Indian Journal of Dermatology
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SYMPOSIUM
Year : 2013  |  Volume : 58  |  Issue : 1  |  Page : 53-55
Our experience in a psychodermatology liaison clinic at Manipal, India


Department of Dermatology, Kasturba Medical College, Manipal, India

Date of Web Publication31-Dec-2012

Correspondence Address:
Shrutakirthi D Shenoi
Department of Dermatology, Kasturba Medical College, Manipal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.105310

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   Abstract 

Psychodermatology is an emerging specialty in dermatology which deals with the interactions between mind and skin. Psychocutaneous diseases can be either primary psychiatric or primary cutaneous, with various degrees of associations between psyche and skin. Unless the dermatologist cultivates a special interest in this field, many an invisible mental disorder may be missed leading to sub optimal treatment of the visible skin condition. Though Dermatology Psychiatry liaison clinics are common in Europe and other western countries, it is just an emerging concept in India.Here we describe the working pattern of psychodermatology liaison clinic established in Manipal in August 2010 and describe briefly the type of cases attended to.


Keywords: Co-morbidity, neuro-immuno-cutaneous-endocrine, psychodermatology


How to cite this article:
Shenoi SD, Prabhu S, Nirmal B, Petrolwala S. Our experience in a psychodermatology liaison clinic at Manipal, India. Indian J Dermatol 2013;58:53-5

How to cite this URL:
Shenoi SD, Prabhu S, Nirmal B, Petrolwala S. Our experience in a psychodermatology liaison clinic at Manipal, India. Indian J Dermatol [serial online] 2013 [cited 2019 Oct 22];58:53-5. Available from: http://www.e-ijd.org/text.asp?2013/58/1/53/105310



   Introduction Top


Psychodermatology is subspecialty of dermatology which studies the interactions between mind and skin. [1] Psychocutaneous diseases can present either as primary psychiatric diseases such as dermatitis artefacta and delusions of parasitosis or as secondary psychiatric conditions such as depression, anxiety or social phobia due to chronic dermatoses like psoriasis, atopic dermatitis, alopecia areata. While in the former group, the diagnosis is usually straight forward, in the latter group such as psoriasis, atopic dermatitis etc the associated psychiatric co-morbidity may be missed or overlooked. Unless the dermatologist has a special interest in mental health, in a busy practice, the relevant history is not sought. It is imperative to treat the 'invisible' mental disease in addition to the 'visible' skin disease.In chronic skin diseases, patients feel stigmatized especially when lesions are widespread and may also experience depression.Even in clinical remission, some may have anxiety about possible relapse in future.

The brain and skin have a common ectodermal origin. The relationship between mind and skin can be understood on the basis of the neuro-immuno-cutaneous-endocrine network. [2],[3] The bidirectional brain and skin influences are mediated by neurotransmitters, hormones and neuropeptides. Stress plays an important role in triggering as well as aggravating certain dermatoses. [4] Nearly 30% of dermatology patients have associated psychiatric co-morbidity. [5]

The dermatology - psychiatry liaison concept originated in Europe and slowly spread to the West. There is a dedicated European Society of Dermatology and Psychiatry that holds a congress biennially. The association for Psychocutaneous Medicine of North American too holds regular meetings. In India, this subject has received scantattention. Case reports and few studies appear from time to time. Whilst dermatologists refer cases to psychiatrists, a dedicated liaison clinic is virtually unknown.

We discuss the working pattern of the dermatology-psychiatry-clinical psychology liaison clinic set up at Manipal in August 2010.


   Materials and Methods Top


The period of study was from August 2010 to January 2012. Patients with chronic dermatoses such as psoriasis, eczema as well as those with primary psychiatric conditions were recruited by the dermatologist from the general dermatology out patients and referred to the liaison clinic which functions once weekly from 2:30 to 5:00 pm. Cases were evaluated independently by the three specialists. The psychologist counseled all patients and if stressors were elicited, coping strategies were taught. The psychiatrist after evaluation determined the need for psychopharmacotherapy. Both specialists discussed the case with the dermatologist and standard dermatologic treatment with or without psychopharmacologic agents and/or psychological interventions were advised. All patients were followed up at regular intervals. Psychological interventions were carried out in the clinical psychology department.

We examined 175 cases (117 females; 58 males) aged between 10 and 75 years maximum being in the second and third decade. Out of 175, primary dermatological cases constituted 154 (88%) [Table 1] and primary psychiatric 21 (12%) [Table 2]. The leading primary dermatosis was psoriasis in 40 (23%) while the leading primary psychiatric disease was neurotic excoriations in 6 (3%) patients. Thirty percent had stressors at the onset of the disease. Out of 92 (53%) who needed psychologic interventions, only 25 (27%) underwent the same. 12 patients (48%) underwent one session while only 3 (12%) had more than five sessions. [Table 3] shows the various psychological techniques that were carried out. Forty seven patients (30%) with primary dermatosis had an associated psychiatric diagnosis [Table 4] the most common being dysthymia in 22 (46%). The three leading dermatoses with psychiatric co-morbidity were psoriasis, prurigo/generalized pruritus and chronic dermatitis. Most of the patients were followed up at regular intervals.
Table 1: Primary dermatologic cases


