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Review Article

DOI: 10.1111/j.1610-0387.2007.06406.x

Skin and psyche From the surface to the depth of the inner world
Helmut Beltraminelli, Peter Itin
Department of Dermatology, University Hospital, of Basel Switzerland

JDDG; 2008 6:814

Submitted: 11. 2. 2007 | Accepted: 27. 3. 2007

Keywords
Psychosomatics Stress Skin Psyche Psychodermatosis

Summary
About 30 % of dermatology patients have signs or symptoms of psychological problems. Dermatologists should be familiar with the basics needed to identify, advise and treat these patients. Because of the complex interaction between skin and psyche, it is difficult to distinguish whether the primary problem is the skin or the psyche. Sometimes the clinical picture is a consequence of interactions between them and other factors. The interactions between skin and psyche are well known in history, art and literature perhaps better known today because the marked emphasis on such images in our modern multimedia society. Aging is increasingly perceived as an illness and not as a physiological process. Through globalization, many different cultural approaches to the skin have entered in our daily life and influence our communication. This article considers the most important dermatoses which often show primary or secondary interaction with the psyche. chological well-being and self-confidence. Anzieu takes this idea even further in his concept of the skin ego [1] which describes, on the one hand, the skin as a boundary between the Self and the environment, and on other, the barely tangible boundary (a fictitious skin) in the psyche that separates an individuals inner life from the outside world. Most physicians are aware of just how quickly one can enter the deepest, darkest reaches of the psyche - the patients unconscious mind during any (more than merely superficial) examination of the skin. As numerous studies have shown, about 30 % of dermatology patients have symptoms of at least one psychological comorbidity [2]. The treatment of psychosomatic disorders is often a challenging and complex process. Yet, it can also be a rewarding experience insofar as patients with psychosomatic disorders can enable the dermatologist a closer look at the mystery of life, providing a valuable experience if for this reason alone. Age, society, and language When one thinks of the role of the skin as an organ of communication, one of the first things that comes to mind are tattoos. Tattooing has been practiced in various cultures throughout history, often as a means of showing that an individual belongs to a certain group (particularly as a form of stigmatization). Tattooing is currently in, especially among younger people; ten percent of Germans have at least one tattoo and the trend is growing in terms of numbers and variety [3]. Various other techniques also exist by which the skin is used to communicate individual characteristics such sex, age, success, religion, social status, health and (often unintentionally) disease. Cosmetics, jewelry, and piercings are a means of

Introduction What do the skin and the psyche have in common? The skin appears to be only a superficial covering, a mere sheath separating the Self from the environment while the psyche, the seat of the personality, encompasses far more. We are what we think (and, unfortunately, increasingly what we own). Yet, the skin and the psyche do indeed share a few things in common: the skin and the brain both develop from the embryonic ectoderm; both are organs of communication, manifesting our emotions, and both are sensory organs. The skin and the psyche each contribute to making human beings individuals - the skin by virtue of its unique appearance, e.g., fingerprints, and the soul by virtue of individual thoughts, perceptions, memories, and character. The skin is a mirror for the soul and the soul a mirror for the skin. Healthy skin, like a healthy soul, is essential for individual physical and psy-

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continual nonverbal communication, capable of even transforming the wearer into a living sculpture, artwork, or canvas. (In Berlin a girl recently offered her breasts on the Internet as advertising space [Berlin, 19 January, 2007].) The word skin also appears in different languages in various figures of speech, often metaphors describing emotions. (The reader is directed to a book by C. Benthien [4] for more detail on interpretation and etymology). Examples of such expressions include : show me your skin, show me your face, and Ill tell you who you are, save your skin, red with anger, green with envy, save ones hide, have a thick/thin skin, feel comfortable/uncomfortable in your own skin. First impressions are primarily based on subjective assessment of external features. In addition to clothing, the condition of a persons skin, hair and nails communicate essential aspects of his or her personality (along with physique, figure, facial expression, voice, speech, odor, jewelry). A maximum of (temporary) conclusions are derived from a minimum of actual information, with noticeable, distinctive features dominating over all other sources of information. These features (excluding speech and voice) are key stimuli in nonverbal communication. Appearance has always been extremely important to human beings and cosmetologists have been around for as long as humanity itself. The art of decorating the body or hiding defects, for instance as a means of enhancing ones sexual attractiveness, has been practiced in every culture throughout the ages. Not only the skin, but also the hair functions as a cultural symbol, serving as a sign of social status and conveying an image of masculinity or femininity; changes in hairstyle are subject to prevailing fashion. The appearance of the skin and hair are related to the perceived health or illness of an individual. Skin changes are frequently viewed by others as contagious and also may be associated with sexually transmitted disease, inadequate hygiene, or uncleanliness. People with skin disease are often considered sexually unattractive [5]. A healthy sex life is important for emotional health. Lewis-Jones has shown that normal-appearing skin is a prerequisite for physical and psychological well-

