Psychiatric illness in patients referred to a dermatology-psychiatry clinic

ELSEVIER

Psychiatric Illness in Patients Referned to a Dermatology-Psychiatry Clinic I? W. R. Woodruff,

E. M. Higgins,

A. W. l? du Vivier,

There is a recognized psychiatric morbidity among those who attend dermatology clinics. We aimed to determine the pattern ofpsychological and social problems among patients referred to a liaison psychiatrist within a dermatology clinic. Notes from 149 patients were reviewed and more detailed assessments performed in a subgroup of 32 consecutive referrals. All but 5% merited a psychiatric diagnosis. Of these, depressive illness accounted for 44% and anxiety disorders, 35%. Less common general psychiatric disorders included social phobia, somatization disorder, alcohol dependence syndrome, obsessive-convulsive disorder, posttraumatic stress disorder, anorexia nervosa, and schizophrenia. Classical disorders suchas dermatitis artefactaand delusional hypochondriasis were uncommon. Commonly, patients presented with longstanding psychological problems in the context of ongoing social difficultiesrather thanfollowing discrete precipitants. Psychiatric intervention resultedin clinical improvement in mostof those followed up. Of the dermatological categories 1) exacerbation of preexisting chronic skin disease; 2) symptoms out of proportion to the skin lesion: 3) dermatological nondisease; 4) scratching without physical signs, the commonest were dermatological nondisease and exacerbation of chronic skin disease. Anxiety was common in thosefrom all dermatological categories. Patients un’th demuztologicalnondisease had the highest prevalence of depression. Skin patients with significant psychopathology may go untreated unless referred to a psychiatrist. The presence of dermatological nondisease or symptoms out of proportion to the skin disease should particularly alert the physician to the possibility of underlying psychological problems.

and S. Wessely

tients who attend dermatology clinics is of the or-

der of 30%40% ill. Perhaps the best described, but least common group of such patients, are those who have a psychiatric illness that leads directly to a dermatology referral, e.g., dermatitis artefacta and delusional parasitosis. More commonly, however, psychological problems are coincident with eczema or psoriasis [2]. In addition, about 40% of those with psoriasis report that stress exacerbates their condition, and this proportion is greater in those with more disfiguring disease 131. Patients also seek help from a dermatologist for a skin complaint, but may have no discernable skin lesion on examination, i.e., dermatological nondisease 141.Here the origins of the complaint lie in psychological problems, often severe, and occasionally these result in suicide [51. Dermatologists therefore commonly see patients with underlying psychiatric problems. Knowledge of characteristics of such patients presenting with skin complaints would alert physicians to refer to a psychiatrist those most likely to benefit. Preference to be treated for physical rather than mental illness, e.g., due to ‘stigma,’ may determine why some patients seek treatment from a dermatulogist as opposed to a psychiatrist. One way of reducing such stigma is to have a psychiatrist working within the dermatology clinic. In such a setting, we performed a clinical study of patients referred to a psychiatrist. We examined clinical patterns of psychiatric illness among a specialized subgroup of dermatology outpatients, i.e., those diagnosed by the dermatologist as having a significant enough psychiatric problem to merit a referral to the Psychiatry Liaison Clinic. The purpose of the study was to 1) identify clinical

Department of Psychological Medicine, Institute of Psychiatry and King’s College School of Medicine and Dentistry, London, England (P W. R. W.); Department of Dermatology, King’s College School of Medicine, London, England (E. M. H.1; King’s College Hospital, London, England (A. W. P. du V.); Department of

Psychological Medicine, Kings College School oi Medicine and Dentistry, London, England 6. W.1 Address reprint requests to: Dr. Woodruff, Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, SE5 SAF, United Kingdom

Abstract:

0 1997 Elsevier Science Inc.

Introduction The prevalence

of psychiatric

General Hospital Psychiatry 0 1997 Elsevier Science Inc. 655 Avenue of the Americas,

19,29-35, New

York,

illness among

pa-

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1997 NY 10010

ISSN 0163-X343/97/$17.00 PTr 50163-P~4~(97)on155-7

I? W. R. Woodruff et al. patterns of psychiatric illness among a subgroup of dermatology outpatients; 2) delineate clinical features of patients more likely to need psychiatric referral; 3) examine skin symptoms in the context of psychiatric, social, and other problems, and 4) determine the effects of psychiatric intervention in the setting of a liaison psychiatry clinic. Previous studies have documented psychiatric morbidity in dermatology outpatients using selfreport questionnaires, which may lead to overestimates of psychological morbidity Ill, or a structured psychiatric interview 121. We used information derived from a full psychiatric interview to estimate the pattern of psychiatric disorders in those referred. We wished to expand on Sheppard et al.‘s [4] descriptive study in a larger sample of psychiatric referrals from dermatologists within a liaison clinic. We also tried to ascertain the usefulness of psychiatric intervention which was not attempted in previous studies.

