Social Distance in COVID-19: Drawing the line between protective behavior and stigma manifestation.

Social stigma has long been defined by Ervin Goffman as an attribute that it is deeply discrediting and reduces the individual who bears it from a whole and usual person to a tarnished one, unfit to be included into the mainstream society.1 As stigma spans time and space and has been documented in other social species such as ants and chimpanzees, one might argue for its adaptive potential. Neuberg and colleagues2 have suggested that humans generate stigmas against threats to effective group functioning, with a notable case being infectious diseases. A similar explanation has been put forward by other researchers who consider stigma to have evolved from disease-avoidance mechanisms.3 Hence, it is not surprising that tuberculosis, HIV and leprosy have been surrounded by stigma and discrimination.4,5 More recently, people who had survived the 2013-2016 Ebola outbreak tackled social exclusion and unemployment after returning to their neighborhoods.6 Nowadays, the global community faces an unprecedented challenge of grappling with the COVID-19 pandemic. From the very outset, social distance measures were introduced in order to contain the spread of the virus, ranging from maintaining 1.5 meters physical distance to strict lockdowns. However, this may easily escalate into stigmatizing and discriminatory behaviours (desired social distance is a proxy of discrimination) against people who have suffered from COVID-19, their relatives and their caregivers, with the United Nations stating that "fear, rumours and stigma" are the key challenges surrounding COVID-19.7 Apart from the psychological distress experienced by the stigmatized individuals, due to anticipated stigma people might start concealing their illness, avoid or delay seeking medical advice or testing until they are seriously ill and be reluctant to collaborate with authorities on tracing contacts. Therefore, timely identifying stigma and addressing it is an integral part of an effective health response to the ongoing pandemic. In spite of its importance, research on COVID-19 related stigma is scarce. From the perspective of the stigmatized individuals, a study in China8 demonstrated that COVID-19 survivors faced heightened levels of overall stigma, social rejection, financial insecurity, internalized shame and social isolation, compared to healthy controls. From the perspective of the general population, a study in US9 substantiated low levels of anticipated stigma and stereotype endorsement; however, respondents who anticipated greater stigma were less likely to seek a COVID-19 test. It is therefore clear that the international literature is still on its infancy with respect to COVID-19 related stigma. In this context, in the First Department of Psychiatry, University of Athens, we conducted a survey on public attitudes to COVID-19 and to mental disorders. The study would inform the design and implementation of anti-stigma initiatives, funded by the Regional Governor of Attica. As physical distancing and social distancing are interwoven, with some researchers and practitioners using the terms interchangeably, and social distancing is also a protective public health measure against COVID-19, we enquired about attitudes and desired social distance from people who had recovered from COVID-19. Nonetheless, it merits noting that evidence from other diseases indicates that stigma may persist even after recovery.10 Moreover, rather than describing public attitudes overall, we were more interested in investigating where COVID-19 related stigma stands as compared to the most stigmatizing health condition to date, i.e., severe mental illness.11 Interestingly enough, which elements of severe mental illness render it the most stigmatized as compared to other conditions is still speculative: is it the fear of madness? the severity and the type of symptoms? the purported incurability or its chronicity? In our study, evidence from a convenience sample of 370 residents of Attica indicates that the general population holds more negative attitudes towards people who have recovered from COVID-19 than towards people with mental disorders. Nonetheless, respondents reported lower levels of desired social distance from recovered COVID-19 cases as compared to mental illness cases in social interactions of graded intimacy; however, the difference between the two groups was found to decrease as the level of intimacy decreased as well. In other words, desired social distance from COVID-19 cases is more easily discernible in transient social encounters, like talking to a stranger. It is therefore clear that social distance is still a public health protective measure rather than a stigma manifestation. For social encounters of greater intimacy, usually a sign of discriminatory behaviours, having recovered from COVID-19 is not a deterrent to interaction. Findings can be explained by the acute (non-chronic) nature of the disease, both in terms of symptoms as well as the 10-day period since symptom onset for being contagious. Nonetheless, with emerging evidence substantiating the notion of long COVID-19, defined as the persistence of symptoms for 3 weeks after infection,12 this might quickly change. Moreover, with many public health protective measures available, such as the use of mask, diagnostic testing and vaccination, people who become infected are more likely to be blamed for contracting the disease and thus deemed responsible for this, in line with the Attribution Theory.13 Specifically, overarching evidence from stigma research in many diseases/conditions indicates that when an illness or a social condition, such as economic disadvantage, is attributed to internal causes, as compared to external, lay people are more likely to hold stigmatizing attitudes.14-16 Therefore, as attitudes towards COVID-19 are worse compared to those towards people with mental illness, if tailored anti-stigma action is not undertaken, it is only a matter of time for prejudices to evolve into discriminatory behaviours, with devastating consequences on both the individuals and the course of the pandemic. Concomitantly, as severe mental illness is neither life threatening nor contagious, but COVID-19 is, it is interesting to explore how stigma is related to evolutionary mechanisms favouring adaptability and survival as well as which elements are the drivers of stigma development and establishment. Therefore, comparing and contrasting the stigma surrounding these conditions may shed light on the underpinnings of social stigma and facilitate effective interventions to reduce it and eventually eliminate it.

