Why is trichotillomania not categorized as cutaneous sensory disorder?
Below is the abstract and I will try to include as much fo the article as possible but you need a subscription to access it fully; https://onlinelibrary.wiley.com/doi/full/10.1111/ijd.14629
“Abstract: The study of psychocutaneous disease involves a comprehensive understanding of the complex and often neglected psychoneuroimmunologic components and pathways. Patients suffering from the many disorders that blur the interface between the fields of psychiatry and dermatology are often misdiagnosed and mistreated because of the lack of knowledge and awareness of the underlying disease‐causing mechanisms. Individuals with psychodermatologic disease also experience a general lower overall quality of life as it has negative implications on psychosocial, emotional, and cognitive well‐being. Factors like early life interactions, body image dissatisfaction, and societal stigma play a crucial role in the development of psychosocial stress experienced by individuals with visible skin conditions. This heightened level of stress serves as a trigger in the activation of the hypothalamic‐pituitary‐axis (HPA), mediating immune responses that influence cutaneous disease severity and exacerbation. In order to improve the quality of life and treatment outcomes of the patient population impacted by psychodermatologic disease, it is essential to better understand the complex interplay between the various psychosocial factors and pathophysiologic pathways involved.”
When you have trich, you wonder “Am I making this up? Am I crazy? Do I have a psychological problem?”. So having trich is complicated in that way. Doctor’s don’t know what to do with us. After 4 decades of psychologist wanting to tell us what we need to do to “just stop”, maybe they need to see the long-term treatment outcomes of those 40 yrs haven’t helped anyone with trich.
“Various studies indicate that at least 40% of dermatologic patients exhibit a psychiatric comorbidity, calling for a better understanding and awareness of the interplay between the two disciplines”
Model of psychosocial factors implicated in the origin and maintenance of skin‐specific affect/distress, and systemic adaptation response
Figure 1. Model of psychosocial factors implicated in the origin and maintenance of skin‐specific affect/distress, and systemic adaptation response
Sometimes I do find it odd that we blame mothers but not fathers for “pre-disposing factors” listed above. Couldn’t we substitute “parent” instead of “mother”?
Well, looking at the graph it’s no wonder at all why I have trichotillomania but I don’t know if I agree with all of these arrows (the directionality aspect). It has been noted previously that CHRONIC STRESS CAN and DOES dysregulate the immune system response to inflammation (scroll down to another blog post if you want to read it).
Anyways, moving on. There are a few paragraphs about skin conditions leading to personality disorders that I am omitting since it does not interest us since trichotillomania is already classified as a psychological issue. It is not a shocker that having trichotillomania could lead to depression and anxiety.
Although I find this paragraph intriguing;
“Studies examining the mother‐child relationships in atopic dermatitis indicate that the children often faced maternal rejection and feelings that the child was a burden.12 A potential explanation of these feelings may stem from the high levels of stress, ineffective family functioning, and poor psychosocial well‐being and quality of life faced by parents of children with atopic dermatitis.13 These attitudes are not instantaneously formed at the onset of the child’s disease but rather develop over the course of time as the mother's ability to adapt to the chronic stress becomes exhausted and can manifest as alterations in spontaneous response to the child.14”
I think this article does suggest that trichotillomania does also impart additional psychological issues that can go unnoticed but are detrimental;
Psychoneuroimmunology of Skin Disease
“There has been increasing evidence and research identifying the link between stress and cutaneous disorders which is mediated by complex neural integration of immune, endocrine, and autonomic systems. Along with gaining a more comprehensive understanding of the interactions of these systems, the field of psychoneuroimmunology aims to strengthen the “psychosomatic” link of skin disease and stress. Picardi and Abeni23 found promising evidence of the role of stress on the exacerbation of atopic dermatitis, psoriasis, urticaria, and alopecia areata. In addition, Dhabhar24 indicates that stress plays a role in immunoprotection, immunoregulation, and immunopathology in psychocutaneous disease. There is a multifaceted association between psychoneuroimmunologic processes and overall quality of life issues experienced by patients suffering from psychodermatologic disease (Fig. 3).”
Figure 3. Impact of stress on psychocutaneous disease development.
The stress‐adaptation response & stress‐immune spectrum
Stress consists of an exposure to a stimulus that results in the generation of physiologic and behavioral responses.25 The ability to adapt to stressful situations is mediated through the integrated action of neural, endocrine, and immune mechanisms. The presence of chronic stress or high magnitude acute stress can lead to a disease response because of the exhaustion of normally active adaptive mechanisms. Psychophysiologic resilience plays an important role in returning to a health maintenance equilibrium or allostasis.26 Psychological (early experiences, coping mechanisms, optimism, or social support) resilience and physiologic (neuroendocrine reactivity, sleep, or nutrition) resilience impact the duration and magnitude of stress experienced.2
Skin and sensory perception
When there is internal or external stress, several dermal and epidermal cell populations become activated to mediate proper immune responses. Langerhans cells and dendritic cells migrate to the epidermis and function to present invading foreign antigens to the lymphoid system. Merkel cells are specialized for the sensation and perception of light touch, while Meissner and Pacinian corpuscles are mechanoreceptors responsible for perception of pain, pressure, and temperature.
The secretion of neuropeptides is vital in neurogenic inflammation like vasodilation, plasma exudation, and migration of leukocytes through their action on neuropeptide receptors and specific immune cells.29 Examples of body areas containing a high density of nerve endings include the ends of the fingers, lips, genitalia, and face. Importantly, certain body‐focused repetitive disorders such as skin picking and trichotillomania occur frequently at the face or scalp.
Neuroendocrine and autonomic nervous system's response
Stress response is triggered by the neuroendocrine pathway of the hypothalamic‐pituitary‐axis (HPA) through the secretion of corticotrophin‐releasing hormone (CRH) and arginine vasopressin (AVP).30 These mediators then travel to the anterior pituitary and influence the release of adrenocorticotropin hormone (ACTH) which stimulates the release of cortisol through the adrenal cortex. In turn, through a feedback mechanism, cortisol suppresses the release of ACTH, CRH, and AVP. The concurrent involvement of the autonomic nervous system acts to modulate the activity of the HPA. A summary of the impact and interactions of stress perception, HPA, and health maintenance equilibrium are shown in Figure 4.”
The study of psychocutaneous medicine aims to better understand the disorders that lie at the interface between dermatology and psychiatry. The integrative field encompasses four major fields (psychiatry, psychology, neurology, and dermatology) to address the link between the nervous system, psyche, and skin. Psychoimmunopathologic factors play a crucial role in the exacerbation of preexisting skin disorders and the development of new cutaneous disease. A more comprehensive understanding of psychologic factors and imunopathologic pathways impacting skin disease in early child development, CBI, and relationship satisfaction are needed to better assist the affected patient population. There has been increased interest and findings in the role of emotional stress in the pathogenesis of skin disorders like atopic dermatitis and psoriasis. Recent research aimed to uncover the pathways involved in the effects of stress on the immune system, and skin provides a potential avenue for clinical interventions to reduce stress‐induced exacerbation of cutaneous disease.”
I guess I was hoping this article would tell it us new things. There are some new “terms” worth looking at. I was hoping it would have other treatment implications or reviews on new studies on novel treatments but it did not. It is interesting but lacks steps going forward to me. I am posting bc maybe it has parts that jump out to you.