Annotated Abstracts of Journal Articles
2014, 2nd Quarter
Annotations by J. Jewel Shim, MD, FAPM
ANNOTATION (J. Jewel Shim)
The Finding: The study authors found a high prevalence of skin diseases in stable outpatients with schizophrenia spectrum disorders, with high rates of fungal infection and dermatitis. They also examined a population-based database, comparing a sample of 7749 patients with a schizophrenia spectrum disorder with 30,996 control patients without these disorders, and found higher rates of hyperkeratotic disorder, fungal and bacterial infections, and dermatitis. Patients with diabetes and obesity had significantly increased risk for fungal and bacterial infections, and schizophrenic patients with diabetes were twice as likely to have a skin infection. In general, in the clinical survey, schizophrenia spectrum disorder patients had a low rate of awareness of these skin conditions (21.2%). The authors also examined the effect of antipsychotics and skin diseases, and found that non-clozapine antipsychotics (NCAA) were associated with higher rates of pilosebaceous disease (acne) and clozapine treated patients had lower rates of fungal infections.
Strengths and Weaknesses: A strength of the study is its size, particularly in the population-based sample. Weaknesses include the cross-sectional study design, which does not allow the investigators to make any definite inferences regarding the nature of the relationship between schizophrenia spectrum disorders and skin diseases or whether specific classes of antipsychotics are more likely to cause skin problems. The clinical survey did not have a control group to compare with the subjects with psychotic disorders. In the population-based sample, the diagnoses of skin conditions was not made by a consistent type of physician. For example, skin disorders may have been diagnosed by a dermatologist or any other kind of doctor, and for this reason, the prevalence of skin disorders may have been either overestimated or underestimated, depending on who saw the patient. The study subjects were all stable outpatients, limiting the generalizability of the findings to this population.
In addition, there are a number of potentially confounding variables that were not acknowledged, nor controlled, including comorbid medical illnesses, concurrent medications, and substance abuse, all of which could contribute to skin problems.
Relevance: Patients with schizophrenia spectrum disorders may be at increased risk for skin disorders, related to poor insight and associated poorer self-care and lack of awareness. It is important in the total care of the patient for psychiatrists to understand this potential vulnerability and possible risk factors.
Objectives: To examine the epidemiology of and possible risk factors for skin diseases in patients with schizophrenia.
Methods: All of 337 patients with schizophrenia were recruited from the therapeutic community of a psychiatric hospital and underwent a detailed skin examination. The National Health Insurance Research Database (NHIRD) was used to compare the prevalence of skin diseases between patients with schizophrenia and those without.
Results: In the clinical survey, fungal infection (61.4%) and dermatitis (46.9%) were the most common skin diseases. Clozapine users had a lower risk of fungal infection than those on typical antipsychotics [odds ratio (OR)=0.49, 95% confidence interval (CI)=0.30-0.81]. Obese patients were more likely to have fungal infections than those without (OR=1.93, 95% CI=1.20-3.09), and those with diabetes had an increased risk of bacterial infection than those without (OR=2.0, 95% CI=1.06-3.75). NHIRD revealed that the overall prevalence of skin diseases, including infections, dermatitis, hyperkeratosis, pilosebaceous disease, androgenic alopecia, xerosis and stasis, were higher in patients with schizophrenia than in those without (75.1% vs. 72.6%, P=.01).
Conclusions: The prevalence of skin diseases is high in patients with schizophrenia, for whom proper skin care is necessary to improve their life quality.
ANNOTATION (J. Jewel Shim)
The Finding: The paper offers a short review of the literature (which is quite limited) on Morgellons, including ethical perspectives. Most were case reports and recommended treatment with antipsychotics or antidepressants, and/or psychotherapy. The data on whether to disclose the suspected etiology, i.e., psychiatric, is mixed, primarily because of concerns that the patient will resist the recommended treatment. The authors categorize the possible communication approaches into three types: 1) the stress strategy, 2) the empirical strategy, and 3) the euphemistic strategy, all of which involve some type of subterfuge, a “grey zone” in which the physician does not inform the patient of his/her full opinion.
Strengths and Weaknesses: This is a review of a very limited literature, and treatment and communication approaches are not evidence-based. However, the paper highlights an important ethical issue in the treatment of patients with delusional parasitosis.
