Psychodermatology: Mind the Skin

Guest Editorial Psychodermatology: mind the skin Julio Torales1,*, Beatriz Di Martino2 1Professor of Psychiatry & Head of the Psychodermatology Unit, 2Professor of Dermatology & Head of the Dermatopathology Unit, School of Medical Sciences, National University of Asunción (Paraguay) *Corresponding Author: Email: [email protected] Skin and nervous system arise from a common the infinite variety of clinical conditions and diseases of embryological origin: the embryonic ectoderm. This the skin, an organ which is able to offer a complex may be the reason by which the skin gives an account nosology that disorients the inexperienced doctor [5] of our mental and emotional state through infections need better attention than they have received so far. and injuries[1]. This is illustrated by the fact that up to 33% of dermatologic patients have concurrent Psychosomatic mechanisms psychiatric disorders or dysfunctional psychosocial aspects[2]. Any approach to the diagnosis and treatment in The importance of skin in the psychic function is psychodermatology should take into account the rooted in it being an organ of communication and fundamental fact of the “hybrid state of psychosomatic expression of emotions, role assumed from the first medicine”, which on the one hand is part of medicine moments of life of the individual. The skin is the organ with its empirical and scientific tradition and, on the of “attachment”, because the initial physical other hand, it is related to psychology and human experiences in the newborn are mainly touch. These sciences, with all its hermeneutic approaches[6]. early (and first) experiences of interaction with the In 1984 a hypothetical scheme of psychosomatic mother (or surrogate), established through the skin, are mechanism was proposed, and it remains useful to date. essential to achieve the proper organic and psycho- In this scheme, it is proposed that psychosocial emotional development of the individual. Since the skin stressors, after being filtered by cognitive activity, are is the most accessible part of the human body, it is not modulated to be printed in the subconscious and trigger uncommon for many people to express through the the mechanism of emotional stress. If this mechanism skin, aggressive, anxious or self-destructive nature takes the path of somatization it will act on the impulses, thereby causing dermatological symptoms. predisposed psychobiology of the individual [6], giving On the other hand, people with dermatological diseases rise to a skin response (in a “reactive” skin site) instead involving self-image (severe acne, psoriasis) may feel of another organ (e.g. “reactive” sites of heart, stomach, depressed, embarrassed or anxious as a result of their lungs, etc.), resulting in a group of dermatosis with high illness[3, 4]. incidence of psycho-emotional factors. In human beings, it is impossible to separate the Therefore, even if we accept, for linguistic physical illness from the mental illness although simplification purposes, the term “psychosomatic” for tragically these are seen as very different conditions. all conditions that the dermatologist sees in his/her This relationship is clearly evident in infectious disease daily medical practice[5,6,7], those conditions have been (where we have an identifiable causal agent), the divided into three groups, that we have adapted to our patient's mental state affects the body's response to daily practice (Table 1). infection and treatment[5]. Also, diseases (mainly chronic) affect the mental state of the patient, which is While all patients from the groups I and II over-imposed on the presentation and course of the primarily belong to the field of dermatology, patients disease process. In addition, there are primary from group III need primarily psychiatric help, but most psychiatric disorders that manifest themselves directly of them go to see first a dermatologist because they as physical signs and symptoms. Often in clinical perceive their skin problem but neglect, fear or refuse to practice this integrated approach is ignored. accept the mental distress or disorder[7]. This Many medical specialties can claim their classification attaches importance to the statistical relationship with psychiatry, since there are many incidence factor and stresses the “psychosomatic diseases linked with mental illness (e.g., inflammatory factor” that afflicts the first two groups of conditions (I bowel disease in gastroenterology, bronchial asthma in and II), while psychiatric illnesses in group III are pneumology, among others). However, in dermatology clearly distinct. Moreover, much importance is given to the relationship is much more evident. Common the group of psychosomatic forms (for example a skin ectodermal origin