Activity limitations in leprosy and their association to cognition and neuropsychiatric symptoms.

OBJECTIVES: to analyze activity limitations in patients with leprosy and their association to cognition and neuropsychiatric symptoms. METHODS: this cross-sectional design study included sixty patients with multibacillary leprosy assisted at a reference center. Participants were divided according to their physical disability and submitted to instruments assessing daily activities (basic and instrumental), cognitive functions, and neuropsychiatric symptoms. The order of the instruments was random to avoid any interference of test sequence on the results. RESULTS: fifty-five percent of the participants presented physical disabilities. All patients were independent in performing basic activities but sixty-six percent presented difficulties in performing instrumental activities. Cognitive decline and neuropsychiatric symptoms were seen in advanced stages of the disease, but they were more associated to patient age than to leprosy. CONCLUSIONS: leprosy patients presented physical disabilities and difficulties in performing instrumental daily activities. Cognitive decline and neuropsychiatric symptoms were more associated to aging than to leprosy itself.

Activity limitations in leprosy and their association to cognition and neuropsychiatric symptoms / Limitaciones de tarea en la enfermedad de Hansen y su relación con cognición y síntomas neuropsiquiátricos / Limitações de tarefa na hanseníase e sua associação com cognição e sintomas neuropsiquiátricos

ABSTRACT Objectives: to analyze activity limitations in patients with leprosy and their association to cognition and neuropsychiatric symptoms. Methods: this cross-sectional design study included sixty patients with multibacillary leprosy assisted at a reference center. Participants were divided according to their physical disability and submitted to instruments assessing daily activities (basic and instrumental), cognitive functions, and neuropsychiatric symptoms. The order of the instruments was random to avoid any interference of test sequence on the results. Results: fifty-five percent of the participants presented physical disabilities. All patients were independent in performing basic activities but sixty-six percent presented difficulties in performing instrumental activities. Cognitive decline and neuropsychiatric symptoms were seen in advanced stages of the disease, but they were more associated to patient age than to leprosy. Conclusions: leprosy patients presented physical disabilities and difficulties in performing instrumental daily activities. Cognitive decline and neuropsychiatric symptoms were more associated to aging than to leprosy itself.

RESUMEN Objetivo: analizar limitaciones de tarea en pacientes con Lepra y su relación con cognición y síntomas neuropsiquiátricos. Métodos: este estudio transversal incluyó 60 pacientes con Lepra multibacilar atendidos en centro de referencia. Participantes fueron divididos segundo la disfunción física y evaluados cuanto a las actividades diarias (básicas y instrumentales), funciones cognitivas y síntomas neuropsiquiátricos. Orden de aplicación de los instrumentos aleatoria para evitar interferencia de la secuencia de tests sobre los resultados. Resultados: de los participantes, 55% presentaron disfunción física. Todos pacientes eran independientes en las actividades básicas, pero 66% mostraron dificultades en las actividades instrumentales. Declive cognitivo y síntomas neuropsiquiátricos fueron observados en etapas avanzadas de la enfermedad, pero estos estaban más relacionados a la edad del paciente que a la Lepra. Conclusiones: pacientes con Lepra evidenciaron disfunción física y dificultades en las actividades instrumentales. Declive cognitivo y síntomas neuropsiquiátricos están más relacionados al envejecimiento que a la Lepra.

