Practical Psychodermatology E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 524

Veröffentlichungsjahr: 2014

Beschreibung

Skin disease can be more than skin deep
Our skin is one of the first things people notice about us. Blemishes, rashes, dry, flaky skin – all these can breed insecurity, even suicidality, even though the basic skin condition is relatively benign. Skin disease can lead to psychiatric disturbance.

But symptoms of skin disease can also indicate psychological disturbance. Scratching, scarring, bleeding, rashes. These skin disturbances can be the result of psychiatric disease.

How do you help a dermatological patient with a psychological reaction? How do you differentiate psychological causes from true skin disease? These are challenges that ask dermatologists, psychiatrists, psychologists and other health care specialists to collaborate.

Practical Psychodermatology provides a simple, comprehensive, practical and up-to-date guide for the management of patients with psychocutaneous disease. Edited by dermatologists and psychiatrists to ensure it as relevant to both specialties it covers:

• History and examination
• Assessment and risk management
• Psychiatric aspects of dermatological disease
• Dermatological aspects of psychiatric disease
• Management and treatment

The international and multi-specialty approach of Practical Psychodermatology provides a unique toolkit for dermatologists, psychiatrists, psychologists and other health care specialists needing to care for patients whose suffering is more than skin deep.

Leseprobe

Table of Contents

Dedication

Title page

Copyright page

Contributors

Foreword

Preface

SECTION 1: Introduction

CHAPTER 1: Introduction

Psychodermatology: interfaces, definitions, morbidity and mortality

The psychodermatology multidisciplinary team

DSM-IV and DSM-5

ICD-10

Models of working psychodermatology services

Setting up a psychodermatology clinic

British Association of Dermatologists Psychodermatology Working Party Report

Psychological interventions

Psychopharmacology

Assessments tools for psychodermatology patients

Global psychodermatology groups

Medicolegal and ethical issues

CHAPTER 2: History and examination

The first visit

Follow-up visits: shifting toward the psychiatric evaluation

SECTION 2: Management in psychodermatology

CHAPTER 3: Psychopharmacology in psychodermatology

Introduction to prescribing antidepressant medications

Introduction to prescribing antipsychotic medications

Psychiatric and dermatologic side effects

CHAPTER 4: Adherence in the treatment of chronic skin diseases

Methods of assessing adherence

Adherence in chronic skin diseases

Factors affecting adherence

Interventions to improve adherence

CHAPTER 5: Psychological assessment and interventions for people with skin disease

Psychologist's initial approach to dermatology clients

Psychological assessment

Psychological interventions

CHAPTER 6: Risk and risk management in psychodermatology

Psychiatric risk and the dermatology patient

Suicide, suicidal thoughts, and suicide risk

Risk to others

Abuse and neglect of children and other vulnerable people

Dermatologists and psychiatric risk assessment

CHAPTER 7: Self-help for management of psychological distress associated with skin conditions

What is self-help?

Stepped care

Implications of stepped care and self-help for assessment

Future research

CHAPTER 8: Habit reversal therapy: a behavioural approach to atopic eczema and other skin conditions

Adults and older children with atopic eczema

Younger children with atopic eczema

Finding out more about The Combined Approach

Habit reversal and other skin conditions

CHAPTER 9: Nursing interventions in psychodermatology

Psychosocial issues in skin conditions

Effective consultations

Assessment of psychological health and quality of life

Psychological interventions

Future research

SECTION 3: Skin diseases with secondary psychiatric disorders

CHAPTER 10: Psychological impact of hair loss

The hair cycle

Psychological stress as a cause of hair loss

Clinical assessment of hair disease

Alopecia areata

Telogen effluvium

Male pattern balding

Female pattern hair loss

Chemotherapy-related hair loss

Scarring hair loss

Hirsutism

Specific psychopathology leading to hair loss or presenting in the hair clinic

Psychological impact of appliances/wigs, camouflage and support groups

CHAPTER 11: Psoriasis and psychodermatology

Epidemiology and defining features of psychological functioning

Pathogenesis

Assessment

Treatment

Future research

CHAPTER 12: Living well with a skin condition: what it takes

Living with a disfigurement

The cultural background

What does this mean for patients?

How to promote successful adjustment

CHAPTER 13: Chronic skin disease and anxiety, depression and other affective disorders

Defining features of key mood and anxiety disorders

Pathogenesis

Clinical assessment

Management

Future research

SECTION 4: Psychiatric disorders with secondary skin manifestations

CHAPTER 14: Delusional infestation

Defining features

Pathogenesis

Assessment

Treatment

Future research

CHAPTER 15: Body dysmorphic disorder

Diagnostic criteria

Clinical features

Epidemiology and presentation

Aetiology

Detection and assessment

Engagement

Psychological and psychiatric treatment

Future research

CHAPTER 16: Pickers, pokers, and pullers: obsessive-compulsive and related disorders in dermatology

Defining features

Pathogenesis

Assessment

Treatment

Discussing treatment and providing referral information

Future research

CHAPTER 17: Factitious skin disorder (dermatitis artefacta)

Defining features

Pathogenesis and common co-morbid illnesses

Clinical assessment

Investigations

Treatment

Future research

SECTION 5: Cutaneous sensory (pain) disorders

CHAPTER 18: Medically unexplained symptoms and health anxieties: somatic symptom and related disorders

Defining features

Pathogenesis

Assessment

Treatment

Specific disorders that may present in dermatology clinics

Acknowledgement

CHAPTER 19: Dysesthetic syndromes

Sensory mononeuropathies

Trigeminal syndromes

Erythromelalgia

CHAPTER 20: Chronic idiopathic mucocutaneous pain syndromes: vulvodynia, penodynia, and scrotodynia

Vulvodynia

Penodynia and scrotodynia

CHAPTER 21: Burning mouth syndrome

Defining features

Pathogenesis

Assessment

Treatment

CHAPTER 22: Nodular prurigo

Clinical features

Pathogenesis

Clinical assessment

Differential diagnosis

Clinical and laboratory investigations

Management

Future research

SECTION 6: Special populations and situations

CHAPTER 23: Child and adolescent psychodermatology

Classification and clinical presentations

Developmental perspective

Treatment

CHAPTER 24: Psychodermato-oncology: psychological reactions to skin cancer

Defining features

Assessment

Psychological morbidity

Coping strategies

Specific forms of psychosocial support

Cancer phobia

Future research

CHAPTER 25: Botulinum toxin treatment in depression

Theory and pathogenesis

Treatment

Future research

CHAPTER 26: The Morgellons debate

Defining features and pathogenesis

Assessment and treatment

CHAPTER 27: Substance misuse and the dermatology patient

Defining features

Pathogenesis

Assessment

Treatment

Emergency situations

Glossary

Appendix: Screening questionnaires and scales

A1 CAGE questionnaire

A2 Dermatology Life Quality Index (DLQI)

A3 EQ-5D-5L

A4 Hospital Anxiety and Depression Scale

A5 Mini Mental State Examination

A6 Patient Health Questionnaire (PHQ)

A7 Patient Health Questionnaire-9 (PHQ-9)

A8 Physical symptoms (PHQ-15)

A9 Dimensional Obsessive-Compulsive Scale

A10 Cosmetic Procedures Screening Questionnaire (COPS)

A11 Screening questionnaire for adults: Do I have BDD?

