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Psychodermatology

Psychodermatology. Angela Rodgers, MD Family Medicine Contra Costa Regional Medical Center. Outline. Introduction Research Management Questions. Outline. Introduction Research Management Questions. Emotional First Aid.

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Psychodermatology

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  1. Psychodermatology Angela Rodgers, MD Family Medicine Contra Costa Regional Medical Center

  2. Outline • Introduction • Research • Management • Questions

  3. Outline • Introduction • Research • Management • Questions

  4. Emotional First Aid • http://www.ted.com/talks/guy_winch_the_case_for_emotional_hygiene?language=en#t-191810 • https://youtu.be/F2hc2FLOdhI?t=1m21s

  5. Definitions • Psychophysiologic disorders: skin conditions negatively affected by stress • Primary psychiatric disorders: psychiatric conditions leading to self-induced skin conditions • Secondary psychiatric disorders: Skin conditions that alter one’s appearance leading to psychological manifestations

  6. Society Values

  7. Real Life

  8. How Can Your Psychological State Affect Our Thinking? • Let’s See What Dr. Winch Has to Say… https://youtu.be/F2hc2FLOdhI?t=10m59s

  9. Doesn’t Everyone Deal with this? • What does this have to do with my dermatology patients?

  10. Quotes “Being in the public eye is frustrating.” “I feel like less of a female.” “Others assume I am really sick so people avoid me…this is very destructive to a person’s self worth.” “It takes effort everyday to maintain happiness.” “I feel numb.” “I have a constant feeling of being different.” “I feel ostracized and made to feel something is wrong with me.” “This condition has dictated who I am and is on my mind.”

  11. Skin and the Mind “Skin, as a tangible and visible part of the body, can have a magnificent effect on psychological status which is continuously involved in socialization processes from childhood to adulthood.” Shahin, A, et al. Int Scholarly Research Notices (ISRN) Dermatology, 2014 STRESS NEGATIVE SKIN EFFECT

  12. Outline • Introduction • Research • Management • Questions

  13. What does the research say?

  14. Dermatological Conditions Associated with Mental Health Disease • Alopecia areata • Acne • Atopic dermatitis (eczema) • Hemangiomas • Icthyosis • Kaposi’s sarcoma • Psoriasis • Rosacea • Seborrheic dermatitis • Vitiligo

  15. Psoriasis Breuer K et al. J EurAcadDermatolVenereol. 2015 • Cross-Sectional Design • Key Findings: • Low QOL (similar to CHF and cancer ): shame, low self-esteem, isolation from social interaction • Clinician assessment of symptom severity is less predictive of well being than patient perceived symptom severity • Poor baseline QOL may adversely affect treatment success

  16. Vitiligo KrügerC. ActaDermVenereol. 2015 • Cross-Sectional Design • Key Findings: • High prevalence of stigmatization • Worse QOL than controls • Significantly higher levels of social anxiety, avoidance, helplessness, and anxious-depressive mood

  17. Vitiligo Abdulrahman, A. et al., ActaDermato-Venerology. 2014 • Cross-Sectional Design • Key Findings: • Parents of children with vitiligo have a poorer QOL and significantly more psychological stress than parents of healthy children • Mothers more adversely affected than Fathers • Parents of affected children “need as much care and attention as their affected children”

  18. Rosacea Moustafa, F. et al., J AmerAcadDerm. 2014 • Systematic Review • Key Findings: • Rosacea negatively impacts QOL and patients with rosacea are more likely to experience depression, embarrassment, social phobia, stress, and higher subjective disease perception • “By acknowledging the psychosocial burden of rosacea, physicians can more comprehensively treat patients and work towards better outcomes” • Consider multifaceted approach to treatment that focuses on the patients' concerns regarding their rosacea

  19. Atopic dermatitis Carroll, C et al. PedDerm. 2005 • Systematic Review • Key Findings: • Often/always frustrated, embarrassed and angry by appearance, overprotected/undisciplined as children, increased incidence of psychiatric disorder as adults • Lower social functioning, mental health scores than those with DM and HTN • Children increased dependency, fearfulness, sleep disturbance; interference with intellectual development, limitation on sports participation and peer/teacher relationship

  20. Alopecia areata Aghaei, S. J IntSch Research Not, 2014 • Case Control Study • Key Findings: • Significant diff in prevalence of depression (P = 0.008), anxiety (P=0.003), neuroticism (P=0.045) • Social, familial and uncontrollable problems influence these patients more so than the general population (coping) • Social support= protective factor for mental and physical health