RESUMO Objetivo: analisar as limitações de tarefa em pacientes com hanseníase e sua associação com cognição e sintomas neuropsiquiátricos. Métodos: este estudo transversal incluiu 60 pacientes com hanseníase multibacilar atendidos em um centro de referência. Os participantes foram divididos segundo a disfunção física e avaliados quanto às atividades diárias (básicas e instrumentais), às funções cognitivas e aos sintomas neuropsiquiátricos. A ordem de aplicação dos instrumentos foi aleatória para evitar interferência da sequência dos testes sobre os resultados. Resultados: dos participantes, 55% apresentaram disfunção física. Todos os pacientes eram independentes nas atividades básicas, mas 66% mostraram dificuldades nas atividades instrumentais. Declínio cognitivo e sintomas neuropsiquiátricos foram observados em estágios avançados da doença, porém estes estavam mais associados à idade do paciente do que à hanseníase. Conclusões: pacientes com hanseníase evidenciaram disfunção física e dificuldades nas atividades diárias instrumentais. Declínio cognitivo e sintomas neuropsiquiátricos estão mais associados ao envelhecimento do que à hanseníase.

Common mental disorders and associated factors among people with leprosy: cross-sectional analysis in Cuiabá, Brazil, 2018. / Transtornos mentais comuns e fatores associados entre pessoas com hanseníase: análise transversal em Cuiabá, 2018.

OBJECTIVE: To analyze the occurrence of common mental disorders (CMDs) and associated factors in people with leprosy with complications in the state of Mato Grosso, Brazil, in 2018. METHODS: This was a cross-sectional study with people attending Júlio Müller University Hospital. The Self-Report-Questionnaire (SRQ-20) was used. Poisson regression analysis was performed to estimate prevalence ratios (PR) and 95% confidence intervals (95%CI). RESULTS: Among 206 people with leprosy, CMDs were found in 70.4% (95%CI 61.10;76.67) and were associated with the female sex (PR=1.29 - 95%CI 1.09;1.53), the 26-45 age range (PR=1.52 - 95%CI 1.09;2.11) and the 46-60 age range (PR=1.40 - 95%CI 1.01;1.95), low family income (PR=1.25 - 95%CI 1.05;1.49), and unsatisfactory quality of life in the physical domain (PR=3.03 - 95%CI 1.12;8.19) and the psychological domain (PR=1.91; 95%CI 1.40;2.61). CONCLUSION: CMDs were frequent and associated with female sex, productive age group, low income and unsatisfactory quality of life. Actions aimed at mental health in this population group are necessary.

Transtornos mentais comuns e fatores associados entre pessoas com hanseníase: análise transversal em Cuiabá, 2018 / Trastornos mentales comunes y factores asociados entre las personas con lepra: análisis transversal en Cuiabá, Brasil, 2018 / Common mental disorders and associated factors among people with leprosy: cross-sectional analysis in Cuiabá, Brazil, 2018

Objetivo: Analisar a ocorrência e fatores associados aos transtornos mentais comuns (TMCs) em pessoas com hanseníase com intercorrências no estado de Mato Grosso, Brasil, em 2018. Métodos: Estudo transversal com pessoas atendidas no Hospital Universitário Júlio Müller. Aplicou o self-report-questionnaire (SRQ-20). Empregou-se regressão de Poisson para estimar razões de prevalências (RP) e intervalos de confiança de 95% (IC 95% ). Resultados: Entre 206 pessoas com hanseníase, TMCs estiveram presentes em 70,4% (IC 95% 61,10;76,67), associada ao sexo feminino (RP=1,29 - IC 95% 1,09;1,53), faixas etárias de 26-45 anos (RP=1,52 - IC 95% 1,09;2,11) e 46-60 anos (RP=1,40 - IC 95% 1,01;1,95), baixa renda familiar (RP=1,25 - IC 95% 1,05;1,49) e qualidade de vida insatisfatória nos domínios físico (RP=3,03 - IC 95% 1,12;8,19) e psicológico (RP=1,91 - IC 95% 1,40;2,61). Conclusão: Os TMCs foram frequentes e associados ao sexo feminino, faixa etária produtiva, baixa renda e qualidade de vida insatisfatória. Ações voltadas para a saúde mental nesse grupo populacional são necessárias.

