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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 34  |  Issue : 2  |  Page : 99-104

Interphase between skin, psyche, and society: A narrative review


1 Consultant Dermatologist, Department of Dermatology, DermaVue Skin and Hair Clinic, Thiruvananthapuram, Kerala, India
2 Department of Psychiatry, National Institute of Mental Health and Neuroscience, Bengaluru, Karnataka, India
3 Department of Psychiatry, Government Medical College, Kottayam, Kerala, India
4 ESI, Bengaluru, Karnataka, India
5 Psychiatrist, Health Sevice, Jammu and Kashmir, India
6 Department of Psychiatry, Medical College, Kolkata, West Bengal, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Dr. Soumitra Das
Department of Psychiatry, National Institute of Mental Health and Neuroscience, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_92_17

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  Abstract 


Disorders of the skin affect the psyche of a person significantly. The interplay between internal and external world can be depicted through the various skin reactions in regard to psychological or physiological stimuli. Psychocutaneous illness could be exclusively psychological or stress related or due to strong psychogenic factors. As per biopsychosocial model, it could be primary, multifactorial, or secondary to disfigurement. Whichever is the condition, invariably stress is a major contributing factor in prognosis and onset of disorders of the skin. Self-explanation, myth, stigma, and diminished self-confidence often lead to depression and suicidality followed by active avoidance of the workplace, in turn, causing significant disability in the individual. The conflict between self-image and perceived image frequently causes fear of rejection leading to social anxiety, reduced self-confidence, interpersonal communication, and impaired sexual intimacy with a partner. Maladaptive sets of coping strategies such as alexithymia, shame proneness, avoidance, concealment, and escape are very common among the sufferers which impair the attachment with family and friends. Children are the extreme sufferers as they develop inferiority, low self-esteem, loss of body image, and social withdrawal leading to rejection from parents and faulty development of attachment pattern. Hence, disorders of the skin can lead to impaired coping, impaired compliance, limitations in quality of life, negative body image, and stigmatization which invariably cause psychological comorbidities such as depression, anxiety, phobia, and somatoform and adjustment disorders. Hence, there is a direct relationship between skin, mind, and society which we are going to explore in a detailed fashion to understand its impact on the psyche and the society.

Keywords: Depression, mind, self-esteem, skin, society


How to cite this article:
Ashwanikumar BP, Das S, Punnoose VP, Basavaraj U, Malathesh BC, Shoib S, Chatterjee SS. Interphase between skin, psyche, and society: A narrative review. Indian J Soc Psychiatry 2018;34:99-104

How to cite this URL:
Ashwanikumar BP, Das S, Punnoose VP, Basavaraj U, Malathesh BC, Shoib S, Chatterjee SS. Interphase between skin, psyche, and society: A narrative review. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Sep 20];34:99-104. Available from: http://www.indjsp.org/text.asp?2018/34/2/99/235669




  Introduction Top


Skin is considered as the “organ of expression” and it serves as the boundary between ourselves and outside world as the “ first point of contact.” Being the largest organ of the body, the ways in which skin can react both to physiological and psychological stimuli highlights the relationship between skin and external and internal factors. Disorders of skin are often visible; hence, definitely, it has profound psychological impact on those who are affected. However, invisible skin disorders like those without having proper clinical or histological features yet diagnosed by an expert dermatologist can also change the mental well being of patients.[1] It affects the social, occupational, and sexual interactions. As skin and mind are interconnected, there is a need to understand the psyche of the person behind the skin conditions.[2] The unique nature of the skin disorders has the potential to make it both easy and difficult for the sufferer. Moreover, how a person copes and adapts to the skin conditions depend on various factors such as the personality, family, and social networks. Hence, knowing the psyche of a patient with dermatological diseases and also finding the impact of diseases on the psyche of the patient is essential.[3]