A12 The Massachusetts General Hospital Hairpulling Scale

A13 The Skin Picking Scale (SPS)

A14 The Skin Cancer Index

A15 The Distress Thermometer for skin cancer

A16 Alcohol Use Disorders Identification Test (AUDIT)

A17 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

Index

For Arnold S. Coren (1922–1997) – for showing me the joy of medicine from the perspective of a patient. His memory continues to guide me.

J.S.R.

For Jeanette Magid (1947–2006) – a traditional mother who encouraged me to break tradition.

M.M.

For Anthony Downey (1963–1990).

A.P.B.

For my parents Alec and Elizabeth Taylor, husband Nicholas Moran, and children Hannah, Austin, and Mehetabel, with thanks for their love and support.

R.E.T

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Library of Congress Cataloging-in-Publication Data

Practical psychodermatology / [edited by] Anthony Bewley, Ruth E. Taylor, Jason S. Reichenberg, Michelle Magid ; foreword by Dr John Koo, Dr Christopher Brigett, and Dr Richard Staughton. p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-56068-6 (cloth)

I. Bewley, Anthony, editor of compilation. II. Taylor, Ruth E., editor of compilation. III. Reichenberg, Jason S., editor of compilation. IV. Magid, Michelle, editor of compilation.

[DNLM: 1. Skin Diseases–psychology. 2. Mental Disorders–etiology. 3. Mental Disorders–therapy. 4. Psychophysiologic Disorders–therapy. 5. Skin Diseases–complications. 6. Skin Manifestations. WR 140]

RL96

616.5'0651–dc23

2013042712

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: © Dreamstime/Ye Liew

Cover design by Meaden Creative

Contributors

Jonathan S. Abramowitz phd

Professor of Psychology

Department of Psychology

University of North Carolina at Chapel Hill

Chapel Hill, NC, USA

Andrew G. Affleck bsc (hons), mbchb, mrcp (uk)

Consultant Dermatologist, Dermatological Surgeon

and Honorary Senior Clinical Teacher

Ninewells Hospital and Medical School

Dundee, UK

Christine S. Ahn ba

Dermatology Research Assistant

Center for Dermatology Research

Department of Dermatology

Wake Forest School of Medicine

Winston-Salem, NC, USA

Emma Baldock phd, dclinpsy, pgdipcbt

Clinical Psychologist & Academic Tutor

Institute of Psychiatry, King's College London

and the South London & Maudsley NHS Foundation Trust

London, UK

Susan Bradbrooke

Skin Camouflage Practitioner

Changing Faces

The Squire Centre

London, UK

Christopher Bridgett ma (oxon), bm bch, frcpsych

Consultant Psychiatrist

Chelsea & Westminster Hospital

Honorary Clinical Lecturer

Imperial College London

London, UK

Alison Bruce mbchb

Consultant Dermatologist and Associate Professor of Dermatology

Mayo Clinic

Rochester, MN, USA

Christine Bundy phd, afbpss, cpsychol, hcpc registered practitioner

Senior Lecturer in Behavioural Medicine

Centre for Dermatology Research

Institute of Inflammation and Repair

University of Manchester

and Manchester Academic Health Sciences Centre

Manchester, UK

Anna Burnside mbchb, mrcpsych, ma

Consultant, Liaison Psychiatry Service

West London Mental Health NHS Trust

London, UK

Maureen Burrows md, mph

Forensic Psychiatrist

Central Texas Forensic Psychiatry Consultation Service

Austin, TX, USA

Lis Cordingley phd, afbpss, cpsychol, hcpc registered practitioner

Senior Lecturer in Health Psychology

Centre for Dermatology Research

Institute of Inflammation and Repair

University of Manchester

and Manchester Academic Health Sciences Centre

Manchester, UK

Fiona Cowdell rn, dprof

Senior Research Fellow

Faculty of Health and Social Care

University of Hull, Hull, UK

Mark D.P. Davis md

Professor of Dermatology

Chair, Division of Clinical Dermatology

Department of Dermatology

Mayo Clinic

Rochester, MN, USA

Wendy Eastwood

Changing Faces Practitioner

Changing Faces

The Squire Centre

London, UK

Libby Edwards md

Chief of Dermatology

Carolinas Medical Center

Charlotte, NC, USA

Steven Ersser rgn, phd

Professor of Nursing and Dermatology Care

and Dean, Faculty of Health and Social Care

University of Hull, Hull, UK

Paul Farrant bsc, mbbs, frcp

Consultant Dermatologist

Brighton and Sussex University Hospitals (BSUH) Trust

Brighton, UK

Steven R. Feldman md, phd

Professor of Dermatology, Pathology & Public Health Sciences

Wake Forest School of Medicine

Winston-Salem, NC, USA

Roland Freudenmann pd dr med

Associate Professor of Psychiatry

Department of Psychiatry

University of Ulm

Ulm, Germany

Tania M. Gonzalez Santiago md, dtm&h

Dermatology Resident

Department of Dermatology

Mayo Clinic

Rochester, MN, USA

Chris Griffiths md, frcp, fmedsci

Professor of Dermatology, Centre for Dermatology Research

Institute of Inflammation and Repair

University of Manchester

and Salford Royal NHS Foundation Trust

Manchester Academic Health Science Centre

Manchester, UK

Lesley Howells ba (hons), mappsci (psychological medicine)

Maggie's Consultant Clinical Psychologist and Research Lead (UK)

Maggie's Centre

Ninewells Hospital

Dundee, UK

Markus Huber md

Specialist in Psychiatry, Consultant Psychiatrist and Assistant Medical Director

Department of Psychiatry

General Hospital Bruneck

South Tyrol, Italy

Sara A. Hylwa md

Dermatology Resident

Department of Dermatology

University of Minnesota

Minneapolis, MN, USA

Ryan J. Jacoby ma

Graduate Student

Department of Psychology

University of North Carolina at Chapel Hill

Chapel Hill, NC, USA

Simon Kirwin beng (hons), msc(eng), mbchb, mrcpsych

Specialty Registrar in Liaison Psychiatry

East London NHS Foundation Trust

London, UK

Sussann Kotara md

Psychosomatic Medicine Fellow

Department of Psychiatry

University of Texas Southwestern

Austin, TX, USA

Tillmann H.C. Kruger md

Consultant Psychiatrist and Associate Professor

Department of Psychiatry, Social Psychiatry and Psychotherapy

Center of Mental Health, Hannover Medical School (MHH)

Hannover, Germany

Peter Lepping mrcpsych, msc

Honorary Professor

School of Social Sciences and Centre for Mental Health and Society

Bangor University

Consultant Psychiatrist and Associate Medical Director

BCULHB, North Wales, UK

Peter J. Lynch md

Professor Emeritus of Dermatology

UC Davis Medical Center

Sacramento, CA, USA

Osman Malik mbbs, mrcpsych

Consultant Child and Adolescent Psychiatrist

Newham Child and Family Consultation Service

London, UK

Sue McHale

Senior Lecturer in Psychology

Department of Psychology, Sociology and Politics

Sheffield Hallam University

Sheffield, UK

Jonathan Millard bsc(Hons), mmedsc, mbchb, mrcpsych

Consultant Psychiatrist

South West Yorkshire Partnerships Foundation Trust, UK

Leslie Millard mbchb, md, frcp(lond), frcp(edin)