Objetivo: Analizar el aparecimiento y los factores asociados s los trastornos mentales comunes (TMCs) en personas con lepra con complicaciones en Mato Grosso, Brasil, en 2018. Métodos: Estudio transversal con personas atendidas en el Hospital Universitario Júlio Müller. El TMCs fue evaluado por Self-Report-Questionnaire (SRQ-20). Se realizó un análisis con la regresión de Poisson para estimar razones de prevalencia (RP) e intervalos de confianza del 95% (IC 95%). Resultados: Entre 206 personas con lepra, los TMCs sucedieron en 70,4% (IC 95% 61,10;76,67) asociados al sexo femenino (RP=1,29 - IC 95% 1,09;1,53), grupos de edad de 26-45 años (RP=1,52 - IC 95% 1,01;1,95) y 46-60 años (RP=1,40 - IC 95% 1,01;1,95), baja renta familiar (RP=1,25 - IC 95% 1,05;1,49), y calidad de vida insatisfactoria en los dominios físico (RP=3,03 - IC 95% 1,12;8,19) y psicológico (RP=1,91 - IC 95% 1,40;2,61). Conclusión: Los TCM en personas con lepra fueron frecuentes y asociados al sexo femenino, a edad productiva, bajos ingresos y calidad de vida insatisfactoria. Se hacen necesarias las acciones dirigidas a la salud mental en este grupo de la población.

Objective: To analyze the occurrence of common mental disorders (CMDs) and associated factors in people with leprosy with complications in the state of Mato Grosso, Brazil, in 2018. Methods: This was a cross-sectional study with people attending Júlio Müller University Hospital. The Self-Report-Questionnaire (SRQ-20) was used. Poisson regression analysis was performed to estimate prevalence ratios (PR) and 95% confidence intervals (95%CI). Results: Among 206 people with leprosy, CMDs were found in 70.4% (95%CI 61.10;76.67) and were associated with the female sex (PR=1.29 - 95%CI 1.09;1.53), the 26-45 age range (PR=1.52 - 95%CI 1.09;2.11) and the 46-60 age range (PR=1.40 - 95%CI 1.01;1.95), low family income (PR=1.25 - 95%CI 1.05;1.49), and unsatisfactory quality of life in the physical domain (PR=3.03 - 95%CI 1.12;8.19) and the psychological domain (PR=1.91; 95%CI 1.40;2.61). Conclusion: CMDs were frequent and associated with female sex, productive age group, low income and unsatisfactory quality of life. Actions aimed at mental health in this population group are necessary.

Relationship between psychological health and quality of life of people affected by leprosy in the community in Guangdong province, China: a cross-sectional study.

BACKGROUND: This paper investigates the relationship between psychological health and quality of life (QOL) of people affected by leprosy (PAL) living in a community in Guangdong province, China. METHODS: A population-based cross-sectional survey was conducted from April to October 2016 in Guangdong province, China. The 12-item general health questionnaire (GHQ12) and World Health Organization Quality of life-BREF (WHOQOL-BREF) were used to evaluate the psychological health and QOL of the participants. PAL recruited for this study included those who were (1) registered in LEPMIS by the end of 2015 and living in the community, (2) able to be contacted by investigators, and (3) willing to provide informed written consent for enrolling in the study. Proportions, medians, and ratios were used to describe the demographics of the participants and χ2 test was used to compare groups with different psychological health states. Pearson's correlation coefficient and logistic regression analyses were used to assess the relationship between GHQ12 and QOL score. RESULTS: A total of 7230 PAL (5527 males and 1701 females, average age 67.3 ± 13.1 years) living in the community participated in the study. The participants averaged 1.7 ± 2.7 points on the GHQ12. Of these, 23.5% had scores meeting a psychological disorder (≥3 points). The scores for the physical, psychological, and social relationships, and environment dimensions of QOL were 17.2 ± 2.4, 20.6 ± 2.7, 9.7 ± 1.7, and 24.6 ± 4.0, respectively. Gender, age, employment, profession, and the four dimensions of QOL were independent factors associated with psychological health of PAL. CONCLUSION: In addition to focusing on the factors associated with poor QOL and psychological health amongst PAL, there is an urgent need for stigma reduction, rehabilitation programs and social integration. This may be achieved by engaging community members together with PAL to design a locally tailored intervention program.

Stigmatizing attitudes of primary care professionals towards people with mental disorders: A systematic review.

