Early recognition and treatment of psychological diseases associated with dermatologic disorders can lead to improved therapeutic outcomes; otherwise, they can affect disease course 1. Psychiatric comorbidity in patients with dermatological conditions ranges between 25 and 43% 2. These include depression (30%) 3, social phobia (anxiety) 4, suicidal ideation (8.6%) 5, and obsessive–compulsive disorders (OCDs) 6.
Depression can have varied presentations and is more relevant clinically in dermatology patients during critical psychosocial periods of development 5. Social phobia (anxiety) is characterized by a marked or persistent fear of one or more social or performance situations in which embarrassment may occur 4. Suicidal ideation and increased suicide risk in patients with skin diseases raise concerns about deliberate self-harm in dermatological patients. Dermatologists may play an important role in recognizing suicidal ideation and preventing fatal self-harm in their patients 5.
OCD is characterized by recurrent obsessions or compulsions severe enough to be time-consuming or cause marked distress or significant impairment. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety and distress to the patient 4. Compulsions are repetitive behaviors or mental acts, such as counting. Obsessive–compulsive behaviors encountered in dermatology include fears of contamination and excessive hand washing, excessive grooming, hair plucking, trichotillomania, onychophagia, picking of a minor irregularity in the skin or lesions on the skin, and repetitive bathing.
Sleep disruption in dermatologic disorders can significantly affect the quality of life and mental health of the patient and, in some situations, may even lead to exacerbations of the dermatologic condition 7. A dermatologist, in addition to being sensitive to the psychological significance of the skin, also pays attention to the significance of human sexuality 8.
Therefore, the present study was carried out to present an analysis of psychiatric comorbidities associated with chronic dermatologic diseases among a group of Egyptian patients in three of the highest patients flow of dermatology outpatient clinics in Cairo. Sexual problems were also identified in the patients studied.
Patients and methods
The study was carried out on 1042 patients with different chronic dermatologic diseases, that is, those with dermatological disease for 6 months or more.
This is a hospital-based cross-sectional study.
All patients were examined clinically and their dermatologic diseases were diagnosed by a resident and confirmed by an assistant lecturer in the clinic and considered a chronic disease if it lasted more than 6 months and 6 weeks in case of chronic urticaria 9. A psychiatric evaluation was carried out using The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) 10 and their disease was diagnosed and confirmed by a psychiatric professor (Table 1).
The patients were recruited from the outpatient clinics of three major referral hospitals working daily in Cairo, Egypt, that serve all patient classes on 2 consecutive days for each hospital: in Al-Haud Al-Marsoud Hospital, 422 patients were recruited on Saturday and Sunday each week, in Al-Husain Al-Azhar University Hospital, 320 patients were recruited on Monday and Tuesday each week, and in Bab Al-Shariah Al-Azhar University Hospital, 300 patients were recruited on Wednesday and Thursday each week. The study was carried out over a time period from October 2014 to May 2015. We recruited all patients, male and female, within the age group of 17–60 years with a chronic dermatologic disease for more than 6 months; a total of 1042 patients were recruited within this period.
Patients with primary psychiatric disorders with secondary dermatological manifestations, such as delusions of parasitosis, body dysmorphic disorder, and olfactory reference syndrome, in addition to patients with systemic chronic diseases such as diabetes, liver and renal diseases, or with systemic treatment such as corticosteroid or isotretinoin were excluded.
All patients in the study were subjected to the following.
- Informed consent: A detailed explanation of the study and its aim was provided and the patient was asked to sign a written consent.
- Full history taking and clinical assessment of the dermatological condition.
- The study was approved by the Research Ethics Committee of the Faculty of Medicine, Al-Azhar University.
- Psychiatric evaluation of patients with different dermatologic diseases according to the DSM-5 10.
Data were analyzed using the statistical program for social science, version 18.0 (SPSS Inc., Illinois, Chicago, USA). Qualitative data were expressed as frequency and percentage. The χ2-test of significance was used to compare proportions between two qualitative parameters. A P-value less than 0.05 was considered significant.
