When Psoriasis Impacts the Mind

The Mind and Body Are Connected

“The idea that we can separate mental health and skin is antiquated,” says Richard Fried, M.D., Ph.D., Yardley Dermatology Associates in Yardley, Pennsylvania, who is both a dermatologist and a clinical psychologist. “We have known for decades that people with psoriatic disease have a higher incidence of depression, anxiety, issues with self-image, [and] higher school and work absence.”

I started developing psoriasis when I was 4 years old. I would cover it with Band-Aids, but soon my arms were so covered in Band-Aids that they ended up drawing more attention. I felt like the world was unfair and developed an intense fear and sadness at times. What I didn’t know was that anxiety and depression were starting to take root. 

At 5 years old, I was convinced that at my next dermatology appointment the doctor would finally hand over the cure for psoriasis. That obviously never came to pass.

From the ages of 4 through 20, I was paranoid about wearing clothes that exposed my skin because of the bullying or exclusion from other kids. “We know there is stigmatization,” says Dr. Fried. “When people see [psoriasis], they blame the person.”

It’s a human tendency, Dr. Fried explains, to protect oneself by avoiding something that looks different and scary. Which is exactly what happened to me.

In kindergarten, I was exiled to a corner of the playground with a girl who wore head gear because no one wanted to play with us.

The emotional stress of the disease and the reactions from classmates made going to school difficult. I was held back in second grade because I had missed so many days.

During that time in my life, a flare-up would cause intense dread and spark memories of past flare-ups – the itching, blood, flakes and stares. My thoughts would spiral downward into panic.

According to Dr. Fried, people with depression are twice as likely to develop a substance abuse disorder. Knowing that, it is no surprise that I started drinking in the seventh grade. I instantly loved the way it made me feel – or rather, not feel. Drinking made me feel like I didn’t care what people thought. I was not self-conscious about my skin, and it gave me that confidence I knew I deserved. I did not care about things when I drank, and I liked that. I liked the confidence.

Alcohol became the way I coped with the emotional and physical pain from psoriatic disease.

Despite feeling better while I was drinking, when I would sober up, my mental health symptoms worsened. But I didn’t want to give up what I thought was the only thing that could make me feel better. And so my anxiety, depression and drinking all continued to progress.

My anxiety progressed into panic attacks. I had my first one at 19, and I would continue to struggle with them several times a week for the next four years.

A bright spot in my timeline came at 20, when I was finally put on a systemic medication to control my severe psoriasis. However, I couldn’t follow the doctor’s orders to quit drinking because of my anxiety and depression and had to change medications.

In addition to seeing the separation of mental health and psoriasis as antiquated, Dr. Fried says that dermatologists should focus on treating mental health and dermatological conditions.

“I think one of the things we can easily do as clinicians, and should do, is be vigilant for how much impact the psoriasis is having on the individual and using that as a gauge of when it’s time to take the next step,” he says. “It can change the way we treat.”

No one in the medical field had ever suggested to me that my depression, anxiety and psoriatic disease were connected. By 23, I was on a biologic, and my skin was clear for the most part, but emotionally I was fried. I was having panic attacks several times a week, suffering from insomnia and having suicidal thoughts.

It literally took a panic attack on stage to get me into therapy, but I was still drinking, so getting to the root of my emotional issues took a lot longer. I was lost in a vicious cycle of anxiety, depression, binge drinking and psoriasis flare-ups. I did not know how else to cope.

Is Inflammation Making Me Feel Depressed?

The connections among anxiety, depression and psoriatic disease may all come down to one thing: inflammation.

Researchers in the medical field are studying whether there is a connection between inflammation and mental illness. Mental diseases are now being looked at as a potential consequence of inflammation.

Dr. Fried says that about five years ago, a “big door opened.” It was the recognition that inflammatory cytokines – which are part of the immune response to an infection or foreign body and cause the skin to pile up, resulting in psoriasis – don’t stay in the skin.

“It’s not like the old adage, ‘What happens in Vegas, stays in Vegas,’” says Dr. Fried. “What happens in the skin doesn’t stay in the skin.”

The presence of these cytokines may be causing inflammation, which is potentially causing the anxiety and depression so commonly seen in people with psoriatic disease.

Everyday life and functions are dependent on neurotransmitters, such as histamine, dopamine and serotonin. These chemical messengers enable the brain to provide a variety of bodily functions such as learning or sleep. However, increased inflammatory cytokines in the skin enter the bloodstream and get into the brain, where they can affect neurotransmitter function. The inflammatory process may decrease availability of neurotransmitters. 

Dr. Fried describes one long-term patient who refused to go on biologics and was continuing to suffer. He put the patient on a common SSRI anti-depressant and explained it would allow more neurotransmitters to be available. A month later, the man’s wife called wanting to know what “miracle drug” had brought back her husband.

Is There Hope?

I honestly believe that if I had never had psoriasis, my anxiety and depression might not even exist, and I may not have developed a drinking problem. I cannot change the fact that I have psoriatic disease and, to an extent, its comorbidities, but I can control how I live with it.

Part of that is getting control of my disease. Dr. Fried admits that finding the right clinician can feel like dating.

“If someone is seeing a physician, and they feel like this clinician gets them – that they understand psoriasis – stay with them,” says Dr. Fried. “If not, move on.”

People deserve to be with someone who cares – who will do for you what they would do for a family member, he says. “The compassion thing is so important. What we sell patients is control. I’m a control freak,” says Dr. Fried. “I want to give people control. People deserve safe and effective tools to have control over their body, and they will have more control over their emotions.”

Along with proper, timely treatment, Dr. Fried suggests the selective use of yoga, tai chi, muscle relaxation, antidepressants and, on occasion, anti-anxiety medications.

You Always Have Other Options

My recent urge to drink is one that I won’t act on because I know it will only make things worse.

Instead of drinking, I manage my anxiety and depression through therapy, medication, walking my dog every day and trying to do one thing a day that makes me happy.

When you are going through a hard time, it can help to reach out to other people who care for you, who can listen or who know what you are experiencing. The National Psoriasis Foundation (NPF) has a Psoriasis One to One program that connects newly diagnosed people with a mentor who can guide them in navigating this chronic disease.

Awareness of the impact that psoriatic disease has on your life and acknowledgment of those feelings are the first steps in the journey to relief. I will forever be grateful to my 28-year-old self for biting the bullet and asking for help. It was from this that I was able to do a 180 in not just my physical health but my mental health as well.

“Part of the efficacy in improving emotional state is improving skin appearance. In addition, modern psoriasis therapies reduce inflammatory cytokine release, which can decrease systemic inflammation throughout the body,” says Dr. Fried. “Furthermore, clinician recommendations for healthful behaviors and mind-body mental health interventions can also help to reduce inflammatory cytokine release. Lessening the quantity of cytokines that can enter the brain could lessen mental health symptoms.”

Dr. Fried says the takeaway is that clinicians need to reduce inflammation in their patients however possible.

Reference:

1. Kurd, S. K., Troxel, A. B., Crits-Christoph, P., & Gelfand, J. M. (2010). The risk of depression, anxiety, and suicidality in patients with psoriasis: A population-based cohort study. Archives of Dermatology, 146(8), 891-895. doi: 10.1001/archdermatol.2010.186.