsive therapy can also be considered in extremely rare cases for treatment of severe somatization on a background of mood disorders. This paper discusses somatization, its relationship to immunodermatoses and its relevance to clinical practice.

Role of burn severity and posttraumatic stress symptoms in the co-occurrence of itch and neuropathic pain after burns: A longitudinal study

Itch and pain are common after burns. Neuropathic mechanisms may underlie both modalities but remain not well-understood. This study aims to prospectively document neuropathic pain symptoms and to identify potential itch symptom profiles that differ regarding duration and co-occurrence with neuropathic pain which may inform underlying pathophysiological mechanisms and respond to different treatments. Adult burn survivors (n = 192) self-reported itch and neuropathic pain at 2 weeks post-discharge, 3, 6, 12, and 18 months post-burn. Based on the presence of itch and pain symptoms over time, participants were allocated to one itch profile: transient itch/pain, chronic itch, or chronic itch & pain. Profiles were compared on itch intensity over time using General Linear Modeling. Age, gender, burn severity, posttraumatic stress (PTS) symptoms and baseline itch intensity were examined as potential predictors of the profiles in a Multi-nominal regression analysis. Neuropathic pain occurred in 54% after discharge which decreased to 24% 18 months later. Itch intensity was highest in the chronic itch & pain profile. Compared to the transient itch profile, the chronic itch & pain profile was associated with higher burn severity and more PTS symptoms. Compared to the chronic itch profile, the chronic itch & pain profile was associated with more PTS symptoms. Findings suggest that biological and psycho-dermatological processes underlie both chronic neuropathic pain and itch processes in burn scars. Further research should elucidate the mechanisms underlying the different itch profiles, with specific focus on skin innervation and psychological factors.

Network analysis on the relationship between posttraumatic stress disorder, psychiatric co-morbidity and posttraumatic growth among Chinese adolescents

BACKGROUND

This study investigated the association between posttraumatic stress disorder (PTSD), psychiatric co-morbidity and posttraumatic growth (PTG) among Chinese adolescents using network analysis.

METHODS

867 Chinese adolescents (male = 424, female = 443) were recruited from three secondary schools. They completed the Posttraumatic Stress Disorder Checklist for DSM-5, the Posttraumatic Growth Inventory, and the General Health Questionnaire-28.

RESULTS

Domains of each construct mainly clustered within their respective communities with several bridging edges identified. The prominent roles of bridging nodes and edges (positive and negative) were highlighted. Key bridging nodes were negative alterations in cognitions and mood for PTSD, anxiety and insomnia for psychiatric co-morbidity and appreciation of life for PTG.

LIMITATIONS

The cross-sectional nature of the present study may preclude the identification of real causal relationships between nodes.

CONCLUSIONS

Following a trauma, adolescents displayed posttraumatic stress along with general psychological disorder symptoms. These distress reactions could affect the way they appreciated life and their motivation to seek future life possibilities. Findings from the current study may provide some clue for the facilitation of posttraumatic growth among clinical patients.

Risk of psychiatric diseases among patients with psoriasis in Korea: A 12-year nationwide population-based cohort study

The association between psoriasis and risk of psychiatric diseases has not been thoroughly evaluated in a large longitudinal cohort of the Asian population. We conducted a nationwide cohort study encompassing more than 1.6 million Koreans with a 12-year follow-up period. Patients were considered to be in the psoriasis cohort if they had an incident diagnostic code for psoriasis and included patients were followed up until they developed any psychiatric disease. In adjusted models, psoriasis patients (n = 10 868) were at an 18% increased risk for depression (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.09-1.26), 16% for anxiety disorders (HR, 1.16; 95% CI, 1.08-1.26), and 21% for somatoform disorders (HR, 1.21; 95% CI, 1.08-1.34) compared with the referent cohort (n = 1 620 055). Patients with moderate-to-severe psoriasis had a higher risk of developing depression and somatoform disorders than patient with mild disease (depression, HR, 1.28; 95% CI, 1.07-1.54 vs HR, 1.17; 95% CI, 1.07-1.27; somatoform disorders, HR, 1.60; 95% CI, 1.26-2.03 vs HR, 1.13; 95% CI, 1.00-1.28). Our results highlight the burden of psychiatric diseases in patients with psoriasis in Korea and suggest that appropriate medical support for possible mental illness is warranted in Asian psoriatic patients.