The study included 1042 patients, 538 (51.63%) males and 504 (48.37%) females, with chronic dermatologic diseases (Table 2). prevalence of psychiatric illnesses in all studied patients are mentioned in Table 3. In psoriasis, depression (42.33%) and sexual problems (40%) were the most common psychiatric problems (Table 4). Female patients with psoriasis showed a significant increase in suicidal ideation (P=0.009), suicidal attempts (P=0.016), and sexual problems compared with male patients (P=0.002) (Table 5). In patients with acne, anxiety (55.34%) was the most common psychiatric problem (Table 6). However, no significant relation was found between psychiatric illnesses and sex in patients with acne (Table 7). In alopecia areata, depression (55.29%), followed by suicide ideation (38.46%) were the most common psychiatric problems (Table 8). There was a significantly higher prevalence of sexual problems in females compared with males (P=0.007) (Table 9). In vitiligo, the most common psychiatric problems were sexual problems (48.15%), depression (46.3%), and anxiety (31.48%) (Table 10), with a significantly increased prevalence in females than males of depression (P=0.043), anxiety (P=0.033), and sexual problems (P=0.048) (Table 11). In atopic dermatitis, sleep disorders (51.82%), anxiety (43.64%), and depression (35.45%) were the most common psychiatric problems (Table 12), with no significant relation with sex (Table 13). In chronic urticaria, sleep disorders (51.82%), anxiety (43.46%), and depression (35.45%) were the most common psychiatric problems (Table 14), with no significant relation with sex (Table 15).
The skin reflect the body image and healthy skin is loved to be seen by every person. Any disfiguring skin disease can affect a patient’s quality of life. Therefore, early diagnosis and management of any skin disease and the accompanying psychiatric illness decrease this drawback 11.
In the current study, we focused on chronic dermatological conditions. The patients were assessed by DSM-5 10, which is the standard classification of mental disorders used by mental health professionals in the USA and contains a list of diagnostic criteria for every psychiatric disorder. It is also a simple tool for collecting and communicating accurate public health statistics about the diagnosis of psychiatric disorders.
The study was carried out on 1042 patients with psoriasis, acne, alopecia areata, vitiligo, atopic dermatitis, and chronic urticaria. Overall, 59.98% of these patients had one or more psychiatric illnesses: depression in 39.25%, anxiety in 34.36%, suicidal ideation in 19.48%, suicidal attempts in 2.98%, sleep disorders in 18.62%, OCD in 4.61%, and sexual problems in 26.49%. These prevalences are higher than those reported in the study by Seyhan et al.2, which found overall psychiatric diseases, associated with chronic dermatological conditions, ranged between 25–43%; depression in 30% and suicidal ideation in 8.6%.
Three hundred patients had psoriasis. These patients had a wide variety of psychiatric diseases: depression in 42.33%, with females affected more than males, but not significantly, and anxiety in 24.33%, with both sexes equally affected, which is not in agreement with the results reported by Dowlatshahi et al.12. The latter reported that only 19% of patients had depression. In the current study, 10% of patients reported that they wished they were dead, whereas only 4.33% had actually attempted suicide at some point during the course of their illness. This is consistent with Gupta et al.13, who reported that 9.7% of patients wished they were dead and 5.5% had active suicidal ideation. Sleep disorders were found in 22% of patients, with both sexes affected equally, whereas OCD was found in only 2.67 and 40% had sexual problems.
Among the 206 patients with acne, anxiety was the most common psychiatric comorbidity (55.34%), with both sexes affected equally. Meanwhile, depression was less common (18.93%), which is not in agreement with Yazici et al.14, who reported that depression was more common than anxiety, 29.5 and 26.2%, respectively. In the current study, only 11.65% of patients had suicidal ideations, whereas 2.43% had actually attempt suicide. Females are at high risk of both suicidal ideation and attempt. However, Picardi et al.6 reported suicidal ideation in 5.6% and death wish in 8.3% of patients. Sleep disruption only affected 1.94% of patients, similar to the result of Tasoula et al.15, who reported no effect on sleep. No significant difference was found in sexual problems between males and females in the current study. Meanwhile, OCD was found in 3.88% of our patients.