Methods Included in the study were 149 consecutive referrals by a dermatologist to a psychiatry liaison clinic situated within a skin outpatients department. Psychiatric and dermatological information from letters and available notes was obtained for each patient who had undergone a complete clinical psychiatric evaluation. In addition, more detailed social, life event, and follow-up data were collected systematically on a subsample of 32 consecutive referrals by one psychiatrist (PW) over 1 year. Social class (l-5) was defined according to that based on the Registrar General’s Classification including separate categories for housewives and unemployed [6]. Case histories were reviewed and the primary psychiatric diagnosis categorized according to the ICD-10 Classification of Mental and Behavioral Disorders [71 as follows: 1) mild to moderate depressive episode or disorder; 2) mild generalized anxiety; 3) severe depressive episode or disorder; 4) severe generalized anxiety; 5) social phobias; 6) obsessive-compulsive disorder; 7) posttraumatic stress disorder; 8) somatization disorder; 9) alcohol dependence syndrome; 10) anorexia nervosa; 11) hypochondriacal delusional disorder (including delusional parasitosis); 12) factitious disorder (dermatitis artefacta); 13) schizophrenia; and 14) no disorder/unwilling to discuss problems with psychiatrist. The skin condition was classified into the following categories: 1) exacerbation of known chronic

30

skin disorders, e.g., eczema, psoriasis, alopecia areata; 2) symptoms out of proportion to the degree of skin eruption, e.g., minor acne; 3) dermatological nondisease; 4) scratching without a dermatological cause; 5) dermatitis artefacta or delusional hypochondriasis. The duration of psychiatric and skin symptoms was classified from 1 (days) to 6 (>l year) according to the operational classification (OPCRIT) 181. The most predominant skin symptom (itching, burning, or appearance) was recorded. The site of skin symptoms included generalized, face, limbs, genitals, mouth/tongue/lips, and head/scalp/neck. Life events were defined as major events that would have a significant psychological impact on most people, e.g., marriage, bereavement. The number of significant life events as specified on the Holmes and Rahe Social Readjustment Rating Scale within 6 months preceding clinic attendance were recorded, as was the time since the last significant life event at any time previously [91. Previous divorce, a precipitating event, or concurrent physical illness were not included as a life event because they were recorded separately Ongoing major social difficulties were judged on the basis that most people would not regularly experience them and would regard them as severely distressing. Examples included violence from husband, social isolation, life-threatening illness in the family, or bereavement of less than 5 years previously, not included as a precipitating event. Previous divorce or a precipitating event if present were excluded from criteria for ongoing social difficulties.

Results Details on All Patients Seen in the Liaison Clinic The mean age of all 149 patients was 44.88 + 17.8 (12-88); 59% were female (mean age 46.8 + 18.2, 17-88) and 41% were male (mean age 41.9 f 16.9, 12-85). The most common psychiatric diagnoses were mild to moderate depression (28%), mild generalized anxiety (25%), and severe depression (14%) (see Table 1). Mild to moderate depression and somatization disorder were more common in females. Forty percent of all patients had a past psychiatric history, 29% has a family psychiatric history, and 29% also suffered concurrent physical illness. Social difficulties were present in 78%, affecting 84% of females and 68% of males (Table 2). Of those with at least one social difficulty, the mean number was 1.66 f 0.86 (range l-5).

Psychiatric

Table 1. Psychiatric

Illness and Dermatology

diagnoses for 149 patients seen in skin liaison clinic

-...

