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Psychosomatics 47:122-128, March-April
doi: 10.1176/appi.psy.47.2.122
© 2006 Academy of Psychosomatic Medicine
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Integration of Multiple Criteria for Psychosomatic Assessment of Dermatological Patients

Angelo Picardi, M.D., Piero Porcelli, Psy.D., Paolo Pasquini, M.D., M.P.H., Giovanni Fassone, M.D., Eva Mazzotti, Psy.D., Ilaria Lega, M.D., Luisa Ramieri, M.D., Emanuele Sagoni, M.D., Damiano Abeni, M.D., M.P.H., Albertina Tiago, M.D., and Giovanni A. Fava, M.D.

Received February 1, 2005; revised April 11, 2005; accepted May 17, 2005. From the Dermatological Institute IDI-IRCCS, Rome, Italy; the Psychosomatic Unit, IRCCS De Bellis Hospital, Castellana Grotte, Italy; the Dept. of Psychology, University of Bologna, Italy; and the Dept. of Psychiatry, State University of New York at Buffalo. Send correspondence and reprint requests to Dr. Picardi, Clinical Epidemiology Unit, Dermatological Institute IDI-IRCCS, Via dei Monti di Creta, 104-00167 Rome, Italy. e-mail: a.picardi{at}idi.it


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Psychological distress has been frequently reported in the setting of skin disorders. The Diagnostic Criteria for Psychosomatic Research (DCPR) have been found to yield valuable integrative information, in addition to DSM–IV nosology, in a variety of medical diseases. The aim of this study was to verify whether this integration could also be helpful in dermatology. A consecutive series of 539 inpatients with various skin conditions was evaluated by means of structured interviews for DSM–IV and DCPR diagnoses. The prevalence of DSM–IV conditions was 38% (mostly depressive disorders and anxiety disorders), whereas that of DCPR clusters (mostly demoralization and somatization secondary to psychopathology) was 48%. Overall, DCPR diagnoses were significantly more frequent than DSM–IV categories, regardless of the presence or absence of a psychiatric disorder. Psychological assessment of patients with skin diseases needs to incorporate both clinical (DSM–IV) and subclinical (DCPR) methods of classification. The health status of these patients can be improved if their psychological problems are appropriately assessed and recognized.

Key Words: Diagnostic Criteria for Psychosomatic Research (DCPR) • Dermatology • Psychopathology

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The skin and the CNS are embryologically related, and they share several hormones, neurotransmitters, and receptors. The skin plays a key role as a sensory organ in socialization processes through the whole life cycle. It is responsive to emotional stimuli, and its appearance greatly influences body image and self-esteem.1,2

Not surprisingly, a relationship between psychological factors and skin diseases has long been hypothesized. There is a common opinion that many cases of skin disease are caused by psychological stress, or are related to certain personality traits, or represent a complication of a psychiatric disorder. This opinion is partly supported by research evidence,3–6 although not all studies gave clearly positive results.7–10 Less attention has been devoted to test the alternative hypothesis that psychiatric disorders may result as a complication or a consequence of a primary skin disease, as a reaction to disfigurement, perceived social stigma, or undesirable lifestyle changes. However, there is at least preliminary evidence that the relationship between mind and skin is not unidirectional. Not only might the mind affect the skin through a "psychosomatic effect," but it is also possible that a "somatopsychic effect" might take place.11

Psychiatric disorders are frequent among patients with skin diseases, with prevalence estimates ranging from 21% to 43%.12–16 Psychiatric morbidity is a source of concern because it causes substantial suffering and is associated with poor medication adherence.17 Although the dermatologists’ awareness of the problem is increasing,18 co-occurring mental disorders go often unrecognized13,19,20 and are believed to be less frequent than they actually are in many skin conditions.21 These research findings highlight the need for a biopsychosocial approach to patients with skin disease.