  Mind–body Problem and Concept of Psychosomatic Disorders Top


Human beings have two characteristics, physical and mental. Physical properties such as size, weight, shape, color, motion through space, and time are public, but mental properties such as consciousness, perceptual experience, emotional experience, beliefs, and desires are possessed by self. It brings up various ontological and casual questions regarding “what is the relationship between mind and body? Are they same? Do they influence each other? Etc. Seemingly intractable nature of these problems gave birth to many philosophical theories such as “dualism” (separation of mind and body), “monism” (both are single and holistic), and then, the behaviorism, functionalism, mind–brain identity theory, and the computational theory were inclined to explain the ability of the mind to modify behavior.[4],[5]

The bond between skin and mind can explain the issue. Skin-to-skin bond in mother–baby or blushing while shy can describe such relationship. Psychosomatic medicine exploring the relationships among social, psychological, and behavioral factors had evolved to overcome the concept of dualism to integrate mind and body through scientific explanation. The immune system in the skin is regulated by stress response system; likewise, many other experiments prove toward a mind–body relationship. Psychodermatology as a specialty is established not to replace the medicine but to augment the patient care in the field of psychosomatic medicine.[6]


  Skin Disease and Psychology Top


Psychological factors are linked to disorders of skin in several and varied ways. Psychocutaneous diseases in the past were categorized using personality-specific conflict and cutaneous symptomatology.

Koblenzer, as well as a latest biopsychosocial model, pointed three main categories of psychocutaneous illness as in [Table 1].[7]
Table 1: Classification of psychocutaneous illness

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It is been estimated that 30%–60% of patients with dermatological diseases experience significant psychological or psychiatric problems. The common skin diseases which have an impact on psyche are chronic disfiguring and visible diseases with increased signs and symptoms. It includes psoriasis, atopic dermatitis, vitiligo, pigmentation disorders, acne, alopecia, vesiculobullous disorders, lupus erythematosus, leprosy, and sexually transmitted infections.[2],[7],[8]

Exposure to excessive stress and strain in skin patients can precipitate the skin diseases, for example, in acne, eczema, neurodermatitis, etc. On the other hand, people with psychological morbidity due to skin disease (such as vitiligo, leprosy, and psoriasis) have inferiority feeling due to visible changes in the appearance of skin which may develop toward suicidal ideation and depression.[9] The uncertain etiology and changing severity can cause the patients to have their own reasoning for their exacerbation, and they start avoiding places and events which eventually affects their quality of life. Disorders of skin (such as leprosy, vitiligo, and sexually transmitted diseases [STDs]) have been often associated with myths surrounding lack of hygiene and contagion along with the idea that a person must deserve the disfigurement as a punishment for previous guilt, sin, or transgressions. This influences others to act negatively toward sufferer, and hence, it generates a feeling of profound stigma which, in turn, makes the patient socially handicapped.[8],[10],[11]


  The Psychological Impact of Dermatological Disorders Top


Negative body image

Body image can be hypothesized as “the inside view.” It pertains to our personalized experience about our own looks. In dysmorphophobia and bulimia nervosa, the body image concept is distorted due to primary psychiatric disease. While in psychosomatic and somatopsychic diseases (alopecia, vitiligo, psoriasis, etc.,), the change in perception of body image is due to visible and disfiguring skin conditions.[12] Change in surface and color of the skin due to skin diseases creates feelings of negative body image. In some cases where skin lesions are present over genitalia, it leads to fear of rejection from partner and loss of sexual intimacy. Emotional vulnerability and insecurity start developing which reduces self-confidence, interpersonal communication, and socialization. These patients may suffer from social phobia, anxiety, depression, and suicidal attempts.[8],[13]