_-__-.--

N = 149 Diagnosis Mild/moderate

depressive

ICD-10 episode/disorder

Generalized anxiety disorder (mild) Severe depressive episode/disorder Generalized anxiety disorder (severe) No psychiatric disorder/ not willing to discuss Delusional disorder (hypochondriacal) Social phobia Somatization disorder Alcohol dependence syndrome Obsessive-compulsive disorder Posttraumatic stress disorder Schizophrenia/Schizotypal disorder Anorexia nervosa Factitious disorder

(dermatitis

artefacta)

42 (8:34) F32.1 F33.0 F33.1 F41.9 F32.2 F33.2 F41.1

F22.0 F40.1 F45.0 F10.2 F42.0 F43.1 F20 F21 F50.0 F68.1

The psychiatric diagnoses within each dermatological category are shown in Table 3. Those presenting with exacerbation of chronic skin disease and dermatological nondisease were most likely to have mild depression or anxiety. There was a sizable number of patients with severe depression in these categories as well as in those with symptoms out of proportion to physical signs. The main dermatological categories from 148 available records were dermatological nondisease (34%) and exacerbation of chronic skin disease (32%), symptoms out of proportion to the skin disease (19%), and scratching without physical signs (11%). The classical psychiatric skin conditions were uncommon (4%) including only one with dermatitis artefacta. Dermatological nondisease was found in 40% of males and 29% of females whereas scratching without physical cause affected 8% of males and 12% of females. Skin symptoms from 133 records included itching (54%), appearance (26%), and burning (13%). Concern over appearance was reported by 30% of males and 24% of females. Burning was recorded in 16.4% of females and 9.8% of males. Skin site, recorded for 107 patients, was mostly either generalized (27%) or focused on the face (25%), limbs (14%), or genitals (13%); 22% of males

(61M:88F) 28.2

YC

N = 32 ------

10

‘rr

31.3

37 (22:lS) 21 (7:14)

24.8 14.1

7 h

21.9 18.7

13 (8:5)

8.7

2

6.3

4.7 4.0 4.0 4.0 2.0 1.3 1.3 1.3

7

3.1

2

6.3

2 1

b.3 3.1

0.7

1

7 6 6 6 3 2 2 2

(3:4) (4:2) (2:4) (1:5) (3:O) (2:O) (0:2) (0:2)

1 (0:l) 1 (0:l)

complained of genital 6% of females.

symptoms

- .-l_l

compared

3.1

with

Detailed Information Over 2 Year Of 42 patients referred, 10 did not attend. The mean age of the 32 attenders was 45 % 18.8 119-W; 21 (65%) were female and 24 (75%) were Caucasian. Social classes 1 & 2 included 14 individuals, 8 were from social class 3 and 5 from social classes 4 & 5; 4 were housewives and only 1 was unemployed. All 32 patients had experienced psychiatric symptoms for more than 1 month and 20 for more than 1 year. A similar longstanding pattern was observed in the duration of skin symptoms. Psychiatric diagnoses, shown in Table 1, follow the pattern of the larger group, with depression and anxiety being the commonest. Skin diagnoses included exacerbation of skin disease @I = 13); dermatological nondisease (N = 12); scratching without cause (N = 3); delusional parasitosis (PIJ = 2); dermatitis artefacta (N = I); and disproportionate symptoms (N = 1). Skin symptoms included itching (N = 19); concern about appearance (N = 6); burning (N = 5); and bizarre complaints (IV = 21, e.g., the sound of a chiming clock in the brain. Other than 12 patients in whom skin complaints

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l? W. R. Woodruff et al. Table 2. Major social difficulties

in clinic patients

over 1 year (N = 32) and the total 149 patients

Type of social difficulties

N= 32

N = 149

Total number of social difficulties experienced Relationship problems with partner Social isolation/housing problems Work problems-redundancy/unemployment

51 15 9 8

160 42 19 25

Sexual problems

7

15

Family problems (excluding marriage)

7

23

Bereavement ~5 years Financial/property

5 0

28 8

were generalized, localized areas such as the face (N = 91, head/neck/scalp (N = 5) were equally affected. Depression and anxiety accounted for all cases of skin complaints localized to the limbs, 7 with facial symptoms and 9 cases of generalized skin complaints. The 2 patients with social phobia had facial symptoms. One female patient who complainted of genital symptoms without genital pathology had sexual difficulties and a history of rape. Itching was a symptom in those with severe depression (IV = 6) and those with milder depression or anxiety (N = 91, as was burning (N = 3). Concern about appearance was evident in those with mild depression and anxiety (N = 4) including 2 individuals with social phobia.