Consultant Dermatologist

Hathersage, Derbyshire, UK

Audrey Ng mbchb, mrcpsych, ma

Consultant Liaison Psychiatrist

West London Mental Health NHS Trust

London, UK

Mark R. Pittelkow md

Professor of Dermatology

Department of Dermatology and Biochemistry and Molecular Biology

Mayo Clinic

Rochester, MN, USA

Steven Reid mbbs, phd, mrcpsych

Clinical Director, Psychological Medicine

Central and North West London (CNWL) NHS Foundation Trust

St Mary's Hospital

London, UK

William H. Reid md, mph, facp, frcp (edin)

Clinical and Forensic Psychiatrist

Horseshoe Bay, TX

Clinical Professor, Texas Tech University Medical Center, Lubbock

Adjunct Professor, University of Texas Medical Center, San Antonio

Adjunct Professor, Texas Tech College of Medicine

University of Texas Southwestern Medical School

Austin, TX, USA

Angharad Ruttley mbbs, mrcpsych, llm

Consultant Liaison Psychiatrist

Imperial College Healthcare NHS Trust

and West London Mental Health NHS Trust

London, UK

Laura F. Sandoval do

Clinical Research Fellow

Center for Dermatology Research

Department of Dermatology

Wake Forest School of Medicine

Winston-Salem, NC, USA

Krysia Saul

User

Changing Faces

The Squire Centre

London, UK

Reena B. Shah bsc (hons), msc, dclin psych, cpsychol

Chartered Clinical Psychologist

Department of Dermatology

Whipps Cross University Hospital

London, UK

Henrietta Spalding

Head of Advocacy

Changing Faces

The Squire Centre

London, UK

Wei Sheng Tan mbbs

Senior Resident

National Skin Centre

Singapore

Mark B.Y. Tang mbbs (singapore), frcp (uk), mmed internal medicine (singapore), fams (dermatology)

Senior Consultant Dermatologist and Director of Research

National Skin Centre

Singapore

Hong Liang Tey mbbs(s'pore), mrcp(uk), fams

Consultant Dermatologist

National Skin Centre

Singapore

Andrew R. Thompson ba, dclinpsy, dip. prac. cognitive analytic therapy, cpsychol., afbpss

Reader in Clinical Psychology & Practising Clinical Health Psychologist

Department of Psychology

University of Sheffield

Sheffield, UK

Rochelle R. Torgerson md, phd

Assistant Professor of Dermatology

Department of Dermatology

Mayo Clinic

Rochester, MN, USA

David Veale frcpsych, md, bsc, mphil

Visiting Senior Lecturer

Institute of Psychiatry, King's College London

and the South London and Maudsley NHS Foundation Trust

London, UK

Alexander Verner bsc (hons), msc (dist), mbbch (hons), mrcpsych

Consultant in General Adult and Addictions Psychiatry

Tower Hamlets Specialist Addictions Service (SAU)

East London Foundation NHS Trust

London, UK

Birgit Westphal md, mrcpsych

Consultant Child and Adolescent Psychiatrist

Paediatric Liaison Team, Barts and The London Children's Hospital

Royal London Hospital

London, UK

Wojtek Wojcik md

Consultant Psychiatrist

Royal Edinburgh Hospital

Edinburgh, UK

M. Axel Wollmer md

Head of Department, Asklepios Clinic North – Ochsenzoll

Hamburg, Germany

Cooper C. Wriston md

Dermatologist

Department of Dermatology

Mayo Clinic

Rochester, MN, USA

Foreword

From the US

“The dermatologist treats the disease; the psychodermatologist treats the patient who has the disease.”

This new book on psychodermatology is extremely comprehensive. The content ranges from psychopharmacology to non-pharmacological approaches such as habit reversal therapy. It covers all age groups from pediatric to the elderly and is applicable to all providers including the nursing staff. This book is indeed a valuable addition to our specialty.

Psychodermatology is much more than delusions of parasitosis. Whereas dermatology has a tendency to focus more on minute details, psychodermatology encourages appreciating the patient as a whole. In fact, in the United States, a new book updating the entire field of psychodermatology is very timely. We are experiencing a radical change in reimbursement rates for physicians, whereby reimbursement becomes contingent on patient satisfaction. This new policy, “value based payment,” increases or decreases compensation based on patient satisfaction as assessed by the Consumer Assessment of Healthcare Providers and Systems (CAHPS), a survey mandated by many insurance payers including the US government. As electronic consumer ratings become more prominent, physicians will be publicly rated, similar to how restaurants are rated on the website. Yelp! The reality that reimbursement rates are becoming contingent on how the dermatologist relates to and is perceived by his/her patient must be faced. Because this is a very subjective variable, it behooves all physicians to be familiar with psychodermatological aspects of their practice.

In short, psychodermatology is a subject matter most worthwhile learning about because of its relevance in our day-to-day practice. It is vital to investigate and appreciate aspects of our patients that are not visible, such as the intensity of emotional stress involved, the presence of depression, or the degree of support a patient needs to be adherent with his/her treatment regimen. As healthcare evolves, psychodermatology expertise will be of growing importance to the way we practice, above and beyond how to deal with a delusional patient.

John Koo

San Francisco, California

December 2013

From the UK

In the early 1970s at Addenbrooke's Hospital, Cambridge, we were fortunate enough to follow each other in the post of Senior House Officer in Psychiatry and Dermatology. The link between the two departments was part architectural, part financial: the Psychiatric Ward was next to the Dermatology Ward, and each service could only afford half a junior doctor. Arthur Rook was one of the dermatologists.

He drew the attention of one of us [CB] to the book Psychocutaneous Medicine by the American dermatologist Maximilian Obermayer. Arthur Rook suggested that this important book was to many UK dermatologists incomprehensible and off-putting. What was needed was an accessible and practically based volume that covered the important and fascinating clinical interface between psychiatry and dermatology.

After Addenbrooke's the two of us went our different ways, one to be a dermatologist, the other a psychiatrist, but 10 years later we found ourselves again working in the same hospital service in London. We decided to start a Psychodermatology Clinic together at the Daniel Turner Clinic, Westminster Hospital. Later at Chelsea & Westminster Hospital, we were fortunate to have working with us an energetic trainee dermatologist, Anthony Bewley.

In 2003 we inaugurated an annual meeting at the Medical Society of London for UK clinicians interested in psychodermatology. After 5 years we were delighted when Tony Bewley and Ruth Taylor agreed to continue to organize this regular event. We now have the pleasure of writing this foreword to a book that we know will provide the resource that Arthur Rook saw the need for 40 years ago.

The editors have here brought together an important spectrum of topics, with authors from a range of disciplines, and many parts of the world. But most important is the attractive layout and practical, hands-on design of the book. Here psychodermatology is no longer an obscure and esoteric subspeciality. This book clearly demonstrates psychodermatology has come of age. It is on the curriculum. Now it is important that patients everywhere with skin complaints can benefit from the important holistic approach that psychodermatology represents.

