Analysis of the Prevalence of Mental Disorders in Psoriasis: The Relevance of Psychiatric Assessment in Dermatology.

BACKGROUND: The boundary between Dermatology and Psychiatry has increasing recognition. Psoriasis is a common psychophysiological skin disease with a major impact on patient's quality of life and a paradigmatic example of a pathology in that boundary. Studies are needed to exactly point out the prevalence of specific psychopathology and mental disorders associated with psoriasis. This work intends to analyse the prevalence of psychopathology and psychiatric comorbidities in patients with psoriasis. METHODS: A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the "5S" model proposed by Haynes. From all the papers retrieved by this search, a total of 34 papers met the inclusion criteria and were then deeply analysed. RESULTS: The most prevalent mental disorders in these patients are sleep disorders (average prevalence: 62.0%), sexual dysfunction (45.6%), personality (35.0%), anxiety (30.4%), adjustment (29.0%), depressive (27.6%) and substance-related and addictive disorders (24.8%). Other mental disorders have been less described, namely somatic symptoms and related disorders, schizophrenia and other psychoses, bipolar disorder and eating disorders. CONCLUSIONS: This updated research shows that the prevalence of psychiatric conditions in psoriasis may range from 24% to 90%. The study of the mind-skin connection in psoriasis may improve the knowledge about psoriasis and its psychiatric comorbidities. The link between psoriasis and associated mental disorders is frequently forgotten or not considered in the clinical practice. Psychiatric disorders in patients with psoriasis may be underdiagnosed. These patients would really benefit from psychiatric assessment, with therapeutic relevance.

Pruritus, Allergy and Autoimmunity: Paving the Way for an Integrated Understanding of Psychodermatological Diseases?

Pruritus is a key symptom in allergology and dermatology, contributing to the global and huge impact on quality of life related to skin disorders, both those which are not related to a primary dermatosis (illness) and those which are linked with primary skin lesions (disease). This is particularly evident within psychophysiological dermatoses, a group of psychodermatological diseases where there is a primary dermatosis, where psychological stress plays a role, and where pruritus may represent a major and shared symptom. The etiopathogenesis of pruritus in those disorders sheds light on the link among psychopathological features, psychological stress and the subtle interface between allergic and autoimmune mechanisms, where mast cells play a pivotal role. Allergy has long been recognised as an altered reactivity to exogenous antigens (allergens), defined as an immediate hypersensitivity mediated by immunoglobulin E (IgE). In turn, the immunological understanding of atopy is related to an immediate hypersensitivity reaction to environmental antigens involving T-helper 2 (Th2) responses and the IgE production. Mast cells are major cells in the early phase of allergy, releasing the mediators involved in the symptoms associated with the allergic disease, including pruritus, when the allergen cross-links with IgE, whose mechanisms can be observed in acute urticaria and atopy. Some allergic reactions may persist and allergy may eventually lead to autoimmunity, with the development of a T-helper 1 (Th1) and then IgE-independent inflammation. For instance, in chronic spontaneous urticaria, the mast cell activation may include autoimmune mechanisms, where autoantibodies against the extracellular α subunit of the high-affinity IgE receptor (FcεRIα) and to IgE are observed, with the involvement of Th1 lymphocytes and the production of interferon-γ (INF-γ). The role of autoimmunity is also suggested in the etiopathogenesis of other psychophysiological dermatoses, namely psoriasis, atopic dermatitis and alopecia areata. In the latter, for example, mast cells were reported to be linked with the loss of immune privilege and they are the key cells involved in the experience of pruritus, whose intensity was reported to precede and be correlated with the onset of the hair loss. Furthermore, considering that the role of hair and skin is wide, from psychosocial aspects (communication and social interaction) to vital functions (such as, temperature control), it is straightforward that they are central in our interactions and synchronization with others and the world; thereby, we may admit that the psychophysiological dermatoses could represent a loss of such synchronization. Furthermore, they are often linked with psychopathology which strongly connects with the concept of desynchronization, namely, sleep disorders and depressive symptoms, the clinical expression of a dysfunction in the interplay among mast cells, pineal gland and melatonin, thus the circadian rhythm, as well as their connection with the hypothalamic corticotrophin-releasing hormone (CRH), well-known for its key role in stress response. Moreover, increasing evidence has supported the existence of cutaneous equivalents for these mechanisms, connecting with those central pathways. Thereby, taking all these concepts into consideration, this review intends to look into the updated evidence on the shared biological mechanisms between allergy and autoimmunity, underlining pruritus as a core element, then revisiting the key role of mast cells and discussing the connection with melatonin and immune-inflammatory pathways in the physiopathology of psychophysiological dermatoses, thus paving the way for the understanding of their psychosomatic correlates and a comprehensive psychodermatological approach.

Psychiatric symptoms and dissociation in conversion, somatization and dissociative disorders.

OBJECTIVE: Conversion, dissociation and somatization are historically related in the long established concept of hysteria. Somewhere along the way they were separated due to the Cartesian dualistic view. The aim of the present study was to compare these pathologies and investigate whether symptoms of these pathologies overlap in their clinical appearance in a Portuguese sample. METHOD: Twenty-six patients with conversion disorder, 38 with dissociative disorders, 40 with somatization disorder, and a comparison group of 46 patients having other psychiatric disorders answered questions about dissociation (Dissociative Experiences Scale), somatoform dissociation (Somatoform Dissociation Questionnaire), and psychopathological symptoms (Brief Symptom Inventory). RESULTS: Dissociative and somatoform symptoms were significantly more frequent in dissociative and conversion disorder than in somatization disorder and controls. There were no significant differences between dissociative and conversion patients. CONCLUSIONS: Conversion disorder is closely related to dissociative disorders. These results support the ICD-10 categorization of conversion disorder among dissociative disorders and the hypothesis of analogous psychopathological processes in conversion and dissociative disorders versus somatization disorder.