Other Factors Associated with Psychiatric Illness Nine individuals were single, 8 divorced and 3 widowed. A third of the patients (N = 11) had concurrent physical illness and a past psychiatric history (N = 10). A family history of psychiatric illness was reported in 7 subjects. A clear precipitating event prior to the onset of psychiatric illness was present in 11 patients and included bereavement (N = 4), work problems (N = 31, skin problems (N = 31, and travel (N = 1). However, only 6 individuals had a major life event in the 6 months preceding clinic attendance and in half, at least a year had elapsed since the last reported major event in their life. However, most (N = 24), as in the larger sample, had longstanding, ongoing major social difficulties outlined in Table 2 (mean number for total 32 patients = 1.96 + 1.10, O-5). There was no temporal

32

Examples of social difficulties for the whole group Violent husband (5); infidelity (4) Unemployment/redundancy (6) Problems with the press (1) Impotence (5); extreme fear of AIDS (3); previous rape (2); transsexual with marital difficulties (1); sexual abuse (2) Ill/invalid family member (10; including life-threatening illness (3)) Violent death (1) House burgled (2); gambling debts (1)

relationship between chiatric symptoms (r relation between the toms and time since -0.33; NS).

the duration of skin and psy= 0.19; NS). There was no corduration of psychiatric sympthe last major life event (r =

Dematological Nondisease with Exacerbation of Chronic Skin Disease In dermatological nondisease, the ratio of males to females was 78 contrasting with the equivalent ratio of 1:2 overall in clinic attenders. Whereas patients with exacerbations of chronic skin diseases and dermatological nondisease were equally represented among social classes 14, those with dermatological nondisease included more housewives and unemployed. A similar number of patients were divorced or separated in both groups. Skin symptoms included all categories but “burning” was present in 4 cases of dermatological nondisease and in none of the patients with exacerbations of chronic skin disease. Skin site in those with dermatological nondisease tended more to be localized to the limbs (4/15) or head, neck, or scalp (5/15X The duration of skin symptoms was long in all diagnostic categories, e.g., 26 months in lo/12 cases of dermatological skin disease and 9/12 in those with exacerbation of chronic skin disease. Only 3/15 patients with dermatological nondisease had a life event recorded in the previous 6 months. there was no difference between patients with dermatological nondisease and chronic skin disease in prevalence of social difficulties, physical illness, family and past psychiatric history, number

Psychiatric Illness and Dermatology Table 3. Psychiatric

and dermatological

diagnoses in 148 patients Dermatological

Psychiatric diagnoses Mild /moderate depressive episode/disorder Generalized anxiety disorder (mild) Severe depressive episode/disorder Generalized anxiety disorder (severe) No psychiatric disorder/not willing to discuss Delusional disorder (hypochondriacal) Social phobia Somatization disorder Alcohol dependence syndrome Obsessive-compulsive disorder Posttraumatic stressdisorder Schizophrenia/Schizotypal disorder Anorexia nervosa --

Chronic skin condition

Symptoms out of proportion to physical signs

diagnoses (N = 148)

Dermatological nondisease

Scratching without cause

15

6

17

3

13

6

10

8

7

6

6

1

1

4

5

3

1

1

4

I

1 2 2

2 1

1 2 3

1 1

._---.

- --.----

Delusional disorder (parasitosis? --_--.-

Dermatitis artefacta 1

1

2

1 1

1 1

of precipitating events, default rate, and acceptance of the need for treatment. Treatment

_-_--- ___

and Follow-up

The majority of attendees (N = 26) accepted the need for the initial psychiatric referral. All but 2 patients needed follow-up treatment, 12 of whom either refused to defaulted from follow-up. Drug treatment for depression as prescribed for 18 patients and 6 received specific cognitive behavioral

treatment. A significant improvement was reported for 15 patients on follow-up and only one showed no improvement.

Discussion Psychiatric referrals for a dermatology clinic are selective, and so the prevalence figures quoted may

1

--..1__-

of an epidemilogically based sample; they can provide an indication of the sorts of probIems clinicians might expect to see in similar clinical settings. We included both the small and larger samples in this study so that the detailed description of the former could complement the overall impression given by the latter. The high prevalence of psychiatric pathology in patients referred from a dermatology outpatient clinic was confirmed. Overall, only 5% either denied or had no psychiatric problem. PvIost of the workload of the liaison psychiatrist was dealing with general psychiatric problems, particularly depression and anxiety. The signifieant levels of severe depression, especially in those with symptoms out of proportion to physical cause, is noteworthy. In the detailed survey, depression accounted for most of the need for drug treatment and improve-

not directly apply to other clinical settings. Furthermore, it may be that more detailed history taking in the subsample led to greater estimates of social difficulties in this group compared with the larger co-

ment of these who attended follow-up; therefore it is particularly important to recognize and treat

hort. Although the prevalence figures are not those

history was longstanding in the context of compli-

these patients. Except those few for which bereavement had precipitated depression, the psychiatric