Relevance: This paper appears to be geared more toward dermatologists and primary care providers, but has relevance for psychiatrists, who may receive these patients more downstream but will have to continue the discussion with the patient regarding diagnosis and treatment. In fact, the PM psychiatrist may be the initial physician having this discussion with the patient. The issues raised can also be extrapolated to other delusional/psychotic disorders.
Morgellons is a medically contested diagnosis with foremost dermatological symptoms. Patients experience fibers emerging from the skin, together with a range of other somatic, psychiatric, and neurological complaints. Within the medical community, it is generally held to be a variation of delusional parasitosis/delusional infestation, which is usually treated with antipsychotics. Little attention has been paid in the literature to the ethical aspects of treating patients with Morgellons disease. The communicative strategies suggested in the literature display significant ethical issues, primarily the use of therapeutic privilege, i.e. withholding information from the patient. Since this limits patient autonomy, that approach is ethically problematic. Instead, the physician has an ethical obligation to respect the patient’s autonomy, provide full information, and seek consent before initiating a psychiatric referral.
Eskin M1, Savk E, Uslu M, Küçükaydoğan N
J Eur Acad Dermatol Venereol 2014 Jan 10 [Epub ahead of print]
ANNOTATION (J. Jewel Shim)
The Finding: The authors cited previous literature on psoriasis and its association with poorer quality of life and psychological distress. They posited that effective problem solving can mitigate psychological distress, and that psoriasis patients in general have poorer problem solving and consequently, poorer associated levels of life satisfaction and higher levels of perceived stress and depression. However, the study did not demonstrate a significant difference between psoriatic patients and controls in terms of these variables, though they did have a significantly lower problem solving score by their primary measure, the Social Problem Solving Inventory (SPSI-R). The investigators found that better problem solving in general correlated with lower levels of depression, perceived stress, negative life events, and higher life satisfaction. In terms of specific problem solving orientation and style (as measured by the SPSI-R), psoriatic patients had higher negative problem orientation and were more likely to have a impulsivity/carelessness style, but it does not appear that these results were significantly different from the control group.
Strengths and Weaknesses: The study is limited by its small sample size. In addition, the cross-sectional design does not allow the authors to make any definitive conclusions regarding the relationship between problem solving and perceived stress, depression, and life satisfaction. The two groups differed significantly in terms of work status and level of education, with the control group having higher levels of both factors. These differences could confound the results; those with higher levels of education may have better problem solving ability. Moreover, unstable employment may have contributed to the higher levels of perceived stress, depression, and lower life satisfaction in the psoriasis group. The degree of severity of psoriasis in the included subjects was mild to moderate, which limits its generalizability to all psoriatic patients. It is also not clear if the subjects had a previously diagnosed depressive or substance use disorder, which could also confound the results.
Relevance: This study highlights that psoriasis patients with depression may have lower problem solving ability than those without dermatoses, and therefore suggests a specific therapeutic approach (i.e., problem solving therapy) which may be more effective in this population.
Background: Psoriasis is a chronic dermatosis which may cause significant impairment of the patient’s quality of life.
Objective: The purpose of this study was to investigate the social problem-solving skills, perceived stress, negative life events, depression and life satisfaction in psoriasis patients.
Methods: Data were gathered by means of questionnaires and clinical evaluations from 51 psoriatic patients and 51 matched healthy controls.
Results: Average disease duration was 16.47 years and average Psoriasis Area and Severity Index score was 3.67. Compared with the controls, the patients displayed lower social problem-solving skills. They displayed higher negative problem orientation and impulsive-careless problem-solving style scores than the controls. Patients tended also to show more avoidant problem-solving style and lower life satisfaction than controls. There was no difference between psoriatic patients and controls in terms of depression, perceived stress and negative life events. Higher social problem-solving skills were associated with lower depression, perceived stress and fewer numbers of negative life events but higher level of life satisfaction.
Limitations: The patient group largely included mild and moderate psoriatic cases.
Conclusion: The findings of the study suggest that problem-solving training or therapy may be a suitable option for alleviating levels of psychological distress in patients suffering from psoriasis.