In the 208 patients with alopecia areata with different severity and lasting more than 6 months, the highest association was found with a variety of psychiatric comorbidities. Depression was found in 55.29% of patients, affecting both sexes almost equally, and anxiety was found in 19.71% of patients. However, Fried et al.5 reported depression in 8.8% of patients, generalized anxiety disorder in 18.2% of patients, and suicidal ideation in 38.46% of the patients, whereas 4.33% actually attempted suicide, but Gupta and Gupta 16 found that alopecia areata is accompanied by increased rates of suicidal ideation in about 45% of patients, with a low percentage of actual suicidal attempts. Sleep disruption occurred in only 2.4% of patients, whereas OCD occurred in 2.88% of the alopecia areata patients; 20.19% of our patients have difficulties in their sexual life which is more distressing in female patients.
Among 108 patients with vitiligo, the results of the DSM-5 showed a variety of psychiatric associations with vitiligo. Depression was prevalent in 46.30% of patients, affecting females more than males, and anxiety in 31.48% of patients, with females affected two-fold more than males. However, Mattoo et al.17 reported that 29% of patients had depressive disorders 18. In this study, suicidal ideation was found in 25% of patients and 3.7% of these patients had attempted suicide. Sleep disorders were found in 4.63% of our patients, OCD in 18.52%, and 48.15% of vitiligo patients suffered from sexual problems in which females were more complaining than males.
In this study, 110 patients had atopic dermatitis; 43.64% had anxiety and 35.45% had depressive symptoms. Females were affected more than males. Hashiro and Okumura 19 reported that patients with atopic dermatitis are significantly more depressed and scored higher for state anxiety than the normal control group. 19.09% of atopic patients had suicidal ideation and some had suicidal attempt. Gupta and Gupta 16 found suicidal ideation in 2.1% of patients. 51.82% of patients in this study had sleep disorders, 2.73% had OCD, and 21.82% had negative impact on the sexual life, females seem to be more affected.
Urpe et al.20 studied patients with atopic dermatitis and reported that psychological factors, such as perceptions of shame, depression, self-confidence, anxiety, fear of negative evaluation, and disease severity, affect quality of life.
Chronic urticaria is a skin disorder characterized by the recurrent eruption of short-lived wheals accompanied by redness and itching for at least 6 weeks 21. The current study included 110 patients with chronic urticaria and anxiety was found in 43.64% of patients and depression in 35.45%, with higher rates in females than in males. Fried et al.5 reported that the severity of pruritus in urticaria increased with increasing severity of depressive symptoms. 19.09% of the chronic urticaria patients had suicidal ideation, but no suicide attempt was made, 51.82% had sleep disorders, 2.73% had OCD, and 21.82% had sexual problems that affected their quality of life.
Patients with skin problems are at high risk of developing psychological problems. The associated psychiatric disorders can range from short episodes of depression to major depression, anxiety, OCD, sleep disorders, and can even lead to suicidal ideation and suicidal attempts. Knowledge of the interaction between the mind and the skin can help to improve patients’ skin conditions and eventually their quality of life.
Because psychiatric comorbidity is high in dermatology patients, it is often essential for the dermatologist to assess the mental state of the patient. Therefore, it is recommended that dermatologists should be aware of the right time to refer the patient to a psychiatrist. This awareness of psychodermatological disorders among dermatologists will lead to a more efficient treatment and better prognosis in this unique group of patients.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2017 Egyptian Women's Dermatologic Society
chronic dermatologic diseases; Egyptian outpatients; psychiatric disorders