The psychiatric contribution to the assessment of psychosocial correlates of medical disorders mainly derives from the DSM–IV22 classification of somatoform disorders and psychological factors affecting medical conditions, other than the identification of Axis I disorders that are comorbid with Axis III medical conditions. However, these criteria have shown problems in application to clinical practice and identifying psychosocial factors that do not meet full diagnostic criteria.23,24 On the other hand, the more comprehensive and overarching biopsychosocial model lacks specificity in providing operational tools that are applicable to the clinical domain.25

The Diagnostic Criteria for Psychosomatic Research (DCPR)26 have been developed with the aim of translating psychosocial variables issued from a wide body of psychosomatic literature into working categories whereby individual patients could be identified. Therefore, they are intended as an integrative tool for evaluating those psychosocial factors that are partially covered or not covered by DSM–IV categories because of lack of diagnostic criteria (as, for instance, for alexithymia or Type A behavior) or insufficient criteria (as for multiple or persistent somatization). The 12 psychosomatic syndromes identified by DCPR are conceived partly as a better specification of the DSM–IV rubric of "psychological factors affecting medical conditions" (the four DCPR categories: alexithymia, Type A behavior, irritable mood, and demoralization) and partly as an alternative to the DSM–IV rubric of somatoform disorders (the remaining eight DCPR categories: disease phobia, thanatophobia, health anxiety, illness denial, functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms, and anniversary reaction).

The DCPR have been applied to different medical settings and groups of patients with a variety of clinical conditions, including functional gastrointestinal disorders,27,28 heart transplantation,29 postmyocardial infarction,30 endocrinological disorders,31,32 and cancer.33 Overall, these studies used the DCPR criteria jointly with DSM–IV, and they showed that the DCPR can identify potential or unrecognized problems.

This study is part of a larger research project on quality of life and psychological well-being of patients with skin diseases. In a previous article,34 we showed that, independently of the presence of a DSM–IV diagnosis, the presence of one or more DCPR cluster was associated with high self-rated psychological distress, impaired functioning, and disturbed emotions. Also, DCPR clusters, but not DSM–IV diagnoses, were associated with high impairment in quality of life related to symptoms of skin disease. The aim of this study was to report in detail on the prevalence and nature of psychological distress, by means of the joint use of DSM–IV and DCPR assessment criteria, in a large sample of dermatological patients.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
The study was carried out at the inpatient wards of the Istituto Dermopatico dell'Immacolata (IDI-IRCCS), a large dermatological hospital located in Rome, Italy. This institution has as its main catchment population the entire population of the province of Rome (approximately 3,800,000 people, of which 3,200,000 are age 18 or more). Also, a number of patients are referred to IDI-IRCCS from other regions, mainly from central and southern Italy.

The study protocol was approved by the institutional ethical committee. All patients age 18 years or more and free from dementia or severe cognitive impairment who were admitted in five of the eight inpatient wards of IDI-IRCCS on predetermined days were contacted by a research dermatologist (AT), who explained the study and asked them to participate. All patients who accepted were invited to sign an informed-consent form, and they were given the research questionnaire to complete.

A total of 641 eligible patients were contacted and asked to take part in the study. Of these, 590 (92%) accepted, signed the consent form, and were scheduled to be interviewed for psychological assessment within 48 hours. However, 45 patients could not be interviewed because they were discharged from the hospital before the scheduled interview. All remaining patients were administered the Structured Clinical Interview for DSM–I (SCID–I); however, the DCPR interview could not be administered to six of them because of logistic problems or lack of time. Hence, the study sample consists of 539 participants (84% of all eligible patients). Mean age, gender distribution, diagnostic distribution, and mean duration of illness were very similar among patients who were interviewed and those who refused participation or were discharged before the interview. The sociodemographic and clinical characteristics of participants are summarized in Table 1.


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TABLE 1. Sociodemographic and Clinical Characteristics of the Sample



Assessment
All patients were administered the Italian version of two detailed semistructured interviews by mental health professionals (IL, EM, GF, ES, LR), who were specifically trained in the use of these interviews. One was the SCID–I,35 which yields psychiatric diagnoses on DSM–IV Axis I according to established criteria. The other interview was the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR),36 which allows investigation of the presence of each of the 12 psychosomatic conditions included in the DCPR. The interrater reliability was tested before the start of the study and on another occasion during the study period. The kappa coefficient was found to be constantly above 0.80 for both instruments.

Statistical Analysis
We used a descriptive analysis to study the frequency distribution of all variables of interest. Confidence intervals (CI) for prevalence estimates were computed with Epi-Info software.37 The z test for the difference between proportions was used to compare prevalence rates.


