Laura J. Dixon and Sara M. Witcraft
Department of Psychology, University of Mississippi, Oxford, MS, USA
Skin represents the largest organ of the human body, and collectively, skin (dermatology) diseases are among the most widespread illnesses in the world. Skin disease affects all ages and encompasses many conditions, including eczema, psoriasis, acne, alopecia, hyperhidrosis, urticaria (hives), fungal skin diseases, cellulitis, viral warts, skin cancer, and rosacea. Given that dermatology is seldom linked to fatality, the impact of skin disease is often underestimated. However, skin diseases represent the fourth leading global cause of nonfatal burden and are associated with significant psychosocial impairment and high rates of psychological comorbidity (Dalgard et al., 2015; Hay et al., 2014). Perhaps unsurprisingly, given the well‐known link between the mind and skin, many skin diseases have a psychological component. Albeit simplified, skin and psychological reactions are posited to be connected through multifaceted responses from the psychoneuroimmunological systems. Psychodermatology addresses this skin–mind connection, and although it is a relatively new subfield, psychodermatology has received increased attention over the past two decades.
Psychodermatological (psychocutaneous) disorders have been classified into three categories—psychophysiologic disorders, primary psychiatric disorders, and secondary psychiatric disorders (Koo & Lee, 2003). Psychophysiologic disorders characterize skin conditions (e.g., acne, eczema) that may be triggered or worsened by psychological factors, such as stress and anxiety. In primary psychiatric disorders, psychopathology contributes to the manifestation of skin symptoms. Examples of primary psychiatric disorders include trichotillomania and delusions of parasitosis. Lastly, individuals affected by secondary psychiatric disorders experience emotional problems as a result of the disfigurement and impairment associated with skin disease. For instance, an individual with vitiligo or alopecia areata may experience depression or social anxiety symptoms due to their visible skin symptoms.
Psychological conditions are catalogued by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) (American Psychiatric Association [APA], 2013). Of the mental health disorders, anxiety represents one of the most common mental health problems among dermatology patients (Dalgard et al., 2015; Picardi, Amerio, et al., 2004). Anxiety is an adaptive component of the normal human experience, but it becomes maladaptive when it is persistent, distressing, pervasive, and interferes with everyday life. According to recent studies, as many as 52–70% of dermatology patients report moderate to severe clinical anxiety symptoms (Gascón et al., 2012; Rasoulian, Ebrahimi, Zare, & Taherifar, 2010), and the prevalence rate of anxiety disorders ranges between 15 and 17% in dermatology patients (Dalgard et al., 2015; Picardi, Abeni, et al., 2004). Furthermore, studies have found significantly higher anxiety symptoms in dermatology samples compared with controls (Fleming et al., 2017; Pärna, Aluoja, & Kingo, 2015). In addition to worsening symptoms of skin disease, anxiety symptoms have been associated with a number of adverse outcomes for dermatology patients, such as the use of poor coping strategies, low quality of life, loss of life meaning, and poor social functioning (Leibovici et al., 2010; Mazzotti et al., 2012). While it is possible that anxiety symptoms may be separate and unrelated to skin symptoms, it is likely that in many cases, these anxiety symptoms may operate within the framework of psychodermatological disorders. In particular, anxiety may be integral in psychophysiologic disorders, with the cognitive, emotional, and physiological symptoms of anxiety exacerbating or triggering skin symptoms, or to secondary psychiatric disorders, such as an individual experiencing social or health anxiety symptoms in response to their dermatological condition.
Though anxiety refers to a broad syndrome, the most recent editions of the DSM have recognized different types of clinical anxiety including social anxiety disorder (SAD), generalized anxiety disorder (GAD), health anxiety, posttraumatic stress disorder, obsessive–compulsive disorder (OCD), and panic disorder/agoraphobia. Given the high prevalence rates and costs of clinical anxiety in dermatology patients, it is worthwhile to further explore these disorders in relation to skin disease.
