PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 3

blog-6

The last in our 3 part series addressing psychological and psychiatric disorders associated with psoriasis.

   Psychological and Psychiatric Disorders –

   Sleep Disorders

   Somatoform Disorders

   Substance dependence of abuse

1, 2, 3

Sleep Disorders

It is thought that psoriasis has a direct effect on the development of sleep disorders due to the cutaneous (skin) symptoms of the condition. The skin is the primary circadian mediator of core body temperature (CBT), and a decrease in CBT in the late evening is an important mechanism for sleep initiation. Psoriasis has been associated with problems with thermoregulation and researchers have indicated that the reduced ability to dissipate heat is one factor in the inability to initiate sleep. Pruritus (itch) is another contributor to sleep disturbance and it is also regulated by circadian mechanisms. The threshold for pruritus is lowered in the evening due to complex circadian-mediated factors such as lower cortisol levels, decreased epidermal barrier function, and increased distal-to-proximal (distant limbs-to-body centre) gradient in skin temperature. Thus pruritus in psoriasis typically manifests or exacerbates mainly in the evening and worsens at night. 4,5,6

 so-tired-1440121-1600x1200

The inflammatory biological mechanism(s) that lead to initiation and exacerbation of psoriasis, also contribute to the development of systemic diseases e.g. depressive disease, hypertension (blood pressure), adverse cardiac events, diabetes, metabolic syndrome and obesity. All of these conditions are known to indirectly give rise to sleep-disordered breathing. The heightened pro-inflammatory state in conditions such as obstructive sleep apnoea syndrome (OSAS) and insomnia could in turn lead to exacerbations of psoriasis.4,5,6

A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified an increased prevalence of OSAS with a 36-81% prevalence in psoriasis versus 2% for women and 4% for men in the general population.4,5  In one study researchers found that some patients with chronic psoriasis and concurrent OSAS showed improvement of their psoriatic lesions while on nasal continuous positive airway pressure (CPAP).6 OSAS leads to severe physical and, possibly, psychological stress to the body, e.g., by hypoxemia (low blood oxygen levels), increased blood pressure, tachycardia (fast or irregular heart rate), sleep fragmentation, reduction of deep sleep, reduction of REM sleep, hypersomnia (excessive sleepiness), and insomnia. It is known that OSAS also dysregulates the function of the patient’s autonomic nervous system and hormone system. It is felt that this might alter the homeostasis of the immune neuroendocrine network in the skin and may cause the initiation of psoriasis in the genetically predisposed individuals.4,5,6

Somatoform Disorders – psychosomatic symptoms

Somatization is the manifestation of psychological distress by the presentation of bodily symptoms such as feeling nausea due to anxiety, stress headaches, falling ill after a trauma and inability to cope with a disease. 

Patients with psoriasis exhibit higher scores of hypochondriasis, hysteria, and somatization. As previously exposed hypochondriasis and hysteria may be connected with specific personality traits of patients with psoriasis of late-onset. Psychosomatic factors, namely stressful life events, lack of social support, and attachment insecurity, may explain why patients with psoriasis have greater scores of somatization. Moreover, the presence of depression in psoriasis may modulate itch perception and then exacerbate symptoms of pruritus.7 (Refer to Part 1 of this series) A systematic review of the psychosocial burden of psoriasis found that social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity. Some psoriasis patients had, even when their lesions were small and mild, levels of stress and loss of confidence that was not in keeping with the severity of their condition – which leads to the conclusion that they had maladaptive coping mechanisms in play e.g. self blame, blaming parents, social phobia, avoidance behaviours, substance and alcohol abuse etc. 9