Coping and adjustment problems

Coping means strategies (cognitive, behavioral, and emotional) used to manage specific stressors. People living with dermatological conditions (vitiligo, leprosy, alopecia, and eczema) have to adjust with personal, social, psychological, and physical distress. Alexithymia (difficulty in emotional expression and experiencing with high sensitivity to anxiety), shame proneness, avoidance, concealment, and escape are seen when there are an adjustment and coping issues specifically in visible, noticeably disfiguring dermatoses. The attachment with family members, spouse, and children get affected. If they are not getting emotional support from spouse and family, it causes increased self-disgust and it facilitates the sense of being insecure and unaccepted among all. Negative comments from others, feeling of shame causes increased avoidance and leads to loneliness and communication difficulties. When patients hold negative implicit attitudes toward self and disease, coping becomes difficult.[8],[14] Studies described that patients suffering from psoriasis use escape avoidance and self-controlling as chief coping strategies as these help them avoiding the conflicting situations and control their emotions. As patients are hypervigilant and anxious, they are always in a mood to escape the situations where they have to face emotional turmoil. They also use distancing which reinforces the behavior of social isolation.[15]

Social withdrawal

Chronic skin disorders, oscillating severity, exacerbations of disease, visible disfigurement or pigmentation, social stigma, inability to cope up with the disease, lack of care, and support are some of the factors that make the sufferer depressed and as a result social withdrawal is seen as avoidance defense mechanism. Patients start keeping secrecy and avoiding activities involving exposure of skin and concealing affected areas by different means. Socially withdrawn patients may have phobia, panic attacks, anxiety, and depression. It may lead to functional and emotional insecurity with deterioration of performance and productivity at personal, occupational, and social level. Thus, the patient is at risk of committing suicide.[16] Due to all of the above-mentioned psychological problems, there is poor compliance of patients for the treatment and follow-up. Certain other factors such as episodic, recurrent, chronic skin diseases, delay in response, and long duration therapy also reduce the compliance. They avoid the interaction with doctors about their disease, and due to depression and withdrawn attitude, there is a loss of hope to continue the medication and get cured. It again causes worsening of skin disease and psychological deprivation too.[13]


  Psychological Impact of Skin Disease on Patient's Family Top


It is well acknowledged that diagnosis of disorders of skin brings a lot of negative impact on the psychological well-being of the patient and family members. It undeniably affects the quality of relationships. Depending on the onset of skin disorder, the reaction pattern of patient and family changes and it poses a challenge for emotional and social well-being.[13] Family members often feel the high-level stigma, appear overwhelmed with fear of future, poor quality of life with chronic insomnia, job loss, constricted relationship with society, etc., The caregiver often shows maladaptive coping with various behavioral disturbances such as chronic frustration, low mood, burnt out, depression, and anxiety.[17]

Child and parents

When a child is affected with visible and severe dermatological conditions either congenital or acquired (ichthyosis, epidermolysis, and autoimmune skin diseases), their parents face psychological issues first. It is difficult for the parents and family members to accept and adjust with child's disease and behave empathically with them. About 36%–42% of parents suffer from anxiety disorders and 26%–36% suffer from depression.[17] Furthermore, rejection of the kid and blaming is a common response from parents. These children are prone to develop inferiority, low self-esteem, loss of body image, and social withdrawal very early in their life. Parents have to understand that the child needs special care and love besides proper treatment.[7],[8],[13]

Partners

How one look and how one wants to look in the eyes of others make powerful contribution in sustaining an intimate relationship, especially between partners. Ideally, partners should support and motivate each other in sickness and health. When one of the spouses is having a skin condition and if the partner's support is lacking, then the disease-related stress expands which leads to interpersonal conflicts and decay in a relationship. Marital harmony, sexual intimacy, and emotional attachment get hampered.[8],[13] It causes fear of proximity, negative perception toward spouse, and sexual criticism. Persistent depressed mood (dysthymia) is the likely result when the sense of belonging is lost. Unaffected partner's acceptance to disease and coping with the complexities of disease and sustaining the unconditional love and support for the patient is needed. Otherwise, it deepens the psychological distress. Empathic coping is a challenge for the partners of diseased patients because it involves understanding the impact of skin disease on their loved one and also on the functioning of their relationships.[18]