The primary feature of SAD (formally known as social phobia) is the fear of being judged, rejected, or negatively evaluated in social situations (APA, 2013). Individuals with SAD experience anxiety in situations or in anticipation of a wide range of situations where they perceive that they may act, speak, or appear foolish, silly, stupid, or incompetent in front of others. SAD is one of the most prevalent and costly mental disorders, affecting 7.4% of the US population each year (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Given the visible nature of skin conditions and potential disfigurement, dermatology patients may be highly susceptible to social anxiety and fear of negative evaluation. Indeed, 33.4% of dermatology outpatients reported clinically significant social anxiety (Montgomery, Norman, Messenger, & Thompson, 2016), and dermatology patients report significantly greater social anxiety symptoms compared with healthy adults (Salman, Kurt, Topcuoglu, & Demircay, 2016). In addition, symptoms of SAD, such as blushing, sweating, and trembling, overlap with various skin diseases. For instance, Davidson, Foa, Connor, and Churchill (2002) found that 24.8–32.3% of individuals with SAD met criteria for hyperhidrosis (excessive sweating).
Social anxiety symptoms may contribute to positive feedback loop among individuals with certain skin diseases, such as rosacea, eczema, acne, or hyperhidrosis. For instance, anxiety in social situations may trigger or aggravate skin symptoms, and then an individual becomes anxious or embarrassed about experiencing visible symptoms, which further exacerbates skin symptoms. Conversely, in long‐term skin conditions like vitiligo, the skin changes over time, and situational social anxiety may not have a strong impact on the course of the disease. Nevertheless, individuals with vitiligo may experience embarrassment, shame, and social anxiety due to the visible distortions of their skin. Studies have found that social anxiety symptoms are associated with greater impairment and disability among patients with hyperhidrosis (Lessa Lda et al., 2014), vitiligo (Salman et al., 2016), psoriasis (Schneider, Heuft, & Hockmann, 2013), and acne (Salman et al., 2016). Despite the clear connections between SAD and skin disease, there is remarkably limited research in this area. Further research examining prevalence rates, mechanisms, and treatments for social anxiety among dermatology patients is warranted as this work could improve the identification and treatment of SAD and ultimately, prevent long‐term personal and societal costs of this mental disorder.
GAD is characterized by persistent, uncontrollable, excessive worry across multiple domains (e.g., health, finances, daily routine; APA, 2013). Individuals with GAD may worry about their health symptoms, but as compared with health anxiety (see below), they also experience pathological worry in other areas in their life. GAD is a relatively common anxiety disorder, presenting in 6.2% of the general population (Kessler et al., 2012). Yet, higher rates of GAD have been observed in dermatology samples. For instance, Woodruff, Higgins, Du Vivier, and Wessely (1997) examined medical records of dermatology patients referred to a psychiatrist and found that 24.8% met criteria for mild GAD and 8.7% met criteria for severe GAD. Although the psychology–dermatology literature is composed of many studies examining “general anxiety” or broadly defined symptoms of distress and anxiety, fewer studies have specifically examined the GAD syndrome. In particular, research in this area has primarily focused on the role of GAD and pathological worry in psoriasis. One study demonstrated excessive worry symptoms were evidenced by 38% of patients with psoriasis, while 25% of the entire sample reported symptom levels consistent with a clinical diagnosis of GAD (Fortune, Richards, Main, & Griffiths, 2000). Beyond the high prevalence rates of GAD in psoriasis, pathological worry has been associated with greater burden of physiological and psychological symptoms. Pathological worry has been found to negatively affect the body and, specifically, has been associated with slower clearance of psoriasis symptoms (Fortune, Richards, Kirby, et al., 2003). Finally, in addition to direct associations with disease symptoms, GAD symptoms have been linked to worse illness‐related beliefs, greater disability, and worse coping strategies in psoriasis patients (Fortune et al., 2000; Fortune, Richards, Corrin, et al., 2003). Given the common occurrence of GAD in the general population coupled with the findings revealed by the psoriasis literature, additional research examining GAD and pathological worry in other skin diseases is necessary.
