All the Skinny On Skin-Deep Stress

DSC_3019Sometimes the stress reaction causes unwanted problems that are only skin-deep. Good thing, you might say. Keeps issues just on the surface. Well, not quite. It turns out that skin inflammation can be one of the most bothersome (and not so rare) consequences of stress and emotion. In 1978, Harvard psychiatrist and dermatologist Robert D. Griesemer authored a comprehensive index of the effect of emotions on various skin disorders that has become a classic in the field. The Griesemer index lists 27 interactions of stress and emotion on the skin and skin disorders that are mediated by the nervous system including the autonomic nervous system, the immune system, and the hormonal system (see the index after the jump). Stress can induce or worsen skin conditions in just a few seconds after the stressor (for neurotic excoriations and pruritus, for example) or up to two to three weeks later, as in the case of nail dystrophy, cysts and vitiligo.

That a direct relationship exists between skin problems and stress is easily demonstrated by the fact that taking medications which reduce anxiety or depression, such as benzodiazepines or selective serotonin reuptake inhibitors (SSRIs) usually results in a complete clearing up of the skin condition, whereas applying topical ointments or creams can have little to no effect. Moreover, nonpharmacologic treatments such as heart rate variability biofeedback, cognitive-behavioral therapy, hypnosis, meditation, relaxation or yoga that counteract the effects of stress and emotion also have a significant beneficial effect on stress-related skin problems.

What are the most important psychological disorders that have a direct effect on the skin? Anxiety tops the charts, followed by delusions, depression, and obsessive-compulsive disorder. Let’s take a look at each one.

Psychological Disorders Affecting the Skin

Acute or chronic anxiety induces or significantly worsens most skin conditions. When anxiety is left untreated, the skin problems it can cause stubbornly refuse to clear up and can become resistant to even the most aggressive dermatological treatment. It is only when anxiety subsides that the skin has a chance to heal.

ZebraStressSpecific monomaniacal delusions of parasitosis, bromhidrosis, or fibers (Morgellons) are particularly resistant to treatment. If the individual believes that his or her skin is affected by one of these conditions, even though from a clinical point of view it isn’t, the only effective treatments have proven to be antipsychotic medications.

One of the most frequent consequences of severe depression is the involuntary (and sometimes unstoppable) scratching, picking, digging, burning, cutting, pulling, or tearing of the skin, hair, or nails. Recent studies have shown that up to 1/3 of patients receiving treatment in a dermatology clinic actually suffer from depression. Once again, treating the psychological condition with antidepressants results in a definitive improvement of the skin condition and puts a stop to the self-harming behavior.

Psychogenic physical symptoms that have no identifiable organic cause are common in dermatology. Similar in etiology to irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis, stress-related dermatological diseases include pruritus, urticaria or angioedema, self-induced dermatoses such as dermatitis artifacta and trichotillomania associated with dissociative states. A somewhat more psychological psychosomatic condition is body dysmorphic disorder, which is an excessive and often unfounded preoccupation with one’s skin or hair. Not unlike other stress-related disorders, these psychosomatic manifestations respond well to exercise and psychotherapy and not so well to medical procedures and injections.

Stress-related problems with the management of impulse can prevent individuals from being able to avoid or stop picking at their skin or twisting and pulling on their hair, thus causing acne excoriée, neurodermatitis, and trichotillomania. Cognitive behavioral psychotherapy, hypnosis and self-hypnosis appear to work well in resolving skin conditions by focusing the treatment on the underlying psychological problem of impulse control.

Finally, obsessive-compulsive disorder is often the aggravating factor of many skin diseases such as acne, atopic dermatitis, and psoriasis. For skin complications aggravated by OCD, the combination of cognitive behavioral therapy and the prescription of SSRI antidepressants appear to produce the most long-lasting results.

And you thought that skin-deep stress was just a superficial problem.