being and is an important factor in sexual attractiveness [6]. Pasini has similarly shown evidence of the occurrence of modifications in emotional and affective distance in intimate relationships due to longer use of topical dermatological agents (some with an unpleasant odor) in various inflammatory skin diseases [7]. Given that the skin is an organ of communication, as well as the heightened importance in the modern era of seeming and appearing, many patients also view age-related skin changes as restricting (nonverbal) communication. The normal process of aging is often treated as a disease and a social problem resulting in a global run on products that promise rejuvenation. People increasingly believe that the skin should appear young and firm, and that outward appearance is very important. According to the American Society of Plastic Surgeons (www.plasticsurgery.org), in the last 15 years there has been a marked increase in plastic surgery (+775 % in 2005, compared to 1992), the most common interventions being breast enhancement, liposuction, rhinoplasty, eyelid procedures, and abdominoplasty. Modern media and advertising, which propagate an unrealistic ideal body image, along with various healthcare professionals, bear a certain responsibility. The faces of the elderly, lined with wrinkles, were previously viewed with respect, having borne witness to a lifetime of experience and evidencing the wisdom that comes with it, presenting open book on an individuals life history. In an era in which people have no qualms about publicly revealing the most intimate aspects of their lives, there is an attempt at masking certain other signs of the life a person has lived, based on the underlying assumption that looking younger boosts self-confidence and improves social connections. It is as if the desire to be healthy has been confused with the illusion of looking perfect. The psychological effects of agerelated skin changes clearly outweigh any physical effects since from a biological standpoint aging is not a disease. Psychosomatic dermatology general information Psychoneuroimmunology is concerned with investigating the connections between the mind, body, and immune

system. During the past 30 years, a number of studies have shown how mood and stress can alter the immune system [810]. The term stress (derived from the Latin stringere, meaning to draw tight) can be used to refer to external stimuli (stressors) which elicit psychological or physiological reactions in humans or animals which enhance function, or it can refer to the resulting physical and mental stress. Epidermal permeability [11] and wound healing also appear to be influenced by stress. The human body contains a multidirectional psychoneuroimmunologic network consisting of various polypeptides and their receptors which are found in the nervous and immune systems [12]. (Langerhans cells, for example, contain neuropeptides as well as neuropeptide-receptors that allow bi-directional communication between the immune and nervous systems [13].) Individual health depends on a wide array of variables. Lutgendorf and Costanzo [14] have proposed a biopsychosocial model for interpreting their interactions that contains several levels: psychosocial processes (individual differences, mood, resources), biological factors (genetics, exposures), healthy behavior (lifestyle), stress factors (illness, accidents, socio-economic status), psychological interventions, and neuroendocrine processes of adaptation which, depending on emphasis, lead to a certain vulnerability or resistance. Symptoms appear later, eventually leading to clinical exacerbation of the disorder and ultimately playing a critical role in the survival and quality of life of the patient. In psychosomatic disorders, stress, as well as inner psychological conflicts and early-childhood trauma play an important role in the development of disease; psychosomatic disorders are reactive skin diseases. Various classifications exist for different forms of psychodermatosis [15, 16]. Their main value is didactic. In terms of pathophysiology and biopsychosocial factors, they are not always useful given that in many instances multiple factors contribute to psychodermatosis and also interact with each other. Table 1 provides a classification system based on current knowledge which divides skin diseases of primary psychological origin from secondary psychological disorders and multifactorial etiologies. Dermatology