Substance – Dependence of Abuse

In our previous blog Psoriasis and Alcohol (ethanol), we stated that patients with psoriasis experience considerable emotional distress, depression and social isolation due to the visibility of skin lesions, especially when the lesions are widespread and severe. Whilst it would be demeaning to state that all psoriasis patients with mild to severe psoriasis suffer from alcoholism, it has been confirmed in several Quality of Life studies that the percentage of psoriasis patients who admit to having a drinking problem may be as high as 32%. Research indicates that men are more likely to use alcohol excessively as a coping mechanism with the psychosocial burden of psoriasis. Consequently they are at a higher risk of developing depression – with the alcohol misuse and psoriasis as underlying causes. 4 Another study indicated that for women, excessive alcohol intake above a certain threshold (?30.0 g/d), may be associated with a significantly increased risk of Psoriatic Arthritis (PsA).5

have-a-drink-1-1510449-640x480-1

Alcohol is known to inhibit inflammation and immune responses; however acute and chronic alcohol consumption have opposite effects on inflammatory cell activation. Results indicate that acute alcohol exposure is inhibitory, whereas chronic alcohol exposure leads to an increase in inflammatory cell responses.6

Research has confirmed that alcoholics are more susceptible to infections, as streptococcal infections are trigger factors for psoriasis, this increased susceptibility may be involved in the onset and progress of the disease. It is also known that measurable quantities of ingested ethanol are secreted through human skin. Transdermal ethanol derives from two processes: active secretion by eccrine glands, primarily sweat glands, and passive diffusion through the lipid layers of the skin. Ethanol disrupts the dermal barrier enhancing skin permeability for numerous chemicals and increases the solubility of penetrating chemical compounds.6

Research into the the use of illicit drugs and psoriasis is extremely limited. Methylenedioxymethamphetamine (MDMA), also called Ecstasy, has been reported to initiate Guttate Psoriasis. The researchers theorized that “While MDMA [the main ingredient in ecstasy] is taken for its psychomimetic effect, pharmacologically it increases the level of noradrenaline, serotonin and dopamine by inhibiting the reuptake mechanism. It is known that Patients with psoriasis already have increased levels of noradrenaline.”7 There are also anecdotal stories on support websites where psoriasis sufferers have spoken about the exacerbation of their psoriasis with the use of “meth” (Methamphetamine, Ice). Within our clinic we have had several patients whose psoriasis was initiated and exacerbated by the use of cannabis (street not medicinal), once they ceased the use of cannabis their psoriasis resolved. As long as they did not use cannabis they remained free of any psoriatic lesions.

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Brenaut E. et al.; Alcohol consumption and psoriasis: a systematic literature review. J Eur Acad Dermatol Venerol. 2013 Aug;27 Suppl 3:30-5. doi: 10.1111/jdv.12164.
  • Shaowei Wu et al.; Alcohol Intake and Risk of Incident Psoriatic Arthritis in Women; J Rheumatol. 2015 May ; 42(5): 835–840. doi:10.3899/jrheum.140808.
  • Farkas A, Kemény L.; Psoriasis and alcohol: is cutaneous ethanol one of the missing links?; • British Journal of Dermatology 2010 162, pp711–716
  • Tan B., Foley P.; Guttate psoriasis following Ecstasy ingestion; Australasian Journal of Dermatology45(3):167-9 September 2004?

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 2

blog-5

WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

 CHART 1: Comorbidities Associated with Psoriasis

    Psychological and Psychiatric Disorders –

   Personality Traits and Personality Disorders

   Schizophrenia and other psychoses

   Sexual Dysfunction

1, 2, 3

Personality Traits and Personality Disorders

It has also been proposed by a number of researchers that patients with skin disease usually present with certain psychological traits that makes them vulnerable to stress. Although a specific personality structure for psoriasis patients has not yet been defined, psoriasis patients are reported to have more obsessive compulsive, avoidant, schizoid and passive-aggressive properties than healthy controls, however the research surrounding personality and psoriasis is still controversial. 4

The term personality represents the different behavioural styles that individuals present in their habitual habitats or environments.4 In one study of male psoriasis patients and a control group the psoriasis group scored significantly higher scores than the control group in Extravagance (NS3), Disorderliness (NS4), Novelty Seeking (NS), Anticipatory Worry (HA1), Shyness with Strangers (HA3), Fatigability and asthenia – weakness – lack of energy and strength (HA4), Harm Avoidance (HA), Dependence (RD3), Reward Dependence (RD), Self-forgetfulness (ST1), Transpersonal Identification (ST2), Spiritual Acceptance (ST3) and Self-Transcendence – the ability to focus attention on doing something for the sake of others (ST).5

