Introduction
Psoriasis is an autoimmune mediated genetically determined common dermatological disorder which affects the skin, joints and has numerous systemic manifestation. Quality of life in psoriasis is affected and patients includes social activity, home life and emotional domain of life. Kurd et al1 has found suicidability, depression, anxiety associated with psoriasis. The commonest disorders associated with psoriasis are depression, anxiety, psychosis and cognitive impairment.
Depression
Kumar et al 2 reported 90% was the highest percentage of depression. Dowlat et al has reported high prevalence of depressive mood in psoriasis ranging from 6% to 78%. 1L – 1, 1L - 16 are elevated in psoriasis and depression, indicating the inflammatory process may be contributing to account of psychological morbidities rather than psychological effects of psoriasis. Danish national cohort study, that the incidence rate of depression in severe psoriasis cases was significantly greater than in patients with mild psoriasis (Jonsen et al3 2016) cytokines like IL 6, IL-17, TNF - α were reported raised in patients with psoriasis.
Dermorhan et al4 2012 Bongueon and Misery 2013 has reported manic episodes in few cases of psoriasis. MRI studies have shown low level of activity in insular cortex of patients in psoriasis.
Anxiety
Considering anxiety the prevalence rate was reported as 7-48%. Severe psoriasis is associated with higher risk than mild psoriasis.
Psychosis
Is a comorbid disorder in psoriasis was reported in case report studies by shiva kumar et al5 2016. Psoriasis was associated with family history of schizophrenia and non-affective psychosis (Eaton et al 6 7 2010, Bensors et al 2014.
Psoriasis and Depression
Incidence levels of anxiety, suicide risk, and depression was estimated by Kurd et al (2010). Depression in psoriasis is associated with 30% higher incidence of proinflammatory cytokines like 1L-1, TNF α and C-reactive protein which affect the metabolism like dopamine, serotonin and glutamate and serotonin resulting in neurotoxicity and neuronal apoptosis immune cell migration may be pointed by ICAM-1, IL-6 and 1L-11, depression and anxiety affected patients show high level of cytokines, TH17 and 1L-17A . Psoriasis treatment may improve depression, and treating depression may improve psoriatic symptoms.
Psoriasis and Stress
Immune system is weakened by stress and proinflammatory cytokines are increased. Two neurotransmitters are generally associated with stress and psoriasis. Decreased levels of 5 hydroxytryptamine levels are increased in inflammatory mediators such as TNF- α and 1L-1B, which induces the activation and deterioration of keratinocyctes via NF- KB which is activated by IL-17A in prefrontal cortex and in the hippocampus. Dopamine might be considered as a risk factor for psoriasis leading to release of proinflammatory cytokines. Damage associated molecular patterns stimulate innate immune cells to produce IL -6 and TNF- α and to recruit increasing number of monocytes that begin to circulate in blood circulation . Amine section by sympathetic nervous system leads to proliferation of myeloid cells.
Psoriasis and Dementia
Psoriasis is a chronic inflammatory skin disease associated with psychosomatic and neurological disorder including dementia. Vasculopathy associated with psoriasis, including arterial stiffness and impaired endothelial function, may predispose to vascular dementia. Oxidative stress in psoriasis and proinflammatory cytokines, may impair neurogenesis and synaptic plasticity leading to neurodegeneration causing cognitive decline.
Cognitive Impairment
Cognitive functions are crucial for percieving and judging, there is information processing, learning production of language and executive function. Visuospatial working memory and attention is reduced in psoriasis Gisondi el al8 2014; Sarkar et al,9 2014; Different parts of prefrontal cortex is involved in psoriasis Neuroimaging of individual with psoriasis has found significant decline in cortical thickness. Marek – Jose fowicez et al10 2017 found out that cognitive impairment was correlated with neither severity nor the duration of last exacerbation of the disease. High possibility of dementia was associated with cognitive dysfunction in the future. The correlation between psoriasis and dementia was controversial.
Personality Triats
Psoriasis patients were characterized by certain personality types like dependent, avoidant, compulsive and schizoid by Rubino and Zanna et al11 1996. In another study done by Mazzethi et al,10 1994 schizophrenia trial and anxious personality was commonly found. Alexithemia is a term which describes deficiency in understanding and describing and processing emotions (sifnen 1973). Three dimensions of alexithemia are difficulties in identifying and describing feelings and impairment of externally oriented thinking. Crosta et al, 12 2014 has found high prevalence of Alexithemia which was reported in psoriasis. The common personality traits associated with psoriasis is somatic trait, psychiatric trait, embitterment, mistrust stress susceptibility trait, verbal trial aggressive trait.