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Table 1: Classification of psychodermatoses after Harth and Gieler, 2006 [17]. True artefacts, para-artefacts (neurotic excoriation, acne excorie, morsicatio buccarum, cheilitis factitia, pseudo-knuckle-pads, onychophagia, trichotillomania), simulations Parasitosis, obsession with own body odor, hypochondria, body dysmorphic disorder, folie deux Somatization disorder, hypochondria, somatoform autonomic function disorder, dysesthesias Compulsive washing, lichen vidal

Artefacts

Skin disorders of primary psychological origin

Skin diseases resulting from delusion or hallucination Somatoform disorders Skin disorders resulting from obsessive-compulsive behavior Atopic dermatitis, acne vulgaris, psoriasis vulgaris, alopecia areata, anal eczema, dyshidrosiform hand eczema, herpes labialis, hyperhidrosis, hypertrichosis, lichen ruber, lupus erythematosus, perioral dermatitis, sclerodermia, prurigo, rosacea, seborrheic eczema, leg ulcers, urticaria, verrucae vulgaris, vitiligo Congenital disfiguring skin disorders and sequelae (genodermatoses)

Multifactorial skin disorders

Ichthyoses, epidermolyses, lipomatoses, phakomatoses Infections, autoimmune skin diseases, trauma, keloid, neoplasias Depressive disorders, anxiety disorders, obsessive-compulsive disorders, adaptive disorders, dissociative disorders, personality disorders

Secondary psychological disorders and comorbidities

Congenital disfiguring skin diseases and sequelae

Comorbidities

occupies a special position within psychosomatic medicine in that it deals with an organ that is readily accessible to sight and touch. Such a level of exposure has clear psychological implications. Examples of comorbidities Depression Depression is a psychiatric disorder commonly encountered in dermatologic practice. Gupta et al. have observed a direct and statistically significant correlation between the severity of pruritus and the severity of symptoms of depression in patients with psoriasis, atopic dermatitis, and chronic urticaria [18]. Chronic dermatoses alter the appearance of the patient, potentially contributing to significant psychological distress. Severe pruritus and skin diseases causing severe cosmetic problems have been associated with an increased frequency of suicidal thoughts [19]. Dehen and colleagues reported that 23.6 % of derma-

tology outpatients had symptoms of depression [20]. There was a statistically significant difference between patients with and without appointments, whereby symptoms were more marked in the latter group (especially in men). Those receiving inpatient care for psoriasis and those being treated on an outpatient basis for acne were most frequently depressed; in another study, patients with atopic dermatitis were also among those with depression [21]. Dermatologists should not hesitate to address such issues, including suicide, in patient consultations. If, as a practicing dermatologist, one feels uncertain or unqualified to accurately assess such a situation, psychiatric evaluation should be obtained. Anxiety disorders Anxiety is the fear of potential suffering. It describes a situation of perception and behavior consisting of uncertainty and

tension triggered by an actual or anticipated event (e.g., pain). It is important to distinguish between acute panic disorder, chronic anxiety, and specific phobia. In dermatology, cortisone phobia has been repeatedly reported [22]; patients with social phobia, which may manifest as flushing or palmar hyperhidrosis, are less often encountered. Obsessive-compulsive disorders Obsessive-compulsive disorders encompass obsessive thoughts and compulsive actions (e.g., hand-washing or disinfecting, and rubbing the skin or hair). Dermatologic sequelae include eczema and lichenifictaion, as well as infections. Dissociative disorders Somatoform dissociation, formerly known as conversion, is another comorbid condition. In somatoform dissociation, psychological conflicts manifest as somatic symptoms. Classic examples