Christopher Bridgett and Richard Staughton

London

December 2013

Preface

Psychodermatology is an emerging subspecialty of dermatology. It encompasses the management of patients with primary psychiatric disease presenting to dermatologists (e.g. delusional infestation, body dysmorphic disease and factitious diseases), together with patients who have primary dermatological disease (e.g. psoriasis, atopic eczema, hair disorders and others) where there is a large psychiatric or psycho­logical co-morbidity.

There are a number of psychodermatology clinics starting out globally, and there has been provenance in the pioneering of psychodermatology by illustrious dermatological colleagues such as Dr John Koo from the US and Drs Richard Staughton, John Cotterell, Les Millard and John Wilkinson from the UK. But psychodermatology requires the input of a multidisciplinary team. In the UK, Dr Chris Bridgett, a consultant psychiatrist, helped found psychodermatology services. In mainland Europe, colleagues such as Dr John de Korte (The Netherlands), Françoise Poot (Belgium), Dennis Linder (Italy), Klaus-Michael Taube (Germany), Sylvie Consoli (France), Uwe Gieler (Germany), Gregor Jemec (Denmark), Andrey Lvov (Russia), Jacek Szepietowski (Poland) and Lucía Tomás (Spain) have provided inspiration and leadership in the field of psycho­dermatology for many years.

In Practical Psychodermatology two derma­tologists (Drs Anthony Bewley and Jason Reichenberg) have combined forces with two psychiatrists (Drs Michelle Magid and Ruth Taylor) to edit a practical guide to the man­agement of psychodermatological conditions. We aimed to emphasize the practicality of this book. Often, colleagues ask us “How do you manage a patient with delusional infestation?” or “What's the best way to engage a patient with dermatitis artefacta?” and so we wanted to produce a practical, hands-on approach to the management of patients with psychocutaneous disease. We are mindful that the management of patients with psychodermatological disease requires the input of a wide multidisciplinary team including dermatologists, psychiatrists, psychologists, primary care physicians, nurses, paediatricians, pain specialists and a whole range of other healthcare professionals HCPs. We have tried to include authorship of as wide a range of HCPs as possible, and we hope that Practical Psychodermatology will appeal to all those who are involved in the care and support of individuals with psycho­cutaneous disease. We have also tried to encompass the views of individuals who live with psycho­cutaneous disease, and we have specifically asked patient advocate groups such as Changing Faces to contribute to Practical Psychodermatology. In doing so, we aim to guide HCPs to useful resources that can be accessed either online or via other means of contact.

Just a note about the use of English in this book. We have kept the written English consistent with the author's origin, so where American English is used we have kept it as such and similarly for British English.

Finally we intend that Practical Psychodermatology is a text that trainees in dermatology, psychiatry, psychology, medicine, nursing and other HCP training programmes will find useful in their studies and clinical preparations. We are aware that colleagues are beginning to set up psychodermatology clinics across the globe and we hope that this practical guide will provide a helpful reference clinically and a source from which colleagues can access further research.

Anthony Bewley, July 2013

Over the past several months, as I began to review each of the submitted chapters for this textbook, I was struck by clear differences in the chapters written by authors from different countries. I was not surprised by variations in language or patient demographics , but instead by the large differences between the authors' concept of what it meant to offer a “practical” approach to patient care.

The chapters written by authors from the US are focused, precise guides to medication management, psychiatric care, or therapeutic techniques, varying by the disease type discussed. I found them very useful in my day-to-day practice and in teaching students who are new to psychodermatology. Just what I needed! The chapters written by authors from the UK, however, were not what I expected. They focused on patient resources, family education, and spoke about multidisciplinary care. It was clear the authors had many years' experience in working on healthcare “teams” and shared a common vocabulary of acronyms such as “CPA” and “NICE.” This information has helped me to greatly improve collaboration and patient care in my practice. Before I read these chapters, I did not know what I was missing.

In the UK, it is clear that the practitioners have spent their careers working within a system where patient-centered, evidence-based medicine was expected. In the US, there has been a recent shift toward coordination of care and quality of life measures, but these ideas have not been in play for very long. I hope that readers from outside of the UK (myself included) will take a cue from these authors and utilize all the “practical” approaches in this book.

Jason Reichenberg, July 2013

SECTION 1

Introduction

CHAPTER 1

Introduction

Anthony Bewley,1 Michelle Magid,2 Jason S. Reichenberg3 and Ruth E. Taylor4

1 The Royal London Hospital & Whipps Cross University Hospital, Barts Health NHS Trust, London, UK

2 Department of Psychiatry, University of Texas Southwestern, Austin, TX, USA

3 Department of Dermatology, University of Texas Southwestern, Austin, TX, USA

4 Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK

Psychodermatology: interfaces, definitions, morbidity and mortality

Psychodermatology or psychocutaneous medicine refers to the interface between psychiatry, psychology and dermatology. It involves the complex interaction of the brain, cutaneous nerves, cutaneous immune system and skin. Psychocutaneous conditions can be divided into three main categories, as illustrated in Figure 1.1.

Figure 1.1 Psychodermatology interfaces (courtesy of Trevor Romain).

Most patients attending psychodermatology clinics have either a primarily dermatological disease with secondary psychosocial co-morbidities or a primarily psychiatric disorder with a significant cutaneous symptomatology (Table 1.1). Clinical research has shown that there is an increasing burden of psychological distress and psychiatric disorder amongst dermatology patients [1]. In addition, stress is frequently reported as a precipitant or exacerbating factor of skin disease and is a major factor in the outcome of treatment [2]. Skin conditions may have a detrimental effect on most aspects of an individual's life, including relationships, work and social functioning. A national survey undertaken by the British Association of Dermatologists (BAD) in 2011 [3] to assess the availability of psychodermatology services, revealed poor provision despite dermatologists reporting:

17% of dermatology patients need psychological support to help them with the psychological distress secondary to a skin condition;14% of dermatology patients have a psychological condition that exacerbates their skin disease;8% of dermatology patients present with worsening psychiatric problems due to concomitant skin disorders;3% of dermatology patients have a primary psychiatric disorder;85% of patients have indicated that the psychosocial aspects of their skin disease are a major component of their illness;patients with psychocutaneous disease have a significant mortality from suicide and other causes.

Table 1.1 Psychocutaneous disease

Primary dermatological disorders caused by or associated with psychiatric co-morbidity (Figure 1.2)Primary psychiatric disorders that present with skin disease (Figure 1.3)Psoriasis, eczema, alopecia areata, acne, rosacea, urticaria, vitiligoVisible differences (disfigurements)Inherited skin conditions (e.g. ichthyosis)May be caused, exacerbated by or associated with:Depression, anxiety, body image disorder, social anxiety, suicidal ideation, somatization, psychosexual dysfunction, schema, alexithymia, changes in brain functioningDelusional infestationBody dysmorphic disorderDermatitis artefactaObsessive-compulsive disordersTrichotillomaniaNeurotic excoriationDysaesthesiasSomatic symptom disordersSubstance abuseFactitious and induced injuryOthers

Figure 1.2 Patients with dermatological disease such as vitiligo may have psychological co-morbidities even if the condition is hidden or “milder”. Such patients may feel out of control of their bodies, desperate and disempowered.

Figure 1.3 A patient with severe dermatitis artefacta (factitious and induced illness) of the scalp who required the careful input of a psychodermatology multidisciplinary team that included dermatologists, psychiatrists, plastic surgeons, nursing staff and psychologists in order to resolve her dermatological and psychosocial problems.