Posttraumatic Stress Disorder and Chronic Idiopathic URTICARIA: the Role of Coping and Personality

This study compared the severity of chronic idiopathic urticaria (CIU) and psychiatric symptoms between patients with different levels of posttraumatic stress disorder (PTSD) and investigated a model depicting the interrelationship between PTSD from past trauma, personality traits, coping strategies, CIU severity and psychiatric symptom severity. One hundred CIU and 60 allergy patients participated in the study, completing measures on PTSD, psychiatric symptoms, personality traits and coping strategies. The results showed that for CIU patients, 7%, 40 and 34% met the diagnostic criteria for no-PTSD, partial-PTSD and full-PTSD respectively whereas for allergy patients, 15%, 45 and 18% met the same criteria. Apart from CIU, psychiatric symptom severity differed significantly between diagnostic groups. PTSD was associated with coping strategies which were in turn associated with CIU severity and psychiatric symptom severity. PTSD was not significantly associated with personality. Emotion-focused coping mediated PTSD and CIU severity, PTSD and psychiatric symptom severity and neuroticism and CIU severity. To conclude, psychiatric symptom severity varies depending on the level of PTSD among CIU patients. Neurotic patients with a high level of PTSD from past trauma show raised CIU and psychiatric symptom severity when using emotion-focused coping strategies.

Posttraumatic stress disorder, emotional suppression and psychiatric co-morbidity in patients with chronic idiopathic urticaria: a moderated mediation analysis

BACKGROUND

There is evidence suggesting that posttraumatic stress disorder (PTSD) symptom severity and CIU severity are linked and partially mediated by the high-anxious defense mechanism. What is unclear is whether emotional suppression, as a defense serving the opposite purpose for high-anxious defense, can also act as a mediator and whether this mediational effect is partly influenced by time since trauma and trauma type.

AIMS

To investigate whether emotional suppression mediated the links between PTSD and CIU symptom severities, and PTSD and psychiatric co-morbid symptom severities. It then examined whether the mediating effect would be moderated by how long ago the trauma occurred and trauma type.

METHODS

One hundred CIU patients were compared with 60 allergy patients. They completed questionnaires measuring PTSD, psychiatric co-morbidity and emotional suppression.

RESULTS

Suppressing depression mediated the relationship between PTSD and psychiatric co-morbidity. How long ago the trauma occurred and trauma type moderated the mediational effect of suppressing depression.

CONCLUSIONS

Following a past trauma, CIU patients may develop PTSD symptoms which influence their psychological well-being through using different levels of emotional suppression, especially suppressing depression. The levels depend on the severity of PTSD symptoms, trauma history and whether they experienced interpersonal traumas.

Somatization in the dermatology patient: Some sociocultural perspectives

Somatization in dermatology patients is a challenge to diagnose and manage. Somatization presents as medically unexplained dermatologic symptoms, which are commonly encountered in dermatology and psychiatry practices. These cutaneous symptoms are often intriguing and do not fit into any particular known dermatologic condition. Sometimes, they may evoke negative feelings in the practicing dermatologist. The dermatologic somatic symptoms might be one way of communicating psychologic distress in a culturally acceptable method. These somatic symptoms may be masking another psychiatric disorder such as depression. They could also be an adaptive response to a difficult psychosocial situation and means of coping in a culturally meaningful way; therefore, the underlying conflicts need to be understood and managed in the sociocultural context of the symptoms. This chapter discusses the various unexplained physical symptoms in dermatology patients and the need for comprehensive evaluation.

