Psoriasis & Depression: What’s the Connection?

Recently, I was hit with some unexpected life stressors that sent me into a tailspin. The experience got me thinking about a cycle that I’ve experienced over and over in my life— the co-amplification of psoriasis, stress, and disorder of mood.

When I am confronted with significant stress, I often neglect the healthy habits that I typically live by. When overwhelmed, I can very easily justify foregoing the exact behaviors I know will keep my skin healthy and my mood positive. And, in this most recent case, I did just that, which resulted in worsening skin, mood, and it weakened my ability to handle stress. (Many readers may know first hand what I am talking about!) 

Unfortunately, my experience is all too common. According to research, the combination of stress and psoriasis can make a bad situation worse. Depression is twice as likely in those with psoriasis than in the general population. The risk of being diagnosed with anxiety is 31 percent higher, and sadly 10 percent of people with psoriasis consider suicide.

The social and emotional challenges of living with this complex disease can be largely attributed to the physical discomfort and shame that many with psoriasis experience.  However, the disease process itself also has a direct and significant detrimental effect on brain health.

Therefore, no discussion about psoriasis is complete without addressing the complex interplay between stress and psoriasis, and how it can impact your mood and quality of life.

#1. Psoriasis Can Cause Emotional Stress

The social and physical burden of simply living with psoriasis often causes extreme distress.

The skin can feel tight. It’s often itchy and painful. Movement can cause cracking, bleeding, and increased discomfort. The lesions are irritated by many types of clothing materials. (Wool is out of the question!) And clothing is often chosen according to how well it covers the lesions. As a result, awareness of disease is almost omnipresent.  

These painful reminders can fill the mind with a flood of emotions such as frustration, anger, shame, and anxiety. It takes a significant amount of mental energy simply to divert the physical sensation of the disease, let alone the challenge of maintaining self-esteem and hope.  

As Christopher Griffiths, a dermatologist at the University of Manchester in the UK, so poignantly stated, “While people correctly point out that psoriasis is not life-threatening, the disease certainly ruins lives”.

Due to human nature, in addition to a lack of public education about psoriasis, those of us with the disease often feel and experience social stigma. Some people with psoriasis have been asked to leave public swimming pools, they have been asked if they are contagious, school children have been teased, shunned and bullied. People who have psoriasis on their hands or face believe it decreases their chance to get a job. And many with psoriasis avoid intimacy for fear of rejection, embarrassment, and shame.  

These experiences cause serious emotional distress; enough to change the function of our brains.

A clever study demonstrated that people with psoriasis fail to recognize the expression of disgust. Volunteers with and without psoriasis were placed in front of a computer screen and went through a series of pictures of actors with varying levels of expressions of fear or disgust.  The volunteers were asked to push a button upon recognizing either emotion. There was no difference between those with and without psoriasis in the recognition of fear on the actor’s face. However, while the volunteers without psoriasis identified disgust with an intensity of 20 percent, those with psoriasis required upwards to 70 percent intensity to perceive this facial emotion.

What this tells us is that our brains are trying to protect us from the painful recognition that others may feel disgust when seeing our skin. This study helps us understand just how difficult it is to have a disfiguring skin condition such as psoriasis. I am also humbled and saddened by this example, which illuminates just how vulnerable we all are to social stigma.

#2. Stress Can Cause Psoriasis Flares or Exacerbations

While simply having psoriasis can cause stress,stress itself can be a trigger for psoriasis – both in onset and exacerbations. Emotional stress is the number one cited trigger for flares. The correlation between stress and psoriasis has been known for decades.  However, we are just beginning to scratch the surface on the physiology behind this relationship.

The brain-skin axis has deep biological roots. During the embryonic phase our brain and our skin both develop from the same tissue — ectoderm. Nerve cells, skin cells, immune cells and signaling molecules remain intricately connected. It is, therefore, not surprising that stress plays a role in diseases of the skin, including psoriasis.

Recent research points toward a dysfunction in the system that regulates the stress hormone, cortisol. Normally, cortisol is released in response to stress. But, in those with psoriasis, this response is blunted. Scientists believe this occurs as a result of increased activity of the cortisol system due to chronic stress.