Health anxiety, also known as illness anxiety disorder and hypochondriasis, is a preoccupation having or acquiring a serious illness. These concerns are accompanied by either avoidance of medical visits altogether or, at the other extreme, excessive medical visits and tests despite being told that there is nothing physically wrong (APA, 2013). A recent epidemiological study revealed the lifetime prevalence rate of illness anxiety disorder was 5.7% (Sunderland, Newby, & Andrews, 2013). Unfortunately, health anxiety is often unidentified in medical settings, and medical providers may ineffectively, albeit unintentionally, respond to patients’ anxieties about their health problems by offering reassurance and conducting unnecessary medical tests (Tyrer, Eilenberg, Fink, Hedman, & Tyrer, 2016). Very few studies have investigated health anxiety in dermatology patients, and to obtain more information about this phenomena, Long and Elpern (2017) conducted a study examining health anxiety in dermatology outpatients. They found that 31% of dermatology patients reported that they worried “a lot” about a health problem, 17% reported that they worried the problem was more serious than a doctor described, and a total of 46% expressed some degree health anxiety. The findings from this study suggest that health anxiety is particularly relevant for dermatology patients, and given these staggering numbers, further research is needed to explicate health anxiety in dermatology samples.
Posttraumatic stress disorder (PTSD) is characterized by anxiety and distress following a potentially life‐threatening event such as a car wreck, natural disaster, or a physical or sexual assault. Further, the anxiety is associated with recurrent, involuntary, and distressing memories of the trauma; attempts to avoid cues that remind the individual of the trauma and physiological arousal (e.g., hypervigilance, exaggerated startle reaction, panic symptoms); and increased negative mood and cognitions (APA, 2013). Despite the fact that many individuals will experience at least one potentially traumatic event in their lifetime, PTSD has a relatively low lifetime prevalence rate of 8.0% in the general population (Kessler et al., 2012). Interestingly, skin disease has been found to be higher among individuals with PTSD compared with those without PTSD. A recent review of co‐occurring PTSD and dermatology suggested that skin conditions are common among individuals with PTSD due to the increased autonomic and sympathetic arousal, which activates skin symptoms (e.g., sweating; Gupta, Jarosz, & Gupta, 2017). Notably, in a large case–control trial, patients commonly reported psoriasis, alopecia, skin allergies, and other skin diseases, and individuals with PTSD (versus without PTSD) were twice as likely to have dermatology conditions (Britvić et al., 2015).
OCD is composed of two components—(a) uncontrollable, unwanted, recurrent thoughts that cause distress (obsessions) and (b) mental acts or ritualistic behaviors that are instigated by obsessions and are conducted to reduce anxiety (compulsions; APA, 2013). OCD is a chronic, though relatively rare, disorder, with a lifetime prevalence rate of 2.7% (Kessler et al., 2012). Nevertheless, the prevalence of OCD in dermatology patients is much higher, with studies finding that between 9.1 and 24.7% of patients with skin disease meet criteria for OCD (Demet et al., 2005; Sheikhmoonesi, Hajheidari, Masoudzadeh, Mohammadpour, & Mozaffari, 2014). Interestingly, whereas most of the empirical work examining anxiety disorders has been conducted within specific dermatology conditions (e.g., psoriasis), studies investigating OCD have done so with an unselected dermatological sample. OCD symptoms can interact with skin symptoms in several ways, and within OCD, obsessions or compulsions may relate to or be in response to skin symptoms. The most common obsessions reported by dermatology patients include somatic obsessions, pathological doubt, and contamination (Demet et al., 2005; Ebrahimi, Salehi, & Tafti, 2007). These obsessions may interfere with management of skin symptoms (e.g., doubt about taking medication) and may increase distress about the status of skin symptoms (e.g., intrusive thoughts about the severity of a skin lesion or breakout). The most common compulsions reported by dermatology patients include washing and checking (Demet et al., 2005). Chronic washing behaviors may lead to dry or raw skin and even abrasions, which may directly worsen skin symptoms and contribute to excoriation and skin picking. Similarly, though the study did not specify the type of checking behaviors, repeated checking of skin symptoms may result in decreased memory confidence and greater reactivity to perceived changes in skin status. Given the focus on skin and somatic symptoms, these individuals often present to dermatology or primary care clinics rather than seeking psychological or psychiatric services.