Posttraumatic stress disorder (PTSD) and the dermatology patient

Dermatologic symptoms can be associated with posttraumatic stress disorder (PTSD) in several situations: (1) as features of some core PTSD symptoms, such as intrusion symptoms manifesting as cutaneous sensory flashbacks, as autonomic arousal manifesting as night sweats and idiopathic urticaria, and as dissociation manifesting as numbness and dermatitis artefacta; (2) the cutaneous psychosomatic effects of emotional and physical neglect and sexual abuse (eg, infantile eczema, cutaneous self-injury, and body-focused repetitive behaviors such as trichotillomania and skin picking disorder) and eating disorders, which can have dermatologic effects; (3) the direct effect of physical or sexual abuse or catastrophic life events (eg, earthquakes) on the skin; and (4) as a result of significant alterations in hypothalamic-pituitary-adrenal and sympatho-adrenal medullary axes, which can affect neuroendocrine and immune functions, and can lead to exacerbations of stress-reactive inflammatory dermatoses such as psoriasis, chronic urticaria, and atopic dermatitis. Elevated levels of inflammatory biomarkers and impaired epidermal barrier function have been reported in situations involving sustained psychologic stress and sleep deprivation. Some PTSD patients show hypothalamic-pituitary-adrenal axis hyporesponsiveness and higher circulating T lymphocytes, which can exacerbate immune-mediated dermatologic disorders. PTSD should be considered an underlying factor in the chronic, recurrent, or treatment-resistant stress-reactive dermatoses and in patients with self-induced dermatoses.

Dermatitis artifacta of tongue: A rare case report

Dermatitis artifacta is a psychiatric disorder in which the patient deliberately produces self-inflicted skin lesions to satisfy an unconscious psychological or emotional need, often a desire to receive medical treatment. We present a case of a 20-year-old female with pain in abdomen, pain during urination, and multiple skin lesions, mostly in the reach of her dominant hand and in tongue. She gave a history of several episodes of similar illnesses with admission in various hospitals. She was improved with selective serotonin reuptake inhibitor, supportive and insight-oriented psychotherapy.

A Long-Term Psychological Observation in an Adolescent Affected with Gardner Diamond Syndrome

Gardner-Diamond syndrome (GDS) is an uncommon disease clinically characterized by a wide spectrum of psycho-emotive symptoms associated with painful ecchymoses/purpuric lesions and positivity of auto-erythrocyte sensitization skin test. Herein, a perspective clinical and psychological observation of an adolescent GDS is firstly reported focusing on her psychological features long-term monitored for a 1-year period. The administration of a standardized tools battery allowed us to define psychological features of the young patient over time and to monitored clinical course and response to treatment.

Psychiatric Features in Neurotic Excoriation Patients: The Role of Childhood Trauma

INTRODUCTION

Neurotic excoriation is a psychodermatological disease of primary psychological/psychiatric genesis, responsible for self-induced dermatological disorders. Childhood traumatic events are closely related with self-injurious behaviors. The aim of this study is to evaluate the psychiatric features of neurotic excoriation and to investigate the effect of childhood traumatic events on the disease.

METHODS

Thirty-eight neurotic excoriation patients who did not receive any psychiatric treatment within the past year and 40 healthy individuals having similar sociodemographic features were included in the study. For clinical evaluation, the Structured Clinical Interview for DSM-IV Axis I Disorders, Beck Depression Inventory, Beck Anxiety Inventory, and Childhood Trauma Questionnaire-Short Form were applied to all the individuals.

RESULTS

In this study, we observed that 78.9% of neurotic excoriation patients were diagnosed with at least one Axis I psychiatric disorder, the most frequent diagnoses of which were major depressive disorders and anxiety disorders. The anxiety and depression levels were significantly higher in the patient group than in the healthy individuals. Regarding the Childhood Trauma Questionnaire, emotional neglect, emotional abuse, and physical abuse subscales and weighted average total scores were found to be significantly higher in the patient group (p<.05).