  21. Alopecia areata Alfani, S. ActaDermVen, 2012 • Cross Sectional Study • Key Findings: • Depression, anxiety, family relationships, hysteria, hypochondriac tendencies, and conflict with social environment more common in AA patients than matched controls • Increased health concerns frequent, abnormal health worries, feeling more unwell than general population unnecessary clinic visits/emails/calls, increased spending and time

  22. Outline • Introduction • Research • Management • Questions

  23. Dual Approach Dermatology + Psychology

  24. Why Should We Be Concerned? • Mental health negatively affects • Quality of life (QOL) • View of self and relationships with others • Derm disease • Management of derm disease • Job search, discrimination (contagious) • Data that chronic disease in children have long term negative impact on future health outcomes

  25. Why Should We Be Concerned? • Adverse Childhood Experiences (ACE) http://www.cdc.gov/violenceprevention/acestudy/findings.html

  26. What Can We Do? • Recognize signs • Changes in mood: sad, tense, worried • Changes in behavior: adherence to treatment / appointments, substance use, sleep, etc. • Changes in relationships: disinterested, uninvolved • Other: difficulty concentrating, unexplained wt loss, unexplained physical symptoms (HA, stomach aches) • Ask and Listen ( = screening) • Know how to respond

  27. I Need 1 Volunteer  • Let’s see how realistic this is within 5 mins • Goal: Become psychiatrist • Goal: Quickly assess a part of your patient’s skin disease experience + find effective ways to connect your patient to support

  28. It is the end of a really busy day in clinic and you are a bit behind schedule. You had a full load of patients. Your last patient is someone you know very well so you expect the visit to be quick. However, just as you are wrapping up the visit something makes you worried that he/she is not doing well. You remember this lecture and even though your time is tight, you decide to ask how your patient has been doing emotionally.

  29. Take Home Points • Recognize signs • Changes • mood • behavior • relationships • unexplained physical symptoms • Ask, listen, and consider brief questionnaire • Know how to respond • Emergencies

  30. Barriers? • Physician • Patient • System

  31. Medication • Anxiety • Depression

  32. Asking About Suicidal Ideation/Intention? • Cross Sectional Study • Key Findings • 40 patients (8.6%) reported SI in past 2 weeks [95% CI 6.2-11.5] • Prevalence 15% inpatient and 5% outpatient • Increased risk: female, inpatient, hx depression/anxiety disorder

  33. How Do We Know Screening Helps? Picardi, A. J Psych Research, 2004 • Cross Sectional Study • Key Findings: • Good test performance characteristics: Sensitivity (87%) and NPV (84%) • Easy, quick, well accepted, simple scoring • Routine use screening questionnaire may help increase recognition of psychiatric disorders in dermatological patients http://www.gl-assessment.co.uk/products/general-health-questionnaire/faqs?css=1

  34. Resources • What resources already available at CCRMC regarding support? • Contra Costa Crisis Center Hotline: 800-833-2900 • Psych Emergency Services (CCRMC) • George & Cynthia Miller Wellness Center • http://cchealth.org/mentalhealth/

  35. What Resources are Available? • Online • Phone • In person • Group • Referral

  36. National Alopecia Areata Foundation (NAAF) • History • Resource for over 30 years • Mission: • Support: patients and medical providers • Research: funding, clinical trials • Education: advocacy, awareness

  37. Conferences

  38. Support Groups

  39. Benefit? • Systemic Review • Key Findings: • benefit coping, QOL, symptoms of distress, problem solving, goal setting, parent-adolescent relationship, communication skills, health knowledge • Skill-based psychological interventions delivered over multiple sessions may give the most positive results in adolescents and young adults who live with chronic illness.” “Every year my son comes home from camp he stands taller. He is more confident in himself and his abilities.” Parent “I believe she comes back with more self-confidence.” Parent “They have no preconceived ideas about her, which helps boost her self-esteem. She needs people around her that don’t judge her.” Parent

  40. Role Models

  41. Education • Patients self-advocacy • Public awareness

  42. Education

  43. Advocacy • Meet with governmental officials to encourage increase funding for AA research and health insurance coverage of wigs and hair prostheses

  44. Support Websites • ALOPECIA: National Alopecia Areata Foundation www.naaf.org • ECZEMA: National Eczema Association http://nationaleczema.org/ • PSORIASIS: National Psoriasis Foundation https://www.psoriasis.org/ • ROSACEA: National Rosacea Society http://www.rosacea.org/

  45. In Summary… • Understand relationship between physical health and emotional health • Be aware of increased prevalence of mental health issues in dermatologic populations • Enhance ability to identify and respond to emotional distress • Feel comfortable discussing available supportive resources with your patients

  46. Outline • Introduction • Research • Management • Questions

  47. References • Available Upon Request

  48. Questions?

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