Another study found that the severity of pruritus (itch) and the severity of psoriasis was associated with significantly higher scores for depression and anxiety, and showed the personality traits of somatic anxiety (physical reactions to anxiety e.g. sweating, nausea etc.), embitterment, mistrust, and physical trait aggressiveness. However, the researchers also found that the severity of itch was not associated with the severity of psoriasis from a PASI score perspective. In fact they found that there was a higher severity of itch reported in 30% of psoriasis patients in which the greater majority of these had very few lesions.6

Psoriasis Patients often report felt or perceived stigma, referring to the negative attitudes and responses that they perceive to be present in society and the sense of shame and fear of being discriminated against because of being ‘flawed’ due to the physical appearance of their lesions. The actual experiences of stigmatization range from –  people showing disgust or aversion, making negative comments or totally avoiding contact.6

Stigmatization contributes considerably to disability, depression and reduced quality of life in psoriasis patients, and can be considered a stressor. As distress can be a trigger for psoriasis exacerbation, this can become a vicious self-perpetuating cycle. The Type D personality has previously been associated with increased risk of cardiovascular morbidity and mortality and impaired health behaviour e.g. smoking and alcohol dependence, which are both frequently reported in psoriasis. The two main features – SI (social inhibition) and NA (negative affectivity) – may both increase the impact of perceived stigmatization. SI refers to conscious or subconscious avoidance of a situation or social interaction because of the possibility of others disapproving of their feelings or expressions.  Whilst NA refers to negative emotions, including anger, contempt, disgust, guilt, and fear, and nervousness. Furthermore, individuals with high levels of NA may be more likely to perceive social interactions as negative, due to the associated cognitive bias to negative feedback. In one study researchers found that perceived stigmatization was particularly predicted by disease impact, as well as by lower age, lower education, greater disease severity and visibility, longer disease duration, higher levels of SI, having a type D personality and being single. 6

The researchers concluded that it seems likely that patients with psoriasis who are prone to feelings of helplessness regarding the disease may also experience a larger impact of psoriasis and magnify negative reactions of others. Type D personality and its subcomponent SI were found to be significant predictors of perceived stigmatization. The fear of disapproval that leads individuals to inhibit emotions or behaviour in SI may explain its relation to perceived stigmatization. They stated that socially inhibited individuals may be more sensitive to the reactions of others and may therefore perceive themselves to be stigmatized more readily. They found that not only was SI in itself, but also the combination of higher levels of SI and NA (type D personality) was a significant predictor of perceived stigmatization, which  corresponded with previous studies that suggested that type D was associated with social impairments. 6

It was suggested that Practitioners should screen for feelings of Stigmatization and related problems, and implement with the patient, targeted interventions that may focus on the impact of the condition on daily life, considering that this was the largest predictor. Therapy, such as Cognitive Behavioural Treatment, which should include social skills training, has shown promise as an intervention treatment. Previous research indicates that it can decrease perceived stigmatization in skin conditions, improve psychological and disease-related outcomes in psoriasis patients, and decrease feelings of helplessness, which shows high correlations with disease severity and impact. 6

It is extremely important that psoriasis sufferers do not cut themselves off from social interactions and it is highly recommended that they join a support group that is not only internet based but one that meets socially on a face to face basis. 

frustrated-1439244-640x480

Schizophrenia and other psychoses

 The psychiatric morbidity in psoriasis is considered an important indicator of the disability experienced by the patient than the dermatologic aspects of the disorder, sometimes more so than the physical aspect of the lesions. Some studies have found a possible connection between psoriasis and psychosis, including schizophrenia. Schizophrenia is a polygenic (involvement of 2 or more genes), multifactorial disorder and recent neuroanatomical and neurobiological being related to the nervous system as well as environmental and genetic studies have suggested that inflammatory pathways are also involved in its pathogenesis. Because psoriasis is also considered a state of chronic systemic inflammation involving several genes and is a related immune processes might explain the link between psoriasis and its comorbidities.7

