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New resource helps to identify psychiatric comorbidities

Two Canadian clinicians have published an update that summarizes the current state of psychodermatology, a field that deals with the link between skin and mind.

In the update, they outline the changes relevant to psychodermatology in the Diagnostic and Statistical Manual of Mental Disorders 5 the edition (DSM-5) and synthesize them with the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines.

Published in Skin Therapy Letter (May 2016; 21(3):4–7), the paper was created as a resource to be a tool to help dermatologists and other physicians easily recognize psychiatric comorbidities in

skin conditions, and to provide them with options on how to proceed when they do identify patients with such comorbidities, said Dr. Dominik Alex Nowak, one of the paper’s authors.

Comorbidities common

“Up to one-third of our patients with skin disease will also have a psychiatric issue,” said Dr. Nowak. “Skin is the interface through which our patients interact with the world, and it is clear to see how the main harm of skin disease will often be its effect on self-image, mind and mood.”

Dr. Nowak developed the paper with Dr. Se Mang Wong, dermatologist and director of Undergraduate

Education in the Department of Dermatology & Skin Science at the University of British Columbia,


“The World Health Organization cites major depression as the second leading cause of disability worldwide, but we often fail to pick it up. These patients slip through the cracks.”

Although clinicians often screen for non-skin complications of skin disease, such as checking for psoriatic arthritis in patients with psoriasis and referring to a rheumatologist where appropriate, screening for depression or other mental illness in these same patients is much less common, he said.

Social stigma, a press for time, and difficulty in referral all play a role, said Dr. Nowak.

“Waiting lists can be long, and conversations around mental health can be tough. We may not want to

open this Pandora’s box,” he said.

However, he says that making the effort could save lives.

Dr. Nowak cites a paper from 2015 (Journal of Investigational Dermatology Apr. 2015; 135(4):984–

991) that looked at almost 5,000 general dermatology outpatients.

“Nearly 13 per cent of dermatology outpatients they studied had suicidal ideation,” he reported. This meant they either hoped they would not wake up in the morning or they hoped to take their own life.

“Patients with psoriasis, for example, had 17.3 per cent association with suicidal ideation in this study,” he added. “Two-thirds of these patients reported that their suicidal ideation was a direct consequence of

their skin condition. But, especially when dermatology patients do not have a good relationship with a primary care provider, we are missing this co-morbidity altogether.”

Psychiatric co-morbidities addressed in Dr. Nowak’s paper include depressive disorders, anxiety

disorders, obsessive-compulsive and impulse-control disorders (such as self-harm of the skin), psychotic and delusional disorders (including delusional parasitosis), and cutaneous sensory disorders (such as sensations of itching, burning, pain, and formication—the feeling of insects crawling on or under the skin). The CANMAT guidelines for both pharmacologic and non-pharmacologic therapies for these co-morbidities are also explored.

What’s new in the DSM-5s

The most significant changes between the fourth and fifth editions of the DSM related to psychodermatology have been within the obsessive-compulsive and related disorders, said Dr. Nowak.

“The [DSM-5] authors clarified many aspects within the obsessive compulsive and related disorders.

More evidence has emerged that these disorders are not only related to one another, but that it is clinically useful to group these disorders together. The two new diagnostic groups in this chapter include excoriation disorder, which involves skin picking, and trichotillomania, which involves hair pulling,” he said.

In previous editions of the manual the two disorders did not have their own classification, said Dr.

Nowak. Skin-picking disorder would have been found under ‘stereotypic movement disorder with self injurous behaviour’ or ‘other disorders of infancy, childhood, or adolescence,’ though the condition is not truly limited to young people. “This [new classification] is much more explicit. It allows us to say exactly what the disorder is and lists specific diagnostic criteria.”

Body dysmorphic disorder (BDD) has also been reclassified. This condition may have a prevalence as high as 15% among plastic surgery and dermatology patients, compared to up to 3% in the general public, said Dr. Nowak.

It involves a preoccupation with a perceived physical flaw, and by repetitive behaviours surrounding this flaw.

While earlier editions of the DSM would have classified BDD as a delusional or psychotic state, in the new edition BDD falls under the umbrella of obsessive-compulsive and related disorders. BDD patients will rarely be satisfied with a cosmetic outcome. More importantly, one-quarter will have a suicide attempt in their lifetime.

Acknowledging that time is a tight resource in most clinics, Dr. Nowak said that screening for many

mental health comorbidities of skin disease can be done very quickly.

Screening can be done quickly

“There is a validated ultra-rapid depression screening tool called the PHQ-2,” said Dr. Nowak. The Patient Health Questionnaire-2 (PHQ-2) is a two-item questionnaire that can be administered by the physician or completed by the patient in the waiting room.

“It asks two straightforward questions around the major criteria of depression. First, it asks for anhedonia. That is, in the last two weeks have you had little interest or pleasure in doing things? The second question asks for depressed mood. That is, have you been feeling down, depressed, or hopeless?

These questions take only a moment and will catch most patients with major depression who need further assessment.”

This makes the PHQ-2 a very feasible addition to a standard appointment. The tool can help identify

patients with one of the most common psychiatric comorbidities, which is also one of the most negatively impactful to patient quality of life, he said.

He recommended dermatologists align themselves with a ‘skin-emotion specialist’ be it a psychiatrist, social worker or other mental health professionals.

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