Demographic and mental health factors associated with pathological dissociation in a Portuguese sample.

Pathological dissociation has been extensively studied in many countries; however, little is known about it in Portugal. This research examined the role of demographic variables and mental health on dissociation in Portugal. We assessed 505 participants from 6 samples consisting of dissociative patients (n = 37), conversive patients (n = 26), somaticizing patients (n = 59), posttraumatic stress disorder patients (n = 50), other psychiatric patients (n = 174), and nonclinical subjects (n = 159). Dissociation was measured by Portuguese versions of the Dissociative Experiences Scale and Somatoform Dissociation Questionnaire; the LEAD procedure and subscales of the Brief Symptom Inventory indicated mental health. Pathological psychological dissociation was significantly more frequent in women, in the youngest of the participants, and in those with less education. Multiple logistic regression revealed that psychoticism, paranoid ideation, and depression symptoms made both men and women more vulnerable to psychological dissociation. Furthermore, psychological dissociation was more probable in men having symptoms of obsession and paranoid ideation and in women having symptoms of psychoticism and paranoid ideation. Pathological somatoform dissociation was significantly more probable in women with less education. Moreover, somatoform dissociation was more likely in women with somatization symptoms and more likely in men with symptoms of somatization and psychoticism. Even though significant associations were found, causal relations could not be established because the study was cross-sectional.

Dissociative disorders and other psychopathological groups: exploring the differences through the Somatoform Dissociation Questionnaire (SDQ-20).

OBJECTIVE: The Somatoform Dissociation Questionnaire is a self-report questionnaire that has proven to be a reliable and valid instrument. The objectives of this study were to validate the Portuguese version and to determine its capability to distinguish patients with dissociative disorders from others with psychopathological disorders. METHOD: 234 patients answered the translated version of Somatoform Dissociation Questionnaire. The Portuguese Dissociative Disorders Interview Schedule was used to validate clinical diagnosis. Patients with dissociative disorder (n = 113) were compared to a control group of 121 patients with various anxiety and depression disorders. RESULTS: Reliability measured by Cronbach's a was 0.88. The best performance of the Portuguese form was at a cut-off point of 35, which distinguishes between dissociative disorder and neurotic disorders with a good diagnostic efficacy (sensitivity = 0.73). The somatoform dissociation was significantly more frequent in dissociative disorder patients, conversion disorder patients and post-traumatic stress disorder patients. CONCLUSIONS: These findings suggest that dissociative disorders can be differentiated from other psychiatric disorders through somatoform dissociation. The Portuguese version of the Somatoform Dissociation Questionnaire has fine psychometric features that sustain its cross-cultural validity.

Dissociative disorders and other psychopathological groups: exploring the differences through the Somatoform Dissociation Questionnaire (SDQ-20)

OBJECTIVE: The Somatoform Dissociation Questionnaire is a self-report questionnaire that has proven to be a reliable and valid instrument. The objectives of this study were to validate the Portuguese version and to determine its capability to distinguish patients with dissociative disorders from others with psychopathological disorders. METHOD: 234 patients answered the translated version of Somatoform Dissociation Questionnaire. The Portuguese Dissociative Disorders Interview Schedule was used to validate clinical diagnosis. Patients with dissociative disorder (n = 113) were compared to a control group of 121 patients with various anxiety and depression disorders. RESULTS: Reliability measured by Cronbach's a was 0.88. The best performance of the Portuguese form was at a cut-off point of 35, which distinguishes between dissociative disorder and neurotic disorders with a good diagnostic efficacy (sensitivity = 0.73). The somatoform dissociation was significantly more frequent in dissociative disorder patients, conversion disorder patients and post-traumatic stress disorder patients. CONCLUSIONS: These findings suggest that dissociative disorders can be differentiated from other psychiatric disorders through somatoform dissociation. The Portuguese version of the Somatoform Dissociation Questionnaire has fine psychometric features that sustain its cross-cultural validity.

OBJETIVO: O objetivo deste estudo foi adaptar, validar e determinar a confiabilidade da versão portuguesa do Somatoform Dissociation Questionnaire e determinar a sua capacidade de discriminar doentes que dissociam de outros doentes. Método: O Somatoform Dissociation Questionnaire foi traduzido para o português e retrovertido para o inglês de forma a garantir a sua base conceitual. Os sujeitos responderam também à versão portuguesa do Dissociative Disorders Interview Schedule de forma a validar o seu diagnóstico clínico. O estudo incluiu 234 sujeitos divididos entre 113 doentes com patologias dissociativas e 121 doentes com outras patologias do foro ansioso e depressivo. RESULTADOS: O Somatoform Dissociation Questionnaire versão portuguesa mostrou o seu melhor desempenho no ponto de corte 35, apresentando uma sensibilidade de 0,73. O alfa de Cronbach revelou uma consistência interna de 0,88. A dissociação somatoforme foi significativamente mais freqüente nos doentes com patologias dissociativas, patologias conversivas e distúrbio de stress pós-traumático. CONCLUSÕES: A versão portuguesa do Somatoform Dissociation Questionnaire mostrou-se um instrumento útil para discriminar doentes com patologia de foro dissociativo de outros doentes.