Live patient discussion Sandra Ros (MA), Dr Lluís Puig

Transcription

1 Department of Dermatology Hospital de la Santa Creu i Sant Pau op yr ig ht I P C N O V A R T I S P S O R I A S I S P R E C E P T O R S H I P C Live patient discussion Sandra Ros (MA), Dr Lluís Puig Barcelona, July 9th-10th, 2013

2 Psychological and QoL Impairment. Progressive Life Damage in psoriasis Sandra Ros Clinical Psychologist Dermatology Department Hospital de la Santa Creu i Sant Pau. Barcelona

3 I just want to hide and stay away from everyone a 23 year old female patient, at first visit.

4 Psoriasis Psych & skin disease Psoriasis is a chronic, inflammatory & multystem disease. Model of dermatologic psychosomatic disease The disfigurement that psoriasis can cause gravely affects self-steem, influences the way people perceive themselves and how they are perceived by the world.

5 Main Factors in Psoriasis Visibility Stress Previous psychopathology and personality traits

6 Role of Stress Acute stress vs chronic stress State of prolonged tension from internal or external stressors, which may cause various physical manifestations e.g., asthma, back pain, arrhythmias, fatigue, headaches, irritable bowel syndrome, ulcers, and suppress the immune system % SVE 2-4 weeks

7 The role of stress in psoriasis STRESSFUL LIFE EVENTS STRESS DUE TO PS ONSET OF PSo EXACERBATION OF PSo Vulnerability? Age, physical symptoms, genital areas, visibility skin lesions, personality traits, alexhitimia

8 Psychological impact Visibility /chronic disease Stigmatization Psychopathology Self confidence anxiety depression Self image Self -steem Psychosocial impact (QoL) Depression Anxiety Sd. Adjustment Dis. Social Phobia Suicidal Ideation Substance Abuse: alcohol/smoking Sexual dysfunction Social occupational family relation ship & sexual

9 STIGMATIZATION Visibility DISTURBANCES IN BODY IMAGE LOWERED SELF-CONFIDENCE Anticipation of rejection Feelings of being flawed Sensitivity to the attitudes of others Guilt and shame Secretiveness

10 QoL and psychosocial impact Social impairment Avoidance of public places or diminished social activity Cover-up clothing Change in daily routines Discomfort in the company of new people or situations Relationships & sexual impairment Sensation of lack of physical attraction Fear/ insecurity in close relationships Fear/ insecurity in sexual relationship Works impairment Feeling of unfavorable appearance Negative experience of the disease at work Days lost due to outbreaks of the disease Days lost for long treatment therapies

11 Psychological impact Visibility /chronic disease Stigmatization Psychopathology Self confidence anxiety depression Self image Self -steem Psychosocial impact (QoL) Depression Anxiety Sd. Adjustment Disorder. Social Phobia Suicidal Ideation Substance Abuse: alcohol/smoking Sexual dysfunction Social occupational family relationship & sexual

12 Psychological comorbidities Depression Anxiety Sd. Adjustment D. Social Phobia Suicidal Ideation Substance Abuse: alcohol/smoking Sexual dysfunction ü Prevalence psychological co morbidities : 30-40% ü Anxiety, depression, smoking and alcohol abuse have been found to have significantly higher prevalence among Pso patients than healthy controls ü Risk Factors : physical symptoms, evolution, treatment and psychological treats

13 Depression: signs and symptoms Tiredness and loss of energy. Sadness that doesn t go away. Loss of self-confidence and self-esteem. Difficulty concentrating. Not being able to enjoy things that are usually pleasurable or interesting. Avoiding other people, sometimes even your close friends. Feelings of helplessness and hopelessness. Sleeping problems - difficulties in getting off to sleep or waking up much earlier than usual. Very strong feelings of guilt or worthlessness. Finding it hard to function at work/ college/school Loss of appetite. Loss of sex drive and/or sexual problems. Physical aches and pains. Thinking about suicide and death. Self-harm

14 Depression: signs and symptoms in Pso Prevalence : 10-62% / 30% Thinking about suicide and death: 9% - 5% Risk factors: Decrease QoL Perception of Pruritus Sleeping problems Demoralization and dissatisfaction with treatment Treatment adherence

15 Anxiety disorders Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The person finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. Restlessness. Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

16 Anxiety disorders in Pso Prevalence : 43% Generalized anxiety disorder and social phobia Pathologic worrying and social anxiety are strong components of anxiety in ps patients Feeling of stigmatization and anticipated difficulty in interpersonal relationships

17 Adjustment disorders in Pso Having emotional or behavioural symptoms within three months of a specific stressor (pso) occurring in your life Experiencing more stress than what would normally be expected in response to the stressor or having stress that causes significant problems in your relationships, at work or at school An improvement of symptoms within six months of the stressful event coming to an end Signs and symptoms of adjustment disorder may affect how you feel and think about yourself or life, including: Sadness Hopelessness Lack of enjoyment Crying spells Nervousness Thoughts of suicide Anxiety Worry Desperation Trouble sleeping Difficulty concentrating Feeling overwhelmed

18 Alcohol misuse in Pso Ps is associated with an increase alcohol intake. Prevalence 22-32% Patients with ps have a significantly higher mortality from alcohol-related causes compared with the normal population Alcohol misuse may increase ps severity and is associated with anxiety and depression in ps patient Self reports of alcohol intake underestimate consumptions. Treatment adherence