33

I? W. R. Woodruff

et al.

cated chronic social problems. This was confirmed by the high level of social problems observed overall. Anxiety and “stress” in those not clinically depressed was commonly experienced, in parallel with the presence of social difficulties likely to perpetuate these feelings. Social problems often concerned close relationships; anxiety invoked by the violent husband or guilt induced in the unfaithful man; sexual difficulties associated with impotence, rape, fear of AIDS; the stress induced by looking after an ill or invalid relative; the insecurity, isolation, and loss of bereavement. Such examples serve to emphasize the need to enquire about personal problems in anxious patients. The impact of skin disorders on appearance affected an equivalent number of males and females. Despite evidence that females may be more concerned about appearance in some clinical settings, e.g., dental malocclusion [lo], there may be little gender difference in reported concerns over appearance in those with skin conditions such as psoriasis [ll 1.The behavioral expression of this concern may, however, differ between the sexes. For instance, in a study by Lanigan and Cotterill 1121 of people with port wine stains, the majority of all subjects (male and female) felt the need to hide their birthmark, although women used makeup more than men to achieve this. The site of the skin complaint may have had symbolic significance for some patients in whom the complaint was disproportionate to the pathology, e.g., cheilitis in two women with unfaithful partners, lip lesions in two men who had recently had an affair; penile rash in two men with impotence, and pruritus of the upper thigh in a girl sexually abused by her grandfather. These examples illustrate the importance of placing skin symptoms in their social and psychological context in individual cases. However, as a group, psychiatric conditions were not associated with specific skin symptoms or site. This observation parallels the finding of Wessely and Lewis [21 that the extent of skin affected was not related to psychiatric morbidity. Dermatological nondisease was common in males as well as females, a finding consistent with the work of Sheppard et al. 141and Cotterill [5]. The complaint of “burning,” usually associated with depression, was more common in dermatological nondisease than in other skin conditions. Dermatological nondisease was associated with high rates of psychiatric disorder, particularly depression, as also reported by Wessely and Lewis 121and Cotterill [5]. In some cases, depression may be sufficiently se-

34

vere to result in suicide [51. It is especially important therefore to enquire about depressive symptoms in those who present to a dermatologist without visible skin disease.

Conclusions Much of the psychiatric workload in the skin liaison clinic is general. Depression and anxiety were the commonest psychiatric conditions found in those referred to the liaison clinic. Important, but less common psychiatric diagnoses included delusional parasitosis, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder. The so-called psycho dermatology conditions such as dermatitis artefacta and delusions of infestation, although emphasized in textbooks, are in fact uncommon, except perhaps in specialist psychiatric outpatients. Such patients referred by dermatologists are associated with significant psychiatric morbidity, Psychiatric symptoms were long-standing and associated with severe chronic social difficulties often concerning problems with close relationships. Exacerbation of chronic skin disorders, disproportionate concern with skin symptoms, dermatological nondiseases, and scratching without cause showed considerable overlap in psychiatric symptoms. However, dermatological nondisease was relatively more common in males who complained of burning in their limbs, head, scalp, or neck. Patients presenting with this condition should be referred to a psychiatrist for assessment. Skin symptoms were of long standing and there appeared little temporal relationship between their onset and that of psychiatric symptoms. It is possible that in the majority of cases, a steady accumulation of social difficulties rather than definite precipitants determine the patient’s decision to be seen by the dermatologist. Most of those patients who attended the liaison clinic responded to their respective treatments whether it was medication, supportive, or specific psychotherapy.

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application of operational criteria in psychotic illness: development and reliability of the OPCRlT system. Arch Gen Psycho1 48:764-770, 1991 Holmes TH, Rahe RH: The social readjustment rating scale. J Psychosom Res 11:2X3--218, 1967 Helm S, Petersen PE, Kreiborg S, Solow B: Effect of separate malocclusion traits on concern for dental appearance. Community Dent Oral Epidemiol 14:217220,1986 Gupta MA, Gupta AK: Age and gender differences in the impact of psoriasis on quality of life. Int 1 Dermat01 34(10):700-703, 1995 Lanigan SW, Cotterill JA: Psychological disabilities amongst patients with port wine staines. Br J Dermato1 121:209-215, 1989

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