Updates on Mental Health and Psoriasis at EADV 2022

Marijana Vičić, MD, PhD, postdoctoral researcher, assistant lecturer, and research associate at the University of Rijeka School of Medicine, Department of Dermatovenereology and a dermatologic fellow at the Clinical Hospital Center of Rijeka, Croatia, discussed mental health related to psoriasis and challenging mental health cases at the European Academy of Dermatology and Venereology (EADV) Congress 2022 in Milan, Italy.¹

“Psoriasis is defined today as a chronic, recurrent, immune-mediated inflammatory disease, but also psoriasis is a multifactorial disease caused by a complex intersection of genetic, immunological, and environmental factors, including trauma," said Vičić.

Mental stress is a well-known factor of psoriasis. For example, psychosocial trauma can induce psoriasis. Psychosocial stress plays a critical role in the pathogenesis of psoriasis, as it can cause the onset or the first appearance of psoriasis, or worsening of the disease.

Extrinsic risk factors of psoriasis include mechanical stress, air pollution, drugs, vaccination, infection, smoking, and alcohol. Intrinsic risk factors of psoriasis include metabolic syndrome, obesity, diabetes mellitus, dyslipidemia, hypertension, and mental stress.

“Over 70% of psoriasis patients report having some stress-related event prior to the onset of exacerbation of psoriasis, mostly 12 months prior,” said Vičić.

Previously, dermatologists only looked at psoriasis as an exclusive skin disease, but recent studies prove that psoriasis is a real systemic disease where extensive systemic inflammation can affect multiple organ systems and cause numerous comorbidities, including psychiatric comorbidities. Some of the most common psychiatric comorbidities include depression, anxiety, sleep disorder, suicidal thoughts, and schizophrenia.

There are common pathophysiological mechanisms between psoriasis and psychiatric comorbidities, including inflammation. Neuroinflammation in the brain skin axis is caused by the over-activation of the hypotalamic-pituitary-adrenal axis, over-activation of the sympathetic nervous system, or the increased release of proinflammatory cytokines.

It’s crucial for dermatologists to remember that mental health is part of the psoriasis severity assessment and should be screened carefully.

Next, Vičić reviewed psoriasis patient cases with links to mental health distress. Patient 1 is a 62-year-old female with no family history of psoriasis. Their psoriatic lesions appeared 1.5 years ago, and they received no formal treatment until 2 weeks prior to seeing Vičić. The patient scored a Psoriasis Area and Severity Index (PASI) score of 37.6 and a Dermatology Life Quality Index (DLQI) score of 26. The patient had other comorbidities of hypercholesterolemia.

Vičićstated that the patient seemed introverted and afraid to speak. After a mental health assessment, specialists diagnosed her with depression. The patient stated that they recently retired 2 years ago, and the onset of their psoriasis lesions began shortly after. According to Vičić, retirement was their psychological trigger. The patient started on methotrexate.

Psychological characteristics of psoriasis patients include:

• Type D (distressed personality)- negative affectivity and social inhibition
• Early maladaptive schemes - emotional deprivation/inhibition
• Social isolation
• Vulnerability to harm
• Alexithymia
• Lack of body awareness (body ignorance)

“These characteristics can cause psychological disturbances, especially if we deal with ‘at-risk’ subgroups of psoriasis patients, like females, younger patients, patients with severe psoriasis, and patients with visible psoriasis,” said Vičić.

Studies also confirm that psoriasis is frequently linked to psychiatric comorbidities including depression, psychosocial distress, anxiety, alexithymia, sleep disorder, alcohol abuse, schizophrenia, and suicidality, all of which have a significant mental health burden. The #1 most common comorbidity is depression, accounting for 30% of all psoriasis patients.

Depression and anxiety affect all aspects of psoriasis patients’ lives, including their emotions, thoughts, behaviors, and physical being. Social, sexual, and occupational aspects of patients’ lives are also affected by severe psoriasis. Psoriasis significantly decreases the quality of life in patients as much as cancer, diabetes, heart disease, high blood pressure, and arthritis.

In her closing remarks, Vičić stresses that dermatologists must be aware of the psychological factors in psoriasis, complete regular screenings for psychological comorbidities (with an emphasis on “at-risk” groups), improve listening and counseling skills to give patients the opportunities to express their needs and concerns, refer to mental health specialists, and create a trusting and supportive relationship.

Reference:

1. M. Vičić. Challenging Case 4: Mental Health. International Psoriasis Council. Presented at European Academy of Dermatology and Venerology 31st Annual Congress. August 7-10, 2022; Milan, Italy.