Pak J Med Res ORIGINAL ARTICLE

Vol. 47, No. 1, 2008

Pattern of Dermatoses and Underlying Psychopathological Disorders in Patients Attending Dermatology Clinic in Earthquake Affected Areas of Azad Kashmir

Faria Asad, Shahzana Naqqash, Sabrina Suhail Pal, Nabeela Shahzadi, Ali Hasnain, Altaf Qadir*, Irfan ul Bari**

King Edward Medical University Lahore, Postgraduate Medical Institute, Lahore*,

Combined Military Hospital Muzaffarabad**

ABSTRACT

Background: Psychological stress such as sexual assault, major earthquake, or plane crash has long been recognized as an etiological or precipitating factor in dermatological disorders. Treatment of these patients comprises of not only management of dermatological disorders but also on treating the underlying psychopathological diseases. These disorders can be identified by the application of the twelve item General Health Questionnaire (GHQ-12) which is a self-administered screening tool requiring only few minutes to complete and score the findings.

Objectives: To recognize different types of dermatoses and screen the patients for associated psychopathological disorders using General Health Questionnaire (GHQ-12) in the earthquake affected areas of Azad Kashmir.

Subjects and Methods: An outpatient dermatology clinic was set up in the earthquake affected area of Muzaffarabad for four days. As it was advertised to be a dermatology specific clinic, so all patients presenting with some dermatological disorder were enrolled using non-probability convenient sampling technique. Demographic data was filled by social workers and clinical data was recorded by dermatologists on a specially designed proforma. The patients were asked to complete 12 items General Health Questionnaire (GHQ) which was filled by patients who were literate while for others social workers assisted. Chi-Square test was used for data analysis.

Results: A total of 522 patients with different skin diseases were enrolled Dermatological infestations were seen in 207 (39%) cases followed by eczemas 90 (17.3%) and infections 80 (15.3%). Stress mediated dermatological problems like acne 40 (7.6%) and psoriasis 27(5%) were found in these cases. Overall 192 (36.8%) patients were living in shelter based homeless situation and psychiatric morbidity was seen in 55% (173) cases having dermatological illness.

Conclusion: Infestations, infections and eczemas were the most common skin diseases seen in earthquake victums and increased psychiatric morbidity may be responsible for rise in stress related dermatological disorders.

Keyword: Psychocutaneous diseases, earthquake

Corresponding Author:

Dr. Faria Asad

King Edward Medical University

Lahore

Ph: 03334234480

On October 8^th 2005 an earthquake measuring 7.8 on the Richter scale devastated northern areas of Pakistan and killed around 75,000 individuals and injured 150,000 people. Two and a half million people were left homeless.¹ In catastrophic events like earthquake, acute dermatological symptoms result from physical injuries, exposure to hazardous environment, malnutrition, unhygienic conditions and limited access to health care.

Psychological stress has long been recognized as an etiological or precipitating factor in a wide range of dermatological disorders.^2-5 Psychological trauma refers to events that overwhelm an individual’s capacity to cope. Successful treatment of these patients depends not only on the management of dermatological disorders but also on recognizing and treating the underlying psychopathology.^{6,
7}

Several studies have reported an increased incidence of bacterial, fungal and parasitic infections in homeless people. Over crowding in shelters increases the risk of cutaneous infections due to exposure to pathogens.^8,9

Psychological trauma can also result in chronic and recurring dermatological symptoms that persists even after the trauma subsides. Examples are cutaneous sensory flashbacks (which may be fragments of the sensory components of the traumatic experience), autonomic hyper arousal (profuse sweating or flare-up of an underlying stress-reactive dermatitis), conversion symptoms (numbness, pain or unexplained cutaneous symptoms), and cutaneous self-injury (trichotillomania, dermatitis artifacta, and neurotic excoriations).⁴ It has been noted that the number of patients visiting dermatology outdoor increases after such traumatic incidences. These patients can have underlying psychopathological diseases which can be identified by the application of a twelve item General Health Questionnaire (GHQ-12) as self-administered screening questionnaire.^10-12 The performance of GHQ-12 is useful in recognizing psychopathological problems in patients with skin diseases. The procedure takes few minutes to be completed and scored.

The screening is beneficial in identifying skin patients having associated psychopathological problems, so that they can be referred to a psychiatrist for management. Failure to identify such patients can lead to chronic morbidity and poor quality of life and burden on the economy.

The study was conducted over one month period where 2 visits to Muzaffarabad were made and outpatient dermatology clinics were set up at two different places (CMH Muzzafarabad and Abassi hospital). Written permission was taken from the hospital administration to carry out the research project. Duration of each visit was four days.

A prior announcement was made in the study area for consultation and treatment of patients having skin problems. Clinical evaluation of each patient with skin disease was be made by a team of dermatologists. The relevant clinical details in history and examination were recorded on specially designed proforma. Patients with known psychiatric disorders or medical illnesses with psychiatric problems like inherent component or history of drug or alcohol abuse were excluded from the study.

Those fulfilling the inclusion criteria were explained the procedure and asked to give a written consent in the form of signature on the proforma, while illiterates gave verbal consent. Cases above the age of 12 years filled GHQ-12 questionnaire which consisted of self-rating of 12 items. Each question had four possible responses; less than usual, no more than usual, rather more than usual or much more than usual. Cut-off point for high scoring was set at a positive response (more or much more than usual) to at least 4 of the 12 items. Positive response meant some underlying psychiatric disorders.

