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.

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.

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.