Cortisol regulates the immune system and, therefore, decreased cortisol is considered to be a link to the process of chronic inflammation that is present in psoriasis. This phenomenon, known as hypocortisolism, is present in other stress disorders, including other diseases with chronic inflammation, atopic dermatitis (eczema), chronic fatigue, chronic pain, post traumatic stress disorder (PTSD), and those with a history of childhood stressful events.

Interestingly, there is a subgroup of people with psoriasis that seem to not have stress-responsive disease; their skin does not worsen with stress. It is thought that individual patient characteristics, such as attitude and coping strategies, likely play a role. How we respond to stress can have significant implications for our skin. Modification of our response patterns can alter our physiology. Cognitive behavioral therapy has recently been shown to be an effective tool.  (More on that below…)

#3. Psoriasis Can Increase Risk for Depression and Anxiety

So far we have learned that psoriasis causes stress and that stress causes psoriasis. A vicious cycle can ensue whereby an acute stressor results in a worsening of psoriasis which then increases stress along with a lowered threshold for dealing with it. You can imagine the amplification process at play here.

But, here is where things really become unfair. Psoriasis puts you at risk for depression and anxiety, not only for the direct emotional challenges it poses, but because of the physiologic changes that occur as a result of the disease process itself.  

Psoriasis is a disease of chronic inflammation. The inflammatory mediators that we see in psoriasis, such as tumor necrosis factor (TNF), are some of the same inflammatory mediators that are present in depression. These inflammatory cytokines cross the blood brain barrier where they send signals that result in a decrease in the neurotransmitters serotonin, norepinephrine, and dopamine. Depletion of these neurotransmitters is central to the development of mood disorders such as depression and anxiety.

Therefore, not only does the emotional distress of having psoriasis increase the risk for mood disorders but, in addition, the ongoing systemic inflammation is a direct cause for the significant number of people with psoriasis that suffer with a mood disorder.

 

There Is Hope!

All of this may seem overwhelming and insurmountable. But, there is hope.

When patients are effectively treated for their psoriasis, their depression often also resolves. In fact, in clinical trials with biologics, medical investigators have reported an improvement in depression even before seeing improvement in the skin. Biologics act by blocking disease-specific inflammatory cytokines, and thereby decrease the total body inflammation associated with the disease. Therapies such as phototherapy also improve systemic inflammation and are thought to thus decrease depression as well.

Essentially, decreasing systemic inflammation is the link toward also decreasing depression.  Conventional treatments are one option for improving your skin and your emotional health. However, this is not the only effective approach.

Total body inflammation can be managed through lifestyle measures such as diet, exercise, and mindfulness. As long as your psoriasis treatment plan includes eliminating chronic inflammation, your depression will likely also improve or resolve.  

Cognitive Behavioral Therapy Can Help

Recent clinical trials have demonstrated the effectiveness of cognitive behavioral therapy (CBT) in patients with psoriasis. There is now clear evidence that individualized emotion-focused CBT can have a positive effect on psoriasis severity, distress, and overall quality of life. That’s certainly a win-win! CBT counteracts everything I have discussed above, and should not be neglected in a comprehensive approach to the treatment of psoriasis.

CBT is a type of therapy which aims to identify and change negative or distorted thoughts, beliefs, and attitudes. This therapy also provides the individual with coping and stress management strategies. CBT requires discipline, practice, and a good therapists trained in using this technique.

Mindfulness meditation-based stress reduction interventions have also been shown to speed the clearance of psoriasis. Although other interventions such as hypnosis, psychotherapy, and somatic therapy have not been well studied, it would be inaccurate to conclude that these approaches are not of value and I would encourage you to do your own exploration in this area.

The father of modern medicine, Hippocrates, had insight into the connection between mind and body. As medicine has advanced, we have left behind this more subtle and seemingly evasive aspect of health. However, tapping into our mind and the intimate connection it has to our body, may just be our most powerful tool toward health.  

 

A Comprehensive Approach

Treating psoriasis should focus on many elements of lifestyle and behavior through a multi-pronged approach. CBT is an important component, however, addressing the various factors that lead to chronic inflammation will give synergistic power toward improving your skin, your mood, and your overall health.

 

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Friday, March 16th, 2018

Gluten & Psoriasis: Part 2