CONCLUSION

Our study has shown a close relationship between neurotic excoriation and childhood traumatic events as well as the accompanying psychiatric problems. We suppose that early interventions by both dermatologists and psychiatrists and especially a detailed investigation of childhood traumatic events by establishing a therapeutic collaboration are highly important and that using psychotherapeutic interventions can result in better treatment outcomes in many patients.

Gender differences in depression and anxiety among atopic dermatitis patients

Background:

Dermatological patients invariably suffer one or the other psychological problems which may escalate to the extent of a mental disorder. One of the most common dermatological disorders is atopic dermatitis (AD), but the literature has limited data on gender differences for psychiatric morbidity in such patients.

Aims:

To evaluate and compare gender differences in the prevalence of depression and anxiety in AD.

Materials and Methods:

This cross-sectional study with consecutive sampling was done in an outpatient clinic of Dermatology at a Tertiary Care Center. AD subjects giving informed consent were evaluated on a brief semi-structured performa for collecting demographic and clinical information. Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess the presence of psychiatric symptoms in these patients. Descriptive analysis was done for the socio-demographic profile and independent sample t-test, Chi-square and Cramer's V test was carried out to find in-between group differences for males and females.

Results:

A total of 81 patients were included in the final analysis (males = 36, females = 45) with no significant difference in mean age between male and female subjects (36.14 ± 17.62 and 33.98 ± 14.49 years, respectively; P = 0.54). When including moderate to severe grade of depression or anxiety, the current study found prevalence rates of 15% and 12% respectively. Females had significantly more anxiety and depression scores than males (P = 0.04 and P = 0.03 respectively).

Conclusions:

There is a female preponderance of depression and anxiety disorder in AD patients.

Psychodermatological aspects of atopic dermatitis

Psychodermatology is an evolving area of science that focuses on the interaction between the mind, skin and body. It is known that various neuroendocrine mediators - including adrenocorticotropin, β-endorphin, catecholamines and cortisol - are produced in response to stress. The resulting increase in endogenous glucocorticoids can disrupt the skin's barrier function, leaving it vulnerable to inflammatory disorders like atopic dermatitis (AD). In turn, AD is associated with high levels of stigmatization, social withdrawal, anxiety and depression among patients and their carers. It is well known that the stress caused by AD can make the symptoms of the disease worse. Therefore, the goal of psychodermatological treatment is not only to improve the condition of the skin, but also to teach patients/carers how to cope with the disease. This requires a multifaceted approach, and time and patience, to ascertain the needs of individual patients. A multidisciplinary team that includes a dermatologist, psychiatrist and psychologist will be necessary to deliver high-quality, tailored care to patients.

Managing the patient with psychiatric issues in dermatologic practice

Patients often communicate emotions through their bodies and physical symptoms; the skin commonly serves as a means of expression in the patient-doctor relationship. It is important for the dermatologist to be able to indentify psychological issues that manifest in the skin and the interplay between psychiatric and dermatologic conditions. Delusional parasitosis, dermatitis artefacta, trichotillomania, and somatoform disorders all represent dermatologic conditions with underlying emotional causes. Many chronic dermatoses, such as psoriasis, atopic dermatitis, and acne, modulate and are influenced by psychosocial factors. Special issues, including significant medication interactions and the treatment of the "difficult" patient, are reviewed.

Cognitive behavioral therapy for PTSD and somatization: an open trial

No treatment, to date, has been developed to improve both posttraumatic stress disorder (PTSD) and medically unexplained physical symptoms (MUPS), despite mounting evidence of high comorbidity between PTSD and MUPS. This study assessed the feasibility, acceptability, and treatment outcomes of an adapted cognitive behavioral therapy for PTSD and abridged somatization in a sample of eight participants. Fifteen percent of completers did not meet PTSD criteria after treatment completion and 62.5% improved their somatic symptoms. There was a significant difference between pre- and post-treatment depression symptoms, as well as in psychological and physical functioning measures. Results indicated a small to moderate effect size (d = 0.27-0.78) in PTSD severity scores, and moderate to large effect size in depression symptoms and psychosocial and physical functioning variables (d = 0.39-1.12). Preliminary evidence of acceptability indicates that the current CBT intervention may be suitable for Latinos individuals with PTSD and MUPS.