These findings are not unusual and are mirrored throughout Europe, North America and globally.

The psychodermatology multidisciplinary team

Though patients often present to dermatologists, dermatologists are not usually able, in isolation, to manage patients with psychocutaneous disease. For these patients, there is increas­ing evidence that a psychodermatology multidisciplinary team (pMDT) can improve outcomes [4]. Specialists who make up a pMDT require dedicated training in the management of patients with psychocutaneous disease, though such training is difficult to obtain (Box 1.1). This book, then, is aimed at being a practical, hands on guide to the management of psychodermatological diseases by all healthcare professionals. We are not saying that each patient with a psychocutaneous problem needs to be reviewed by a pMDT as that would be impractical and probably unnecessary. We are saying that for some patients with psychocutaneous disease, a pMDT will be essential for their speedy, appropriate and effective management.

Box 1.1 Possible members of the psychodermatology multidisciplinary team (pMDT)

DermatologistsPsychiatristsPsychologistsDermatology and other nursing colleaguesChild and adolescent mental health specialists (CAMHS)PaediatriciansGeriatricians and older age psychiatristsSocial workersTrichologistsPrimary care physiciansChild and/or vulnerable adult protection teamsPatient advocacy and support groups

DSM-IV and DSM-5

The American Psychiatric Association (APA) has recently published the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (www.dsm5.org). The fourth version of the DSM (DSM-IV-TR, with a text revision) was published in 2000. The aim of the DSM manual is to provide general categorizations and diagnostic criteria for psychiatric disorders. These manuals are tools for healthcare professionals and do not represent a substitute for expert clinical opinion. It is also important to note that categorization of psychodermatological disease is difficult and patients may exhibit symptoms of a variety of DSM diagnoses. For example, a patient with body dysmorphic disease (classified as an obsessive-compulsive related disorder) may have clear psychotic symptoms as well as being depressed at the same time; or a patient with psoriasis (a physical skin disease) may have symptoms of severe anxiety and depression as well as a substance use disorder.

The DSM-IV-TR consists of five axes (broad groups):

Axis I: Clinical psychiatric disorders (e.g. depression, schizophrenia)

Axis II: Personality disorders and mental retardation

Axis III: General medical conditions

Axis IV: Psychosocial and environmental problems

Axis V: Global assessment of functioning (0–100 scale of functioning level)

Of note, the DSM-5 work groups felt that there was no scientific basis for this separation and abandoned the axis system.

ICD-10

The tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) offers a general classification of all disease. As with the DSM-5, it does not include all psychodermatological conditions, but can be helpful in organizing psychodermatological conditions.

We have specifically designed Practical Psychodermatology to be as user friendly and hands on as possible. To this end, we have divided the chapters into the following sections:

1.Introductory chapters – introduction and psychodermatological history and examination.

2.Management in psychoder­matology – these chapters aim to address psychological assessments as well as assessment of risk and management strategies for patients with psychocutaneous disease. The chapters include psychopharmacology; adherence in the treatment of chronic skin disease; psychological assessment and interventions for people with skin disease; risk and risk management in psychodermatology; self-help for management of psychological distress associated with skin conditions; habit reversal therapy; and nursing interventions in psychodermatology.

3.Skin disease with secondary psychiatric disorders – including psychological impact of hair loss; psoriasis and psychodermatology; living well with a skin condition; and chronic skin disease and anxiety, depression and other affective disorders.

4.Psychiatric disorderswith secondary skin manifestations – including delusional infestation; body dysmorphic disorder; obsessive-compulsive and related disorders; and dermatitis artefacta and other factitious skin disease.

5.Cutaneous sensory (pain) disorders – including medically unexplained symptoms and health anxieties: somatic symptom and related disorders; dysesthetic syndromes; chronic idiopathic mucocutaneous pain syndromes: (vulvodynia, penodynia and scrotodynia); burning mouth syndrome; and nodular prurigo.

6.Special populations and situations – including child and adolescent psychodermatology; psychodermato-oncology: psychological reactions to skin cancer; botulinum toxin treatment in depression; the Morgellons debate; and substance misuse and the dermatology patient.

By sectioning Practical Psychodermatology in this way we are intending that readers understand and logically access the broad sub-groups of psychocutaneous disease. We have where possible cross-referenced specific chapters to direct readers to further reading material.

Models of working psychodermatology services

There are several models of how psychodermatology services are delivered, all of which are compatible with a pMDT. These include:

a dermatologist who refers a patient to a psychiatrist or psychologist who is in an adjacent room;a dermatologist who refers a patient to a psychiatrist or psychologist who is in a remote clinic;a dermatologist who has a psychiatrist sitting in clinic at the same time and a patient is seen by both specialists concurrently;a dermatologist who has a psychologist as a clinical adjacency (psychologists rarely sit in on clinics with dermatologist or psychiatrists).

Much of how a service is developed depends on local factors (availability of interested colleagues, finance) and there is little evidence that any one model is preferred over another. However, research makes it clear that at least regional psychodermatology services are es­­sential [5] to cost- and clinically-effectively meeting the demands of psychodermatology patients [6].

Setting up a psychodermatology clinic

Many colleagues ask about how to set up a psychodermatology clinic in their area. The recommendations for setting up a psychodermatology service include [7]:

Financial investment – managing psychodermatology patients in a general dermatology clinic is both frustrating and difficult. Dedicated psychodermatology services are mistakenly perceived as being expensive as there may be more than one healthcare professional (HCP) involved in the patient's care and because patients require longer consultations than routine dermatology patients and may need greater follow-up care. Joint delivery of care by dermatologists and psychiatrists can double the medical costs. So, it is important to cost psychodermatology services accordingly. This may require a specific psychodermatology tariff or reimbursement. Hospitals and managers will expect a business case outlining the requirements of the service, especially for joint clinics. There is increasing evidence that psychodermatology services provide cost-effective use of resources (as otherwise psychodermatology patients will see a plethora of specialists without having their physical and psychological disease managed successfully) [6,7].The team – psychodermatology is a multidisciplinary sub-speciality. Developing expertise among nursing staff, psychiatrists and psychologists requires access to training.Clinic templates – consultations are often lengthy and appointments should be 45 minutes for new patients and 30 minutes for follow-up patients. Psychologists usually see patients for hour-long appointments.Separate dedicated time to coordinate care and to liaise with other healthcare providers.Facilities – counselling and consultation rooms are ideally situated within the dermatology unit and in a quiet, undisturbed area suitable for psychological interventions. For joint clinics, the consulting room will need to be of an appropriate size to accommodate two clinicians, the patient and a caregiver.

British Association of Dermatologists Psychodermatology Working Party Report

In 2012 the BAD reported the minimum standards required to support psychodermatology service provision in the UK [7], mindful of the UK Government's document No Health Without Mental Health [8]. The working party recommended:

formalization of regional and national clinical networks to identify training needs of staff;development of at least regional dedicated psychodermatology service with a trained specialist psychodermatologist;development of at least regional dedicated clinical psychologist support;access to cognitive-behavioural therapy (CBT), delivered by a trained individual;that all dermatology units have a named lead dermatologist who has some experience and expertise in psychodermatology, and access to the Child and Adolescent Mental Health Service (CAMHS), integrated specialist adult psychiatric services, old age psychiatric services and community mental health teams.