Sexual D ysfuntion
Sexual desire is decreased in psoriasis. Psoriasis is associated with erectile dysfunction, orgasmic disorder. Molina leyva et al,13 Gupta and gupta 1997 et al14 have reported increase in joint involvement and presence of psychiatric morbidities like depression, hypertension and hyperlipidemia were correlated with sexual dysfunction with psoriasis. Molina levya et al, 2015 have reported higher rate of unprotected sex, and lower age of first sexual intercourse in psoriasis.
Sleep Disorders
Gowda et al, 2010 have reported nocturnal and early morning awakenings and day time sleepiness and comorbid condition like obstructive sleep apnea syndrome in psoriasis has prevalence of 36-81.8%.
Alcohol and Smoking Misuse
Patients with psoriasis are more prone to consume alcohol. Psoriatic patients use alcohol as copying up strategies to control stress associated with chronic health condition. Severity of psoriasis is associated with increased in alcohol consumptions.
Smoking is a well-recognized risk factor for developing psoriatic arthritis, a comorbidity that affects 20% of patients with psoriasis.
Eating Disorders
Studies have found the correlative between psoriasis and eating disorders. Obesity is more prevalent in psoriasis than in general population. Recurrent episodes of eating large amounts of food is called binge eating disorder associated with psoriasis.
Table 1
Preclinical studies on relevant shared mechanisms of chronic skin inflammatory diseases and depression and / or anxiety in animal models.
Table 2
Populationbased studies mentioning the association between psoriasis and psychosis.
Various indices associated with psychiatric morbidity in psoriasis
DLQI is the most frequently used instrumentation in the studies of dermatology to access the quality of life. DLQI questionnaire comprises of 10 questions concerning patients perception of impact of skin disease on their heath related quality of life over last week is assessed. Patients assess the burden of the conditions and clinicians evaluate and monitor the treatment efficacy and psychological burden.
Psoriasis Disability Index
This is a self-explanatory questionnaire are to assess disability in patients with psoriasis.
Generalized anxiety disorder questionnaires – 7 (GAD 7)3
This seven item questionnaire was developed to screen patients for anxiety and rate the severity of anxiety. 4 point scale for severity of symptoms score of 5, 10, 15 are taken as the cut off for mild, moderate and severe anxiety respectively.
Multi-dimensional aspect of percieved social suport scale
This is a social support scale comprising of 12 times that are divided into three subscales on the source of support. Each group consists of 4 items. These are family domain, friend’s domain and spinal person domain stems are noted on 7-point scale. Definitely yes or definitely no are the two options.
Patient Health Questionnaire
This is a brief self-administered depression scale that evaluates each of nine criteria of the diagnostic and statistical manual.
Each rated from 0-3.
I nternalized Stigma of Mental Illness (ISMI) S cale
ISMI scales is an interview based instrument to assess self-stigma / internalized stigma. It comprises of 29 questions, with point rating scale. The various items of the scale are grouped under 4 dimensions: alienation, stereotype, endorsement, Perceived discrimination. Social withdrawal and stigma resistance basically reflex the ability of the person to fight back. Accordingly, higher stigma resistance indicates higher ability to withstand the pressure of stigma. Calculation of weighted score is done.
Conclusion
There is a high prevalence of different psychiatric and neurological disorders reported in psoriasis cases. Psychiatric disorder associated with psychosocial burden of chronic skin diseases may impair the response to outcome of the treatment and the disease process itself which may worsen mental symptoms, thus contributing to undermine the patients quality of life. More emphasis should be made on studies which are centered on psychological evaluation done by clinician rated instruments and by patients themselves which includes stigma, cognitive functioning, coping up strategies.
Regular treatment of skin under proper supervision clubbed with climate therapy and nutrition monitoring with psychological intervention helps in coping up with disease with respect to psychological and social consequences of psoriasis.
Finally, an integrated approach is necessary between dermatologist and psychiatrist to identify mental health disorders at earlier stage to provide quality health care and reduce the financial burden of mental health disorders to the society, care givers and researchers.
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