Change in social behavior among family members

Social withdrawal is the response to the damaging effects of social stigma. Denial is very commonly seen in family members of skin patients. They prefer to hide the talk and discussion about the skin disease and diseased person. Avoidance of family functions by patients is considered as a protective way by family. Hence, patients develop embracement and anxiety when meeting people. They become a victim of rude negative comments in the face of public ignorance. It changes functioning of the relationship of a patient with parents, siblings, partner, and children which indirectly affects the social network of the patient and family too. Acceptance of disease by family members without changing the emotional attachment with the patient is important in coping with relationships in skin patients. The counterbalancing support from friends and family is essential to keep the patient's mental and physical stamina to face his disease in a better way.[13],[18]


  Psychological Impact of Skin Disease on Society Top


Stigmatization

Stigma can be defined as a mark or sign that not only sets a person apart from others but also leads to their devaluation. It occurs because of some threat to orderly social interaction. Strong geographical and cultural taboos are also responsible for stigma. Stigmatization is common in visible and disfiguring skin diseases. It is considered that skin diseases are due to curse of God or previous transgressions. People in society have concept that all skin illness is contagious and coming in proximity with skin patient can increase their chance of acquiring the disease.[10],[11] People with dermatological diseases often complain that their main difficulties arise from others' negative reactions to their disease, rather than the disease itself. There are certain beliefs about stigmatization in skin patients such as anticipation of rejection, the feeling of being flawed, sensitivity to opinions of others, secretiveness, and negative attitude. One of the important predictors of such beliefs is previous experience of rejection.[13] When a person is explicitly rejected on the basis of their disease, it gives a direct negative experience which is called as an enacted stigma. While when a person sees someone else getting the negative experience of rejection and expects to be treated in similar ways, it is called as vicarious stigmatization. Patients suffering from psoriasis, vitiligo, leprosy, HIV, and STDs face such type of stigmatization commonly.[13],[19],[20] Staring look and intrusive questioning made by by others, avoidance of physical contact such shake hands, avoidance of used materials of patient often cause embarrassment and sense of rejection. A kind of rejection sensitivity develops in patients who are stigmatized in society. The patient becomes vigilant for the presence of further stigmatization, interprets neutral events as stigmatizing because of the feeling of shame, and attempts to conceal their appearance from others.[13]


  Psychological Comorbidities Secondary to Skin Diseases Top


The high prevalence of psychiatric disorders (>30%) is present among patients with skin disorders such as acne, pruritus, urticaria, alopecia, and herpes virus infections. In a clinic bases study in India, with predominant sample of acne vulgaris (24.13%), psoriasis (22.14%), lichen planus (10.70%), vitiligo (13.18%), and urticaria (19.4%), the maximum number of patients was suffering from depression 36.32% followed by anxiety disorder 18.41% and somatoform disorder 7.96%. Obsessive-compulsive disorder was diagnosed in 6.47% followed by adjustment disorder 4.98% and alcohol dependence syndrome 4.98%.[21] An another study from western literature depicted about 74% of lifetime prevalence of various psychiatric disorders with a predominance of depression, anxiety, and substance abuse in alopecia. Hence, the prevalence varies according to location and type of skin disorders.[22] Here, in [Table 2], epidemiology of psychiatric comorbidities in some common skin disorders is depicted but these vary widely depending on the setting, geographical location, age group, gender, specific disease, etc.
Table 2: Psychiatric comorbidities in skin disorders

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Depressive disorders

Depression is a therapeutic problem in dermatological disorders. About 18% and 24% of patients with alopecia areata and psoriasis are estimated to be suffering from depression as per Indian clinic-based study.[29] These patients usually have chronic itching, neurotic excoriations, reduced self-esteem, suicidal thoughts, and hypochondriacal concept about disorders of the skin. Low mood, loss of interest, reduced energy, increased tiredness, and limitation of daily activities are the foreground for diagnosis of depression.[30] Dysthymia (long-lasting persistent depressive mood) is seen in many patients with chronic, recurrent, and exacerbating skin diseases. Common skin disorders with depression are psoriasis, atopic dermatitis, acne, prurigo, etc.[8],[31],[32]