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include pseudoneurologic symptoms in hysterical paralysis or in the realm of dermatology vague skin sensations such as a feeling of something crawling or running on my skin. Patients frequently exhibit artefacts, pruritus, numbness, and pseudoallergic reactions. As Saxe and colleagues have shown, skin disease is found more often in patients with dissociation compared with a control group [23]. The main characteristic of a dissociative disorder is partial or complete loss of normal integrative functions such as memory, consciousness, perception, and control over bodily functions. Dissociative disorders involve repression (as a defense mechanism) of stressful emotions and experiences such as trauma. Personality disorders The skin plays a symbolic role in borderline syndrome, a previously unsatisfactorily defined disorder that involves psychosis, neurosis, and personality disorder; today, standardized diagnostic criteria by Kernberg are used [24]. Patients may exhibit signs of autoaggression and 4-9 % of patients with borderline syndrome commit suicide [25]. Patients with borderline syndrome who consult a dermatologist usually have artefacts and para-artefacts (worsening of pre-existing skin disorders). Autoaggression takes various forms: patients may cut, scratch, stab, pinch, burn, cauterize, slash, carve, inject, bite, or hit themselves; wound healing is also often prevented. Various levels of autoaggression are defined in the literature. These generally range from mild (superficial) to moderate (resulting in scarring) or severe (resulting in mutilation) bodily injury. Examples of skin diseases of primary psychological origin Somatization Somatization is the process of bodily symptoms (somatoform symptoms) arising as a sign of underlying psychological distress, for example, anxiety disorder or psychosis. Table 1 lists several somatoform disorders. Dermatologic disorders such as dysesthesias, pruritus sine materia, belief that ones body odor is offensive, facial or bodily ticks, localized cutaneous pain, artefacts, vulvodynia, glossodynia, and hypochondria are examples of a certain type of body language and may mask psychiatric disease.

Body dysmorphic disorder is another example of somatic disease (somatoform disorder, classified under hypochondria). Affected patients are excessively preoccupied with their (basically normal) appearance and view even the most minor skin irregularity as disfigurement. That the incidence of disease is on the rise reflects the age in which we are living. Patients also have a high comorbidity for depression and social phobia. The consequences of body dysmorphic disorder include social isolation, jobrelated problems, psychiatric hospitalization, suicidal thoughts, and suicide. Patients frequently attempt to hide perceived deficits with their hair, make-up, or clothing. Unfortunately, correct and early diagnosis is rare [26]. Why does somatization occur? It is difficult to provide a scientifically sound answer. The skin is so accessible, it often becomes the target of various tensionreducing bodily ticks. Also, from the time of childhood, the skin serves as the primary organ of communication and probably stores body memories [27]. Patients who are not sufficiently able to verbalize personal problems in particular come to rely on the skin as the most visible organ of communication. Castillo and colleagues have published an analysis based on a review of the literature on somatization among immigrants and refugees (asylum-seekers) [28]. Immigrants, especially refugees, have often had traumatic experiences (war, fleeing their home country, fear of death); they are living far from home and often feel lonely and isolated in their new country. All of these factors can lead to psychosocial stress, and it is therefore not entirely surprising when symptoms of somatization develop. Clearly, immigrants and refugees are not alone in developing somatization; identical symptoms are observed in non-immigrant patients. Dermatitis artefacta (factitial dermatitis) The skin changes that occur in dermatitis artefacta have a characteristic morphology with typical locations, sharplydefined geometric shapes, and often a linear pattern; women are affected more often than men. Various lesions have been reported, including vesicles, blisters, erosions, ulcerations, purpura, erythema, edema, granulomas, and scarring. The disease involves abnormal per-