The total of 522 patients presented during the study period. The mean age of the respondents was 22.8 years. Males out numbered females and most of them belonged to urban areas. The demographic data is shown in table 1.

The most skin disorder was infestations followed by infections. Other commonly seen diseases were various types of eczemas, acne and melasma. Stress mediated dermatological diseases like psoriasis, vitiligo, urticaria and neurodermatitis were also seen. The pattern of dermatoses in Muzaffarabad is shown in table 2.

Out of 522 patients, 315 met the inclusion criteria (>12 yrs age) of filling the GHQ. Psychiatric morbidity was seen in 173 (55%) patients and it was not affected by variables like gender and marital status. Psychiatric morbidity was more in patients who were homeless but it was more or less same in subjects who had severe economic loss, those who suffered major physical injury themselves or their immediate family members.

The control group also showed significant psychiatric morbidity (p-value<0.5).

M : F 1 : 1.2

Married:Unmarried 1 : 1.6

Age range 2 m–80 years

Mean 22.8±15.7yrs

Homeless 192 (36.8%)

Rural:urban 1 : 5.1

History of major injury

Personal 51 (9.7%)

Family 110 (21.1%)

Beloved ones missing or dead

Missing 4 (0.71%)

Dead 73 (14%)

History of economic loss

Total 43 (8.3%)

Partial 62 (11.8%)

Moderate 90 (17.3%)

Severe 208 (39.8%)

Minor 119 (22.8%

Skin problems are generally the most common diseases seen in primary care setting all over the globe and its prevalence ranges from 20-50% in developing countries.^13-16 The present study showed that infestations and infections comprised a large group and even after a year of earthquake the living conditions and the health care facilities were far from adequate. Bari et al studied pattern of dermatoses 4 months after the earthquake in the same region and found that bacterial infections were maximum.¹⁷ However, we found that scabies was more frequent in these patients when compared to bacterial infections. This may be due to massive destruction of infrastructure enforcing people to live in overcrowded shelters for a long time thus promoting the outbreak of this disease. Fungal infections were less commonly seen due to the dry and cold climate of Muzaffarabad.

National disasters resulting in psychological trauma are known to produce a number of stress related dermatological diseases. In the present study, acne and eczemas were seen as the next common disorders. As many of these are precipitated by stress this could be the reason for their increased frequency. A study conducted in Japan in an earthquake area also showed an exacerbation of atopic dermatitis.¹⁸ The other stress aggravated dermatological problems like psoriasis, vitiligo, urticaria and neurodermatitis were also found in higher proportions. In the present study we found more cases of psoriasis (5.1%) as compared to to studies done earlier (1-2%).^19,20

The difficulties in regulation of internal emotional status that are encountered in post-traumatic stress disorder can lead to tension reducing behavior, which can manifest as self injury to integumentary system and can present as trichotillomania, dermatitis artifacta, neurotic excoriations etc. These psycho-cutaneous disorders constituted a very small group in our study. However, Bari et al found considerable increase in these disorders.¹⁷ The difference could be due to the differences in study time period and sample size. A study done in Turkey after an earthquake had shown that dermatological symptoms were most frequent in individuals who were homeless and amongst them psychogenic skin disorders were observed in considerable number.²¹

In the present study psychiatric morbidity was seen in more than half of the dermatological patients and it was more in patients who had history of major economic loss or death of their loved ones. The control group showed significantly higher psychiatric morbidity which shows that even the normal general population is as psychologically distressed by the disaster, referring the need for a study to determine post traumatic stress reaction in that effected region for better health care management. This fact is supported by various other studies which showed increased prevalence of posttraumatic stress disorder and major depressive disorders in survivors of severe earthquake.^22,23

The present study would have gained more strength if, following the administration of the GHQ 12 a structured psychiatric interview had taken place in order to determine the presence and nature of any psychiatric disorder.

Associated psychological problems increase the severity and modify the clinical picture of any medical illness so its identification is needed for the proper management of the patient. The GHQ 12 being easy for patients to answer and for physicians to score may be a practical tool to increase the identification of patients with substantial psychological distress or formal psychiatric disorder. More studies are needed to evaluate the underlying psychological or psychiatric problems for better management.

We are highly grateful to Pakistan Medical & Research Council for supporting and funding the project. We also owe our thanks to Dr. Irfan ul Bari, Dermatologists CMH Muzaffarabad for his support during the field work.

Pattern of dermatoses	No. of patients	Percentage
Acne	4	7.6
Alopecia areata	12	2.3
Bacterial Infection	39	7.5
Connective Tissue Disorder	8	1.6
Eczema	90	17.3
Fixed Drug Eruption	5	0.9
Fungal Infections	32	6.2
Lichen Planus	2	0.4
Melasma	27	5.1
Neurodermatitis	1	0.2
Psoriasis	27	5.1
Pityriasis Capitis	6	1.2
PalmoPlanter Keratoderma	5	0.9
Scabies	207	39.5
Urticaria	6	1.2
Vitiligo	6	1.2
Viral Infection	9	1.8