Objective To examine stigmatizing attitudes towards people with mental disorders among primary care professionals and to identify potential factors related to stigmatizing attitudes through a systematic review. Methods A systematic literature search was conducted in Medline, Lilacs, IBECS, Index Psicologia, CUMED, MedCarib, Sec. Est. Saúde SP, WHOLIS, Hanseníase, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex, through the Virtual Health Library portal ( http://www.bireme.br website) through to June 2017. The articles included in the review were summarized through a narrative synthesis. Results After applying eligibility criteria, 11 articles, out of 19.109 references identified, were included in the review. Primary care physicians do present stigmatizing attitudes towards patients with mental disorders and show more negative attitudes towards patients with schizophrenia than towards those with depression. Older and more experience doctors have more stigmatizing attitudes towards people with mental illness compared with younger and less-experienced doctors. Health-care providers who endorse more stigmatizing attitudes towards mental illness were likely to be more pessimistic about the patient's adherence to treatment. Conclusions Stigmatizing attitudes towards people with mental disorders are common among physicians in primary care settings, particularly among older and more experienced doctors. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need. The primary care physicians feel they need better preparation, training, and information to deal with and to treat mental illness, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.

Has growth mixture modeling improved our understanding of how early change predicts psychotherapy outcome?

OBJECTIVE: Early change in psychotherapy predicts outcome. Seven studies have used growth mixture modeling [GMM; Muthén, B. (2001). Second-generation structural equation modeling with a combination of categorical and continuous latent variables: New opportunities for latent class-latent growth modeling. In L. M. Collins & A. G. Sawyers (Eds.), New methods for the analysis of change (pp. 291-322). Washington, DC: American Psychological Association] to identify patient classes based on early change but have yielded conflicting results. Here, we review the earlier studies and apply GMM to a new data set. METHOD: In a university-based training clinic, 251 patients were administered the Outcome Questionnaire-45 [Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., Burlingame, G., … Reisinger, C. W. (1996). Administration and scoring manual for the Outcome Questionnaire (OQ 45.2). Wilmington, DE: American Professional Credentialing Services] at each psychotherapy session. We used GMM to identify class structure based on change in the first six sessions and examined trajectories as predictors of outcome. RESULTS: The sample was best described as a single class. There was no evidence of autoregressive trends in the data. We achieved better fit to the data by permitting latent variables some degree of kurtosis, rather than to assume multivariate normality. Treatment outcome was predicted by the amount of early improvement, regardless of initial level of distress. The presence of sudden early gains or losses did not further improve outcome prediction. CONCLUSIONS: Early improvement is an easily computed, powerful predictor of psychotherapy outcome. The use of GMM to investigate the relationship between change and outcome is technically complex and computationally intensive. To date, it has not been particularly informative.

Nail tic disorders: Manifestations, pathogenesis and management.

Nail tic disorders are classic examples of overlap between the domains of dermatology and psychiatry. They are examples of body-focused repetitive behaviors in which there is an irresistible urge or impulse to perform a certain behavior. The behavior is reinforced as it results in some degree of relief and pleasure. Nail tic disorders are common, yet poorly studied and understood. The literature on nail tic disorders is relatively scarce. Common nail tics include nail biting or onychophagia, onychotillomania and the habit tic deformity. Some uncommon and rare nail tic disorders are onychoteiromania, onychotemnomania, onychodaknomania and bidet nails. Onychophagia is chronic nail biting behavior which usually starts during childhood. It is often regarded as a tension reducing measure. Onychotillomania is recurrent picking and manicuring of the fingernails and/or toenails. In severe cases, it may lead to onychoatrophy due to irreversible scarring of the nail matrix. Very often, they occur in psychologically normal children but may sometimes be associated with anxiety. In severe cases, onychotillomania may be an expression of obsessive-compulsive disorders. Management of nail tic disorders is challenging. Frequent applications of distasteful topical preparations on the nail and periungual skin can discourage patients from biting and chewing their fingernails. Habit-tic deformity can be helped by bandaging the digit daily with permeable adhesive tape. Fluoxetine in high doses can be helpful in interrupting these compulsive disorders in adults. For a complete diagnosis and accurate management, it is imperative to assess the patient's mental health and simultaneously treat the underlying psychiatric comorbidity, if any.

Application of the SRQ20 and the protocol of psychological assessment in patients with leprosy in a Reference Centre in Brazil.