ception of the self, in particular with regard to body image [29]. Dermatitis artefacta may be associated with various psychiatric disorders (comorbidities), among these are often borderline syndrome or depression. In some patients, the disorder may be considered a cry for help. Around 20 % of patients with dermatitis artefacta have lost either a parent or sibling during the first decade of life as a result of death or divorce [30]. Other social problems and conflicts such as unemployment are also frequently reported [31], and there is an increased incidence of reported sexual abuse, generally occurring during childhood or adolescence [32]. One example of dermatitis artefacta is acne excorie in young women. Some authors (Harth and Gieler, 2006) consider acne excorie to be a para-artefact, an impulse control disorder that leads to manipulation. Early stages are characterized by excessive manipulation of a minimal primary lesion. Most patients with artefacts reject the diagnosis. It is thus preferable not to confront the patient during an initial consultation, but rather to provide empathy and support. The decision to discuss with the patient the diagnosis may be weighed at a later stage after the patients trust has been gained. Referral for psychological or psychiatric support is usually resisted initially. Therapeutic measures that involve a high level of nursing are strongly recommended, e.g., applying occlusive bandages to the ulcerations to protect against further manipulation. Neurotic excoriations (skin-picking syndrome) Dermatitis artefacta should be distinguished from neurotic excoriations. The latter are also a sign of dissociation and are occasionally seen in obsessive-compulsive disease (belonging to anxiety disorders) or depressive syndromes; additional social problems are often discovered. Clinically, the disease presents as rather small, clustered erosions in a linear arrangement as well as scarring and pigmentary changes on easily-accessible areas of the skin (e.g., hands, shoulders, or neck), often in combination with pruritus. Patients tend to acknowledge the self-inflicted nature of the skin lesions and psychiatric or psychological treatment is generally more successful than in patients with dermatitis artefacta.

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Trichotillomania Trichotillomania is the compulsive pulling out of hair. Patients usually pull out the hair on their heads, but may also pull out eyebrow hair, eyelashes, or other body hair; less often, they pull out the hair of a partner or pet. The hair is then often ingested (trichophagia), with the associated risk of formation of a hair ball (trichobezoar) in the gastrointestinal tract, potentially interfering with peristalsis and causing related complications. A special variant is trichokryptomania, a similar disorder in which the hair is not pulled out, but instead the scalp is rubbed so vigorously that alopecia develops. Patients initially exhibit single or multiple areas of alopecia, initially without scarring (though scarring can develop in chronic disease) and usually on the head, less often involving the eyebrows or eyelids. The disorder mainly affects women. Trichotillomania is interpreted as a sign of psychological distress, usually associated with depression, frustration, or anxiety disorder. In terms of pathophysiology, obsessive-compulsive behavior with partial loss of impulse control and/or dissociative symptoms has been suggested. A similar pathophysiological basis is presumed in habitual nail-biting (and ingestion). Both disorders share increased tension immediately before the pathologic behavior followed by relief [33]. The behavior tends to occur in calm situations in which the patient is alone or lost in thought. As elsewhere in medicine, the boundary between a bad habit and a true pathology is blurred and the determination of whether a behavior is one or the other depends on severity, frequency, and site of injury. Patients typically reject the diagnosis; they are often ashamed of their behavior and hide its visible results from others, including their doctors. Multifactorial skin diseases The major multifactorial skin diseases are atopic dermatitis, psoriasis, chronic urticaria, alopecia areata, lichen planus, warts, vitiligo, and acne. This group also includes less commonly occurring diagnoses such as severe burn injuries, neurofibromatosis, extensive angiomas and nevi, ichthyoses, as well as other congenital disorders. In the first group of diseases, the cause is presumed to be an immunological disorder, which, depending on up-regulation or down-regulation

of cytokines, exacerbates the skin disorder. In the second group, the psychological stress of living with a long-standing skin disorder plays a key role. It is worth noting that patients with epithelial skin tumors, i.e., with disease that from a medical and biological standpoint is considered more severe, report a much lower [34] decrease in quality of life compared to patients with chronic inflammatory skin disorders. Wessely and Lewis found that there was no correlation between psychiatric morbidity and the site or severity of skin disease [35] although their findings have yet to be corroborated by other studies. Hospitalization can improve the status of even chronic and recalcitrant skin disorders and in certain situations may even bring about healing, although precise, systematic analyses are needed. Thus it is not certain which of the following factors plays the most important role: intensive treatment carried out by healthcare professionals, eliminating everyday stress, or daily touch (possibly reminiscent of a mothers care and attentiveness [36]). Pruritus Schneider and colleagues have examined psychiatric comorbidity in patients with pruritus who were hospitalized for skin disease, finding 16 psychiatric diagnoses in more than 70 % [37]. Psychosomatic factors and psychiatric comorbidity can influence pruritus on several levels, e.g., perception, handling, and coping. Pruritus has many causes including internal disease (lymphoma, neoplasias, metabolic disorders), neurologic (neuropathies), infectious (parasitosis) and allergies involving the skin. Several triggers are known to be involved in the pathophysiology of pruritus: pH changes, opiates, proteases, cytokines, acetylcholine, neurotropins, and histamine. Given that histamine alone is not responsible for pruritus, H1-antihistamines have a limited antipruritic effect. Pruritus is also seen in various psychiatric disorders. The hypothesis that pruritus is all in the head and that scratching the brain is the actual response, has been described by Paus and colleagues [38] who attribute it to neuronal projections, from centrally processed stimuli, that are felt on the skin. Pruritus is presented as an illusion produced by the brain that something is