Review of somatic symptoms in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.

Psychodermatological disorders: recognition and treatment

Many dermatological disorders have a psychosomatic or behavioral aspect. Skin and brain continually interact through psychoneuroimmunoendocrine mechanisms and through behaviors that can strongly affect the initiation or flaring of skin disorders. It is important to consider these mind-body interactions when planning treatments for specific skin disorders in individual patients. Mind-influencing therapeutic options that can enhance treatment of skin disorders include standard psychotropic drugs, alternative herbs and supplements, the placebo effect, suggestion, cognitive-behavioral methods, biofeedback, and hypnosis. When individual measures do not produce the desired results, combinations of drugs or addition of non-drug therapies may be more successful. Psychophysiological skin disorders may respond well to non-drug and drug therapies that counteract stress. Treatment of primary psychiatric disorders often results in improvement of associated skin disorders. Psychiatric disorders secondary to skin disorders may also require treatment. Therapeutic options for each of these are discussed.

Dialogue for air, air for dialogue: towards shared responsibilities in COPD practice

For the past several years patients have been expected to play a key role in their recovery. Self management and disease management have reached a hype status. Considering these recent trends what does this mean for the division of responsibilities between doctors and patients? What kind of role should healthcare providers play? With findings based on a qualitative research project of an innovative practice for people with Chronic Obstructive Pulmonary Disease (COPD) we reflect on these questions. In-depth interviews conducted with people with COPD, physiotherapists and a pulmonologist show that shifting responsibilities require a supportive attitude from healthcare providers and a dialogical communication between patients and professionals. Our findings show more is needed in order to motivate people with COPD to take responsibility and become co-owners in a process of recovery. The case example illustrates that people with COPD need support from fellow patients to learn to accept their disabilities. Awareness that COPD is more than just a lack of air, that mind and body interact, is a first step to investigate other potential problems and to enhance one's quality of life.

Coherence between emotional experience and physiology: does body awareness training have an impact?

Two fundamental issues in emotion theory and research concern: (a) the role of emotion in promoting response coherence across different emotion systems; and (b) the role of awareness of bodily sensations in the experience of emotion. The present study poses a question bridging the two domains; namely, whether training in Vipassana meditation or dance, both of which promote attention to certain kinds of bodily sensations, is associated with greater coherence between the subjective and physiological aspects of emotion. We used lag correlations to examine second-by-second coherence between subjective emotional experience and heart period within individuals across four different films. Participants were either: (a) experienced Vipassana meditators (attention to visceral sensations), (b) experienced dancers (attention to somatic sensations), and (c) controls with no meditation or dance experience. Results indicated a linear relationship in coherence, with meditators having highest levels, dancers having intermediary levels, and controls having lowest levels. We conclude that the coherence between subjective and cardiac aspects of emotion is greater in those who have specialized training that promotes greater body awareness.

Somatization: the under-recognized factor in nonspecific eczema. The Hordaland Health Study (HUSK)

BACKGROUND

Psychodermatology has focused primarily on depression and anxiety in eczema. Skin symptoms are listed among many others for the ICD-10 diagnosis of somatization disorder. Somatization (unexplained somatic symptoms) is highly prevalent in the general population, but its association with eczema is yet to be empirically investigated.

OBJECTIVES

We therefore explored the association between somatization and eczema by examining the extent of somatization in eczema compared with allergic rhinitis, and by examining if eczema was more strongly associated with somatization than with anxiety and depression. Finally, we aimed to examine the relationship between the site of eczema and somatization for individual somatic symptoms and for somatic symptoms as a whole.