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Table 2: Primary dermatologic cases

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Table 3: Psychological techniques taught


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Table 4: Psychiatric diagnosis in primary dermatological conditions

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   Discussion Top


The need of a liaison psychodermatology clinic has been well established. [6],[7] A major advantage of a combined clinic is the prompt availability of a psychiatrist, dermatologist and a clinical psychologist at a single visit. Quite often patients express displeasure when a psychiatric referral is made. The stigma of visiting the psychiatry department although has lessened in recent time, stillexists. Our clinic functions in an informal manner without any inhibitions for patients about meeting a mental health professional as there are no boards mentioning the designations of the liaison specialists. The number of patients examined cannot exceed four or five as detailed interviews are carried out.

A level-one dermatologist is a well - informed specialist who can treat psychocutaneous diseases but does not bring about psychological change in the patient while a level - two dermatologist is one who liaises with a clinical psychologist or psychiatrist bringing about psychological changes. [8] By liaisoning, patient can be treated in a holistic fashion thereby addressing both the psychological and the physical needs.

In our study more than one-fourth of patients had stressors.Although stress has been implicated in several dermatoses, psoriasis is the one which is mostly associated with. [9] Stress induced derangements of epidermal function may precipitate inflammatory dermatoses. [10] Nonpharmacologic interventions are stress -reducing adjuncts that can enhance the efficacy of standard dermatogic therapies. [11] Some of the therapies useful in dermatologic patients are biofeedback, relaxation training, hypnosis and psycho-education.

In our study majority of patients were non-compliant with psychological interventions. Probably they did not realize the benefit or were not keen on attending the clinical psychology department. This underscores the need for dermatologists to master selected psychological techniques such as relaxation which can easily be taught to patients in the office. 30% of our patients had psychiatric comorbidity which is in agreement with several studies in psychodermatology.

In conclusion, dermatologist should liaise with psychiatrists or clinical psychologists when managing psychosomatic dermatoses. In university teaching hospitals, l liaison psychodermatology clinics should function on a regular basis. Although monetarily not lucrative, it is satisfying as it offers integrative patient care. Dermatologists should familiarize with selected psychopharmacological drugs and simple nonpharmacologic interventions.Screening for common psychiatric conditions such as anxiety and depression should be objectively done using standard questionnaires. Improving the quality of life is the ultimate purpose of a liaison clinic.


   Acknowledgement Top


Dr. PSVN Sharma, Head of the Department of Psychiatry, KMC, Manipal and Mr. Dinesh N, In-Charge of Department of Clinical Psychology, for their encouragement and support.

 
   References Top

1.Koo J, Lebwohl A. Psychodermatology. The mind and skin connection. Am Fam Physician 2001;64:1873-8.  Back to cited text no. 1
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2.Brazzini B, Ghersetich I, Hercogova J, Lotti T. The neuro-immuno-cutaneous-endocrine network: Relationship between mind and skin. Dermatol Ther 2003;16:123-31.  Back to cited text no. 2
[PUBMED]    
3.O'Sullivan RL, Lipper G, Lerner EA. The neuro-immuno-cutaneous-endocrine network: Relationship of mind and skin.Arch Dermatol 1998;134:1431-5.  Back to cited text no. 3
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4.Kimyai-Asadi A, Usman A. The role of psychological stress in skin disease. J Cut Med Surg 2001;5:140-5.  Back to cited text no. 4
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5.Gupta MA, Gupta AK, Ellis CN, Koblenzer CS. Psychiatric evaluation of the dermatology patient. Dermatol Clin 2005;23:591-9.  Back to cited text no. 5
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6.Orion E, Feldman B, Ronni W, Orit B. A psychodermatology clinic: The concept, the format and our observations from Israel.Am J Clin Dermatol 2012;13:97-101.  Back to cited text no. 6
    
7.Fritzsche K, Ott J, Zsehocke I, Scheib P, Burger T, Augustin M. Pyschosomatic liaison service in dermatology. Dermatology 2001;203:27-31.  Back to cited text no. 7
    
8.Poot F, Sampogna F, Omnis L. Basic knowledge in psychodermatology. J Eur Acad Dermatol Venereol 2007;21:227-34.  Back to cited text no. 8
    
9.AlAbadie MS, Kent GG, Gawkrodger GJ. The relationship between stress and the onset and exacerbation of psoriasis and other skin conditions. Br J Dermatol 1994;130:199-203.  Back to cited text no. 9
    
10.Garg A, Chren M, Sands LP, Matsui MS, Marenus KD, Feingold KR, et al. Psychological stress perturbs epidermal permeability barrier homeostasis. Arch Dermatol 2001;137:53-9.  Back to cited text no. 10
    
11.Fried RG. Nonpharmacologic treatments in psychodermatology. Dermatol Clin 2002;20:177-85.  Back to cited text no. 11
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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    Materials and Me...
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