Psychological interventions

Talk therapies such as CBT and habit reversal are backed by strong evidence, as discussed in subsequent chapters. Other treatment modalities that have begun to acquire a following include biofeedback, eye movement desensitization and reprocessing (EMDR), neuro-linguistic programming (NLP) and mindfulness relaxation therapy.

Psychopharmacology

Pharmacology relates to psychodermatology in that:

medication may be necessary for the treatment of psychodermatological conditions;medication used in dermatology may have psychiatric and psychological sequelae;pharmacological treatment of psychiatric conditions may have dermatological side effects.

These issues will be discussed in Chapter 3.

Assessments tools for psychodermatology patients

Many HCPs are able to assess patients' psychosocial co-morbidities through a standard consultation/clinical interaction. However, simple well-validated tools do exist. For example:

Dermatology specific: Dermatology Life Quality Index (DLQI);Skindex 29.Dermatological disease specific (usually validated for physical and psychosocial disease extent): Cardiff Acne Disability Index;Salford Psoriasis Index.Non-dermatology specific: Hospital Anxiety and Depression Score (HADS);Patient Health Questionnaire 9 (PHQ-9).

These indices are used extensively in research, but are becoming increasingly important in everyday dermatology practice as they offer a standardized snapshot of the patient's psychosocial well-being (some also include scores of disease extent). Some dermatology-specific indices may also be disease specific. Assessment tools are discussed in Chapter 5.

Global psychodermatology groups

Psychodermatology is a sub-specialty of dermatology that is gaining a voice and momentum within dermatological practice. There are a number of organizations that champion the clinical and academic excellence of psychocutaneous medicine (Table 1.2).

Table 1.2 Organizations concerned with psychocutaneous medicine

Organization/websiteMeetingsPsychodermatology UKwww.psychodermatology.co.ukAnnually on fourth Thursday in January at the Royal Society of Medicine, LondonThe European Society for Dermatology and Psychiatry (ESDaP)www.psychodermatology.netBiennial meeting which rotates throughout Europe, and a satellite meeting at the spring and autumn meetings of the European Academy of Dermatology and VenereologyAssociation of Psycho-neuro-cutaneous Medicine of North America (APMNA)www.psychodermatology.usAnnual meetings on the Thursday before the American Academy of Dermatology meetingJapanese Society of Psychosomatic Dermatologywww.jpsd-ac.orgAnnual meetings

Medicolegal and ethical issues

Patients with psychocutaneous disease may be medicolegally challenging for a variety of reasons. Some may have personality disorders, which make negotiation with HCPs difficult; some may have forensic psychiatric problems; and some may have a delusional disorder, which may be difficult to manage. These issues will be discussed in Chapter 6.

Practical Tips

Psychiatric and psychological factors are important in up to 85% of dermatology patients, and involve the complex interaction of the brain, cutaneous nerves, cutaneous immune system and skin.Dedicated training in psychocutaneous medicine is essential for healthcare professionals working in psychodermatology services, as psychocutaneous disease carries a substantial morbidity and a significant mortality.Psychodermatology multidisciplinary teams (pMDTs) are essential for the cost- and clinically-effective management of patients with complex psychocutaneous disease.Quality of life and level of disability in dermatology patients is influenced more by associated psychiatric morbidity than by severity of dermatological disease. Quality of life measures are useful verified standardized tools for assessing psychosocial burden of disease and progress with treatment.Therapeutics for psychodermatology patients include psychotherapies, psychopharmacological interventions, and support from family, social workers and patient advocacy groups.Globally, groups are emerging that champion the clinical and academic excellence of the study of psychodermatology.

References

1. Sampogna F et al. Living with psoriasis: prevalence of shame, anger, worry, and problems in daily activities and social life. Acta Derm Venereol 2012; 92(3): 299–303.

2. Fortune DG et al. Psychological distress impairs clearance of psoriasis in patients treated with photochemotherapy. Arch Dermatol 2003; 139: 752–756.

3. Bewley AP et al. Psychocutaneous medicine and its provision in the UK. Br J Dermatol 2012; 167(Suppl 1): 36–37.

4. Mohandas P et al. Dermatitis artefacta and artefactual skin disease: the need for a psychodermatology multidisciplinary team to treat a difficult condition. Br J Dermatol 2013; 169(3): 600–606.

5. http://www.bad.org.uk/site/1464/default.aspx

6. Akhtar R et al. The cost effectiveness of a dedicated psychodermatology service in managing patients with dermatitis artefacta. Br J Dermatol 2012; 167(Suppl 1): 43.

7. http://www.bad.org.uk/Portals/_Bad/Clinical%20Services/Psychoderm%20Working%20Party%20Doc%20Final%20Dec%202012.pdf

8. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf

CHAPTER 2

History and examination

Ruth E. Taylor,1 Jason S. Reichenberg,2 Michelle Magid3 and Anthony Bewley4

1 Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK

2 Department of Dermatology, University of Texas Southwestern, Austin, TX, USA

3 Department of Psychiatry, University of Texas Southwestern, Austin, TX, USA

4 The Royal London Hospital & Whipps Cross University Hospital, Barts Health NHS Trust, London, UK

A psychodermatological assessment requires both a comprehensive dermatological and psychiatric assessment. Most commonly, a dermatologist with an interest in psychodermatology will be the one to complete the initial assessment, with a psychiatrist brought in as the patient accepts the need to address the mind as well as the body. In a formal psychodermatology clinic, a dermatologist and psychiatrist may see the patient jointly.

The first visit

A patient with psychocutaneous disease will usually present to a dermatologist because he/she believes the problem is primarily related to the skin (even if this is not the case). The practitioner should approach a patient with a suspected psychocutaneous disease in the same way as he/she would approach any other patient with a dermatological complaint (i.e. on the first visit, the practitioner should begin with a comprehensive history and physical examination of the patient). Attentive listening and a willingness to “lay on hands” will serve to set the tone for a therapeutic relationship in the future.

Setting expectations

Patients with psychocutaneous disease will require more time than a routine dermatological visit. It is often this time pressure that causes the most strain during the patient–physician interaction. A dermatologist should book these patients at intervals of 30 minutes or more. In a joint clinic setting, an hour is allocated for each new patient assessment. When a patient is encountered during a general clinic and no additional time is immediately available, it can be helpful to point out to the patient that additional appointments may be required to complete the assessment.

The patient should be made aware that skin problems can have a big impact on a person's psychological well-being, and therefore it will be important to evaluate them both physically and psychologically. Patients may be concerned about who will have access to their psychiatric assessment. They should be informed that the conversation is confidential, but that infor­mation will be shared with other healthcare professionals (HCPs) as appropriate (e.g. letter to the referrer and to their primary care provider) and with their permission. When writing letters, the consultant should avoid sharing unnecessary details with other providers and make sure that all of the information in these letters has been discussed with the patient beforehand.

The setting

The unique challenges of seeing a patient with psychocutaneous disease require the consultation room to be chosen with an eye towards safety and confidentiality. Though it is uncommon, patients with psychiatric disturbance may become very agitated or aggressive towards HCPs. The room needs an unobstructed exit with the physician sitting between the patient and the door. There should be a communication system to ensure rapid assistance from outside staff if the need arises.