This study aims to apply the protocol of psychological assessment (PAP) and the SRQ-20 to analyse the psychological profile of 130 leprosy patients, in order to evaluate the incidence of Common Mental Disorders (CMD), and screen patients with higher risk of psychological distress. The following results were found in the PAP: 31.53%, 23.8% and 16.9% reported an unsatisfactory childhood, adolescence and adulthood, respectively; 31.53% are afraid of being discriminated against and 16.9% experienced discrimination. Also, 13.07% reported drastic life changes due to leprosy; 29.23% have low self-esteem, 31.53% have real fear and 22.3% have phantasmal fear. In the SRQ-20, the prevalence of CMDs was 32.3%, with the majority being female, married, with low education (primary education), low self-esteem, and with a drastic change in life. Conclusion: This is one of the few studies on the psychological profile of leprosy patients demonstrating the importance of the application of investigative technologies in psychopathological screening, aiming on adherence to treatment and psychotherapy planning. Furthermore, it provides support for reflection on the integrality of healthcare for leprosy patients and the importance of psychologists in health teams.

Mental disorders in leprosy: an underdiagnosed and untreated population.

OBJECTIVE: To describe the frequency of psychiatric comorbidities in leprosy patients and check if they had been previously diagnosed and were in psychiatric care. METHOD: The study was conducted with a sample of 120 leprosy patients being treated at two reference hospitals for leprosy in Salvador, Bahia, Brazil. Survey participants were more than 18 years of age, had a confirmed diagnosis of leprosy and was undergoing antimicrobial treatment. Patients were evaluated face-to-face with a socio-demographic questionnaire and the Mini-International Neuropsychiatric Interview (MINI-Plus) in Portuguese. The period of data collection was between October 2009 and June 2012. RESULTS: The assessment using the MINI-Plus showed that 34 (28.3%) patients did not receive any psychiatric diagnosis and 86 (71.7%) met the criteria for at least one. Of these 86 patients, 25 (20.8%) had one diagnosis, 26 (21.7%) had two diagnoses and the rest, 35 (29.2%), had three or more psychiatric diagnoses. All patients with a moderate or high risk of suicide had one or more psychiatric comorbidities. CONCLUSION: Leprosy patients have a high prevalence of psychiatric comorbidities. Furthermore, most of them had no previous psychiatric diagnosis and the majority was not undergoing treatment.

Internalized Stigma of Mental Illness (ISMI) scale: a multinational review.

The Internalized Stigma of Mental Illness (ISMI) scale is a 29-item questionnaire measuring self-stigma among persons with psychiatric disorders. It was developed with substantial consumer input and has been widely used, but its psychometric qualities have not been comprehensively evaluated across multiple versions. Here we review the 55 known versions, and provide the 47 available versions, including: Arabic, Armenian, Bengali, Bulgarian, Chinese (Mainland, Taiwan, Hong Kong), Croatian, Dutch, English (USA, South Africa), Estonian, Farsi, Finnish, French, German, Greek, Hebrew, Hindi, Japanese, Khmer, Korean, Lithuanian, Lugandan, Maltese, Polish, Portuguese (Portugal, Brazil), Romanian, Russian, Samoan, Slovenian, Spanish (Spain), Swahili, Swedish, Tongan, Turkish, Urdu, and Yoruba, and qualitative English and Swahili versions, as well as versions for depression, schizophrenia, substance abuse, eating disorders, epilepsy, inflammatory bowel disease, leprosy, smoking, parents and caregivers of people with mental illness, and ethnicity. The various versions show reliability and validity across a wide range of languages, cultures, and writing systems. The most commonly reported findings of studies using the ISMI are that internalized stigma correlates with higher depression, lower self esteem, and higher symptom severity. Initial studies of ways to reduce internalized stigma are promising and warrant further investigation.

Comorbidities in psoriasis.

Moderate to severe psoriasis is associated with concomitant diseases that may have a significant impact on patients. It is necessary for the treating physician to recognize these concomitant diseases, known as comorbidities, early as they influence the management options. Important comorbidities are psoriatic arthritis, metabolic syndrome, Crohn's disease, depression, and cancer. Patients with severe psoriasis may be at an increased risk for myocardial infarction and this subgroup of patients tends to have a reduced life expectancy. The presence of co-morbid diseases is associated with an increase in concomitant medication, some of which may worsen psoriasis; conversely, systemic treatment of psoriasis with certain drugs may impact the co-morbid conditions. As dermatologists are the primary health-care providers for psoriasis, adequate knowledge of comorbidities helps in choosing the appropriate therapy as well as timely intervention.