Anxiety disorders

Persistent fear (generalized anxiety) and acute fear (panic) are two variants in anxiety disorders with a lifetime prevalence of 37.4%.[33] About 4% and 12% had anxiety disorders in groups of alopecia areata and psoriasis in Indian clinic-based sample.[29] Social phobia is common in skin diseases because of visual exposure to skin disease and resultant stigmatization. The patient feels centered around the fear of being closely observed by others. They face the fear of social criticism. It is characteristically associated with avoidant behavior and social withdrawal. Common disorders of skin with anxiety and phobia are eczemas, acne, rosacea, recurrent herpes, acne, seborrhea, ichthyosis, etc.[34]

Compulsive disorders

Compulsive acts are repeated behaviors (handwashing) or ideate acts (praying, counting) to which a person feels compelled as a reaction to a compulsive thought. Common disorders of the skin with compulsive behavior are hand-foot eczema where the patient washes hands and feet repeatedly and another example is body a dysmorphic disorder where the patient looks at the mirror to control or influence their outward appearance.[8]

Stress and adjustment disorders

Serious stress and life events can elicit skin condition such as urticaria or may lead to attacks or deterioration of chronic dermatoses such as in psoriasis and seborrheic and atopic dermatitis.[2] On the other hand, disorders of skin themselves are stressful and may elicit emotional and adjustment disorders. Stress reaction may be seen in the form of numbness, disorientation, limitation in consciousness, inability to process stimuli, depression, fear, withdrawal, and hyperactivity in alternating degrees. Adjustment disorders present as brief to longer depressive episodes, anxiety symptoms, apathy, avoidance, acute eruptions of aggression, rage, fear, or panic.[8],[13],[35],[36]

Dissociative disorders

This is characterized by partial or complete loss of normal integration among memories of the past, awareness of identity, immediate sensations, and control of bodily functions. There is decoupling of physical and emotional functioning of a person. Dermatoses in which dissociative disorders are commonly seen include dermatitis artefacta, urticaria, pruritus, anesthetic skin areas, and pseudoallergic reactions.[37]

Personality disorders

Skin diseases may give rise to change in personality of a person as a whole. Emotionally unstable personality, mainly borderline personality disorders are common in association with disorders of the skin. Women are affected more with high chance of suicidal attempts. There is deep instability in interpersonal relationships and self-image and effect often with intense impulsiveness.[2],[38]

Culture and skin

Cultural influences are evident in most of the disorders in India. Psychosomatic skin diseases are very often influenced by cultural factors such as religious and spiritual beliefs, diet, and style of clothing, sun exposure, and socioeconomic status. In India, light-skinned people are given higher rank in marriage and considered to be a beauty. Hence, people with dark skin often suffer from emotional turmoil in the society. Visiting temples, performing offerings and puja, taking a dip in “holy rivers,” application of urine, and cow dung are common rituals to alleviate skin disorders which often exaggerate the disease. Even various toxic chemicals are used as a part of the ritual in different festivals might exaggerate the illness. Brinjals, black gram, eggs, and chicken such foods are commonly used in an Indian household. These often act as allergens. On the other hand, psoriasis and leprosy impose a great stigma on family and person leading to ostracized in the society which, in turn, cause more disability.[39]


  Conclusion Top


The psychological impact of dermatological diseases leads to impaired coping, impaired compliance, limitations in quality of life, negative body image, and stigmatization which invariably cause psychological comorbidities such as depression, anxiety, phobia, and somatoform and adjustment disorders. The common skin diseases include psoriasis, vitiligo, alopecia, acne, prurigo, chronic urticaria, eczema, atopic dermatitis, seborrheic dermatitis, rosacea, recurrent infections, sexually transmitted infections, and vesiculobullous diseases. In patients with skin illness, the thought process and concerns about diseases are often displaced onto self as a whole. When the sense of “normal” self-falls down, the feeling of shame, fear of criticism, and social anxiety starts setting in the mind. Hence, it is very important to understand the evolution of cognition of skin patients and the ways in which the skin diseases and their sense of being are interconnected.[8],[13],[38],[40]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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