It is common in standard dermatology clinics for there to be a lot of coming and going in the consultation room. This kind of disturbance needs to be minimized when seeing patients with psychocutaneous disease in order to help develop a setting in which patients will feel more able to discuss psychosocial issues that they may find embarrassing or stigmatizing.

Medical history

It is vital that every patient receives a comprehensive medical work-up, even if primary psychiatric disease is suspected. This will ensure that no medical conditions are left undetected and will serve to document and treat (if possible) any underlying disease, even if it is distinct from the patient's chief complaint. In addition, the patient is much more likely to share psychosocial concerns if he/she feels his/her skin and physical health concerns are being addressed.

Even those patients with a previously documented “delusional” disorder can be misdiagnosed; in one study of patients referred for a diagnosis of delusions of parasitosis, 11% were found to have an undiagnosed medical condition contributing to their disease, and 17% had obsessive-compulsive traits and no true delusions [1].

After the patient has received a thorough work-up (including laboratory testing and empiric treatments when warranted), it is important that the patient's other providers and the patient receive a copy of this work. This will prevent the patient from receiving the same work-up and treatment again, which can increase costs and impact on morbidity. It may be necessary on subsequent visits to repeat some investigations (such as examining specimens provided by a patient with delusional infestation) to maintain trust and rapport, but repeat testing should be limited.

The keystone of the first visit with a patient with suspected psychocutaneous disease is the patient interview. Many patients with psychocutaneous disease will have had the experience of being dismissed and rejected by medical professionals, so it is very important to let them ventilate any feelings of frustration and anger, and to fully hear their story.

For many patients, the most important question is: “What do you think is going on?” It is during this conversation that the healthcare provider can assess whether the patient has insight into the psychiatric aspect of his/her disease. Fears should be addressed; most dermatological patients have concerns of cancer or infection, and often will leave the visit not feeling that these issues have been specifically discussed [2].

If there are family members or friends available, it is helpful to ask them to corroborate the history of present illness, if any changes in behaviour have been observed (e.g. delirium or dementia) and what medications the patient is taking. They can also give useful information about the patient's premorbid personality and any changes in personality (see below).

The patient should be asked to provide a list of all the HCPs (including psychiatrists) who have cared for them in the past few years, and records should be obtained for a comprehensive review.

Psychiatric interview

If the patient is being seen in a joint clinic with appropriate time allotted, it is possible to complete a detailed psychiatric assessment at the initial visit. If the patient is being seen only by a dermatologist, the dermatologist should aim to start the psychiatric assessment and continue the discussion at subsequent visits. Some patients are keen to discuss the psychosocial impact of their disorder and are open to the idea of a psychiatric referral. Other patients (often those with delusional disorders or a body dysmorphic disorder) may be hostile to such suggestions. In this latter group, pursuing the psychiatric assessment too soon can be detrimental to the therapeutic rapport to the extent that the patient may not return.

Even given time constraints, as a minimum the dermatologist should ask about the impact the problem is having on the patient's life and enquire about mood, and thoughts of harm to self or others should be assessed. If the patient expresses thoughts of harm, it is mandatory to explore them and make some assessment of how likely it is that the patient will act on these thoughts (see Chapter 5). If the dermatologist is concerned that the risk is high, he/she should seek further advice from psychiatric colleagues. It is therefore important that the dermatologist knows the route for urgent psychiatric referral. Where relevant, child protection issues should be assessed (see Chapter 6).

The dermatologist should aim to eventually cover all of the various areas of psychiatric history and mental state, as outlined in Boxes 2.1 and 2.2. For detailed information about how to conduct a mental state examination, the reader should refer to undergraduate psychiatry textbooks, any of which will cover this in detail.

Box 2.1 Psychocutaneous history

Presenting complaintHistory of present illness: Duration, previous episodes, known triggers?Recent episodes of stress (physical or psychiatric) that may have precipitated psychiatric diseaseCharacter of symptoms (burning, crawling, electric shock)Distribution (dermatomal, sparing inaccessible areas)Previous medical historyPrevious psychiatric historyHistory of substance abuse (see Chapter 27)Current medications: Prescription and over-the-counter medicationsHerbs/medications obtained from non-physician providers such as traditional healersLook for polypharmacyLook for medications that can especially affect the mental state (see Chapter 3):

– Medications with strong anticholinergic activity (e.g. antihistamines and loop diuretics)

– Narcotics

– Steroid-containing medications

Family history (of both physical and mental health problems)Social history: ChildhoodSchoolingOccupationLiving arrangementsRelationship/marital history/childrenPresent social circumstancesSocial supportForensic history: History of legal difficultiesHistory of aggressive or violent behaviourPremorbid personality

Box 2.2 The mental state examination

Appearance and behaviourSpeechMood: subjective and objectiveThought: form and contentPerception (e.g. auditory, visual, olfactory hallucinations)Cognitive assessment, including orientation, attention and concentration, registration and short term memory, recent memory, remote memory, intelligence, abstractionInsight

Assessment of personality

Personality disorders are enduring patterns of behaviours that deviate from the expectations of the individual's culture. These patterns are persistent, inflexible and affect interpersonal functioning, emotional response, impulsivity and cognition (i.e. ways of perceiving the self and others). They usually begin in adolescence or early adulthood. In order to be diagnosed as a disorder, they must have a significant impact on the individual's social and occupational functioning. In assessing personality, it is important not just to rely on the patient, but to also elicit a description of patterns of behaviour from an informant (friend or relative) who knows the patient well.

DSM-5 lists ten main personality disorders, grouped into three clusters. ICD-10 lists nine of the same personality disorders, but classifies schizotypal disorder with schizophrenia and not with the personality disorders. Both ICD-10 and DSM-5 specify criteria that must be met to diagnose a particular personality disorder. The three “clusters” with their typical features are shown in Table 2.1.

Table 2.1 Types of personality disorder

Cluster AParanoidPattern of irrational suspicion and mistrust of othersSchizoidLack of interest in and detachment from social relationships, and restricted emotional expressionSchizotypalPattern of extreme discomfort interacting socially, distorted cognitions and perceptionsCluster BAntisocialPervasive pattern of disregard for the rights of others, lack of empathyBorderlinePervasive pattern of instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivityHistrionicPervasive pattern of attention-seeking behaviour and excessive emotionsNarcissisticPervasive pattern of grandiosity, need for admiration and a lack of empathyCluster CAvoidantPervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluationDependentPervasive psychological need to be cared for by other peopleObsessive compulsive (personality)Characterized by rigid conformity to rules, perfectionism and control

In dermatology clinics, as anywhere in life, any of these disorders may be seen. However, there is a recognized association of dermatitis artefacta with borderline and histrionic per­sonality disorder in females, and paranoid personality disorder in males (Box 2.3 and also Chapter 17).