A panic attack is a sudden surge of anxiety and distress that peaks within 10 min and includes at least four of the following symptoms: palpitations/pounding heart, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, feeling dizzy or faint, nausea or abdominal distress, derealization/depersonalization, fear of losing control or going crazy, numbness or tingling sensations, and chills or hot flashes. Panic attacks may be cued by a specific event or environment (e.g., stressful event, needles, crowded area) or may occur “out of the blue” and for no apparent reason. Epidemiological work has estimated that 28.3% of individuals experience one panic attack at some point in their life (Kessler et al., 2006). Although panic attacks are not inherently tied to pathology, individuals who worry about having another panic attack or change their life to avoid having a panic attack may meet criteria for panic disorder. In addition, individuals with other anxiety disorders may experience panic attacks when they come in contact with a feared situation (e.g., social situations in SAD) and individuals with agoraphobia fear situations (e.g., public transportation, being in a crowd) because they are afraid they may not be able to escape or get help if they develop panic‐like symptoms (APA, 2013). There is little literature exploring panic attacks, panic disorder, and agoraphobia in dermatology patients. One existing study found that patients with chronic skin conditions experienced significantly greater panic and agoraphobia symptoms than individuals in the control group (Pärna et al., 2015). Future research is required to understand panic and agoraphobia in dermatology. For instance, the avoidance and physiological symptoms characteristic of these disorders may amplify impairment and skin symptoms for individuals with skin disease. Moreover, it is likely that symptoms of these disorders may co‐occur with other anxiety‐related disorders as is commonly observed in the general population.
As the empirical literature of and clinical services for psychodermatology continue to evolve, anxiety disorders represent an important area for further development. Although anxiety disorders are common and known to contribute to worse outcomes in skin disease, there is a significant unmet need for treatment for individuals with co‐occurring dermatological and anxiety conditions, as well as large gaps in the empirical literature. Regarding clinical services, psychiatric symptoms are often unrecognized in dermatology patients (Picardi, Abeni, et al., 2004), and even fewer patients receive psychotherapeutic interventions in routine dermatology care (Fritzsche et al., 2001). Several studies have shown promising outcomes for the inclusion of psychosocial treatments in standard dermatology care, and in particular, adjunctive cognitive behavioral treatments have been found to reduce the severity of dermatological conditions, enhance quality of life, and decrease anxiety symptoms (Lavda, Webb, & Thompson, 2012). With regard to research, studies investigating the prevalence rates and risk factors for the different anxiety disorders across skin disease would be beneficial for improving the awareness and identification of anxiety disorders in routine care. Moreover, investigating mechanisms contributing to the interaction between anxiety and skin symptoms would enhance the understanding of psychodermatology processes and has the potential to inform the development of effective interventions to prevent and reduce anxiety in dermatology patients.
Psychoneuroimmunology: Immune markers of psychopathology
Generalized Anxiety Disorder (GAD) and health
Posttraumatic stress disorder (PTSD)
Cognitive Behavior Therapy (CBT), sleep, mood disorders, and health
Laura J. Dixon, PhD, is assistant professor at the University of Mississippi, director of the Health and Anxiety Research and Treatment Laboratory, and licensed clinical psychologist. Dr. Dixon has published numerous scientific articles on the etiology and treatment of anxiety‐related disorders and received an ADAA early career award.
Sara M. Witcraft is a clinical psychology doctoral student at the University of Mississippi. Sara has published several peer‐reviewed articles and book chapters on the treatment, understanding, and underlying factors of anxiety and related disorders. Her current research focuses on transdiagnostic vulnerabilities that underlie anxiety disorders.