  RESULTS

 
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DISCUSSION
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The prevalence of DSM–IV and DCPR diagnoses are shown in Table 2.


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TABLE 2. Prevalence of Psychiatric Diagnostic Categories and DCPR Clusters in the Sample



Psychiatric conditions have been grouped into categories. Most patients had a mood disorder (20.2%; mostly depressive disorder, not otherwise specified [8.5%], and dysthymic disorder [5.0%]), followed by an anxiety disorder (16.7%; [mostly, generalized anxiety disorder, 5.7%], and panic disorder [3.7%]), an adjustment disorder (7.0%; mostly, with depressed mood [3.3%], and with anxiety and depressed mood [2.2%]), and a somatoform disorder (6.9%; mostly, undifferentiated somatoform disorder [6.1%]). One patient had bulimia nervosa. The six more-frequent DCPR diagnoses were demoralization and functional somatic symptoms secondary to a psychiatric disorder (both 14.1%), followed by irritable mood (13.7%), Type A behavior (12%), health anxiety (10.6%), and alexithymia (5.9%). Some DCPR conditions were found to be particularly prevalent in certain skin diseases, as compared with the whole sample. Health anxiety was particularly frequent in patients with severe skin conditions such as malignant tumors (4 patients in 24; 17%) and bullous diseases (3/20; 15%), as well as in patients with contact dermatitis (3/8; 37%). Type A behavior was prevalent in patients with urticaria (8/47; 17%), malignant skin tumors (5/24; 21%), pruritus (3/8; 37%), contact dermatitis (2/8; 25%), and alopecia (22%; 2/9). Alexithymia was particularly frequent in patients with atopic dermatitis (3/17; 18%) and skin ulcers (4/19; 21%). Demoralization was frequently observed in patients with skin conditions usually affecting exposed body parts, such as acne (2/11; 18%), contact dermatitis (2/8; 25%) and lichen planus (3/7; 43%); causing substantial suffering, such as skin ulcers (7/19; 37%) or vasculitis (3/17; 18%), as well as in patients presenting with idiopathic pruritus (3/8; 37%). Although several of these findings are plausible or consistent with theoretical predictions or previous literature, they should nevertheless be interpreted with extreme caution because the small size of most dermatological diagnostic groups decreases the precision of the prevalence estimates and precludes meaningful statistical comparisons.

Overall, 327 participants (60.7%) received either a DSM–IV or DCPR diagnosis. The proportion of patients receiving a DCPR diagnosis (47.9%) was significantly greater than the proportion of patients receiving a DSM–IV diagnosis (37.8%; p<0.01). A total of 135 patients (25.0%) received both a DSM–IV and a DCPR diagnosis. Among patients who were diagnosed only according to one of the two diagnostic systems, the proportion of patients receiving a DCPR diagnosis (22.8%) was significantly greater than the proportion of patients receiving a DSM–IV diagnosis (12.8%; p<0.001).

The overlap of DSM–IV grouped diagnostic categories among different DCPR diagnoses is reported in Table 3; Table 4 shows the overlap of DCPR diagnoses among DSM–IV grouped diagnostic categories. We have reported only the most frequent categories.


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TABLE 3. Distribution of DSM–IV Grouped Diagnostic Categories Among Different DCPR Diagnoses




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TABLE 4. Distribution of DCPR Diagnoses Among DSM–IV Grouped Diagnostic Categories



Patients diagnosed with a DCPR condition most frequently had overlapped DSM–IV diagnoses of depressive (28.3%) and anxiety (26%) disorders, whereas patients with a DSM–IV disorder had substantial overlap with demoralization (30.1%), functional somatic symptoms secondary to a psychiatric disorder (23.8%), irritable mood (18.0%), and Type A behavior (15.0%). Overall, the proportion of patients with a DCPR condition who had an overlapped DSM–IV diagnosis (52.3%) was significantly lower than the proportion of patients with a DSM–IV diagnosis who had an overlapped DCPR condition (66.2%; p<0.01).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The overall results of this study indicate that inpatients with skin diseases have conditions of psychiatric or psychological relevance in proportions ranging from 38% to 61%, depending on the criteria used for the assessment. These findings confirm the frequent occurrence of psychiatric disorders and psychosocial difficulties affecting dermatological patients.19,38 Also, our findings confirm previous reports27,29,30,31,33 that the DCPR clusters are suitable for identifying psychological distress in medically ill persons, and that they might be a useful addition to DSM–IV classification. The number of patients who were identified by a DCPR cluster was greater than those identified by a DSM–IV diagnosis, regardless of the fact that they had or did not have a psychiatric condition. DCPR diagnoses were indeed more frequent than DSM–IV categories when the denominator was constituted either by the total number of patients (Table 2) or by the number of patients with both DCPR and DSM–IV diagnoses (Table 3 and Table 4). Furthermore, when one patient was assigned a DSM–IV diagnosis, he or she was more likely to also receive a DCPR category, whereas the reverse was not true: patients who received a DCPR diagnosis were less likely to be identified by a DSM–IV category (Table 3, Table 4).