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20 CLCI Few skin diseases are life threatening the impact on the patient may not be perceived as severe; however, this view does not take into account the psychological and social impact of disease Patients with psoriasis experience increased stigmatization when combined with certain personality traits, patients self confidence can be significantly undermined Difficult life circumstances or key life events can be heightened by psoriasis, and patients may experience physiological, psychological or behavioural changes in an accumulative manner These changes can result in diminished quality of life and life potential

21 Evaluation of the impact of psoriasis:

22 Quality-of-life instruments

23 DLQI: 1. Over the last week, how itchy, sore, painful or stinging has your skin been? 2. Over the last week, how embarrassed or self conscious have you been because of your skin? 3. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden? 4. Over the last week, how much has your skin influenced the clothes you wear? 5. Over the last week, how much has your skin affected any social or leisure activities? 6. Over the last week, how much has your skin made it difficult for you to do any sport? 7. Over the last week, has your skin prevented you from working or studying? If "No", over the last week how much has your skin been a problem at work or studying? 8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? 9. Over the last week, how much has your skin caused any sexual difficulties? 10. Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time

24 Skindex 16:

25 Clinical psychology tests Beck Anxiety Inventory Beck Depression Inventory Beck Hopelessness Scale Hamilton Anxiety Rating Scale Hamilton Rating Scale for Depression Hamilton Hospital Anxiety and Depression Scale Montgomery-Asberg Depression Rating Scale Social Phobia Inventory Stait-Trait Anxiety Inventory Spielberger Sympton Checklist 90 Derrogatis CAGE questionnaire AUDIT questionnaire

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27 AUDIT AUDIT vs CAGE

28 Personality Traits Psychopathology Coping to illness EACH PATIENT IS UNIQUE

29 Personality traits: alexithimia?

30 What can we do?

31 Psychotherapy psychopharmacology Individual Psychotherapy Relaxation Training Group therapy Stress reduction interventions Psychopharmacological treatment Counselling Support groups

32 Refer to psychologist when patients psychological symptoms or psychological disorders: depression, anxiety and adaptative difficulties describe the onset of the disease or exacerbation of symptoms related to a period of stress do not respond to dermatological treatment due to poor adherence to the treatment present psychosocial effects; e.g.avoid situations are overly concerned in relation to the severity of their psoriasis

33 Psychotherapy Individual Therapy Group Therapy

34 Psychological interventions Psychotherapy is an interpersonal, relational intervention used by trained psychotherapists to aid an individual in life problems Relaxation techniques: Autogenic and progressive muscle relaxation training

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36 Psychological interview Psychopathological aspects sleep disturbances low energy or fatigue low attention and concentration psychic anxiety and somatic anxiety stress Psychosocial aspects» Socio demographic characters» Family support and relationship» Social or occupational impairment Role of the disorder in their life

37 Psychotherapy in psoriasis PSYCHOLOGICAL INTERVIEW evaluating cognitive capacities personal resouches family and social support INDIVIDUAL Discuss results of psychological interview with the patient Plan psychological TREATMENT together with patient FOLLOW-UP

38 Autogenic and progressive muscle relaxation training We perform autogenic and progressive muscle relaxation training individually with each patient 3 steps: focused breathing progressive relaxation imagining a pleasant situation Audiotape with their own relaxation training Once a day

39 Psychotherapy : objective Identify stressful situations Confront feelings that provoke psoriasis Differentiate patient identity from the psoriasis Separate the disease from the patient Identify use of the disease Develop coping strategies

40 Psychotherapy in psoriasis Motivate the patient to change/improve Thoughts Beliefs Habits Attitudes Non-adaptive behaviour Evaluate the relationship between PS and consequences that are generated in the patient Irradicate complaints and evasion Increase daily activities progresivelly Reduce psychophamachological treatments Reduce excessive number of medical appointments

41 Psychotherapy in psoriasis Enhance behavioural changes through way of thinking Transfer attitude from intolerable to manageable Change passive attitude to active, capable attitude Anticipate problems and find solutions Develop coping techniques Create awareness of association between thoughts, feelings and behaviour Improve mood

42 1. Visible psoriatic lesions often provoke social stigmatization and rejection which can have a profound effect on a patient s self-confidence, self-image, sense of wellbeing and interpersonal relationships 2. Traits individual to each person influence the coping strategies they employ; psoriasis patients who use passive coping strategies are more likely to feel a lack of personal control, experience psychological distress and adopt destructive behavioural patterns 3. Increased psychological distress and difficult life issues can lead to psychological comorbidities such as anxiety, depression and suicide ideation; these can result in behavioural changes such as increased social phobia, alcoholism and nonadherance to treatment among patients with psoriasis 4. Psoriasis is an inflammatory disease; the inflammatory process can be linked with other comorbidities such as increased incidence of psoriatic arthritis, cardiovascular disease and metabolic syndrome (hypertension, diabetes, obesity), cancer, depression, and other immune-related conditions such as Crohn s disease 5. The effects of psychological distress and physical damage caused by psoriasis and its co-morbidities lead to higher burden of disease and can decrease quality of life and long-term life potentia

43 ü Multidisciplinary approach can ü Provide tools to confront psoriatic illness ü Detect & treat earlier psychopathological comorbidities ü Improve personal relationships and Qol ü Help to control exacerbations ü Improve adherence

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