METHODS

For this population-based cross-sectional study we employed data from the Hordaland Health Study (HUSK) with 15,225 participants aged 41-48 years. Information on nonspecific eczema, allergic rhinitis, somatization, anxiety, depression and other covariates was obtained by self-report.

RESULTS

The association between nonspecific eczema and somatization was strong and followed a dose-response pattern, as did all somatic symptoms in our index of somatization when analysed separately. The association between nonspecific eczema and somatization was stronger than that between rhinitis and somatization, and also the association between nonspecific eczema and anxiety and depression. In multivariate models, somatization accounted for most of the association between nonspecific eczema and anxiety/depression. In contrast, the association between nonspecific eczema and somatization was robust for adjustment for anxiety/depression.

CONCLUSIONS

Somatization was strongly associated with nonspecific eczema. This applies to a whole range of somatic symptoms constituting the construct of somatization. There is hardly any mention of somatization in leading dermatological journals, in contrast to anxiety and depression which are frequently reported in eczema. We speculate that this under-recognition of somatization in the dermatological literature may correspond to under-recognition of this factor also in clinical practice.

Factors accounting for the association between anxiety and depression, and eczema: the Hordaland health study (HUSK)

Background

The association between anxiety and depression, and eczema is well known in the literature, but factors underlying this association remain unclear. Low levels of omega-3 fatty acids and female gender have been found to be associated with both depression and eczema. Somatization and health anxiety are known to be associated with anxiety and depression, further, somatization symptoms and health anxiety have also been found in several dermatological conditions. Accordingly, omega-3 fatty acid supplement, female gender, somatization and health anxiety are possible contributing factors in the association between anxiety and depression, and eczema. The aim of the study is to examine the relevance of proposed contributing factors for the association between anxiety and depression, and eczema, including, omega-3 fatty acid supplement, female gender, health anxiety and somatization.

Methods

Anxiety and depression was measured in the general population (n = 15715) employing the Hospital Anxiety and Depression Scale (HADS). Information on eczema, female gender, omega-3 fatty acid supplement, health anxiety and somatization was obtained by self-report.

Results

Somatization and health anxiety accounted for more than half of the association between anxiety/depression, and eczema, while the other factors examined were of minor relevance for the association of interest.

Conclusions

We found no support for female gender and omega-3 fatty acid supplement as contributing factors in the association between anxiety/depression, and eczema. Somatization and health anxiety accounted for about half of the association between anxiety/depression, and eczema, somatization contributed most. The association between anxiety/depression, and eczema was insignificant after adjustment for somatization and health anxiety. Biological mechanisms underlying the mediating effect of somatization are yet to be revealed.

Psychological interventions in the management of common skin conditions

The nervous system and the skin develop next to each other in the embryo and remain intimately interconnected and interactive throughout life. The nervous system can influence skin conditions through psychoneuroimmunoendocrine mechanisms and through behaviors. Understanding the pathophysiology aids in selection of treatment plans for correcting the negative effects of the psyche on specific skin conditions. Medication options include standard psychotropic medications and alternative herbs and supplements. Other options include biofeedback, cognitive-behavioral methods, hypnosis, meditation, progressive relaxation, the placebo effect, and suggestion. When simple measures fail, combining medications with other therapeutic options may produce better results. Skin conditions that have strong psychophysiologic aspects may respond well to techniques such as biofeedback, cognitive-behavioral methods, hypnosis, meditation, or progressive relaxation that help to counteract stress. Treatment of primary psychiatric disorders that negatively influence skin conditions often results in improvement of those skin conditions. Abnormal conditions of the skin, hair, and nails can also influence the psyche negatively. Treatment of secondary psychiatric disorders such as anxiety or depression that are triggered or exacerbated by the appearance of these skin conditions or the associated discomfort may also be required.

