Dermatological practice and psychiatry
Authors: L. Millard
Journal: British Journal of Dermatology (2000)

On the face of it, the paper by Picardi et al.1 showing that over 25% of patients attending dermatological outpatients demonstrate psychiatric morbidity might prompt some dermatologists to become stressed and depressed that they are missing psychiatric disease, but to other dermatologists this is perhaps further confirmation that a significant part of skin disease management is about more than treating cutaneous pathology. This study is concordant with reports from other centres2, 3 and raises further questions. Firstly, what do the results of the GHQ-12 and Skindex-29 outpatient questionnaires mean and how valid are they as indicators for further action? The commonest contexts in which such instruments are used are in settings where non-psychiatrists are called upon to assess physical symptoms where no somatic cause is found,4 but they are equally relevant to abnormal illness behaviour that prompts referral to hospital for secondary care. Objective testing may be more revealing than subjective clinical inquiry by the non-psychiatric specialist5 and has been shown to be consistently valid. The practical usefulness of the data is only that of an observation of a mental state at a measured moment and therefore does not differentiate depression, associated with, for example, bipolar disorder from that occurring with anxiety or dementia. Nor does it mean that a quarter of dermatologically referred patients is grossly psychiatrically ill. We can all identify the deeply deluded patient who presents with bits of ‘insects’, the depressed weeping exhausted erythrodermic eczema patient and the infuriating entertaining histrionic whose incapacity to comply with selftreatment makes clinics so memorable. What valuable studies like this and others6 do is to focus our attention on specific groups of patients in the clinic and remind us from time to time to think of psychological factors that may explain why patients with minimal or no disease continue to reappear in clinic. They are not reassured by bald statements that ‘nothing is wrong’ and rather than being reassured by a negative biopsy they take this as an indication that the doctor considered serious disease a distinct probability. This attributional response is commonly part of anxiety and depressive illness masked as a somatic complaint7, 8 and is seen in other medical disciplines, for example, nonorganic (but really experienced) chest or gut pain. Most dermatologists will recognize the predominant groups of patients with highest psychiatric prevalence rates as those with acne, alopecia, pruritus or urticaria.9 While isotretinoin will improve selfesteem and reduce anxiety in many patients,10 residual emotional insecurity may remain, leading to a psychological dependence on maintenance treatment.11 Of the multitudes of men with androgenic alopecia, most do not find their way to a dermatologist yet studies12 show significant distress in those who are interviewed. The individuals who do make it to consultant clinics demonstrate that their subjective experience of this physical change and its relationship to their personality style, is interpreted as an illness despite all the evidence that baldness is common in men. Nonetheless, this illness behaviour needs to be worked out rather than dismissed as it may otherwise lead to ‘consultant hopping’, which may be lucrative for private practice but which will entrench the frustration and dissatisfaction of the patient. The patients in the study by Picardi et al.1 were not all new patients and it is as well to remember that patients with chronic disease get depressed; some of these will become resistant to treatment13 but respond to antidepressants.12 What can we do in the face of this psychiatric morbidity in the clinics? Firstly we need to recognize that it exists, and having done so, we need to identify a pathway of care and referral when necessary. Supportive and directive psychotherapy is most valuable in the clinic setting but is not to be confused with counselling distinguished by mutual hand wringing and a shared box of tissues. More skilled psychotherapeutic techniques, such as cognitive behavioural therapy helps, amongst others, those with destructive excoriative habits. Regrettably, the ready referral to a liaison psychiatrist is the exception in the UK because this service is so hard-pressed, but from my experience such liaison gets better once contacts are opened and maintained.