of the skin and central nervous angioma on the face, does not have psychosomatic system to explain its ability to react together, and also Telangana Journal of Psychiatry, January-June 2016:2(1):5-7 5 Julio Torales et al. Psychodermatology: mind the skin causes, but can cause significant psychological disorders. Everyone has one or more susceptible disorders). organs, which are vulnerable to stress, because of genetic or other causes (post-natal stimuli), so that a Table 1: Psychosomatic Dermatology person can respond with a disorder or cardiac Group I. Dermatologic diseases with high incidence of dysfunction, another with gastric problems and another psycho-emotional factors with skin reactions. Additionally, some individuals Hyperhidrosis Telogen show “psychosomatic” functional responses to stress Dyshidrosis effluvium and injury, in the form of vascular, muscle, stomach, or Pruritus Alopecia other spasms[8]. Hives areata Psoriasis Lichen simplex Classification Atopic dermatitis Seborrheic dermatitis The problems of terminology in the field of Acne psychodermatology are difficult to treat because of the Rosacea Perioral dermatitis special position that this issue occupies in the world of Lichen the pathophysiology, between mind and body. In planus psychodermatology one cannot ignore the fact that Herpes when the patient presents to a dermatologist, with a Nummular condition that provides “reasonable suspicion of eczema psychosomatic factors”, it can be recognized and Group II. Dermatological conditions with psychosomatic diagnosed as rebound 1. A psychophysiological disorder; In children In teenagers In adults 2. A primary psychiatric disorder; or Ichthyosis Acne Rosacea 3. A secondary psychiatric disorder (see Table 2). Alopecia Alopecia Alopecia Epidermolysis Seborrhei Table 2: Classification in psychodermatology bullosa c Group Pathophysiology Conditions Nevus dermatiti Psychophysiological Psychic sphere is Alopecia areata Angioma s disorders involved in their Psoriasis Psoriasis pathology, Neuro- Skin among other dermatitis aging multiple causes. Seborrheic Group III. Psychiatric conditions with dermatological dermatitis expression Primary psychiatric The primary Delusional Self-inflicted Phobias Delusions disorders disease is infestation injuries Dysmorphopho Delusion psychiatric, Dermatitis Dermatitis bia al manifested with artifacta artifacta Glossodynia Infestatio signs or Trichotillomania Body-focused Others ns symptoms in the Excoriation repetitive behaviors skin. (skin picking) Trichotilloma disorder nia Secondary The Vitiligo Excoriation psychiatric dermatologic Alopecia areata (skin picking) disorders disease is the Psoriasis disorder primary trigger Acne Thumb for a sucking psychological Other impact. repetitive behaviors The three groups are very different and individual conditions of each of them require specific treatment. In Some of the old theories on specific types of the first group are included dermatoses in that personality applied to psychosomatic diseases are psychophysiological influence is involved, as another [1] uncertain because of their tendency to simplify . It is element of the pathophysiology of the disease. It is the important that in clinical settings, preconceived ideas case of psoriasis, seborrheic dermatitis or alopecia should be avoided as far as possible, such as “this areata. In general, we tend to consider mental condition corresponds to this personality and this impairment as a trigger or aggravating, rather than a psychic trauma and this drug”, always giving priority in single nexus. This is the case of diseases in the second daily clinical practice to the “non-specific theory” group, the primary psychiatric disorders, in which the which proclaims that any stress or prolonged strong primary disease is mental. The paradigmatic disorder of emotion can cause pathological and/or mental this group is delusional infestation (previously known Telangana Journal of Psychiatry, January-June 2016:2(1):5-7 6 Julio Torales et al. Psychodermatology: mind the skin as Ekbom’s syndrome). The third group includes 5. Romaní de Gabriel J, Chesa Vela D. Psicodermatología dermatologic disorders with psychological impact, en atención primaria [Psychodermatology in primary mainly by altering the image of the individual. In this care]. Piel 2005;20(6):282-289. 6. Panconesi E. Notas introductorias sobre la clasificación case, the direction of the pathophysiology goes from the de las modalidades clínicas en Dermatología skin to the central nervous system, while in the first Psicosomática [Introductory notes on the classification of group it goes from the mind to the skin. In the first and the clinical models in psychosomatic dermatology]. In: the last group there

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