happening on or within the skin. This hypothesis of psychoneuroimmunologic networks could prove useful for treatment, for example in the use of suggestion, hypnosis, and conditioning. Other disorders Certain psychiatric disorders, such as anorexia nervosa, are associated with non-psychogenic skin changes [39]. Some patients with bulimia also have xerodermia (71 %), cheilitis (76 %), nail dystrophy (29 %), dry or damaged hair (48 %), alopecia (24 %), lanugo hairs (62 %), cold acral skin (38 %), acrocyanosis (33 %), livedo reticularis (48 %), periungual erythema (48 %), gingival changes (37 %), pruritus, or carotenodermia. Anorexia nervosa is a typical disease of the times, and is in part encouraged by a society obsessed with unrealistic fashion ideals. (Many models and beauty pageant contestants have a body mass index [BMI] between 16 and 20 [normal: 2025 kg/m2].) Fortunately, the tide appears to be turning (at least partly) and in several European countries, minimum weight standards have been introduced for models. Practical tips In dermatologic practice, it is difficult during a brief patient consultation to evaluate the entire skin as well as various psychological factors, and have a discussion about these with the patient. Gupta and colleagues [40] wrote a didactic paper on psychological evaluation of the dermatologic patient, using examples to illustrate the questions and statements that are best used during such a discussion. Important questions include how the skin disorder and/or psychological stress influences the patients quality of life as well as questions that help assess the patients own view of disease (how he or she interprets and experiences having the disease). Patients with significant psychological distress tend to be less compliant and have difficulty coping, which adds to the challenge of treatment. Poor compliance and skepticism are often the result of lacking or inaccurate communication during consultation. With sound knowledge of psychological profiles of diseases, a motivated dermatologist can turn the treatment of even the most difficult patient into an interesting and stimulating challenge. One

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should keep in mind, however, that for some patients being ill is a way of life; not every patient wishes to be cured [41]. A number of possibilities exist for treating patients with dermatologic and psychological problems [42] (e.g., psychoanalysis, biofeedback, behavioral therapy, relaxation therapy, and counselling). The appropriate approach should be determined individually. Dermatologists should also have basic knowledge of psychotherapeutics since many patients refuse referral to a psychiatrist. Important precautions concerning the use of psychotherapeutics are outlined in a recent review by Navi and Koo [43]. Patients with psychodermatosis need our help and it is important that we are in a position to offer it as often as possible. Conclusion The abundance of information published on this topic evidenced itself on my desk, which came to be covered with a hundred articles and numerous books. At times I was so absorbed in what I was reading that I lost control of my hand and it wandered to easily reachable parts of my shoulder or to my head, searching for places to scratch. Fortunately for me, I was reading about tension and unconscious touching of the skin and was thus aware of my own psychosomatic reactions. Without a doubt, not everyone shares the good fortune of finding the solution to his problems right in front of him, e.g., in his work. It would be a welcome development to see an increased awareness among physicians that the way in which a person lives and experiences life is a crucial factor in healing. As doctors, we should continually strive to inform patients of the relationship between such factors. <<< Conflict of interest None.

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Correspondence to
Dr. H. Beltraminelli Dermatologie, Universittsspital Basel Petersgraben 4 CH-4031 Basel Tel.: +41-61-26 54 08 4 Fax: +41-61-26 54 88 5 E-mail: hbeltraminelli@uhbs.ch

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