In our sample, the prevalence rates of DSM–IV (38%) and DCPR (48%) conditions were closer to those reported in cardiology29,30 (37% for DSM–IV and 38% for DCPR) and oncology33 (38% for DCPR) than in other medical settings, where much higher prevalence estimates were found.27,31 A likely explanation is that medical disorders, being heterogeneous, have different psychological correlates,39 as is also evidenced by the different prevalence of the most prevalent DCPR syndromes within the various medical settings.

This study confirmed that the most frequent psychiatric disorders in patients with skin diseases are depressive and anxiety disorders,14 with prevalence levels in our sample of 20% and 17%, respectively. A clinically significant lowering of mood seems particularly frequent among patients with skin diseases, as suggested by the high prevalence of demoralization (14%) in our sample. This is not surprising, given the strong link between the skin, body image, and self-esteem.1 As regards the frequent occurrence of irritable mood (14%), many studies have pointed to a relationship between irritability, anger, and skin disease. High levels of anger or irritable mood have been reported in a variety of skin diseases, such as acne,40 psoriasis,41 and atopic dermatitis.42 Problems in dealing with anger and hostility,43 particularly with the expression of anger,42,44,45 have also been described among patients with atopic dermatitis and patients with psoriasis. Mood, irritable, and anxious conditions may also generate secondary, functional somatic symptoms (14% within our sample) by means of a vicious circle of selective perception and disease interpretation of somatic sensations, as evidenced by the close association between anxiety, depression, and somatization.46 Type A behavior has been extensively researched in patients with cardiovascular disease.47 The 12% prevalence found in our sample confirms that it can also be fairly common among patients outside the cardiovascular realm, such as those with functional gastrointestinal disorders27 or skin diseases. Also, the elevated frequency of health anxiety (12%) is consistent with previous findings indicating that such anxiety relates to high concern with acute-illness signs, that it may give rise to more severe forms of disease phobia, and that it is common among subjects who are referred to medical services because of their health status.48–50

To our knowledge, this is the largest study on the prevalence of DCPR clusters in medical patients. Two overall conclusions can be drawn from the present findings: First, the high percentage of dermatologic patients with significant psychological distress confirms data from previous literature and points out the mental health needs of these patients referred for medical symptoms. Second, our findings corroborate the notion of endorsing sensitive assessment strategies encompassing subclinical symptomatology in performing clinical studies51–54 and underscore the importance of using both DSM–IV and DCPR for identifying psychosocial syndromes in dermatology. Psychiatric and/or psychological treatments can improve the overall health status of these individuals when psychopathology (e.g., mood or anxiety disorders) is diagnosed or when we identify subthreshold conditions (e.g., functional somatic symptoms secondary to a psychiatric disorder) or specific syndrome subgroups (e.g., demoralization, irritable mood, and Type A behavior). In this regard, the DCPR clusters are showing their clinical relevance in more and more investigations, not only for diagnostic purposes but also as significant predictors of treatment outcome.50 We believe that these issues are worth considering in the forthcoming DSM–V.


  ACKNOWLEDGMENTS

 
The authors are indebted to Simone Bolli, Nidia Melo Salcedo, and Valentina Salvatori for their patient and valuable help in data collection, data input, and quality control. This study was financially supported by a grant from the Italian Ministry of Health in the framework of the "Progetto Ricerca Corrente" to IDI-IRCCS.


  REFERENCES

 
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 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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