Box 2.3 Personality disorders commonly encountered with dermatitis artefacta

Features of borderline personality disorder

Frantic attempts to avoid abandonmentUnstable and intense interpersonal relationshipsUnstable sense of self-image and identityImpulsiveness (e.g. in substance misuse, spending, bingeing or sex)Suicidal behaviour, gestures or threatsEpisodes of emotional instability over a period of hoursChronic feelings of emptinessIntense angerStress-related symptoms that may superficially appear psychotic

Features of histrionic personality disorder

Likes to be the centre of attentionInappropriately seductive or provocativeShallow and changeable displays of emotionUses physical appearance to draw attention to selfSpeech that lacks detail and is excessively impressionisticEmotion that is exaggerated, theatrical and shows self-dramatizationEasily influencedOver estimates degree of intimacy in relationships

Features of paranoid personality disorder

Believes, without grounds, that they are being exploited, harmed or deceivedIs preoccupied with doubts about loyalty and trustworthiness of associatesDoes not confide in others due to fear of information being misused against themSees hidden, demeaning meanings in innocuous events or remarksBears grudgesReacts angrily to perceived attacks not apparent to othersHas recurrent suspicions, without justification, of fidelity of partner

Patients with personality disorders can be difficult to manage and dermatologists should be wary of trying to manage these patients alone. Assessment and advice should be sought from a psychiatrist.

Use of screening questionnaires in psychiatric assessment

There can be pros and cons to the use of questionnaires. When a brief questionnaire is given to all patients as a matter of routine (perhaps while in the waiting room), it can provide useful psychological information without patients feeling threatened. Even if these diagnoses are unrelated to the patient's presentation, if the patient shows signs of depression or anxiety, a questionnaire can allow the practitioner to explore psychiatric symptoms and to bring up the possibility of psychiatric referral in a less confrontational manner. A disadvantage may be that the screen may reveal more psychiatric morbidity than the doctor has time to evaluate. Commonly used questionnaires are listed in Table 2.2 and a few are included for convenience in this chapter (see also the Appendix).

Table 2.2 Focused psychiatric questionnaires for use in psychodermatology clinics

NameNumber of questionsDiagnoses screenedPatient Health Questionnaire-2 (PHQ-2) [3]2DepressionPatient Health Questionnaire-9 (PHQ-9) [3]9DepressionPatient Health Questionnaire-15 (PHQ-15)15Somatic symptom disorderPatient Health Questionnaire (PHQ)59Depression, anxiety, somatic symptom disorder, alcohol, eatingCAGE questionnaire [4]4Substance use disordersHospital Anxiety and Depression Scale (HADS) [5]14Depression, anxietyMini Mental State Examination (MMSE) [6]11Cognitive impairmentBeck depression inventory-II (BDI-II) [7]21Depression

Many questionnaires can be found free online (e.g. http://www.phqscreeners.com/). However, some questionnaires are copyrighted (e.g. Beck Depression Inventory-II, Mini Mental State Examination) and practitioners should be mindful of this issue before using them.

Some questionnaires are so brief that they can be worked into the course of conversation. The Patient Health Questionnaire-2 (Box 2.4) for depression consists of just two questions. The SIG: E-CAPS (Box 2.5) mnemonic is only a little longer, but covers all of the symptoms needed to diagnose a major depressive disorder.

Box 2.4 Patient Health Questionnaire-2 for depression

A score of 2 or more has a 86% sensitivity and a 78% specificity for depression [3]

Box 2.5 SIG: E-CAPS mnemonic for the diagnosis of major depression (originally developed by Dr Carey Gross at Massachusetts General Hospital)

Patient should have low mood plus four or more of the following for a minimum of 2 weeks:

Sleep disorder (either increased or decreased sleep)Interest deficit (anhedonia)Guilt (worthlessness, hopelessness, regret)Energy deficitConcentration deficitAppetite disorder (either decreased or increased)Psychomotor retardation or agitationSuicidality

Physical examination and tissue evaluation

A full skin examination should be performed on all patients with psychocutaneous disease, unless this is likely to threaten the therapeutic relationship. This can often strengthen the therapeutic relationship as patients need to feel their skin condition is being taken seriously. All significant findings should be documented. Table 2.3 provides a guide to the skin examination.

Table 2.3 Significant physical exam findings in psychodermatology

FindingMay indicate:General appearance – dishevelledPoor self-careLowered conscious level – disorientationDelirium/dementiaTerra firma forme (brown spots)Poor self-careBacterial superinfection of woundsSecondary infection, not necessarily primaryLice or parasitic infectionPoor self-careLinear or geometric erosions/burnsFactitious lesions or signs of abuseStretch marks/skin atrophyOveruse of steroidsDermatitis/xerosisIrritation from medications or caustic agentsNail/cuticle frayingObsessive-compulsive tendenciesNail or hair dystrophyNutritional disorderExcoriation/excessive scratchingSkin picking disorder, delusional infestation

Often, patients with psychocutaneous disease have not received a full skin examination because of hesitance on their part or on the part of their other practitioners. For this reason, during this full examination it is important for the practitioner to look for signs of skin cancer and the cutaneous manifestations of internal disease. If drug abuse is suspected, look for cutaneous signs of abuse, as outlined in Table 27.1.

Biopsy and laboratory evaluation

A biopsy may be indicated if primary skin lesions are visible. If time is limited during the evaluation, it may be helpful to ask the patient to return for his/her biopsy on another day, and to ensure the area of concern has not been excoriated or treated with medication.

When patients provide the doctor with “samples”, these should be approached in a methodical manner. A handheld dermatoscope can be used to perform an initial examination. It is helpful to provide the patient with a sample bottle or glass slide and ask him/her to return at the next visit with fresh specimens. Caution should be taken before submitting these samples to a commercial laboratory for evaluation. Speak to the pathologist/microbiologist in advance. They may find worms or bugs without biological significance to human skin disease, and may send a detailed report of their findings that can serve to validate patients' concerns, especially those of delusional patients, and confuse future caregivers. In these cases, the laboratory may just want to write “No human parasites identified”.

There are no “standard” tests for all patients with psychocutaneous disease; laboratory evaluation or other testing should be guided by the patient's presentation and examination findings. For patients with confusion or a change in mental status, it is helpful to perform a baseline evaluation for delirium and dementia (Box 2.6).

Box 2.6 Initial evaluation for delirium, confusion, dementia or changes in mental status (adapted from Magid M et al., 2008 [8])

Pulse oxygenation or other non-invasive measure of blood oxygenation (arterial blood gases should be obtained if any indication of a respiratory or metabolic derangement)Complete blood countSerum electrolytes: sodium, potassium, HCO, glucoseLiver function tests (including bilirubin and ammonia if indicated)Thyroid function testsUrinalysisIron (ferritin)B12, folateHuman immunodeficiency virusRPR with reflex FTA-Abs (tests for syphilis)Urine drug screenC-reactive protein and erythrocyte sedimentation rate (if indicated)Head MRI (if indicated)Complete listing of all medications/herbs taken, with an eye toward those that have psychiatric consequences (see Chapter 3, Table 3.8)

If drug use is suspected, a urine drug screen is more helpful than a blood screen.

Planning for follow-up

If there are signs of delirium or a change in mental status, ask the patient to stop all non-essential medications. If possible, enlist the help of the patient's significant others.

Quick follow-up should be scheduled when possible, and it may be necessary to admit the patient for full medical investigation. The practitioner should allow time before the return visit to review outside records and liaise with other medical professionals.

Follow-up visits: shifting toward the psychiatric evaluation

During all subsequent visits, the practitioner should continue to ask about medications used by the patient and treat any signs of skin disease (infectious, inflammatory or malignant).