The relationship between posttraumatic stress disorder, psychiatric comorbidity, and personality traits among patients with chronic idiopathic urticaria

BACKGROUND

Several studies have highlighted the link between posttraumatic stress disorder (PTSD) and physical illnesses. No empirical studies, however, have investigated the relationship between PTSD and chronic idiopathic urticaria (CIU). The role of personality traits in this relationship was also unknown.

OBJECTIVES

This study aimed to investigate (1) the extent to which patients with CIU fulfilled the PTSD diagnosis resulting from past traumas and (2) whether they developed psychiatric comorbidity, and (3) the relationship between CIU patients' personality traits, PTSD diagnosis, severity of CIU, and psychiatric comorbidity.

METHODS

One hundred patients with CIU and 60 patients with allergy (control) participated in the study. Patients' CIU severity was assessed. Both groups completed the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire-28, the Social Readjustment Rating Scale, the Perceived Stress Scale, and the NEO-Five Factor Inventory.

RESULTS

Thirty-four percent of patients with CIU and 18% of allergy patients met the diagnostic criteria for PTSD. Patients with CIU were 1.89 times more likely to have a current diagnosis of PTSD than the control group. Controlling for life event stress and perceived stress, significant differences were found between groups (CIU PTSD, CIU no PTSD, allergy PTSD, allergy no PTSD) in somatic problems, anxiety, and social dysfunction. Controlling for life event stress and perceived stress, regression analyses showed no significant associations between personality traits, PTSD diagnosis, and the severity of CIU. Posttraumatic stress disorder diagnosis and neuroticism were, however, associated with psychiatric comorbidity.

CONCLUSIONS

Patients with CIU have been shown to have concurrent PTSD resulting from past traumas and developed psychiatric comorbidity. Chronic idiopathic urticaria patients' comorbidity was related to the patients' PTSD diagnosis and their neurotic personality trait.

Skin and psyche--from the surface to the depth of the inner world

About 30% of dermatology patients have signs or symptoms of psychological problems. Dermatologists should be familiar with the basics needed to identify, advise and treat these patients. Because of the complex interaction between skin and psyche, it is difficult to distinguish whether the primary problem is the skin or the psyche. Sometimes the clinical picture is a consequence of interactions between them and other factors. The interactions between skin and psyche are well known in history, art and literature--perhaps better known today because the marked emphasis on such images in our modern multimedia society. Aging is increasingly perceived as an illness and not as a physiological process. Through globalization, many different cultural approaches to the skin have entered in our daily life and influence our communication. This article considers the most important dermatoses which often show primary or secondary interaction with the psyche.

Stigma towards people with mental illness in developing countries in Asia

BACKGROUND

There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.

METHOD

Medline search focusing on English-speaking literature.

RESULTS

Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.

CONCLUSION

This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.

The stigma of mental illness: anticipation and attitudes among patients with epileptic, dissociative or somatoform pain disorder

The aim of this study was to survey the attitudes of 101 consecutive in- and out-patients with epileptic, dissociative or somatoform pain disorders (mean age: 43 [+/-11] years; 58% female) from either the Department of Psychiatry or Neurology toward anticipated mental illness stigma. The patients were administered a modified 12-item version of Links Stigma Questionnaire. Nearly 60% of all 101 patients believe that "most people" would not allow a mental patient "to take care of their children", "most young women" would be "reluctant to date a man" who has been treated for a mental illness and "most employers would pass over" the application of a psychiatric patient in favour of another applicant. Fifty five percent of the respondents assume that "most people think less of a person who has been in a mental hospital" and over a half of all patients interviewed assert that the general population thinks that psychiatric patients are "less intelligent, less trustworthy and that their opinion is taken less seriously by others". Gender, age and education had no influence on the overall results. There is a high stigmatisation concerning psychiatry even in patients with epilepsy and somatoform/dissociative symptoms with psychiatric comorbidity. Fear of being stigmatized is more pronounced among somatoform pain patients as compared to patients suffering from epileptic or dissocative disorders, with particular reference to close personal relationships.