In a systematic review researchers reviewed the published clinical papers on the link between psoriasis and Schizophrenia and other psychoses. The results of the systematic review found that there is some evidence of a relationship between schizophrenia and/or disorders with psychotic features and psoriasis. In one case-controlled study the authors concluded that schizophrenic patients have a higher probability of having a diagnosis of psoriasis whilst other studies highlighted that psoriasis patients have a higher risk of having schizophrenic traits. The main characteristics of schizoid character are social isolation, intimacy avoidance and restricted affections. Although for a long time was considered that a schizoid character was related to schizophrenia, this has been found to be not always true. Nevertheless, schizoids may be more susceptible to psychosis. This personality shares with schizophrenia, although with its own subtleties, the problem of the distinction between the “self” and the “other”. Several studies have reported on the occurrence of psoriasis in schizophrenia patients being treated with cyclosporine A and olanzapine. And other schizophrenia patients with existing psoriasis found that treatment with haloperidol and levomepromazine actually also improved the patients psoriasis.7

 For some psoriasis patients it was found that whilst they were experiencing a worsening of their skin lesions their existing psychotic condition also worsened, and as their skin improved so too did their psychotic condition.7 The hypothesis is that psoriasis, schizophrenia and other psychotic conditions share similar pathways.

Sexual Dysfunction

Sexual health is an important part of general health and sexual dysfunctions can negatively affect self-esteem, confidence and interpersonal relationships. The impact of psoriasis upon sexual function seems to be substantial and it has a significant impact in quality of life. One study found that when compared to a control group, the psoriasis group showed significant impairment of all the components of sexual function: sexual interest, sexual arousal, orgasm, erection and sexual satisfaction. “Sexual interest” and “global sexual satisfaction” were the most negatively affected components. Male patients with psoriasis showed an increase in erectile dysfunction compared to controls. The prevalence of sexual dysfunction was 53.7% in patients with psoriasis vs. 17.5% in the healthy control group. The researchers also found that psoriasis lesions on the genitals, buttocks, abdomen or lumbar (back) region were significantly linked to sexual dysfunction and those psoriasis patients with sexual dysfunction had higher scores for depression (32.5%) and anxiety (50%). 9

Certain components of sexual response, such as sexual interest, depend primarily on psychological factors, and are impaired by conditions such as anxiety and depression, while others such as erection and orgasm can be affected by psychological and physical causes.

It has also been suggested that the sexual dysfunctions might not be as a direct result of depression, but rather of low self-esteem or other emotional problems. As sexual impairment in psoriasis patients was seen to occur in all components of the sexual response, the researchers concluded that this suggested that sexual dysfunction in psoriasis must be a consequence of several combined factors.9,10

If you have a concern about depression, bipolar, schizophrenia or sexual dysfunction please discuss your concerns with your General Practitioner.

Read also PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 1

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Martín-Brufau R. et al.; Personality in Patients with Psoriasis; Chapter 11 rfrom the book Psoriasis Downloaded from: http://www.intechopen.com/books/psoriasis
  • Ak M. et al.; Temperament and character properties of male psoriasis patients; Journal of Health Psychology; pg 1-8; 2011; DOI: 10.1177/1359105311423863
  • Remröd ;  Pruritus in Psoriasis: A Study of Personality Traits, Depression and Anxiety; Acta Derm Venereol 2015; 95: 439–443;
  • Ferreira BR, Pio Abreu JL and Figueiredo A.; Psoriasis, Schizophrenia and Disorders with Psychotic Features: Are They Linked?; J Schizophr Res. 2015;2(1): 1006.
  • Molina-Leyva A. et al.; Distribution pattern of psoriasis, anxiety and depression as possible causes of sexual dysfunction in patients with moderate to severe psoriasis; An Bras Dermatol. 2015;90(3):338-45
  • Sarbu, Maria Isabela; Tampa, Mircea; Sarbu, Alexandra Elenda; and Georgescu, Simona Roxana (2014) “Sexual Dysfunctions in Psoriatic Patients,” Journal of Mind and Medical Sciences: Vol. 1: Iss. 1, Article 5.