Understanding the Psychiatric Premise Behind Psychocutaneous Disorders

In a literature review of psychotherapeutic treatment of psychocutaneous disorders, researchers found that the majority of psychocutaneous disorders can be categorized under 3 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) disorders, which are depressive disorders, anxiety disorders, and obsessive-compulsive related disorders.¹

Psychocutaneous disorders affect the mind and the skin simultaneously, and 30 percent of patients with a dermatologic disorder present with a psychiatric comorbidity. Zagami et al hoped to share common points and bring light to those areas where dermatology and psychiatry merge.

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Dermatologic Disorders with Psychiatric Manifestations

Many skin diseases create psychological disorders for patients. Acne vulgaris and alopecia areata present with obvious physical signs but can be caused by depressive and anxiety disorders, attention deficit/hyperactivity disorder, and in the case of acne, substance use disorder. Recommended therapies to address the psychiatric condition include yoga, meditation, journaling, and aerobic exercise. Pharmacologic treatments for comorbid depression and anxiety include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), atypical antidepressants, and anxiolytics.

One treatment approach for acne is to take baseline photographs and at periodic intervals show the patient how their condition has improved. As patients with acne are often adolescents and nonadherent, this could require agreements with the patient to be compliant. For alopecia areata, mindfulness therapy for stress reduction could help ease patient concerns during administration of pharmacologic therapies.

Other diseases such as atopic dermatitis (AD), psoriasis, hyperhidrosis, seborrheic dermatitis, and rosacea can also have underlying psychiatric conditions including anxiety and depressive disorders, mood disorders, and in the case of psoriasis, personality disorders.

Patients with AD often exhibit anxiety and depression, which can increase itch perception and cause scratching. Psychotherapy including brief dynamic or cognitive behavioral therapy (CBT) along with meditation, yoga, and relaxation techniques can be used in addition to psychotropic drugs such as TCAs, bupropion, naltrexone, SSRIs, and anxiolytics to treat AD. Patient education about AD is also critical so patients understand the proper use of moisturizers and the need to avoid irritants.

For all these conditions, non-pharmacologic therapies such as meditation, yoga, and journaling, and in some cases biofeedback and aerobic exercise, can also benefit the patient.

Psychiatric Disorders with Dermatologic Manifestations

In patients with body dysmorphic disorder (BDD), the patient imagines or magnifies imperfections that others do not see or that are insignificant. In the dermatologist’s office this can present as a focus on fine lines or wrinkles that are imperceptible. BDD is classified as an obsessive-compulsive and related disorder in the DSM-5. Medical and surgical procedures are almost always unsuccessful in these cases. Psychotropic drugs or antidepressants may be helpful, as well as psychotherapy. A possible treatment approach for a patient complaining of imperceptible lines is for the dermatology clinician to show photos of people with obvious wrinkles so a comparison can be made.

Anorexia nervosa and bulimia nervosa are eating disorders that can create skin manifestations, including asteatotic skin and follicular hyperkeratosis, carotenoderma, hyperpigmentation, acrocyanosis and perniosis, acne, and pruritus. More than half of the patients with eating disorders have a history of depression. Obsessive-compulsive disorders (OCD), social phobia, anxiety disorders, and substance use disorders are other associated psychiatric disorders.

“Psychotherapy is the key to successful treatment of an eating disorder. The goals of psychotherapy include reduction of distorted body image and dysfunctional eating habits, return to social engagement, and resumption of full physical activities.” Medications may also be helpful in treating eating disorders but should be used in conjunction with psychotherapy.

Patients with delusions of parasitosis imagine they have an infestation of a parasite and pick at the skin to remove the parasite or calm the area. Common psychiatric comorbidities include anxiety disorders, OCD, personality disorders, substance abuse disorders, and eating disorders.

Once an infestation has been ruled out, other possible medical explanations such as hypothyroidism, neuropathy, or drug abuse can be explored. If no parasites are found on microscopy, the patient should be “educated that the brain may be interpreting sensory information as infestation, however, these symptoms can be treated with medication. The patient should never be misinformed that psychotropic medications can treat the parasite.”

In the condition trichotillomania, patients pull hair on the scalp, eyebrows, eyelashes, beard, trunk, or pubic area, with the scalp being the most common area affected. Trichotillomania is classified as an obsessive-compulsive related disorder. Topical steroids may be effective, and covering the hands with gloves or socks or cutting hair close to the scalp may help. Behavioral treatments such as biofeedback, self-monitoring, CBT, and hypnotherapy may be successful treatments.

Zagami et al concluded that the “information that was gleaned from the review of the literature helps both the dermatologist and the mental health professional understand what core issues must be addressed for resolution of the presenting problem.”

Reference

1. Zagami M, Klepper E, Wienecke E, Andrzejewski M, Sikder A, Ahmed A, et al. A review of psychocutaneous disorders from a psychotherapeutic perspective—toolkit for the dermatologist. Skin Health Dis.  2023;3(4):e211. https://doi.org/10.1002/ski2.211