Assessing clinical significance of treatment outcomes using the DASS-21.

Standard clinical significance classifications are based on movement between the "dysfunctional" and "functional" distributions; however, this dichotomy ignores heterogeneity within the "dysfunctional" population. Based on the methodology described by Tingey, Lambert, Burlingame, and Hansen (1996), the present study sought to present a 3-distribution clinical significance model for the 21-item version of the Depression Anxiety Stress Scales (DASS-21; P. F. Lovibond & Lovibond, 1995) using data from a normative sample (n = 2,914), an outpatient sample (n = 1,000), and an inpatient sample (n = 3,964). DASS-21 scores were collected at pre- and post-treatment for both clinical samples, and patients were classified into 1 of 5 categories based on whether they had made a reliable change and whether they had moved into a different functional range. Evidence supported the validity of the 3-distribution model for the DASS-21, since inpatients who were classified as making a clinically significant change showed lower symptom severity, higher perceived quality of life, and higher clinician-rated functioning than those who did not make a clinically significant change. Importantly, results suggest that the new category of recovering is an intermediate point between recovered and making no clinically significant change. Inpatients and outpatients have different treatment goals and therefore use of the concept of clinical significance needs to acknowledge differences in what constitutes a meaningful change.

Psychodermatology: a comprehensive review.

Psychodermatology is an interesting domain of dermatology that overlaps with psychiatry. This arena in dermatology has received limited diligence, partly due to lack of training in this realm. We present here a comprehensive review of salient features and treatment updates in primary psychiatric dermatoses and have also discussed the role of psyche in psychophysiological cutaneous disorders. Secondary psychiatric morbidity is relatively common among patients visiting the dermatologists but often overlooked and uncared for. Dermatologist should be able to initiate basic pharmacotherapy, should be knowledgeable about various non-pharmacological treatments and know the right time to refer the patient to the psychiatrist. Awareness and pertinent treatment of psychodermatological disorders among dermatologists will lead to a more holistic treatment approach and better prognosis in this unique group of patients.

Gaining a comprehensive understanding of pruritus.

Pruritus is a common symptom associated with many dermatoses, systemic abnormalities, and psychiatric / psychosomatic diseases. Additionally, pruritus is one of the most intractable symptoms due to its complex pathogenesis involving an increasing number of mediators and receptors, undefined neurophysiologic pathways, unclear cerebral processing, and psychophysiology interaction. Clinically, the first challenge of dermatologists is how to get general and interdisciplinary vision of pruritus and to preliminarily figure it out whether there might be underlying systemic or psychosocial disorders. The second challenge is to select efficient individual tailored anti-pruritic treatment, which includes targeted drugs and cognitive-behavioral therapy.

Neuropathic pain and psychological morbidity in patients with treated leprosy: a cross-sectional prevalence study in Mumbai.

BACKGROUND: Neuropathic pain has been little studied in leprosy. We assessed the prevalence and clinical characteristics of neuropathic pain and the validity of the Douleur Neuropathique 4 questionnaire as a screening tool for neuropathic pain in patients with treated leprosy. The association of neuropathic pain with psychological morbidity was also evaluated. METHODOLOGY/PRINCIPAL FINDINGS: Adult patients who had completed multi-drug therapy for leprosy were recruited from several Bombay Leprosy Project clinics. Clinical neurological examination, assessment of leprosy affected skin and nerves and pain evaluation were performed for all patients. Patients completed the Douleur Neuropathique 4 and the 12-item General Health Questionnaire to identify neuropathic pain and psychological morbidity. CONCLUSIONS/SIGNIFICANCE: One hundred and one patients were recruited, and 22 (21.8%) had neuropathic pain. The main sensory symptoms were numbness (86.4%), tingling (68.2%), hypoesthesia to touch (81.2%) and pinprick (72.7%). Neuropathic pain was associated with nerve enlargement and tenderness, painful skin lesions and with psychological morbidity. The Douleur Neuropathique 4 had a sensitivity of 100% and specificity of 92% in diagnosing neuropathic pain. The Douleur Neuropathique 4 is a simple tool for the screening of neuropathic pain in leprosy patients. Psychological morbidity was detected in 15% of the patients and 41% of the patients with neuropathic pain had psychological morbidity.